Am I just being too sensitive...

[Sarah and Buzz]

...or is there some thinly disguised PZI-bashing going on? Maybe not bashing per se, but definitely not supportive of it. Between that horrible Think Tank thread (which was people bashing, AFAIC) and the other thread over on Health from the newish person asking questions about insulins, I feel like so very many people just write PZI off.

I mean, if they have no experience with it, that's fine to not be on the PZI bandwagon, as it were, but it just seems like the tone is so dismissive, like Lantus is the only insulin that works and if you put your cats on anything else, you're just taking your chances with remission and even their lives. I really wanted to post something in regards to the statement, "I know PZI has worked out okay for SOME cats" (might have gotten that misquoted a little; I don't have it here in front of me) but I decided that was just poking back.

I guess that TT thread really made me sort of disenchanted with this place. I'm going to stick to our cozy little PZI land and trying to help newbies on Health and that's it.

 

[Sherri & Stash (GA)]

Sarah, I think it's the same feeling I had when were were still on Vetsulin, and others were fleeing in droves.

We came to FD *after* the PZI issues (discontinued, whatever) so I don't have any PZI knowledge other than the handful of folks who post. When we arrived, Vetsulin was widely used, but was waning towards Lev/Lantus. We left Vetsulin because Stash was staying high and stagnant... I had been thinking about it for some time and the FDA warning pushed me into action.

I would think that once the new ProZinc becomes more familiar, vets will be prescribing it and it will gain popularity (so to speak). But it will take quite some time for FDMB to circle around PZ.

Just my .02¢ worth...

 

[Sarah and Buzz]

I totally agree with what you said, Sherri. And I don't mean for it to sound like I think it should be a popularity contest, like "Waaaaahhhhhh, no one likes MY insulin!" :sad:

I know that just by numbers alone, the people who like Lantus will outnumber pretty much anyone else, so it's obvious that we will get more opinions saying "Lantus rocks!" than we will for PZI or Levemir or Vetsulin.

I guess what I feel is missing is that it doesn't REALLY matter what insulin you use, if it works for YOUR CAT. If you concoct some crazy homebrew of insulin in your kitchen, and it works for your kitty and doesn't harm them, more power to you!

Geez, I don't even know what I'm talking about anymore! I think this weather is getting to my brain cells. Sherri, did you get any of the ice that hit Texas? My Texas geography is horrible so I have no idea where it even hit.

 

[Andrea and Seymour]

hey, i just saw your post and want to reassure you that that thread over in TT really in all honesty had a lot more to do with board politics than much else unfortunately. i used pzi myself and it didn't work for us. plain and simple. it has worked for many people, but we weren't one of them. we made the switch to lantus for that reason and have found that it has worked better so far. are seymour's numbers perfect, not by far. he does however spend many more times in decent numbers than not and feels better.

just because it didn't work for us, doesn't mean that pzi won't work for you. i'm sorry you had to read all the "bashing". it happens occasionally here, but appears to have settled down.

 

[LynnLee + Mousie]

i suppose one could read it as some serious pzi bashing but i wouldn't. fact is there is like 50 people on other insulins to every 1 of us still on pzi. with idexx discontinuing theirs, compounded pzi's not trusted, and prozinc too new to know much about, of course the L's are gonna be more used and more cheered on. granted i can't argue the success being seen with lantus that's for sure. but, before the lack of pzi insulin issues, pzi was the insulin to be on too so i wouldn't take it too seriously. i'm sure the same thing happened back when the first humulins that worked so well for some were discontinued.

personally though i do think it's a good idea to read it all and take in what you can because at any point in time anybody can be faced with an insulin switch. for instance, what if next week they find that prozinc is causing heart attacks in cats and they recall it and you don't have a bunch of idexx stockpiled??? or lantus disperses a bad batch that has some disgruntled employee's pee in it??

i for one haven't had any problems with my pzi and Mousie has done really well on it and she's a happy feisty little squirt but i still read at least part of Lantus ISG every day and occasionally scan levemir & high dose as i can't say what i'll run into some day

 

[Sarah and Buzz]

hey, i just saw your post and want to reassure you that that thread over in TT really in all honesty had a lot more to do with board politics than much else unfortunately. i used pzi myself and it didn't work for us. plain and simple. it has worked for many people, but we weren't one of them. we made the switch to lantus for that reason and have found that it has worked better so far. are seymour's numbers perfect, not by far. he does however spend many more times in decent numbers than not and feels better.

just because it didn't work for us, doesn't mean that pzi won't work for you. i'm sorry you had to read all the "bashing". it happens occasionally here, but appears to have settled down.

I appreciate your reply, Andrea. I know that politics comes into play in just about every aspect of life, unfortunately, but I still prefer to hide my head in the sand over most of it.

I am also truly glad that Lantus worked for you and Seymour. As I said above, I hope that every kitty can find an insulin that works for them and can enjoy the success that so many have had. The most important part is Seymour's (or anyone's) health, and if he is spending more time in good #s and feels good, then who on earth can argue with that?

PZI did definitely work for Buzz, as she went into remission on it just a month ago. However, her #s are back up in the last couple of days and I suspect infection. We have a vet appt. tomorrow to confirm or deny that. If she does need insulin, we will have to switch to Lantus because our bottle of PZI has pooped out. I got my vet to write a prescription for Lantus when they had the free offer last month, and so we have 5 pens. I am VERY nervous about the switch, but I am hoping that it won't even come to that, that she will get back under control with antibiotics. If we do have to use insulin, you will certainly see me on the Lantus board tomorrow!

