Alicia & Beau - coming over from ProZinc tonight or tomorrow

[alicia.1771]

Hey folks,

Beau & I have joined FDMB in early July when he was first diagnosed. Since he was started on ProZinc we have been posting in the PZI forum. It has been 4 months of struggle and we have not been able to get him regulated on ProZinc so will be switching to Lantus either tonight or tomorrow depending on how ready I feel at shot time which is currently around 8:30am/pm PST. He's numbers have been high and flattish for the past 3 days and I have no idea what's going on. We are running towards the end of our first bottle of ProZinc (maybe 20% left?) and I'm thinking it's possible the insulin is losing its potency?

I just picked up the 5pk SoloStar pens from Costco this afternoon and I have U100 insulin syringes with 1/2 markings (UltiCare 3/10cc - 5/16" - 31Ga). I test with Relion Micro and get at least 4 readings a day (amps, pmps, 1 mid-cycle each) and curve on the weekend. And I test ketones whenever I catch him pee.

I have read and re-read the stickies several times, but just to make sure I have the following is correct since handling ProZinc seem to be very different from Lantus:

1. Store both opened and un-opened pens in the fridge --> does it matter if it's standing up or must lay down flat? Do most of you keep them in the box they come in?
2. Do not roll the pen before use.
3. Do not inject air into the pen.
4. Do not let the solution get sucked back into the pen from the pen's vacuum pressure, so after drawing the solution, must hold the plunger firm to pull out the needle, then flicker to get air bubble out and eject excess insulin into air --> is this a really serious problem? do I have to throw the entire pen away if the solution accidentally gets sucked back into the pen?
5. Get spot checks --> Beau nadirs around +5 on ProZinc, what's the typical nadir hour for Lantus?
6. Due to the shed factor, must stick to 12/12 schedule as much as possible with 15min variation and at most 30min variation in any given 24 hours.

I need help determining his stating dose and no-shoot number. Beau currently weights 13.2 lbs ~ 6kg and is on ProZinc between 1.4 to 2.0u BID. Vet said to start at 2U BID which I think it's a bit high. I'm thinking either 0.5U or 1U? Beau has not had a PS number < 250 for the last few months but just want to get an idea on no-shoot number for Lantus users.

 

[mybuddybinks]

Re: Alicia & Beau - coming over from ProZinc tonight or tomo

i just lay our pen down in an egg carton...don't know that it matters whether it stands on end or not..

I'll let others respond to your other questions...
but just want to say WELCOME!!!

you'll have fun here

celi & binks

 

[Marje and Gracie]

Re: Alicia & Beau - coming over from ProZinc tonight or tomo

Hi Alicia and Beau!

Welcome to Lantus Land. Sounds like you've made a great start and we hope to see you posting here daily. We're a close knit group and it's an active community; we're spread all over the place so the chances of you being able to get help most of the time are pretty good. Anytime at all you have any questions, please be sure and ask. We recommend that you not only read the stickies (which you've done) but also print them out.

To answer your very good questions:

1. Store both opened and un-opened pens in the fridge --> does it matter if it's standing up or must lay down flat? Do most of you keep them in the box they come in?

Yes...store them both in the fridge. We usually recommend a vegetable or cheese drawer where the temp is more stable and not as affected by the door opening and closing. Don't store in the door...the opening and closing of it is too much movement and it's more prone to unstable temps. I store my pens in the box laying down; but the one I am currently using is just laying flat by the box cushioned so it doesn't roll. Some people wrap their pens they are using in bubble wrap.

2. Do not roll the pen before use.
3. Do not inject air into the pen.

Correct....do not roll the pen and do not inject air into it.

4. Do not let the solution get sucked back into the pen from the pen's vacuum pressure, so after drawing the solution, must hold the plunger firm to pull out the needle, then flicker to get air bubble out and eject excess insulin into air --> is this a really serious problem? do I have to throw the entire pen away if the solution accidentally gets sucked back into the pen?

I think it's more of an issue to not inject the solution back into the pen. So if you overdraw, squirt it out onto a napkin or in the sink...never inject insulin back into the pen. I haven't had a situation where the insulin gets sucked back into the pen; the biggest concern there is that the syringes have a silicone in them to keep them moving and you chance getting silicone back into the pen. If a little bit of insulin accidentally gets sucked back in the pen, you can still use the pen but watch it very closely for any floaties....if it has floaties...time to ditch it. Or if his numbers start getting wonky if they've been relatively stable.

