Advice on dosing increase

C.W. Gortner

C.W. Gortner

Member Since 2016
Hi all,
My cat Mommy was diagnosed in December of last year. She ended up hospitalized with pancreatitis and was severely underweight. She was initially put on 2 u 2x daily of Lantus after she came home and over a period of four months or so, she stabilized so that her BG started to drop too low. But getting home readings on a regular basis became a challenge, too; she's an ex-feral, very fearful, if trusting of us, but as soon as we instituted daily home testing she started hiding and avoiding us. It made giving her her shot much more difficult. After several talks with my vet, we decided to not BG test her at home but rather watch her urine and water intake; she was doing very well based on regular spot-checks at the vet. He said she was stable. Her dose was later reduced to 1 unit 2x a day, which she responded well to.

In the last week or so, however, her appetite started to decrease. She's always been a finicky eater and she's not peeing more or drinking any more that we can tell (we monitor her water bowl constantly) but she does seem nauseous. I finally gave in and BG tested her tonight. She's due for her PM shot in an hour and her BG was 440, which startled me. She was stressed, of course, by the testing (she hates the poke) but not to the point of hissing and I did her test fast.

My question is, should I increase her dose to 1.25 tonight? We're due for a vet appointment on the 28th so I don't want to make any radical changes off the cuff or based on one reading, but this reading does seem pretty high for me after nearly a year on Lantus.

Also, I refrigerate her Lantus and the expiration date on the bottle is 12/2019. I check it every time for discoloration or any other signs of degradation; it looks perfectly clear. It has never frozen or been left out in light or heat. Can Lantus lose its potency anyway, after nine months? My vet assured me that if it's refrigerated, it won't, but I'm perplexed as to why her BG would suddenly be so high.
 
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It might be worthwhile to get some new insulin

Although it's possible it's still good, we usually say about 4-6 months.

That's why most of us use the pens instead of the vials. Each pen holds 300 units and the rest of the 5 pack stays unopened and refrigerated so it's good until the expiration date...usually at least 2 years
 
I did call my vet today. I tested her again this a.m. before her shot and it was 430, so she's running high. The vet seemed a bit perplexed over the viability of an open vial kept well stored and refrigerated, with no visible signs of degradation, but agreed it could be lack of potency, albeit with a touch of skepticism. I can't think of what else it would be unless my cat has suddenly become insulin resistant. She does have dental issues that I made an appt for on the 28th to deal with - she probably needs extractions - so there could be some underlying inflammation that's affecting her BG. I read this is possible.

In any event, if she only gets 1u 2x a day, what type of Lantus pen should I buy? I need one with as little insulin as possible per pen so I'm not tossing out hundreds of dollars. The current vial cost $350 and is still half full. It sucks, but I don't trust its efficacy now.
 
There's only 1 kind of pen. The Lantus SoloStar pen that holds 300 units....and usually you have to buy a 5 pack (not many pharmacies will break open a pack and only sell one pen but you can call around and ask....sometimes you get lucky)

You still use the same insulin syringes to pull the insulin out of the pen....we don't use the special needles that you have to buy separately that work with the "dial-a-dose" mechanism

Most of us are buying our Lantus from Canada because it's so much cheaper.

Here's the information on buying insulin from Marks Marine Pharmacy ….they really are great!!

They WILL sell individual pens, but the 5 pack is the better buy and as I said last night, they usually don't expire for at least 2 years so you have plenty of time to use them.

It takes about a week from the time you order to delivery.
 
THANK YOU for this! I'll get a new scrip on the 28th and order my next Lantus from there. I just had to fork out $336 at Walgreens because if Mommy's insulin is failing, I need to replace it ASAP, but going forward, I can order the pens from Mark's and save money. Even the vial at Mark's is $200 less than here in the U.S.

My vet is on vacation until the week of my appointment - of course - so when I called the practice today to ask about her high BG and request a new scrip for pens rather than vials, they said I'd have to bring her to be seen. As they have no regular appointments available until after the one I'd already scheduled, they wanted me to bring her to their emergency area, which is twice as expensive. It's such a racket here in SF. They know her history, they have her medical files, so not giving me a new scrip is bullshit. But my doc is cool, a specialist and low-key; if he were available, I know he'd have given me the new scrip, no problem. The practice, however, is a pain in the ass - though they deliver excellent care, which you pay for through the nose.
 