 

[Sarah and Buzz]

i suppose one could read it as some serious pzi bashing but i wouldn't. fact is there is like 50 people on other insulins to every 1 of us still on pzi. with idexx discontinuing theirs, compounded pzi's not trusted, and prozinc too new to know much about, of course the L's are gonna be more used and more cheered on. granted i can't argue the success being seen with lantus that's for sure. but, before the lack of pzi insulin issues, pzi was the insulin to be on too so i wouldn't take it too seriously. i'm sure the same thing happened back when the first humulins that worked so well for some were discontinued.

I definitely can't argue with the success of Lantus either, and in fact I myself have encouraged some newbies to look into it when they've said that their vet was going to prescribe Vetsulin. If Idexx were still manufacturing, or if we knew more about ProZinc, I would have recommended PZI just because of my own experience with it.

personally though i do think it's a good idea to read it all and take in what you can because at any point in time anybody can be faced with an insulin switch. for instance, what if next week they find that prozinc is causing heart attacks in cats and they recall it and you don't have a bunch of idexx stockpiled??? or lantus disperses a bad batch that has some disgruntled employee's pee in it??

I totally agree with that sentiment, and also with regard to other health issues. I don't read every thread on every problem, but I do read about CRF, or about subQ fluids, or about food problems, because you just never know when that could be you, right? And as to the disgruntled pee....well, I don't even want to imagine it!

i for one haven't had any problems with my pzi and Mousie has done really well on it and she's a happy feisty little squirt but i still read at least part of Lantus ISG every day and occasionally scan levemir & high dose as i can't say what i'll run into some day

Do you have a stockpile of Idexx, just out of curiosity? Don't worry, I'm not going to hit you up for any, just wondering. Although if you lived closer, I might be tempted to ask you if I could just borrow a few drops...

 

[LynnLee + Mousie]

i have about 5 1/2 vials of it. just checked my stock last night actually to see how much for sure i had. for us that will last us at least a few years as long as the insulin itself holds up. remember, Mousie is considered a youngster in the diabetes world so i figure i'll be treating her for many many years :smile:

i've also got the 5 lantus pens though too....haven't decided what to do with that yet though.

 

[Joanna & Bix (GA)]

I have definitely seen some board politics since I got here, and have heard rumors that person abc or xyz doesn't like PZI, etc. There are definitely some strong personalities around (understatement? ;-) ), and sometimes I find it pretty frustrating. Having seen some clashes before and been pretty shocked and disillusioned (I've have come 1mm away from departing for good a couple times), I was disappointed to see this latest, but not terribly surprised.

My takeaway overall, especially after this latest round, has been to try to separate content from personal battles. I thought about posting some PZI defense, explaining how valuable Terri's advice (and others) has been for me, and how well PZI has worked for Mr. B. But ultimately I concluded that the hoopla wasn't really content-related for the most part, and would just add fuel to the drama and look like I was taking sides, etc., blah blah.

It has reminded me though that I feel a lot better when I don't spend as much time on the board as I have been lately. With the switch to the new SW I got caught up in things, and need to get back to keeping some space between myself and the nastiness. Sad but true. I think there is some history of bad feelings between a small # of people, and whether it is intentional or not, I think there is a tendency to overreact (myself included) and get into battles that are completely unnecessary.

I have been happiest too when hiding out in PZI land. My first foray into TT was a shocking awakening (I posted some strong views and got initiated really fast!!!!!). I've been so happy that we've been having a nice time in PZI Land lately. Things were pretty tense here too for a while, and while I'm sorry that some who have left haven't been back lately (I want everyone to be happy and to be friends!!!!), I can respect people's need for time away, and that sometimes when it's tense, it's better to just let things go than to try to work through every detail to clear up all the baggage. Of course I'd love to see that and have everyone make up and get along, but I'm not holding my breath (at least not for the TT crowd, I still hope for a couple PZIers to join back in someday!).

I try to remind myself too that on a board like this, you really never know what is going on with other people - what problems they might be going through, how many of their furries are sick or recent GAs, etc., and in my maturer moments ;-) I'm able to cut people some slack on that front. I know I posted an over-the-top complaint/criticism on Health on the day Tiki died. Duh - probably shouldn't have even been on the board that day, let alone posting. Thankfully that one we made nice & apologies all around, etc. But given that virtually everyone is here *because* they have furries with health problems, right there I figure almost everyone has a certain stress level they are starting out with, that I probably don't know about.

Not ready to get back to cheerleading though yet. cat(2)_steam Maybe tomorrow. :sad:

 

[Gator & H (GA)]

All I can say is that I've been trying to 'defend' PZI since I just about arrived here. I did not even become a member [but was a very strong lurker] until I had H regulated because I did not want to hear 'it'. I was already getting enough 'it' from our vets [it was very hard to stand up / stand my ground to the experts]! And I just about always feel on the defensive about how I dose. But ultimately you can take the horse to water but you can't make 'em drink.

In particular it bothered me when I arrived that folks were suggesting to avoid PZI because PZI Vet was ending. Not only was there ProZinc in the works [that admittedly most did not know about] but there are other PZI's too. Anyway, I think I was successful in ending that. The new mantra is that, "there just isn't enough info on ProZinc" [and to a certain degree they are absolutely right]. But that excuse can only last so long if ProZinc turns out OK.

Another thing that sometimes gets me is that people will suggest one insulin over another without knowing everything that's going on with a cat. I'm obviously prejudice about PZI and cats with appetite [or even potential appetite] issues.

