? 4/5 - Kitty - Switch from Novolin to Glargine Dose Advice

[Corey & Kitty]

Hi everyone,

Here's a link to my new member post in the health forum: https://felinediabetes.com/FDMB/threads/new-diagnosis-kitty.261378/

Here's a little info about Kitty:
Name: Kitty
Gender: Female
Age: ~10
DX: March 7th, 2022
Current insulin: Novolin N, 3 units twice daily
Diet: 3oz can Fancy Feast Classic Pate & 1/4 cup + a little more Purina Pro Plan Vet Diet DM dry food (she gets these both twice a day)

I was able to pick up her prescription for insulin glargine pens today.


I'm hoping someone can help me figure out a starting dose as the vet had no idea how to prescribe this, he only did it because I asked him to. Being a technician at the pharmacy, I had to walk him through it, I read him word for word the dosing info from the AAHA, and he still put to give her 2.7 units twice daily.

Also, I'm wondering if I should wait until I have a couple days off to start the new insulin. I have every Sunday & Monday off from work so I could stay home those two day. If I'm going to start then, it would be on 4/10.

I'm assuming I'll be going with the SLGS method and I'm wondering how this is going to fit into my schedule and how often I need to be testing her BG. On my work days I can only check it once during the AM cycle and its usually anywhere from +4 to +7. PM cycles I usually stay awake until +3 or +4. I'm wondering if this is going to be sufficient, but I see on other people's spreadsheets they are testing a lot throughout the day.

I have some anxiety about changing to this new insulin. I understand for the most part how the depot works, but I worry that if she's given too high of a dose that the effects of it remain for some time and I wont always be able to stay with her to monitor and give extra carbs when needed on work days. I understand that I'm to start at a low number of units and only increase as needed at small increments Also, I have been looking at some other people's spreadsheets and I see them shooting at very low numbers and it makes me nervous. I'm assuming that glargine doesn't drop BG as sharply as I've been seeing with the Novolin N. I've ready somewhere that 80 - 120 is a desirable BG for cats but it seems some people are keeping them at consistently lower numbers. I'm just worried about hypos. I see people talking about low numbers and having to wait 30 minutes and retest before feeding and giving insulin, but I don't always have the luxury of time to wait around because of work.

I also worry about DKA in the beginning if we start at a low dose and she's not getting enough insulin. I have urine strips, checked her urine the other day just to see if I could get a sample from her, it tested negative for ketones. I also have a blood ketone meter on the way which is supposed to arrive tomorrow.

EDIT: I have no reason to believe ketones are an issue for her. I tested her urine last week and they were negative. I just worry that changing insulin and her diet will create conditions for ketones to rise.

I also want to continue transitioning her to full canned food, but I was told that its probably best to get her on the new insulin first and then proceed with the diet change.

 

[FrostD]

Glad to see you got it!

so the concept of the depot is scary at first, but in the end it's not a big a deal as it seems. As long as the dose is reached methodically, the depot usually isn't too much of an issue. And people here are so good at reading spreadsheets, they'll be able to advise when to do something like skip a shot to help drain the depot.

I suspect the advice will be to start at 3U since she's seeing ok nadirs on it, but wait for others to chime in. She's doing ok on Novolin so I don't see the harm in waiting til the weekend if that makes you feel better.

The spreadsheets you see with the lower numbers are people doing Tight Regulation (TR), where the goal is 50-100 (on a human meter) as much as possible - that's also the reason you see a lot more testing in tightly regulated cats, it's necessary to keep them safe. TR has a few benefits - that BG range allows the pancreas to heal better, better chances of remission, allows for faster increases most of the time, and obviously keeping the body in the numbers it would normally operate at. It does require an all low carb wet food diet.

That said, as you alluded to, it simply is not possible/feasible/comfortable for all caregivers to follow TR due to work schedule, personal circumstances, etc.

Since you have to start with SLGS anyway, that will give you some time to figure out your comfort zone. There is no harm in starting with SLGS, then as she gets more regulated saying "hey you know what, I'm happy with this" or say "hey you know maybe I do want to give TR a try". Some people choose to modify SLGS as well, saying I'll reduce below 80 instead of 90 for example.

