Dealing with a New Vial of Lantus

[PirateLuke]

First, a celebration. I've had Pirate Luke for a year now and he's now officially moved into Foster Fail territory and we're transferring ownership to me! Yay!

Secondly, a question. I've had his vial of Lantus since March and we've been able to consistently reduce his dose and keep him in decent numbers.

Until recently.

Now it doesn't really even make a dent in his blood sugar. I have tried raising the dose a few times to little avail. So I think I need a new vial.

When changing vials from one which has lost potency, do you go back to the last good dose when the insulin seemed potent or what? Don't want to overdose the fella but I do want him back on track! TIA

 

[Staci & Ivy]

Congratulations on Luke being a foster fail! He;s so precious, how could you not just fall in love with him!
If you feel the vial of insulin may be ineffective, you could certainly try a new one.

Can you get Lantus pens instead? They are a smaller volume and a box will last quite a while and if you need to toss it you are losing a smaller amount.
They are used just like a vial, you withdraw the insulin from the rubber stopper tip.
I but a box of 5 pens (how they come).

Or is there any reason to think something else is going on? Could he need a dental or some other type of inflammation could cause glucose to go up.
Sending sweet Pirate Luke lots of belly rubs

 

[Tim & Pookey]

Congrats!! He is so handsome. I hope to see that face in our 2027 Calendar submission form.

Definitely seems like time for a new vial. What is that, 6 or 7 months? I got 6 months out of ours, but I see it talked about a lot on here that that is the cutoff point. Staci has some good points above too.

As far as the dose, I really don't know. I wonder if you could bring his dose down a smidge with the new vial for a few days just to see what's going on. I don't have first hand experience with this though, maybe @Marje and Gracie or @Wendy&Neko do.

 

[PirateLuke]

Congratulations on Luke being a foster fail! He;s so precious, how could you not just fall in love with him!
If you feel the vial of insulin may be ineffective, you could certainly try a new one.

Can you get Lantus pens instead? They are a smaller volume and a box will last quite a while and if you need to toss it you are losing a smaller amount.
They are used just like a vial, you withdraw the insulin from the rubber stopper tip.
I but a box of 5 pens (how they come).

Or is there any reason to think something else is going on? Could he need a dental or some other type of inflammation could cause glucose to go up.
Sending sweet Pirate Luke lots of belly rubs

He is wonderful and such a character as well. I just can't part with him now!

No, there's been no reason why he should have an issue. Food is the same. Health seems fine. So I can only think it's just the insulin degrading or he's just being a weirdo. He has never had typical diabetes. He's young, never been overweight, and no-one really understands why he has it at all. It's very unusual. I've upped his dose by half a unit for now, which has FINALLY got things moving. I have ordered a new prescription too.

I could only get the vial this time around as I'd have to do a full health check and vet visit to ask the vet to change it to a different prescription. But I broke my foot a few weeks back and am only just weight-bearing now so there is no way I could carry him into the vet. I can't even carry shopping yet! So I just asked online for a repeat of what we were last given, which was a vial. But I will bear it in mind for next time.

Pirate Luke says thanks for the belly rubs. He loves em!

 

[PirateLuke]

Congrats!! He is so handsome. I hope to see that face in our 2027 Calendar submission form.

Definitely seems like time for a new vial. What is that, 6 or 7 months? I got 6 months out of ours, but I see it talked about a lot on here that that is the cutoff point. Staci has some good points above too.

As far as the dose, I really don't know. I wonder if you could bring his dose down a smidge with the new vial for a few days just to see what's going on. I don't have first hand experience with this though, maybe @Marje and Gracie or @Wendy&Neko do.

Aw, thank you. He is indeed a cutie. But ALL cats are! I didn't know about the calendar. What a cool idea!

Yes, we got the old vial right at the beginning of March, I think March 3rd, so I guess it's losing potency.

 

[Staci & Ivy]

He is wonderful and such a character as well. I just can't part with him now!

No, there's been no reason why he should have an issue. Food is the same. Health seems fine. So I can only think it's just the insulin degrading or he's just being a weirdo. He has never had typical diabetes. He's young, never been overweight, and no-one really understands why he has it at all. It's very unusual. I've upped his dose by half a unit for now, which has FINALLY got things moving. I have ordered a new prescription too.