Maybe you are being to sensitive [you're entitled to be sensitive] :smile: it's just a cat forum after all... I don't find the board politics to be a problem - but I think that people should be aware that there ARE some seriously diverging opinions with some back stories and they should factor that into their decisions.

I don't know how other insulins would work for H, but I do know that I sleep well at night knowing that when H goes into full food protest that PZI is not that long lasting.

I like PZI Land too. cat_pet_icon

 

[Sarah and Buzz]

Joanna and Gator, you both make some good points. Thank you for your thoughts and opinions. I've pretty much decided that I am being too sensitive about this particular topic and just need to let it go. Because really, I don't care what other people think about PZI (or any insulin). If they believe that it isn't for them, then so be it. Idexx certainly doesn't need me defending their product; results speak for themselves. And soon enough, ProZinc's results shall speak for themselves as well.

I don't want to get bogged down in politics here and a personality warfare. I am happy with the people here who I talk to on a daily basis, and I am happy trying to help newbies and others where I can. I will focus on that and on interesting threads on Community. I am happy with what we all have made PZI land into. We have fun and are supportive and I, for one, absolutely trust the thoughts and advice that come out of here (as well as other places on FDMB).

So, with all that, I think it's time to drinking11 !

 

[Sherri & Stash (GA)]

Geez, I don't even know what I'm talking about anymore! I think this weather is getting to my brain cells. Sherri, did you get any of the ice that hit Texas? My Texas geography is horrible so I have no idea where it even hit.

Christmas Eve... Christmas Day... yes, we were in the thick of it. Right now we're in the Artic Freeze. It was 17 when I left the house this morning, with a wind chill around 5.

 

[judy and squamee(GA)]

PZI was certainly the answer for Squamee, so I am a fan. I think perhaps some of what goes on is related to history with this board and YDC (your diabetic cat), because that board strongly supports the use of PZI. But that is a guess on my part, I have no knowledge.
I think it is also human nature to believe your own way is the best or right way---even tho it is rarely the case that there is only 1 right way to do anything.
I tend to be a more peace loving person, so PZI forum is the right place for me. However, I do think sometimes a good fight can be therapeutic (gets the blood circulating, counteracts depression, etc) and we have the ultimate safeguard---can't come to blows! :mrgreen:

 

[Janet & Binky (GA)]

I'm probably one of the perceived PZI-bashers, so I thought I would give my point of view. Please pardon the length as I reiterate some history!

For many years, it was widely known on FDMB that changing to a low-carbohydrate and highish-protein diet, along with giving insulin, sometimes resulted in the cat going off of insulin altogether. For that reason, many people including me recommended an immediate switch to a low-carb diet -- and we met a lot of resistance at first who didn't think that diet mattered so much. But the results eventually spoke for themselves.

Although we never compiled statistics, other research suggested that the remission rate from a dietary switch was around 1/3 of cats. Not a lot, but nothing to sneeze at, either. There was no observation that the insulin type mattered -- N, Lente, Ultralente, PZI, Caninsulin/Vetsulin -- cats on all of these insulins could come off of insulin, because it was cutting the carbs that did the trick.

About 5 years ago, Dr. Hodgkins and Steve & Jock burst on the scene, both claiming that there was a sure-fire path to remission that involved changing the diet and tightly regulating the insulin. Although in theory it made sense, the proposed method of tight regulation was thought to promote hypoglycemia, and many of us thought that it wasn't reasonable to expect the newly-diagnosed to deal with the rather complicated protocol. Additionally, there was no actual data showing that it was superior to what we already knew. (No, I still don't believe Dr. H's numbers weren't cherry-picked -- and I saw people leaving YDC from sheer frustration, or being blamed for doing it wrong when it didn't work for their cat.)

However, around the same time, Dr. Rand came out with a small study of 24 cats. She showed that using a tight regulation technique resulted in the usual 1/3 of cats on Caninsulin or PZI going into remission -- but it worked for all 8 cats on Lantus. Small though the study was, the results were highly statistically significant (I ran the numbers myself). I estimated that the true remission rate was likely to be 70% or greater (95% confidence interval).

More recently, the Tilly study was published, and indeed, the remission rate looks like it's in the 70% range, more than double the previously-known rate.

In other words, about 1/3 of cats will naturally go into remission with any insulin and a change in diet. Another 1/3 won't go into remission at all. But the middle 1/3 -- their destiny can be altered by an aggressive approach with a safe insulin.

I think that not having to get insulin is superior to having to get insulin, both for the cat, and for the human. And therefore, I believe that it would be a disservice to the newly diagnosed not to mention that, just as it would be a disservice not to advocate for a change in diet.

I don't intend to bash PZI, N, or any other insulin out there (well, okay, I do bash the use of R and 70/30 as a daily insulin). Once it's established that a cat isn't in that lucky 70%, he/she should get whatever insulin works best for both the cat and the human.

If it should turn out that PZI has a similar track record to Lantus, it should also be promoted. But I've been asking for the data for 4 and a half years now, and I'm still waiting. Even the fierce advocates at YDC never kept track of how many started, how many attained remission, how many gave up or disappeared, and how many didn't attain remission but stuck with it because they like the approach.

So please don't let your own happiness with PZI blind you to the evidence. The evidence doesn't mean that PZI doesn't work for *you*. It just means that, with what we know now, using the Rand/Tilly approach with Lantus or Levemir, seems to be the best bet for a newly-diagnosed cat if one hopes for remission.