You don't need a prescription specifically for the pens if you buy from Marks.

In Canada, insulin is OTC, so if your script is for a vial, all you have to do is call them and ask for pens instead. The pharmacist can switch those without any problem
 
Another question: The Lantus website says the pens should not be refrigerated after opened and thrown out after 28 days. Now, I know that's mostly manufacturer-covering-their-ass talk, but how long can you reasonably expect an open pen to last before you need to use a new one? Mommy is on 2u 2x a day, so technically, if a pen contains 300u, it could last her 150 days, right? But that's about 5 months, so way over the manufacturer's stated throw-away date. I got my vial to last about 8 months, as I suspect this recent BG hike is indeed recent, so I'm leery now of overestimating efficacy.

How should I proceed in terms of reliability with a pen? I've stated home testing is spotty due to my cat's feral nature, but I am going to try again to aim for a least once-weekly tests, if at all possible. Given that I can't keep daily readings on her, I have to guess-estimate probable efficacy duration once I switch to the pen.
 
Oh, that's cool. I do have an extra Lantus scrip from the vet, but it's dated from 12/2017, so I don't know if Marks would still consider it valid. The current scrip, which I used to refill today, is already in the computer at Walgreens (the practice faxed it over right after Mommy's discharge last year) but the vet still gave me a written scrip that I never submitted.

I'll call Mark's tomorrow to see if they'll accept it.
 
Since we use regular insulin syringes, not the special needles, we keep it in the refrigerator.

The manufacturer says not to refrigerate "open" pens because it can cause the "dial-a-dose" mechanism to stick. Since we're not using that mechanism, it doesn't matter.

The ONLY reason there's a 28 day limit on Lantus is because that's all the company asked the FDA to test for......so legally, that's all they can say it's good for!! What a racket, right?

2U twice a day is 75 days per pen, not 150;)
 
Sorry, my oops. She actually gets 2 units total a day: 1u 2x a day, or 1u every 12 hours.

I'll use my regular syringes, too. So, I can refrigerate the pen. Excellent. At her dosage, any advice on how long I should rely on an open pen before I'll need to toss it?

I read about the FDA testing limitations on Lantus and my jaw just dropped. Insulin is so expensive in the US; they should require a lengthier time to determine when a vial that is stored as directed actually does run the risk of expiring, rather some arbitrary short-term end-date. It's a total racket to keep people buying fresh supplies. And for those without insurance, imagine the cost! I mean, it's bad enough with a cat, but it must be a financial nightmare for human diabetics who lack adequate coverage.
 
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I will use pretty much the whole pen unless the numbers indicate it might be losing efficacy

Generally, 4-6 months is a good time period to plan on
 
C.W. Gortner said:
It's a total racket to keep people buying fresh supplies. And for those without insurance, imagine the cost! I mean, it's bad enough with a cat, but it must be a financial nightmare for human diabetics who lack adequate coverage.
Click to expand...

Exactly.....when I first "found" Marks several years ago, I spent about 2 hours talking with the pharmacy manager. He said they get a lot of their insulin business from the US, especially along the east coast where it can cost even more....he said he'd heard of people paying up around $800 for a vial!

I saw a piece on the national news just a couple nights ago....people are restricting their insulin to make it go further because they can't afford it.....which in the long run just leads to higher medical bills when their diabetes isn't well controlled and they go blind, need amputations, etc.

Big Pharma has this country in a choke-hold and they're not going to let go easily (and despite the promises of certain politicians, as long as there's money involved, nothing is going to change)
 
Thanks so much! Four to six months per pen would be fantastic. I'd pay anything for my cat, but to be gouged by Big Pharma just pisses me off. That said, I'll call Marks tomorrow to see if they'll accept / convert the scrip I have but haven't used yet. If not, I'll get a new scrip from my vet on the 28th, as I already bought this overpriced new vial. I'm hoping it's just a loss of insulin potency and not something else driving up her BG. She's such a great cat, I rescued her and her son Boy (in my avatar pic) and they've been wonderful companions. I adjusted their diet, too, for both of them - only low-carb wet Fancy Feast - and not a drop of dry kibble; it took a while for Boy to get used to it, but he eventually did. He still comes racing when he hears the dry kibble we use to feed the myriad ferals who show up in our garden; I'm overrun by wild cats here. We trap as many as we can, but it's a never-ending cycle.

