My cat is not responding to Lantus

[tabbylvr]

Hi,

My cat Jeckle was diagnosed with DM in January of this year. He's an almost 11 year old neutered DSH with IBD. I believe his DM may have been caused by the use of steroids (Budesonide). He has always been a very skinny cat.
He had an ultrasound and was officially diagnosed with IBD in October 2018 because of constant loose stools (not watery, urgent diarrhea but pudding like stools often orange in color). For the last couple of years I have tried several prescription diets for gastro issues due to another cat having small cell lymphoma (he passed last August ), i.e. Royal Canin HP and Gastro Moderate Fat, Hill's z/d and d/d. There was always an issue with one of the cats and diarrhea/loose stools. I now have 3 cats, all related, mother and 2 sons. Both boys have IBD and the mom stage 2 renal failure.
Things improved tremendously on the RC Gastro diet. Not perfect but better. I keep a poop chart (sad life I know) and there are always days of solid stools followed by soft stools. Once put on Budesonide I felt like Jeckle's health was slowly deteriorating. His belly looked distended to me. He didn't look right. I weaned him off Budesonide but things didn't get much better. At some point I took him to the vet (I work there too) because of his big belly and xrays revealed nothing other than a thicker fat layer. A month later I took him in again because he looked and felt super skinny - within a month he had lost 2 pounds and become a full blown diabetic I had been complaining about increased water intake and ravenous appetite but I was still shocked.
His labs showed glucose of 385. He was hospitalized on fluids and immediately put on m/d kibble and DM canned. His numbers initially weren't that bad. He was started Friday 1/25 on 1 unit bid Lantus. Saturday morning values were 325 @ 9 am and 274 @ 11:30 am. His numbers remained in the mid 300s for a little while and then slowly crept up in the 400s on 1 unit.
Curve results on 2/6 were as follows (done in hospital):
485 @ 8am
344 @ 10:30am
350 @ 12:30pm
302 @ 2:30pm
232 @ 4:30pm
411 @ 5:30pm
Insulin was increased to 1.5 units bid.
The diabetic diet caused lots of loose stool in both boys. After calling Hill's, we decided to switch to w/d which is also labeled as glucose management. It improved stool quality pretty much overnight. They get 0.75 can twice a day and free feed kibble. After about 2 weeks on the food the stool quality started cycling between loose and solid again without noticeable cause.

Curve done at home on 2/17:
498 @7:30am
458 @ 9:50am
434 @ 11:50am
442 @ 1:50pm
520 @ 3:50pm
497 @ 5:50pm

I did get a couple of weird really low readings a couple of times (sample size to small is my best guess). My vet asked me to repeat the curve at our hospital to rule out somogi overswing.

Curve done at hospital 2/18:
557 @ 8:15am
550 @ 9:50am
527 @ 10:50am
469 @ 11:50am
447 @ 1:50pm
439 @ 2:50pm
392 @ 3:50pm
406 @ 5:50 pm

The numbers keep getting higher the more insulin he gets!!!!
Dosage was increased to 2 units bid.

Curve done at home on 3/14:
428 @ 8:05am
439 @ 10:20am
351 @ 12:20pm
376 @ 2:20pm
447 @ 4:20pm
423 @ 6:20pm

Dosage was increased to 3 units bid.

Today I was going to do another curve at home but his pre food/insulin number was 511. I just don't understand!

Can anyone help?

I'm using the Lantus Solostar pen. I've tried both the pen needles and regular syringes. The latter works best. There was some initial confusion about refrigeration. According to the pen's instructions, it should not be refrigerated once opened. My Dr looked on VIN and the common recommendation is to refrigerate. So the pen has been exposed to both "climates". I started it on 2/22. Also lots of contradictory information out there...use it until it's gone, 3 months, 28 days...I discarded it today. I stopped the curve today - no sense poking him all day. With a 511 pre value I know what the other numbers will likely look like. So new pen tonight and curve will be done on Sunday. Maybe the insulin lost its potency (that would be the easiest fix).

I know the food could be the problem! Although we have a diabetic cat at the clinic that eats Science Diet Urinary kibble and 2 tablespoons of wet and is perfectly regulated at 5 units bid. It IS possible but requires more insulin.