 

[Gator & H (GA)]

Janet-

I'm very appreciative for you taking the time to present your argument in a very sensible way based on the data. It is obvious you care about kitties very much and that this very favorable [for Lantus] data drives your opinion.

I cannot nor will I not argue with the data.

However, H is a lifer and more than that I view PZI as working well with our life and his complications [that ultimately affect his appetite] and medication that magnify his lack of opportunity for remission. I know your approach is data based and there is a lot to be said about that. But, I would hope that the "whole cat" would also be considered before any decisions made or advice given. This is my primary concern. I don't think it is fair to owners or their kitties to just say "It just means that, with what we know now, using the Rand/Tilly approach with Lantus or Levemir, seems to be the best bet for a newly-diagnosed cat if one hopes for remission." I sure know that when Lantus was suggested to me without folks knowing the full story I was kind of like "whoa." And I don't think it speaks especially well for the Lantus crowd when such recommendations are made.

H is not the only lifer in here either and nor am I the last lifer [or non-lifer] with complications to show up on this board. When I started all of this, I was under the impression that H had 3 months to live! Remission and the high and mighty data was of no concern I promise you. My objective was to get H regulated FAST [so he could have the greatest number of days in comfort] - and that's what we did within just a couple days [he'd been on insulin but the wrong dose + high carb for 2 month prior]. For me this kind of similar to how the University recommended insulin to us - it was based on their "data" and not looking at the whole cat. Fortunately, it turned out to be the right insulin for H but not for the reasons they recommended it.

Data shmadas - this is my cat and his name is H. We're both pleased to meet you. :smile:

edited to clean up points, spellings etc.

 

[Joanna & Bix (GA)]

Thanks for the info Janet - always nice to get some perspective when we who are newer here see some of these arguments break out. It's clear there's a backstory, but often I, at least, can only guess at what it is.

I'd be curious to see if PZI did as well as Lantus if we had a nice Tilly-like protocol. That's what I've seen as most confusing here in PZI Land, and what delayed Bix getting regulated (in addition to dry food). With virtually everyone I've seen come through here, there is a whole lot of confusion and guesswork as to how to use PZI effectively. Mix that in with the rebound factor that I gather works differently in L & L, and it's often a big mess for the average newbie (who usually arrives here AFTER their vet has gotten their cat to some wild dose, with no clear sense they can tell us of whether that dose is justified or not).

Thankfully I had some awesome advisors (Terri & Lucy & chriscleo) who showed me the ropes and got me on track after some serious stumbles I made. But without that, I think it's very likely I would have given up on PZI and switched to one of the L's. With the combo of a tidy protocol and a bigger set of experienced hands to give advice, that certainly makes the Ls more appealing from my POV, but no clarity on whether that truly means PZI is NOT as effective. Thankfully, it's worked great for Bix!!!

:RAHCAT

 

[Terri and Lucy]

with what we know now, using the Rand/Tilly approach with Lantus or Levemir, seems to be the best bet for a newly-diagnosed cat if one hopes for remission.

This sentence, with I sort of agree with, claims that success depends of two variables--method and insulin. Methodology, or how you structure any problem solving activity including research, matters. That's the point I was trying to make on Think Tank before I used a specific example and pissed everyone off.

Last year Chris and I proposed using a modified Tilly approach with a willing participant. The individual was an experienced caregiver and had already switched from Lantus to PZI and was considering a switch back to Lantus out of frustration with her ability to keep her cat regulated for more than a couple of days at a time. The cat had severe pancreatitis and really needed some relief. It was, in my opinion, a perfect way to test the theory--that a systematic approach to tight regulation that wasn't quite as aggressive as Dr H's approach and gave guidelines instead of rules--could make PZI easier to use and increase the cat's chances of regulation and possibly remission. Unfortunately, Chris and I were accused of being reckless with a cat's life, despite the fact that the bean was in full agreement with the plan and the experiment was halted. So IMHO the lack of a defined methodology for PZI is the result of board politics.

Suffice it to say that IMHO HOW any insulin is used (timing of shots and food, dosing adjustments, etc.) has to be considered as an equally important variable as the insulin itself and food. If the bean is too timid to give enough insulin, the insulin simply cannot work regardless of anything else. If the bean is too aggressive and gets into a chronic rebound situation, the insulin simply cannot work regardless of anything else. Both of those scenarios could happen with Lantus or Levemir. Is Tilly the only approach that can work? No, we know it isn't. But it's systematic and it gives the caregiver the information needed to be consistent and make decisions instead of all the dose hopping we see with PZI. That's why Chris and I proposed the single-cat experiment with PZI and Tilly. We never anticipated the outrage we encountered. It's too bad because I still think that approach could work.

 

[Janet & Binky (GA)]

Gator: I appreciate your points. The problem is, we still don't know exactly which cats are capable of remission and which are not, although the Tilly study suggests that we can look at time since diagnosis, steroid use, and neuropathy as indicators.

Although I agree that people should look at the whole cat, I'd hate for someone here to say to you (or anyone), "Looking at your case history, it appears that your cat isn't a candidate for remission, so let's just discuss the properties of the various insulins." And you would probably be bristling if someone here *did* have the arrogance to say that!

But there's a difference between "prescribing" an insulin -- which no one here has *any* business doing -- and pointing people to the Roomp and Rand study (http://www.ncbi.nlm.nih.gov/pubmed/19592286) and saying, "There's a way to remission if you're willing to be bold. We think it's relatively low-risk." If you say "no thanks, I don't think remission is possible," you will lose the people who think you should try it anyway, but you'll pick up other people who can guide you in other ways. Hopefully no one will be as rude about it as some people here have been toward people who say "No thanks" to the low-carb approach.