Technically SLGS only requires the preshot tests, and a curve once a week. But as she gets into lower numbers you may find it is necessary to test more often (and to be honest, we still recommend getting whatever spot checks you can on SLGS just for good measure).

It really comes down to your comfort level, and desires for her BG range and overall health. And it is a bit of a moving target at times

 

[FrostD]

*and I should clarify

When I initially said wait to transition food, i thought you'd be getting the glargine that same day or the day after. If you're going to wait til this weekend to switch to glargine, I'd just start the food transition now (in part because it will allow you to follow TR and potentially do faster increases if ketones are a big concern for you).

If you want to transition food now, let me know in your other post so I can attempt to advise on the Novolin dose...you will want to proactively decrease that before transitioning food

 

[tiffmaxee]

Welcome to LLB. Kitty wasn’t on Novolin too long and you are eliminating the dry food so I don’t think I would start with 3.0 units. I’m thinking 2.0. Usually we start at 1.0 lantus if following SLGS and feeding any dry or .50 if you have switched to all wet. We do take the previous insulin dose into account though. It will take up to 7 days for the depot to build but some cats have a big reaction to the first dose.

I suggest seeing what happens to the bg as you eliminate the dry food and then we can suggest a dose. Will you be starting Saturday? What time zone are you in? What is your shot time?

 

[Corey & Kitty]

Welcome to LLB. Kitty wasn’t on Novolin too long and you are eliminating the dry food so I don’t think I would start with 3.0 units. I’m thinking 2.0. Usually we start at 1.0 lantus if following SLGS and feeding any dry or .50 if you have switched to all wet. We do take the previous insulin dose into account though. It will take up to 7 days for the depot to build but some cats have a big reaction to the first dose.

I suggest seeing what happens to the bg as you eliminate the dry food and then we can suggest a dose. Will you be starting Saturday? What time zone are you in? What is your shot time?

I would probably start on Sunday AM since I have Sunday and Monday off. I'm in the US, Eastern Standard Time, shot times are 8am and 8pm but sometimes they get pushed around a little because of work, but always within an hour of the usual shot time.

 

[tiffmaxee]

I’ll ask someone on the east coast to help you Sunday morning. I am on the west coast so won’t be up. I think Melissa is on the east coast and Bhooma is in India so will be around. I can see your tests through Saturday night and give my input then too.

 

[FrostD]

Welcome to LLB. Kitty wasn’t on Novolin too long and you are eliminating the dry food so I don’t think I would start with 3.0 units. I’m thinking 2.0. Usually we start at 1.0 lantus if following SLGS and feeding any dry or .50 if you have switched to all wet. We do take the previous insulin dose into account though. It will take up to 7 days for the depot to build but some cats have a big reaction to the first dose.

I suggest seeing what happens to the bg as you eliminate the dry food and then we can suggest a dose. Will you be starting Saturday? What time zone are you in? What is your shot time?

Hi Elise - sorry we've got two separate threads going, one in Main Forum.

After some more questions/answers, I actually think the dry food is keeping her afloat on Novolin and preventing the nastier drops we usually see on Novolin. So I advised to keep the dry for now for safety reasons, give Lantus a week at the starting dose and then transition food.

Whatever happens on the Lantus side is Elise's call though, go with what she says

 

[tiffmaxee]

Thanks for explaining, Melissa.

 

[Corey & Kitty]

Welcome to LLB. Kitty wasn’t on Novolin too long and you are eliminating the dry food so I don’t think I would start with 3.0 units. I’m thinking 2.0. Usually we start at 1.0 lantus if following SLGS and feeding any dry or .50 if you have switched to all wet. We do take the previous insulin dose into account though. It will take up to 7 days for the depot to build but some cats have a big reaction to the first dose.

I suggest seeing what happens to the bg as you eliminate the dry food and then we can suggest a dose. Will you be starting Saturday? What time zone are you in? What is your shot time?