I could only get the vial this time around as I'd have to do a full health check and vet visit to ask the vet to change it to a different prescription. But I broke my foot a few weeks back and am only just weight-bearing now so there is no way I could carry him into the vet. I can't even carry shopping yet! So I just asked online for a repeat of what we were last given, which was a vial. But I will bear it in mind for next time.

Pirate Luke says thanks for the belly rubs. He loves em!

Oh I’m so sorry about your foot! I hope you heal quickly. That’s so painful (she says from experience)
The vial will be fine for now instead of the pens. Just giving you options for the future!

It sounds like it’s just time for a new vial.

I hope he grows out of this condition, especially since he’s so young!

 

[Marje and Gracie]

First, a celebration. I've had Pirate Luke for a year now and he's now officially moved into Foster Fail territory and we're transferring ownership to me! Yay!

Secondly, a question. I've had his vial of Lantus since March and we've been able to consistently reduce his dose and keep him in decent numbers.

Until recently.

Now it doesn't really even make a dent in his blood sugar. I have tried raising the dose a few times to little avail. So I think I need a new vial.

When changing vials from one which has lost potency, do you go back to the last good dose when the insulin seemed potent or what? Don't want to overdose the fella but I do want him back on

Congratulations that you have decided to make him yours permanently!

It’s very hard to answer your question because you haven’t been following any dosing method we have here. If you are doing SLGS, you would hold every dose for one full week, unless he drops below 90, and then determine if he needs an increase or not. If he drops below 90 at any time, you reduce the dose by 0.25u.

At no time should you do dose increases or decreases by less than 0.25u unless he’s high and flat all the time above 300. The reason he’s making no progress is because the dose changes are too minimal. Again, when you increase or decrease, it should be by 0.25u. Even with PZ, that’s the way we would correctly dose.

You’ve been changing the dose in tiny increments way too often. And while I understand you have data but don’t always enter it, it’s vital for us to see if you want us to answer a dose question.

With Lantus, we don’t dose primarily on the preshot which is what you’ve been doing lately. It’s not like PZ. We dose primarily on the nadir. Lantus dose increases take a minimum of six cycles to settle in to where we could tell which dose might be best for him but, again, under SLGS, you hold the dose a week.

To answer your question, normally, we would give the dose he was on before his BG headed up but there isn’t enough data there for me to tell if that was a good dose or not. But, when I look at what he was doing on 1u, I can tell he needed more insulin and the increase would have been to 1.25u bid. That’s where I would suggest you start.

I’d also like to suggest you follow SLGS exactly as it is written and it’s really critical you always get a preshot test. Too many times, I’ve seen members fail to get one because the BG was high at night only to test at +1 or +2 and kitty was at 20 and showing hypo symptoms. Not only can this result in death but a Lantus hypo can go on for several cycles due to the depot.

 

[PirateLuke]

Congratulations that you have decided to make him yours permanently!

It’s very hard to answer your question because you haven’t been following any dosing method we have here. If you are doing SLGS, you would hold every dose for one full week, unless he drops below 90, and then determine if he needs an increase or not. If he drops below 90 at any time, you reduce the dose by 0.25u.

At no time should you do dose increases or decreases by less than 0.25u unless he’s high and flat all the time above 300. The reason he’s making no progress is because the dose changes are too minimal. Again, when you increase or decrease, it should be by 0.25u. Even with PZ, that’s the way we would correctly dose.

You’ve been changing the dose in tiny increments way too often. And while I understand you have data but don’t always enter it, it’s vital for us to see if you want us to answer a dose question.

With Lantus, we don’t dose primarily on the preshot which is what you’ve been doing lately. It’s not like PZ. We dose primarily on the nadir. Lantus dose increases take a minimum of six cycles to settle in to where we could tell which dose might be best for him but, again, under SLGS, you hold the dose a week.

To answer your question, normally, we would give the dose he was on before his BG headed up but there isn’t enough data there for me to tell if that was a good dose or not. But, when I look at what he was doing on 1u, I can tell he needed more insulin and the increase would have been to 1.25u bid. That’s where I would suggest you start.

I’d also like to suggest you follow SLGS exactly as it is written and it’s really critical you always get a preshot test. Too many times, I’ve seen members fail to get one because the BG was high at night only to test at +1 or +2 and kitty was at 20 and showing hypo symptoms. Not only can this result in death but a Lantus hypo can go on for several cycles due to the depot.