Joanna: I'm not going to lie, and I'm sure you've read the old Think Tank threads anyway. Of course there have been personalities and politics involved, and a lot of bad blood. But generally the insulin wars were based on claims and philosophies, and the personal dislikes generally grew from those disagreements, rather than vice versa. All that is mostly in the past now, with the collapse of YDC last year.

Perhaps if there were an approach like Rand/Tilly, PZI would do as well as Lantus. In fact, there is a TR approach geared toward users of PZI, and that is the Hodgkins protocol. So I have to ask, after five years, why isn't this considered a gold standard protocol, if not by vets, then by people here? Or if not that approach, then a modified version? I can think of three reasons, but there may be others. 1.) The protocol isn't in fact that successful in terms of remission; 2.) The protocol is successful when properly applied, but is too difficult for most people to properly apply it; 3.) The protocol is successful when properly applied, but there aren't enough people who can provide useful guidance to newbies on how to properly apply it.

I lean toward the first option, myself. Good theory, but the cats won't cooperate.

-- Janet

 

[Gator & H (GA)]

Janet -
So wait. I am I understanding correctly that you are saying/implying that the standard advice for ALL cats is that they should first try intensive blood glucose control with Lantus for say 6 months? Then they are free to make up their own mind?

Also, I think "There's a way to remission if you're willing to be bold," is a little overstating the data? I think you are aware of this and probably just forgot to slip a modifier in there [freudian slip? ;-) ].

Good idea, I'm adding "no thanks, I don't think remission is possible" in my signature. (a joke - my attempt to bring some levity - not at your argument's expense)

 

[Terri and Lucy]

In fact, there is a TR approach geared toward users of PZI, and that is the Hodgkins protocol. So I have to ask, after five years, why isn't this considered a gold standard protocol, if not by vets, then by people here?

A protocol is a specific set of rules. Dr Hodgkins had some rules (like the no-compromise position on low-carb wet food and shooting into rebound), but she also required people to customize the treatment through the development of the sliding scale. So her "protocol" just wasn't as simple and straightforward as Tilly is. Plus her whole theory was based on the highly controversial assumption that cats on an appropriate diet wouldn't/couldn't hypo. There was always more discussion of that aspect of her theory than of the actual effectiveness of the sliding scale. There was also the (very) bad feeling between her and this board from the years before she started YDC which made anything she said highly controversial here on FDMB.

 

[Sarah and Buzz]

Janet-

I had a whole post working in my head in reply to your very thoughtful one, but I am not really myself just now and don't have the brain power to type it out. So for now, let me just say that I truly do appreciate you taking the time to post that history and go into all that detail. This discussion is now what I hoped it could be on the other thread: people discussing numbers and protocols and being rational.

I had read the basics of the 24 cat study when I was considering switching to Lantus because a) I wanted to be informed and b) I couldn't, in good conscience, ask my vet to read something that I had not read myself (and I wanted her to read it so she would prescribe Lantus; she does not prescribe it at all and knows nothing about it). The numbers are great, of course, and very swaying.

I can already feel thoughts getting too jumbled and I don't want to force you to hire a decoder to figure out what I am saying, so let me wrap it up for now by saying this: Although I am happy with PZI, all I can say is that it has worked FOR MY CAT. I would never NOT mention Lantus (or any other insulin) just because I myself have been happy with PZI. In fact, I have told people to consider Lantus, mostly people who were going to switch from PZI due to it being discontinued.

I didn't mean to come off as sounding like people shouldn't recommend or mention Lantus (again, or any insulin) just because others have had success with PZI. That would, as you mention, do a disservice to humans and kitties, and it would be doing exactly the same thing I am being too sensitive about.

I have really enjoyed reading this thread, so thank you all for stepping in and having a good discussion.

 

[Janet & Binky (GA)]

Janet -
So wait. I am I understanding correctly that you are saying/implying that the standard advice for ALL cats is that they should first try intensive blood glucose control with Lantus for say 6 months? Then they are free to make up their own mind?

There will probably be exceptions, but mostly yes, I think that we (and vets) should suggest this, and explain why. Of course, the human is free to make up their own mind from day 1. Many people won't be willing to do it, and if so, that's the end of that.

More passively, if the reasoning behind the recommendation is incorporated into documents here, that will increase the number of people who express interest in trying it.

Also, I think "There's a way to remission if you're willing to be bold," is a little overstating the data? I think you are aware of this and probably just forgot to slip a modifier in there [freudian slip? ;-) ].

Mea maxima culpa! I hate when people do that! :lol: Let's change that to "There's a potential way to remission, it requires a little risk-taking on your part, and it seems to work for most cats, but not all." Or something like that.

Terri: The no-hypo thing was controversial from the get-go, of course. But Dr. H also felt that hypo was extremely unlikely because the initial sliding scale was conservative, and the scale would be adapted to the specific circumstances. In that respect, it was supposed to be like SLGS but with an entire scale to adjust, rather than one number (the BID fixed dose).

If the bean is too timid to give enough insulin, the insulin simply cannot work regardless of anything else. If the bean is too aggressive and gets into a chronic rebound situation, the insulin simply cannot work regardless of anything else. Both of those scenarios could happen with Lantus or Levemir.