5. Get spot checks --> Beau nadirs around +5 on ProZinc, what's the typical nadir hour for Lantus?

Every cat is different (ECID) on when they onset and when they nadir. A "typical" lantus curve looks like this:

+0 - PreShot number.
+1 - Usually higher than PreShot number because of the last shot wearing off. May see a food spike in this number.
+2 - Often similar to the PreShot number.
+3 - Lower than the PreShot number, onset has started.
+4 - Lower.
+5 - Lower.
+6 - Nadir/Peak (the lowest number of cycle).
+7 - Surf (hang around the nadir number).
+8 - Slight rise.
+9 - Slight rise.
+10 - Rising.
+11 - Rising (may dip around +10 or +11).
+12 - PreShot number.

You will have to do enough checks on Beau over the next few weeks to gather data and see when he nadirs. However, with lantus, the nadir can move even from cycle to cycle so don't get too married to a particular nadir. I suggest that the first few days, if possible, you get a +2, +4, +6, +8 alternating the next cycle with +1, +3, +5, +7, +9. I typically recommend that after the first cycles when you are building data, that you always get a +2 as it will give you lots of info. If it is not close to or higher than your PS, you should be prepared for a possibly active cycle. I also think a +10 or +11 is a really good number to get as it will tell you whether he gets a lantus dip or not.

6. Due to the shed factor, must stick to 12/12 schedule as much as possible with 15min variation and at most 30min variation in any given 24 hours.

Yes...the key to lantus is consistency in shooting time and dose. There are times when you have to be off or stall and some times you may have to shoot a reduced dose....we'll help you through that if you let us know you need help.

Remember, too, that we dose lantus based primarily on nadirs, not pre-shots so you don't have the change in dose that you have with PZI. So don't let high PSs tempt you into changing the dose. Always ask if you have questions about changing the dose...that's why we are here....to help you with dosing.

The recommended starting dose for cats for lantus is .25u/kg. So 6kg x .25u is 1.5units bid. I agree that 2u is too high. You can start him at 1u if you prefer and then increase per the protocol. Remember that lantus has a shed to fill so you may see some high numbers for several days. That is why we recommend you hold the initial dose for 5-7 days (10-14 cycles) unless he has really high, flat numbers or is prone to DKA.

I hope that helps. Just keep asking as many questions as you want. It's a steep learning curve and we're here to help you get through the initial info.

 

[Sandy and Black Kitty]

Re: Alicia & Beau - coming over from ProZinc tonight or tomo

Hello Alicia and Beau - and welcome!

Any other health issues for Beau?

As far as a starting dose, below is from the Tight Regulation protocol we use, the details of which are in a sticky.

Using a weight based formula for determining a starting dose of Lantus or Levemir:

the formula is 0.25 unit per kg of the cat's ideal weight

if kitty is underweight, the formula frequently used is 0.25 unit per kg of kitty's actual weight

if the cat was previously on another insulin, the starting dose should be increased or decreased by taking prior data into consideration

Going by this guideline, the starting dose for Beau would be 1.5u. I feel like that may be high. You can certainly start with .5u or 1u if you are more comfortable with that. The starting dose is typically held for 5-7 days, to establish the storage depot or "shed".

Regarding the storage and handling of Lantus, back when my BK was using insulin we always kept the insulin refrigerated, handled with care and pitched it after 28 days. We had a choice of vials or cartridges back then - I have no experience with the pens, so I will defer to someone else regarding that. Definitely no rolling.

Below is an example of a lantus curve_
+0 - PreShot number.
+1 - Usually higher than PreShot number because of the last shot wearing off. May see a food spike in this number.
+2 - Often similar to the PreShot number.
+3 - Lower than the PreShot number, onset has started.
+4 - Lower.
+5 - Lower.
+6 - Nadir/Peak (the lowest number of cycle).
+7 - Surf (hang around the nadir number).
+8 - Slight rise.
+9 - Slight rise.
+10 - Rising.
+11 - Rising (may dip around +10 or +11).
+12 - PreShot number.

However, ECID and nadirs can vary, and move over time.
Consistent dosing, both in amount and timing is key to success.

The most important thing for someone switching over is to know that Lantus dosing decisions are based on nadir values, with only some consideration given to PS numbers.
It's a great insulin - slow acting and gentle. I think you'll be happy with it.

 

[Marje and Gracie]

Re: Alicia & Beau - coming over from ProZinc tonight or tomo

Wow Sandy...it's scary how consistent you and I are :lol: :lol: :lol: :lol: :lol: :lol:

 

[alicia.1771]

Re: Alicia & Beau - coming over from ProZinc tonight or tomo

Hi Marjorie & Sandy! Thank you so much for the welcome and answering my questions.

Beau doesn't have any "active" health issues other than his diabetes that I know of. He had PU surgery 10 years ago which makes him prone to UTI, but he hasn't had one in years. He had 2 episodes of pink-tinged urine and we did culture & sensitive in July and Sep and both came back negative. He still went through a course of Orbax just in case. He also had a dental cleaning in early Sep with 3 extractions. He has asthma (not officially diagnosed) and coughs a few times a year. His last episode was early October when the cleaning lady used some really strong chemicals in our room. Since we asked her to stop using chemicals he hasn't coughed since. He has lost a little bit of weight since diagnosis (he was 14.2 lb) and I have noticed dandruff again in his hair coat in the last few days, which I believe is a symptom of unregulated diabetes.