Mommy's diagnosis initially turned us upside down, especially as she ended up so sick, we feared she might not pull through. She's a fighter, though, and while an older gal, has a lot of spunk in her from years of being feral. She's been doing so well. This disease is so insidious and it's hard to find the useful info you need, so bless you for helping me here. I'm so grateful for this site.

For example, I just watched a video on the Lantus Handling sticky here and it says to never roll the vial. Well, I roll it every time because that's what the vet told me to do. I mean, the guy is really good at his job, but vets seem kind of clueless at times when it comes to the details. No one at his practice gave me thorough instructions, so I just rolled the vial, and if I overdosed into the syringe, shot the excess insulin back into the vial. Big no-no. I'm surprised I managed to squeeze as much time out of that vial as I did, given my shoddy practices. Live and learn.
 
Took Mommy to emergency today; she just looked miserable this morning and I really started to fear her pancreatitis had returned. Turns out her BG spike is probably due to an infected abscess in her left molar, along with overall severe periodontal disease. I knew she had teeth issues - she's a senior and at her last check-up six months ago, my vet mentioned she was going to require a dental - but as the emergency vet said, when teeth stuff starts to go bad, it goes fast. This emergency vet is incredible, she saved Mommy's life when my cat was first diagnosed, and she also said that they use refrigerated open Lantus vials for a year at their practice, that it's not as "delicate" as people think, and the 28-day expiration is a Big Pharm rip-off (which we, of course, know). She doubts my first vial Lantus has lost its potency; any underlying infection / inflammation in a cat's system will spike their BG. She ran blood-work and a fructosamine test, just in case we need to adjust dosing. To my surprise, despite her scarce appetite these past few weeks, Mommy had only lost a quarter pound of weight since her last visit there.

I'm seeing my regular vet on the 28th for a follow-up, as well as the dentist (both work in the same practice as emergency; it's the VIP of veterinary specialist centers and their prices reflect it. I need a GoFundMe page for my vet bills!) Mommy will probably have to get most of her teeth extracted, once the infection is under control. She's on a week of antibiotics and a pain med now. The pain med did wonders. Within a few hours of coming home on the med, she was purring, wanting belly-rubs, and hungry. She didn't eat much, but enough to give her PM shot and the rest of her meds. The antibiotic is Clavamox, which can be gnarly on the stomach.

So, in sum, thanks for all your help here!! My emergency vet also agreed to give me a new scrip for Lantus to send to Canada, and told me that yes, Lantus is much cheaper there and she's all for it. I told her about Mark's and she said a lot of her clients with diabetic cats will appreciate the information, because they're all in the same boat as we are.
 
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Oh yeah.....any infection/inflammation or pain can wreak havoc with the blood glucose levels!

It's great that you got her in and are working to take care of it!!

You're also totally right that Clavamox can cause nausea, so if she goes off her food, you may need to consider a different antibiotic like Clindamycin (which is usually better for dental infections) and/or get some Cerenia to help with nausea.

It's also wonderful to hear of a vet that encourages their clients to save money and will spread the word about Marks to others!!
 
It did not go well at all today for Mommy's follow-up. In fact, it was devastating. I'm still struggling to process it all and figure out what to do next.

When Mommy went into crisis and was hospitalized last year, we discovered her diabetes. At the time, the vet said her outlook was very uncertain; she had pancreatitis, but we persisted and she pulled through. Her blood work at the time also indicated stage 1 CKD, with a high "normal" creatinine of 1.8. With 1 unit of Lantus twice daily, we got her diabetes under perfect control. She was fine for eight months. Then this tooth infection crisis happened last Monday, so we did the week of Clavamox, plus Buprenex for the pain, and sub-q fluids because her creatinine at her emergency visit for the tooth had jumped to 7.6. The vet expressed panic at these values and wanted her hospitalized immediately for IV fluids, until I refused and offered to do sub-q fluids at home. With her insulin, Mommy needs to eat and she wouldn't when she was hospitalized before; we had to visit her twice a day and sing to her, getting her to eat a little, but never enough. I did sub-q at home, the Clavamox and Buprenex took their toll - she became very nauseous and sedated by day 5 - but we gave her Cerenia, which helped. On Sunday, within 24 hours of ending the pain med and antibiotics, she was eating again. On Monday, she ate her three meals and seemed like her sweet self again.