I agree on the timidity question, which is why Lantus seems to be better for the inexperienced, because there's less reason to be timid. As for rebound, you may recall a thread on Think Tank last year in which we discussed whether hidden rebound could occur -- and there appeared to be some thought that with Lantus (and I presume Levemir) it's not an issue, because the hypo that would result from too much insulin would be obvious and long-lasting.

Sarah, I'm glad PZI worked for you. When I first came here, PZI was an insulin of last resort for cats who couldn't handle the cheaper and more accessible Humulin -- but it definitely worked miracles when it was needed, and people loved it. (I'm still trying to figure out how it became a short-acting insulin rather than a long-acting insulin comparable to Ultralente.) If it hadn't been for Rand's research, it might still be the insulin of choice. If the group here can figure out a way to make it work as well for the inexperienced and scared, you can do a lot of potential good.

-- Janet

 

[Joanna & Bix (GA)]

Joanna: I'm not going to lie, and I'm sure you've read the old Think Tank threads anyway.

I did start to once, and I got a stomach ache and stopped!!!! LOL. I have found I am a much happier person when I give TT a wide berth - need to get back to that perspective soon! It's good (for me) to stop by there now and then and read posts with info that I am interested it, but not visit too often (and quickly move on when the fights break out!!!).

Perhaps if there were an approach like Rand/Tilly, PZI would do as well as Lantus. In fact, there is a TR approach geared toward users of PZI, and that is the Hodgkins protocol. So I have to ask, after five years, why isn't this considered a gold standard protocol, if not by vets, then by people here? Or if not that approach, then a modified version? I can think of three reasons, but there may be others. 1.) The protocol isn't in fact that successful in terms of remission; 2.) The protocol is successful when properly applied, but is too difficult for most people to properly apply it; 3.) The protocol is successful when properly applied, but there aren't enough people who can provide useful guidance to newbies on how to properly apply it.

I found the general concepts I got from YDC (learning about TR, LC food, and the possibility with PZI to shoot early to keep as close to TR as you can) invaluable. Some of the rest (the sliding scale they present, which I shudder when I see anyone bring up around here to a newbie, the aggressiveness, etc.) I find truly frightening.

I wouldn't put my money on a modified version of that - I think shooting more often than BID is simply out of the question for most beans, and not very practical to pursue as part of a standard protocol. It seems to me that for cats that get good enough duration/overlap on PZI (as Bix has), a modified Tilly (noting that while I've read through Tilly a couple times, I've never pored over it or used it) would be what makes more sense. Something between SLGS and Tilly I guess, taking into account PZI-specific concerns. And for those who don't get as good duration, it would be nice to have guidelines of what your options are, since you can still work it with PZI if you want to give it a go.

Never having used Lantus, and thankfully having missed out on much of the arguing to date I can't say I have any preference for PZI over Lantus, simply that PZI, used with guidance from the board, has worked well for Bix. In my case, my vet was unwilling to prescribe Lantus or Lev since she didn't know much about them, so my options were to convince her, find another vet, go it on my own with the help of FDMB (all of those options were well beyond my stress-level capacity at the time of making a decision), stick with Vetsulin (no way I was going to do that), or try PZI. So it was PZI.

I was actually so convinced when I started him on it that he *wouldn't* get duration, that I goofed up dosing for a while (shooting TID when it wasn't actually needed, for instance) - in part from prior YDC readings, in part from readings on FDMB, and in part from my own Vetsulin baggage. When I finally stuck with BID and got to the right dose, I was pleasantly surprised to find that he did just fine. I'm guessing though he's in the 1/3 that would have done well on any insulin - Vetsulin didn't go well, but he was on dry food at the time, so I can't even say he wouldn't have done well on that once he got on LC canned.

I've felt some twinges of guilt on PZI that "maybe I'm not doing the best I could for BIx and getting him on the best insulin there is" (my words, inferred from reading around), but thankfully he got regulated, and now that he is an OTJ wannaby it's a non-issue, at least for the moment. By the time I got here though he wasn't newly diagnosed, so our success story can't count in the stats on that one (if anyone is counting!).

Anyhow, those are my long-winded musing for now.

 

[judy and squamee(GA)]

Thanks for all the info, people. This is a very interesting discussion. I know very little about these insulins, so forgive me if I missed something obvious, but why is there less reason to be timid with Lantus?

And what happened to the YDC site?

 

[Janet & Binky (GA)]

Thanks for all the info, people. This is a very interesting discussion. I know very little about these insulins, so forgive me if I missed something obvious, but why is there less reason to be timid with Lantus?

And what happened to the YDC site?

Hi, Judy. Lantus has a very long-acting and gentle action, with a pretty slow onset, and because of that, the probability of hypoglycemia is reduced. (Contrary to myth, cats can and do hypo on Lantus, though.) Lantus users seem to feel pretty comfortable giving shots on lowish pre-shot values, knowing that the previous dose will wear off before the current dose kicks in.

PZI with the Hodgkins protocol is supposed to work the same way -- shoot on a low-ish number post-peak (although Hodgkins says don't shoot below 150). One of the places they went wrong, IMO, is to take as gospel that any value after hour 6 is post-peak. As Nelson's study shows, glucose nadir can occur as late as 8 or 9 hours.

I don't know exactly what happened to the YDC site. One day, I logged in (under an assumed name, of course!) to discover that many of their most faithful posters had been banned. Many of them moved to a different site, which requires registration to view, and the traffic at YDC slowed down considerably after that.

 

[Terri and Lucy]

Janet -
So wait. I am I understanding correctly that you are saying/implying that the standard advice for ALL cats is that they should first try intensive blood glucose control with Lantus for say 6 months? Then they are free to make up their own mind?