Because of my work schedule I will not be able to get more data mid-day except for 1 test around +5-6, so I think I will start the first dose tonight to get more data this weekend. Seems 1.0u is a good starting dose. Wish me luck!

 

[Marje and Gracie]

Re: Alicia & Beau - coming over from ProZinc tonight or tomo

Good luck....we're here if you need us. Please post his numbers in the subject line as you see others do.

 

[julie & punkin (ga)]

Re: Alicia & Beau - coming over from ProZinc tonight or tomo

hi alicia, i just wanted to say welcome.

sounds like you watched the video on how to care for lantus from the stickie - that was our pen that developed a negative pressure and sucked the insulin back into the pen. i have no idea how common that is, but the point is that the syringes have a lubricant in them and you don't want to have that lubricant go back into the lantus. some people see-saw their lantus in and out of the syringe/bottle to get the dose correct. just waste the excess from the syringe when you're trying to get the dose right. it's better than contaminating the lantus.

the way you can tell if it gets contaminated is - you lose regulation and the numbers start going up and you can't figure out why, or the lantus develops floaties or stringy particles in it. it should be completely clear.

and glad you're here. we started on ProZinc too, although i wasn't home testing so don't know much about it. Hopefully this will be a good change for Beau and you'll start seeing some better numbers.

post often and people will be glad to answer your questions and give you a hand on how to apply the tight regulation protocol to Beau's situation.

 

[alicia.1771]

Re: Alicia & Beau - coming over from ProZinc tonight or tomo

Hi Julie! Thank you for the welcome and also for doing the video. It was very helpful to see where and how to draw insulin out of the pen with a syringe. I learn much better by watching a video vs. simply reading instructions or looking at still images. I wish there is a more detailed video on injection sites for cats as sometimes I still feel I'm not doing it correctly or shooting into the right "space" (subQ).

I just gave Beau his very first Lantus shot (1.0u). A few issues I ran into:

1. Lantus solution seems thicker compared to Prozinc when drawing into the syringe it kind of stick to the walls of the syringe with a big air bubble on top. Since I can't draw back and forth as I did with the Prozinc bottle I tried to flick the syringe which made things worse. I pulled back/forth the plunger (after it's separated from the pen) and flicked some more but still ended up with half a bubble in the syringe so my dose may be a little off. Any suggestion in getting rid of the bubbles?

2. After injecting I pulled the needle out while squeezing the skin in between my fingers as I always do so no solution will be lost. But when I looked there is a big drop of solution hanging at the tip of the needle! I pulled the plunger back and can see more solution inside the syringe even though I pushed the plunger all the way down. How is that possible? So I ended up sticking Beau again to try to get the remaining dose into him. Anyone ever run into the same problem? Should I change syringes? What syringes do most of you use?

 

[Marje and Gracie]

Re: Alicia & Beau - coming over from ProZinc tonight or tomo

I've never used ProZinc but use levemir and it is even thicker than lantus. We did use lantus for many months.

Many of us use Monojects. I've tried Relions and BDs and like the MJs the best but others are very happy with the first two. I draw the insulin slowly so it has time to pull the bubble up. Once you remove the syringe from the pen, if you pull the plunger back and draw air into the syringe then it should gather all the bubbles together; then you should be able to very slowly express it and get them out the top while dialing in your dose. Most of us twist the plunger to get to the correct dose.

Once I insert the syringe into Gracie, I make sure the plunger is pushed all the way in and then hold it for ten seconds. I continue to hold the plunger in as I withdraw the syringe. One thing I do to inject is I lift her fur and roll it back over my hand to expose a patch of skin. I don't tent. With the skin exposed, I am less likely to give fur shots.

Maybe others will have additional suggestions.

 

[julie & punkin (ga)]

Re: Alicia & Beau - coming over from ProZinc tonight or tomo

what brand of syringes are you using? some definitely seem to be better than others for avoiding bubbles. i use the Terumo, which are less common and more expensive, but i really like them. they're pretty good about not having bubbles.

i don't have a great idea for it, other than what you've heard. however, try marj's suggestions and if you still have problems, at some point edit your subject line to ask for ideas on bubbles. people will all offer their favorite solution and perhaps one will work for you. the smaller the dose, the more the bubbles matter in getting an accurate measurement.

i could do a video on shooting, but i shoot in the scruff and there's some controversy about shooting there. so . . . probably not the best for me to do it. i'm a little afraid to shoot anywhere else.