Thanks for congrats- I'm lucky to have him.

He has a Libre so I know his data for the entire day and always check the preshot.

I do have enough historic data to know I have to deviate from going up or down in quarter units, because, for example, his "sweet spot" previously was not 1 or 1.25, but somewhere in between. Also I can't do strict SLGS (or TR) because I know exactly how long he takes to settle properly into a dose. I have had to go for what works for him.

I am dosing based on the nadir. But we are doing "loose control" as well because nothing else works for him. He is too bouncy, and he has rarely had nice smooth curves. So my aim is to keep under the renal threshold as much as possible with a reasonable nadir. I look at symptoms as well as numbers, which my vet has agreed is best for him.

It's just very recently that he's suddenly needing more insulin when we have consistently needed less and less insulin, and then he was quite steady for some time, so I'm guessing the insulin, which is now 6-7 months old has perhaps degraded as there have been no other changes.

I appreciate that you can't answer dosage questions if you don't have all the data I do. But I really wasn't asking what exact unit dose to give him. It was more a general question of what one might usually do when transitioning from a perhaps degraded insulin to a fresh fully-potent batch. I assume most of us have to do this at some point.

My guess is you'd be cautious and maybe give a bit less? But I don't know because I've not had to do it yet. So I thought other people who have done it might know. If I do start the fresh batch, I will obviously do it during a time when I can be around to monitor him closely.

Anyway for now, I've increased using the old insulin and his numbers are moving again with much better nadirs (which are on the spreadsheet).

Thanks for your help and this forum

 

[Marje and Gracie]

Thanks for congrats- I'm lucky to have him.

He has a Libre so I know his data for the entire day and always check the preshot.

I do have enough historic data to know I have to deviate from going up or down in quarter units, because, for example, his "sweet spot" previously was not 1 or 1.25, but somewhere in between. Also I can't do strict SLGS (or TR) because I know exactly how long he takes to settle properly into a dose. I have had to go for what works for him.

I am dosing based on the nadir. But we are doing "loose control" as well because nothing else works for him. He is too bouncy, and he has rarely had nice smooth curves. So my aim is to keep under the renal threshold as much as possible with a reasonable nadir. I look at symptoms as well as numbers, which my vet has agreed is best for him.

It's just very recently that he's suddenly needing more insulin when we have consistently needed less and less insulin, and then he was quite steady for some time, so I'm guessing the insulin, which is now 6-7 months old has perhaps degraded as there have been no other changes.

I appreciate that you can't answer dosage questions if you don't have all the data I do. But I really wasn't asking what exact unit dose to give him. It was more a general question of what one might usually do when transitioning from a perhaps degraded insulin to a fresh fully-potent batch. I assume most of us have to do this at some point.

My guess is you'd be cautious and maybe give a bit less? But I don't know because I've not had to do it yet. So I thought other people who have done it might know. If I do start the fresh batch, I will obviously do it during a time when I can be around to monitor him closely.

Anyway for now, I've increased using the old insulin and his numbers are moving again with much better nadirs (which are on the spreadsheet).

Thanks for your help and this forum

I think most members see things in the SS that are not there. I know I did with Gracie and I relied on my mentor to see the bigger picture.

What I mean by that is I don’t see any of your observations bearing out. For example, I understand about TR and most cats, when getting close to a good dose, take 10+ cycles to settle in. That’s five days. And with SLGS, they will have easily settled into a new dose within seven days so that doesn’t make sense to me that you can’t do TR or SLGS as written. Yes, TR might be a little aggressive for your life but I haven’t seen a cat yet that can’t do SLGS as written.

All cats bounce and there is no such thing as “loose control”. Often feeding at appropriate times and the correct dose of insulin helps to flatten the curve. He’s actually outside of renal threshold for most of the day.

And it is very common for cats to go up and down between two doses separated by 0.25u. Years of experience and knowledge passed down has shown us those “in between” doses generally don’t work unless kitty is on a very low dose (under 0.5u).

Actually, I did respond to your question about what dose to give him when starting this new vial: 1.25u. Bexause he had not been on a consistent dose but 1u didn’t work for him even if the last vial was good was my basis for 1.25u.