I’ll ask someone on the east coast to help you Sunday morning. I am on the west coast so won’t be up. I think Melissa is on the east coast and Bhooma is in India so will be around. I can see your tests through Saturday night and give my input then too.

Hi,

Just checking in. Tomorrow AM is when we are making the switch. I'm wondering if anyone has a solid answer as to what number of units I should start with.

I'm also wondering wondering what I should expect starting out. Will I see lower numbers? Higher numbers? About the same?

When is the typical nadir with glargine in cats? When I'm around all day, what hours should I be testing?

You said that some cats have a big reaction to the first dose. Would it be safer to start lower?

Also, any tips on drawing out of a pen? I've never done it before. I'm going to practice tonight with a small amount, just so I can be familiar with it. I saw a video floating around here where the woman in the video said not to draw out of the pen and then shoot back up into the pen because there is lubricant inside the syringe that can contaminate the insulin. I had never heard of this lubricant, I've been dispensing syringes to patients for years and had never come across this. I also asked the pharmacist his thoughts and he too has never heard of lubricant inside of diabetic syringes. Can anyone confirm this information?

One more thing, since I began giving Kitty insulin a month ago, I have always had an issue with there being a small bubble on the plunger that I cannot get off, this happens with every dose. The vet told me to try my best to get any bubbles out because at these small doses the bubbles really make a difference. I suppose at least its been consistent since its always there. Any tips on getting the bubble to release from the plunger? Do different brands of syringes make a difference?

@tiffmaxee
@Bandit's Mom

Thank you so much for all of your help! My Kitty and I really appreciate it.

 

[Sienne and Gabby (GA)]

Ordinarily, you can make a unit-to-unit switch from another insulin to glargine providing the numbers on the original insulin aren't dropping BG levels too low. The other factor is the dry food. If you're transitioning off of a high carb diet (and the DM dry food is high in carbs), it may dictate a lower dose.

I also want to correct what Melissa (@FrostD) said about SLGS. As she noted, you need your two pre-shot tests. You should also get at least one additional test each cycle. One difference between glargine and other insulin is that dosing is based on the nadir. Getting additional tests helps you figure out what's going on with how your cat is responding to insulin.

The likelihood is that with switching to glargine, you may see numbers in a higher range until the depot is established. It takes approximately 5 - 7 days for the depot to stabilize. For some cats, they have a surprising drop in numbers the first day or two but that is not typical.

With regard to nadirs, they can and do change. The textbook answer to your question is that the nadir is roughly mid-cycle (+6). That said, some cats have early nadirs and some late nadirs. My cat's nadir was generally at +3 or +4, except when it wasn't. (Cats do not like to be predictable!) This sticky note on The Basics has a typical cycle laid out.

The reason for not shooting insulin from a syringe back into the pen is that the pens operate on a negative pressure system. If you've seen how the pens work, there is a plug that migrates down the cartridge as you draw off the insulin. This keeps the insulin at the tip of the pen. If you draw insulin off and then inject insulin or air back into the pen, it could have an effect on the negative pressure mechanism. As for lubricant, most syringes have a silicone-oil lubricant. You can do a Google search on "Lubricants in syringes" -- this is an article that mentions it. I'd also suggest you take a look at the sticky note on Insulin Care and Syringe Info.

I was looking for information on dealing with bubbles. I couldn't find what I was looking for. I'll give my spin on this. First, do NOT shake or roll glargine -- it's in solution vs Novolin which is a suspension. You may have been getting bubbles because you need to get the Novolin mixed. Move the syringe plunger up and down a few times. Over draw your dose by a small amount, tap/flick the syringe to get any bubbles to the tip, and then twist the plunger to zero in on the dose. Some members have mentioned that they have had better luck with Sure Comfort syringes.

FWIW, I managed Gabby's FD on my own while working a full time job. I also tested a lot! One of the things I found helpful was considering when I tested. I settled on 5:00 -- despite not being a morning person. Gabby had an early nadir. The 5:00 AM test time meant I could get a few early tests in before I left for work. If her numbers concerned me, I left out food and set up a timed feeder. (I actually used the timed feeder regardless so she would have access to food if her numbers were dropping.) It also meant that I wasn't up all night if her numbers were dropping during the PM cycle.