The follow-up today was to re-check her renal values and schedule her dental, which she needs. I'd thought her elevated kidney values - they've just shot so high in eight months - was due to her untreated tooth infection, so I was certain the values would be at least lower, if not yet back to her Dec '17 level. Instead, her creatinine came in at 8.9 and her BUN was 140. Higher than before. Stage IV kidney disease, said the vet. She was gentle but grim; she told me it was likely "a matter of weeks" before we'd have to let Mommy go.

Of course, I started to cry, as I know these numbers are dire. Paradoxically, her BG came in so low - it measured 32 at the vet - they told me to discontinue all insulin for two weeks. She was eating until this vet visit today; we were at that practice for two solid hours, because they always run late, and the dental consult, which we had immediately following her follow-up, was interrupted by my vet with the in-house kidney panel they'd run. It was then, as the dentist slipped out, that my vet delivered the news.

Once we got home, Mommy went under the bed and refused to come out. She was exhausted and stressed out, so I let her rest. In the evening, we had to do sub-q fluids again - the vet now wants it daily - so I had to get her out. She showed immediate interest in food, but after nibbling a bite or so, she made a strange movement, as if she was either in pain or nauseous, lowering her head and staying very still as I soothed her. She tried again to eat a bit later, but took another bite and stopped. I couldn't tell if it was nausea or pain, but I gave her Cerenia and the fluids. She's now very lethargic. She went back under the bed and has stayed there. She's not eating at the moment, which is a very abrupt switch from this morning even, when she gobbled down her breakfast and asked for more. She was purring and resting in her usual spot. Two hours at the vet and she's a completely different cat.

To complicate matters, I've been reading up as much as I can on CKD and she's not showing any of the classic symptoms of stage IV, except in her blood work. She did have significant nausea on the Clavamox, but her appetite returned. Her BG hitting so low freaked me out, too, but the vet said this is common; as kidney function deteriorates, insulin requirements shift. I'll home-test her BG as best as I can for these next two weeks. She doesn't mind the sub-q fluids or insulin shot, but BG home testing - mainly, the pricking of her ear - was never her cup of tea, and she'll evade / hide much more if I do it too often. Her entire temperament reverts to feral. She's very sweet, not a snarler or claw-swiper, but we simply haven't been able to get her fully comfortable or adjusted to daily BG home testing. Go, figure.

The vet basically offered me no alternatives except daily sub-q, Cerenia as needed, and to "watch and wait." She was very gentle, as I said, but firmly convinced that nothing more could be done, even though this dental issue could very well still be an issue. When she mentioned euthanasia, I kept repeating that Mommy's diabetes was under control. She was fine, happy. Eating. She had this awful tooth flare up and suddenly, her renal values skyrocket. I know CKD is incurable and progressive, but how can she go from stage 1 to stage IV in eight months? Something in my gut keeps telling me it's her dental issues, but maybe that's my denial. She is a senior, but no more than 13 at most, so this has all hit me like a falling brick wall. I never expected it.

I'm not sure if being CKD asymptomatic at her extreme renal values is even likely, either. The vet did admit the entire practice was in awe of Mommy; according to them, most cats at these values will display unkempt coats, frequent urination, little to no appetite and significant ongoing nausea plus other obvious signs. Mommy has shown none, except the nausea and no appetite, which coincided with the tooth infection, and both resolved after treatment, but the vet now refuses to even consider a dental, saying anesthesia will kill her.

I don't want to go to heroic measures, as I realize CKD will eventually win, but I do want to do as much as I can for Mommy. We love her so much. Any advice is welcome. Could her values eventually decline on daily sub-q fluids? Was taking her values only a week after an infection too little time? Was a week of Clavamox enough and/or might she need a different antibiotic for more time? The vet said, no, that as the values went up, not down, that's it. She's on her way out. Though this an expensive specialty veterinary practice in San Francisco, in their opinion, it's hopeless. I tend to look at things more holistically, but I'm near-despair.
 
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