Normally, when starting a new vial, you would start at the dose you were already giving unless he had either earned a reduction or it was clear that dose wasn’t working and it was time for an increase.

I’m not sure why you increased to 1.5u and basically skipped quickly through a couple doses. That isn’t how to use Lantus.

I can only look at his SA and give you my opinion based on 16.5 years of experience and having looked at literally thousands of SSs. But he’s your cat.

 

[PirateLuke]

I think most members see things in the SS that are not there. I know I did with Gracie and I relied on my mentor to see the bigger picture.

What I mean by that is I don’t see any of your observations bearing out. For example, I understand about TR and most cats, when getting close to a good dose, take 10+ cycles to settle in. That’s five days. And with SLGS, they will have easily settled into a new dose within seven days so that doesn’t make sense to me that you can’t do TR or SLGS as written. Yes, TR might be a little aggressive for your life but I haven’t seen a cat yet that can’t do SLGS as written.

All cats bounce and there is no such thing as “loose control”. Often feeding at appropriate times and the correct dose of insulin helps to flatten the curve. He’s actually outside of renal threshold for most of the day.

And it is very common for cats to go up and down between two doses separated by 0.25u. Years of experience and knowledge passed down has shown us those “in between” doses generally don’t work unless kitty is on a very low dose (under 0.5u).

Actually, I did respond to your question about what dose to give him when starting this new vial: 1.25u. Bexause he had not been on a consistent dose but 1u didn’t work for him even if the last vial was good was my basis for 1.25u.

Normally, when starting a new vial, you would start at the dose you were already giving unless he had either earned a reduction or it was clear that dose wasn’t working and it was time for an increase.

I’m not sure why you increased to 1.5u and basically skipped quickly through a couple doses. That isn’t how to use Lantus.

I can only look at his SA and give you my opinion based on 16.5 years of experience and having looked at literally thousands of SSs. But he’s your cat.

Thanks for the advice. I usually never go up this quickly. (In fact what I meant with SLGS is tricky is that it usually takes just OVER a week with him to really settle into a dose, so I usually increase slower than SLGS).

It's just that his blood sugar suddenly seemed to be barely responding to the insulin at all! And he has been running around like crazy and distressed with ridiculously high numbers like he hasn't had in a long time. And he also started attacking my civvie, who is a wobbly Cerebellar Hypoplasia cat, which I can not have happening because she can not defend herself. So I suppose I panicked and wanted to fill the depot more quickly. I hate seeing him so unhappy.

This is an example of what I mean by Loose Control: Loose-control of diabetes mellitus with protamine zinc insulin in cats: 185 cases (2005–2015) - PMC It's where you are focusing on the clinical symptoms being well-managed rather than just strictly looking at the numbers although ideally you try to get the kitty to stay below renal threshold. In this study, the remission probability was 56.2%.

It is actually an approach that has been studied by the Royal Veterinary College, London, in their special Diabetes Remission Clinic (which is my vet, luckily). And they have even suggested that a cat is just as likely to go into remission using this approach as aggressively trying to control the numbers.

I am basing his insulin on nadir and sometimes if I go up by a whole quarter, then he just goes into potential hypo numbers. But then if I go back down by a quarter, he is much too high again, which is why I have tried fattening and skinnying doses to try and find his sweet spot. (I know there are whole swathes of time and data missing from the spreadsheet so you can not see this). I do give Pirate Luke spaced low-carb meals to help control him but it only helps moderately. It has not stopped the above from happening.

I can not keep him within the renal threshold all day. He simply bounces himself out when his blood glucose goes too low for "his tolerance". Or starts getting crazy hungry when his glucose goes too low for his tolerance. And I mean, crazy hungry. And then he is very unhappy again.

He's a strange case. No-one understands why he has diabetes. He's very young, never been overweight, and only developed it after he developed a life-threatening infection near his brain (which thankfully we removed via operation). He is such an unusual case that RVC's Internal Medicine Specialist at the main hospital was actually interested in studying him.

He has never had DKA thankfully, so in fact, I am much more concerned about hypo than DKA. In fact, because he's such a strange case, I'm not even sure we are looking at remission as a goal (which may be impossible), but his overall quality of life.