 

[Corey & Kitty]

Thank you Sienne, that information is all very helpful. Thank you for helping to explain.

I do have a few other questions. When it comes to feeding, I understand that I no longer need to check AMPS, feed, wait 1 hour, then shoot. From what I've gathered in other posts, I can just check AMPS, feed, and shoot all in a matter of minutes.

One difference between glargine and other insulin is that dosing is based on the nadir.

Am I not concerned about the AMPS and PMPS at all when it comes to giving a shot? Is there ever a time when the AMPS or PMPS dictate not giving a dose?

You should also get at least one additional test each cycle.

On work days, I can only get one test in during the AM cycle. Occasionally I can get an extra test very late in the AM cycle (+10). Two days off a week I am able to get more tests in. Hopefully that will be enough to sort of get an idea of when her nadir will typically occur, although I understand when you say it could change.
Moving forward, if there comes a time that I need to adjust the dose, are there any tricks/advice on quarter unit dosing and how to measure those accurately in the syringe or is it just a matter of getting the plunger as close to a quarter unit in between the half unit marks?

Also, with the glargine being a longer acting insulin that the Novolin N, would it be expected to start seeing lower numbers later in the cycle?

 

[griffinsmom]

Hi,

Also, any tips on drawing out of a pen? I've never done it before. I'm going to practice tonight with a small amount, just so I can be familiar with it. I saw a video floating around here where the woman in the video said not to draw out of the pen and then shoot back up into the pen because there is lubricant inside the syringe that can contaminate the insulin. I had never heard of this lubricant, I've been dispensing syringes to patients for years and had never come across this. I also asked the pharmacist his thoughts and he too has never heard of lubricant inside of diabetic syringes. Can anyone confirm this information?

I'm a new member and new to diabetes in cats but not new to drawing medication into syringes, a trick I use to get the air bubbles out: draw your dose in the syringe and a tiny bit extra, then remove your syringe from the vial hold the syringe needle up then tap the side of the syringe with a pen, a good hard tap with a pen usually brings the air bubbles to the top, then you can press or twist the plunger to bring your dose to the right amount pushing the air out.

 

[Sienne and Gabby (GA)]

Unlike with Novolin, with glargine you can test, feed, and shoot all within minutes. I would test, put Gabby's food down, and shoot while her head was in the bowl.

The pre-shot tests are important from the standpoint of safety. You don't want to be in a position of shooting a low number and leaving the house. While with glargine, you will ultimately be able to shoot progressively lower numbers, I would encourage you to read through the sticky note on dosing methods. There are guidelines for what to do if you have a lower than expected pre-shot number. With SLGS, you can stall and see if numbers are rising, skip the shot, or shoot a reduced dose. If you get a lower than expected number, post and ask for help.

Most people eyeball the 0.25u dose when it doesn't fall on the unit or half unit line. The alternative is to use digital calipers. We have instructions on how to use calipers if you opt to do that.

Ideally, as your cat becomes better regulated, you'll see lower numbers and flatter cycles. The ideal glargine "curve" really isn't a curve. It's flat and in normal numbers.

Two additional suggestions.... First, read the sticky notes at the top of the board. There's a huge volume of information in those notes. If no one is responding to a question, they are a "go to" for most of the questions you may have. It will also help as you're transitioning from using Novolin to glargine. Second, look at other members' spreadsheets. It will give you a feel for how other members cats are progressing.

 

[Corey & Kitty]

Thanks, I’ve read through all the stickies in this forum. The amount of information is a lot to take in. I’ve read some of the stickies twice since I read them when I first joined this site a couple weeks ago, and again today. I’m more so looking for boiled down information, relatable experiences, and reassurance (sorry, I’m a generally anxious person). I, like my cats, enjoy routine in my life, and so this change in insulin has me worked up. I have been studying as many spreadsheets as I can for as long as I’ve been on this site.

I think I’m going to start with 2 units tomorrow AM since I do plan on eventually eliminating the dry food from the diet.