There will probably be exceptions, but mostly yes, I think that we (and vets) should suggest this, and explain why. Of course, the human is free to make up their own mind from day 1. Many people won't be willing to do it, and if so, that's the end of that.[/quote.]

I don't believe FDMB has any business recommending a particular insulin. For the "board" to advocate for Lantus/Levemir is unfair to all the newbies who will soon be coming here on PZIR. As for recommending tight regulation, what happened to the past 5 years of debate about what is "safe" for newbies? How will the decision be made as to what to put in the new document?

I agree on the timidity question, which is why Lantus seems to be better for the inexperienced, because there's less reason to be timid. As for rebound, you may recall a thread on Think Tank last year in which we discussed whether hidden rebound could occur -- and there appeared to be some thought that with Lantus (and I presume Levemir) it's not an issue, because the hypo that would result from too much insulin would be obvious and long-lasting.

Are you sure that Lantus is easier for the inexperienced or is it the case that people who come to the support system on FDMB have it easier because someone is there explaining and interpreting Tilly, etc.?

And yes, I remember the "there is no such thing as rebound" discussion. Lucy (who is on Levemir at this time) can rebound the same as she did on PZI and Humulin L, so I don't agree with the board experts. You wrote "because the hypo that would result from too much insulin would be obvious and long-lasting." Is there a typo in this phrase? I don't understand what you're trying to say.

 

[Janet & Binky (GA)]

Rebound is a problem when you don't know it's occurring, or you don't know *whether* it is occurring.

If a.) an overdose of a particular insulin always results in hypo, or b.) when you're systematically increasing the dose of an insulin, there's a window of doses which always result in hypo, then you can avoid getting to a dose which results in rebound without hypo. If you'd prefer to substitute the phrase "insulin resistance" for rebound, that's fine -- the point is that we're talking about a situation in which giving too much insulin results in high flat curves without apparent improvement.

If in fact Lantus and Levemir don't have that property, then you're right that rebound (or insulin-induced insulin resistance) is a problem.

As for TR, it amuses me that we are now arguing on opposite sides of this issue from where we were a few years ago. Back then, you argued that newcomers deserve to know that TR exists, because it will increase the probability of remission. I argued that we shouldn't be making promises when we didn't know for a fact that TR was the magic bullet, because of the risks involved.

Now I'm arguing that newcomers should learn that Lantus/Levemir along with TR (and the experience found here or at Tilly's site), and you're objecting for reasons of safety.

If the truth is that the probability of remission is higher on L/L than on PZI, then it is not unfair to let PZI consumers know this. It would be unethical not to tell them. And yes, the risks should be outlined, and so should the fact that experienced guidance is recommended.

In the past, when groups of people have disagreed on what to say in the FAQ, the compromise was to say what most people thought, and then present the minority view as a counter-argument. At the moment we have the state of the thinking from about 2005 or 2006, with the Rand study tossed in as a "by the way". But now there is published evidence in favor of the Rand protocol. So the PZI advocates should probably hash out a reason why you think that cats whose vets prescribed PZI don't need to switch to Lantus.

When I'm ready to think more about this, I'll put specific proposed phrasing up on Think Tank. I'd like to see more anecdotes from people who have tried both Lantus (or Levemir) and PZI, and who decided that they prefer PZI. I would exclude those who have only used L/L with the Hodgkins protocol, because both groups agree that this is an unworkable combination.

-- Janet

 

[Terri and Lucy]

As for TR, it amuses me that we are now arguing on opposite sides of this issue from where we were a few years ago. Back then, you argued that newcomers deserve to know that TR exists, because it will increase the probability of remission. I argued that we shouldn't be making promises when we didn't know for a fact that TR was the magic bullet, because of the risks involved.

Now I'm arguing that newcomers should learn that Lantus/Levemir along with TR (and the experience found here or at Tilly's site), and you're objecting for reasons of safety.

I still believe that newcomers should know about the TR option, regardless of what insulin they are using. I also believe that newly diagnosed cats should start on a tight regulation treatment approach as soon as feasibly possible for the bean. My question was simply one of curiosity. I'm surprised that one study with such a small sample size is sufficient to change your opinion on TR so completely. We don't even know whether the researchers were attempting TR for the PZI and/or Lente cats.

When cats on PZI come to the board, do you think they should be following a TR treatment approach too, or just the Lantus/Lev cats?

So the PZI advocates should probably hash out a reason why you think that cats whose vets prescribed PZI don't need to switch to Lantus.

If the cat's vet prescribed PZI, I don't see that it's up to us to convince them that their vet is wrong.

 

[Gator & H (GA)]

There will probably be exceptions, but mostly yes, I think that we (and vets) should suggest this, and explain why.

Who is going to judge those exceptions? Would such exceptions be included in any documentation advocating this?

I promise I won't take your response personally and get all crazy, but at this current moment would you suggest that H and I ditch PZI and try intensive glucose control with Lantus for 6 months?

I did not even become a member [but was a very strong lurker] until I had H regulated because I did not want to hear 'it'. I was already getting enough 'it' from our vets [it was very hard to stand up / stand my ground to the experts]!

First I need to clear this up - I actually looked back and I was a member slightly before he was regulated, but we did not get any direct dosing assistance and I only asked about two very specific questions. And I generally did not present our sitch. When I said 'it' part of it was the proselytizing of various things that are done here. And I'm no shrinking violet. I think the turn off factor should be considered too. How many will be turned off by the proselytizing that could have been brought into the fold by trying to be more inclusive and understanding of the "whole cat?"