So this is why I am not just looking at numbers, but also is he happy, playful, calm, no excessive wee, thirst, hunger, aggression etc. (Loose Control)

But you are completely right about not increasing as aggressively as I just did. But I was feeling desperate. I am home all day at the moment recovering from a broken foot, so I am here to monitor him and intervene if he goes too low.

I know I don't always get things right, but I am trying my best for my complicated boy.

 

[Marje and Gracie]

This is an example of what I mean by Loose Control: Loose-control of diabetes mellitus with protamine zinc insulin in cats: 185 cases (2005–2015) - PMC It's where you are focusing on the clinical symptoms being well-managed rather than just strictly looking at the numbers although ideally you try to get the kitty to stay below renal threshold. In this study, the remission probability was 56.2%.

This is a pretty old article and it is not actually a scientific study but more observational. They call it “loose control” but it is not a recognized method of regulation and I bet the RVC is not using it now. As a scientist myself, there are things I look at in an article to determine how significant its findings are and one is repeatability and the presence of controls which this is lacking. But I found this statement interesting:
“Three factors significantly influenced remission: steroid-associated diabetes, lower mean blood glucose during treatment, and lower mean insulin dose.”

We have to resist looking for something “scientific based” to try and justify an approach that isn’t really a valid approach. Long ago, we determined managing FD by clinical observations and not home testing was dangerous.

It is important for any of us to be sure in treating FD our cats feel well and act normal. That’s across the board and following TR or SLGS s written can easily allow cats to do that.

Maybe you have it in your records but nowhere on his SS do I see any evidence that he is anywhere near “hypo numbers”. And it doesn’t matter if he’s bouncing or not, the minute his BG goes over 200-250 (some cats real threshold is even lower), he’s spilling glucose into his urine and since he’s doing this daily, then you aren’t ever getting him below renal threshold as it takes a while for glucose to clear the urine and thus the kidneys.

Having said all that, all I can do is present you with information.

 

[PirateLuke]

This is a pretty old article and it is not actually a scientific study but more observational. They call it “loose control” but it is not a recognized method of regulation and I bet the RVC is not using it now. As a scientist myself, there are things I look at in an article to determine how significant its findings are and one is repeatability and the presence of controls which this is lacking. But I found this statement interesting:
“Three factors significantly influenced remission: steroid-associated diabetes, lower mean blood glucose during treatment, and lower mean insulin dose.”

We have to resist looking for something “scientific based” to try and justify an approach that isn’t really a valid approach. Long ago, we determined managing FD by clinical observations and not home testing was dangerous.

It is important for any of us to be sure in treating FD our cats feel well and act normal. That’s across the board and following TR or SLGS s written can easily allow cats to do that.

Maybe you have it in your records but nowhere on his SS do I see any evidence that he is anywhere near “hypo numbers”. And it doesn’t matter if he’s bouncing or not, the minute his BG goes over 200-250 (some cats real threshold is even lower), he’s spilling glucose into his urine and since he’s doing this daily, then you aren’t ever getting him below renal threshold as it takes a while for glucose to clear the urine and thus the kidneys.

Having said all that, all I can do is present you with information.

I just linked that article to show you what I meant by Loose Control and that it does exist because you said it didn't. And yes, RVC are using it now. They are literally my vet that I go to in Camden, London. It is in their current booklet about treating Feline Diabetes. I was actually going to link that instead but it's a PDF, so I just linked an article that talked about it instead so you knew what I actually meant by the term. But you can look RVC's own booklet up if you like.

My vet at the RVC has always told me that symptom control matters more than numbers. Of course numbers are important. They are to my vet and to me, too, otherwise I wouldn't have learned to fit the Libre myself so that I know his numbers at all times of the day and night and when I'm not home as well.

But numbers are not the whole picture, especially when dealing with a case of ECID. My boy got diabetes at less than 2 years old basically out of nowhere. He is not a typical case and never has been.

I rarely ask on this board for actual dosing advice because I know my spreadsheet is not complete and I may be dealing with him using a slightly different approach from most of FDMB. When I ask questions, I am looking for general or hypothetical advice. What I was trying to ask is basically what do you do if you're going from a possibly expired/ineffective vial to a new, likely more potent vial. That was the thing I actually wanted to know. Because it seems to me that you risk overdosing your cat if you give exactly the same amount - because the new one will be more potent. That was the tenor of my question, not what dose would be suggested for my cat.