No surprise, I'm pretty much in agreement with Terri. When newbies arrive they have a lot on their mind and are really mixed up emotionally [at least I was]. And to start telling them that their vet is wrong about the insulin [let alone the food and everything else] they were given is maybe taking things a step in the wrong direction. I do agree with you Janet that the data should be presented, but so should language of exceptions and coming to ones own conclusions and more be presented too. Owners sometimes pay a big intangible price for not following their vets instructions. And I can imagine this being more so for a prescribed medication [let alone the bag of PM dry food they were sold].

Janet - I know you know the place I'm talking about [which will go unnamed]. But I was made to feel very uncomfortable about home testing and using U-100 syringes by a vet [not the one with the DM research] at that place. You have no idea the battle that went on and my efforts I took to try to help them feel comfortable about this. And I'm pretty sure that vet will not communicate with us at this point. Anyway, I paid a big price for going my own way as that vet is the expert in fields unrelated to H's DM. Not sure where I'm going with this but to say that sometimes enough coloring outside the lines is enough let alone having beans question a medication that was prescribed - especially in the heat of first diagnosis. EDIT - To extend this point further I've frequently seen beans come through here that live in rural areas and only have one vet option. Spoiling that relationship for a bean could be worse for the cat in the long run.

I know that I'm probably an exception but I found PZI very easy to deal with when I was inexperienced. I did not have any direct help with dosing from anyone here or elsewhere. I was also dedicated to testing and I probably had more confidence than a lot of newbies do. Also, I started very low 0.2U then moved up rapidly until I found the dose that H responded to and I also was lucky that we had a ceiling that I most likely knew was too much. So the in depth research I did [that most new PZI users do not have the opportunity to do] and use of U-100 syringes and starting nearly at the bottom and gathering data gave me the confidence I needed. Back to Terri's point that it is likely the lack of specific guidance for PZI that causes a lot of the unconfidence.

Does anyone keep their cat well regulated on PZI without the use of U-100 syringes?

 

[Sarah and Buzz]

So the PZI advocates should probably hash out a reason why you think that cats whose vets prescribed PZI don't need to switch to Lantus.

Cats whose vets prescribed PZI might indeed need to switch to Lantus. Maybe the cat doesn't react well to PZI. Maybe the bean isn't happy with the way it's performing (too much bouncing around from high to low to high comes to mind, although there certainly could be other reasons). Maybe PZI is cost-prohibitive. Maybe there are a ton of reasons that we don't even know about. Or maybe they don't need to switch to Lantus because PZI is working well for them. That should be enough of a reason; the beans in question shouldn't need us to present reasons NOT to switch from an insulin which is working for them.

I don't think that it's our (or anyone's) job to convince people to use one insulin over another. I think it is our job to present all the options, along with supporting research and data, and let the bean decide for themselves which insulin they want to put Kitty on. We can't, and their vet can't, make a decision for them. I should say, we shouldn't make a decision for them.

 

[Joanna & Bix (GA)]

How about something like "Lantus, when used with appropriate dosing guidelines, has been shown to have a high remission rate in newly-diagnosed cats. Other insulins, such as PZI and Levemir, have also been successful for many cats, and for some cats are preferred to other insulins. The remission rate for shorter-acting insulins such as Vetsulin/Caninsulin is lower, however they can still work well for the 30% of cats that are likely to go into remission with a diet change and the use of any type of insulin." (That may not all be accurate & I left out the non-newly-diagnosed, just going for tone & neutrality here as an example, & leaving the details to the experts.)

Somewhere in the L stickies one of the studies (will go look for the passage in a minute & come back!) says that xyz is the preferred insulin, zyx is choice #2, etc. and that an insulin should be tried for 6-8 weeks and if regulation is not achieved, move on (at least the shorter-term insulins, not sure what the recommended timeframe is for the longer-term ones before deciding to move on if not regulated) . It makes sense to me that here we might reference that, but as others have said, no need to make an official FDMB recommendation....?

To me what is important here is 1) give people access to information that helps them make informed decisions and 2) support the decisions they make (within reason) and what is available to them. i.e. not make people who are already stressed out (and could be considering euthanizing their cat, who knows), feel like they are doing the wrong thing if they don't go for the "ideal" approach when it's something that their vet isn't supporting anyway. I think keeping it in reference materials/links, rather than an official FDMB position, helps us be able to meet both goals.

Above-mentioned passage, from UQ link2.pdf. I'm not sure what insulin is considered Lente:

NB. Lente is the 3rd insulin of choice and NPH the 4th of choice insulin for control of diabetes mellitus in cats,
behind glargine or detemir (1st choice) and PZI (2nd choice), Lente and NPH result in lower remission rates
compared to longer acting insulins. Marshall R & Rand J. Treatment With Insulin Glargine Results In Higher
Remission Rates Than Lente Or Protamine Zinc Insulins In Newly Diagnosed Diabetic Cats. (Abstract) J Vet
Intern Med 2005; 19 (3):425

Lente insulin is only recommended as a first choice of insulin in countries where an insulin registered for
veterinary use is required to be used initially, and PZI is not registered for veterinary use. If remission has not
occurred in 6-8 weeks after initiation of lente therapy, the insulin should be changed to glargine or detemir.
Remission rates decrease with time after diagnosis, so early control of blood glucose concentrations is
imperative for maximizing the probability of remission. NPH insulin is only recommended when no other longeacting
insulin is available.