I do think the old Lantus is the problem because he was super-high again all night and pretty high today as well on 1.5 units. Much higher than he has been very recently on 1 unit. That doesn't make sense. I have my new Lantus now and will do as you advised and start that tonight with 1.25 units. If that doesn't change things then I will make an appointment at RVC and see what else might be underlying his sudden reduced response to insulin when previously he was becoming more sensitive to it.

 

[Marje and Gracie]

I just linked that article to show you what I meant by Loose Control and that it does exist because you said it didn't. And yes, RVC are using it now. They are literally my vet that I go to in Camden, London. It is in their current booklet about treating Feline Diabetes. I was actually going to link that instead but it's a PDF, so I just linked an article that talked about it instead so you knew what I actually meant by the term. But you can look RVC's own booklet up if you like.

My vet at the RVC has always told me that symptom control matters more than numbers. Of course numbers are important. They are to my vet and to me, too, otherwise I wouldn't have learned to fit the Libre myself so that I know his numbers at all times of the day and night and when I'm not home as well.

But numbers are not the whole picture, especially when dealing with a case of ECID. My boy got diabetes at less than 2 years old basically out of nowhere. He is not a typical case and never has been.

I rarely ask on this board for actual dosing advice because I know my spreadsheet is not complete and I may be dealing with him using a slightly different approach from most of FDMB. When I ask questions, I am looking for general or hypothetical advice. What I was trying to ask is basically what do you do if you're going from a possibly expired/ineffective vial to a new, likely more potent vial. That was the thing I actually wanted to know. Because it seems to me that you risk overdosing your cat if you give exactly the same amount - because the new one will be more potent. That was the tenor of my question, not what dose would be suggested for my cat.

I do think the old Lantus is the problem because he was super-high again all night and pretty high today as well on 1.5 units. Much higher than he has been very recently on 1 unit. That doesn't make sense. I have my new Lantus now and will do as you advised and start that tonight with 1.25 units. If that doesn't change things then I will make an appointment at RVC and see what else might be underlying his sudden reduced response to insulin when previously he was becoming more sensitive to it.

Yes I would like to see that because this guide is what RVC is showing now and there is no mention of loose control. I still contend it is not a valid method of regulation but I’d love to see anything which refutes that.

 

[PirateLuke]

Yes, that is it. They do not talk about Loose Control here. They talk about FLEXIBILITY. And treating each case individually. And Principles trump Protocols.

I am working with my vet from the RVC on this basis.

And for my cat, who they personally know and have seen literally every week for months at a time at some points during our journey, they believe it is better for him that we place more weight on the symptoms than his numbers. They prefer Loose Control for him right now with us using the Clinical Scoring Guidelines in that booklet as the most important aspect for him.

In fact, right now, my vet doesn't really want to see my particular cat ever go below 4.4mmol (79.2 mgdl). Shocking, right? This is a vet at the top Veterinary Science university and hospital in the world suggesting that TR is not the best way for my cat.

Would they automatically suggest that for any other cat? No. They would base it on the individual cat.

I am not arguing that Loose Control is a valid method of regulation. My vet at RVC, which has a specialist Diabetes Remission Clinic and are pioneers in the field of Veterinary Medicine, is saying that. These people have already saved my cat's life once when he had a life-threatening brain infection. They did a wonderful job in a very complex case. I trust them and their judgment.

This forum is excellent, and I appreciate it and have learned a lot from it. But I am basing my cat's actual treatment on the advice of a vet I completely trust and am grateful to have.

I post here to ask the odd question that I haven't had the chance to ask my vet about or if I can not get to see my vet for a while.

So, for example, I re-ordered his repeat Lantus prescription online, so I didn't speak to my vet. So I asked here about the transition from an old insulin to a new, potentially more potent one, because I also trust you guys, some of whom must have already had experience doing that whereas I have not.

I hope that explains it.

I think you guys do a wonderful job guiding others through TR and SLGS and all the ups and downs. But I am here just looking for odd general advice and not complete treatment guidelines. I am closer to SLGS than TR, which is why I have that in my sig. But it's not strictly that. Maybe I should change it so it doesn't confuse anyone who I know is only trying to help.