The reasons I've been hesitant to switch to all canned:

1. They seem to need a high fiber diet to control loose stools. At least the boys. Even then nothing works 100% of the time. I know I could add Miralax to any wet food which I probably will end up doing. I was just afraid they wouldn't eat it if I started mixing in too much stuff.

2. I tried all canned before and both boys didn't eat enough and lost a lot of weight. Neither one needs to lose weight and Jeckle can't afford to lose any more weight!! Years ago I even tried making my own cat food - so not appreciated by my cats .

3. What canned food to get???? They all contain something harmful or are way too expensive. I know Hill's has a bad rep and to this day I cringe and shudder when I read the ingredient list but at least they're doing food trials. When feeding all canned nowadays, it's full of carrageenan, locust gum, xanthan gum, etc. Friskies and FF have artificial colors included. I feel like there aren't any healthy choices out there. I do like Tiki cat and Weruva but all their formulas are very low calorie making them absolutely unaffordable. What do you feed? Any suggestions? I've spent more hours doing research on cat food than I'd like to admit. I'm very familiar with Dr Pierson and practically lived on catinfo.org and catnutrition.org for several years (pissing my vet off to no end). It just seems that my cats don't read her information and play by their own rules...I fed all Friskies for a long time and Jeckle's brother lost so much weight I could feel his spine. Plus, has anyone noticed Friskies now contains wheat starch, soy isolate etc????

Another big problem is that I cannot always give insulin 12 hours apart. The last week and a half I have been able to (even though the numbers don't reflect it!) but I also do pet sitting and sometimes don't get home until 8 or 9pm. I'm trying to limit that drastically and am not taking on new clients but it's a catch 22. I need the extra money to afford the medical care for the cats... Luckily those times that insulin has to be spaced out further are decreasing in frequency!

I'm sorry this is so long. My vet helps me a lot too and we already called a specialist twice for recommendations. To me, it's either going to be the insulin itself or the food. Now that I wrote it all down and looked at the numbers, I feel it even points to the food being the culprit...

Any help would be greatly appreciated.

 

[Julie and Honey]

Hi there,

I see you joined today.

There is a lot involved, but you are in the right place. We will help you all we can. Suggest reading the yellow stickies at tops of Lantus and Health forums for more info too.

Lantus should be refrigerated to keep longer. The mfr says 28 days, that is for humans that usually take it with them and don’t refrigerate.

It has been verified it will keep 3-6 months if refrigerated. Many people here get the pens from Marks Marine pharmacy in Canada for the best price. Not sure if you are in the states? If so, you can save over 60% getting Lantus from Canada. We also use syringes to draw the insulin from the cartridge. The pens are more economical than the vial and the pens last longer.

Sometimes too much insulin can produce high numbers if cat dropped low and their liver can release stored sugar to prop up sugar levels when their body thinks it is in trouble.

If not testing daily it is possible the ideal dose may have been passed up even with the curves. Initial curves were done at vets and those are not always accurate because cat is usually highly stressed at vet and numbers can be elevated significantly from stress. If dosing is then based on higher numbers it is possible a higher dose was given than needed and that just continued.

It sounds like your vet is trying to do the right things, but we have seen in the past, not all vets have a lot of experience with feline diabetes. Some do, but we have seen cases where cats were prescribed too high doses because they were only looking at one high number and just keep increasing dose. I am not saying that is your vet at all, I am just saying it happens more than you would believe and something to be aware of. The people here are not vets, but many have had decades of experience with diabetic cats and have had great success with getting them regulated and sometimes into remission.

If you can create a signature with your cats details that would help and it will show up with each of your posts and we won't have to keep asking the same questions.

Here's how:
click on your name in the upper right corner of this page
click on "signature" in the menu that drops down
type the following in the box that opens: kitty's name/age/date of diabetes diagnosis/insulin you're using and dosage amount /glucose meter you're using/what (s)he eats/any other meds or health issues (s)he has. You can add your name, and a geographic location (sometimes the time zone matters) Be sure to SAVE when you are finished.

We use a spreadsheet here to record the insulin and testing data to see how the insulin is affecting our kitties. Then we can take a look at it before offering any suggestions or advice. See link below.

http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/

Some more members should chime in with more advice on diet. Your situation is a little different due to other medical issues.

 

[tabbylvr]

Hi Julie,

Thank you for your response. I created my signature

My vet is pretty cool and willing to help me and ask for help with specialists. She is, however, a firm believer in Hill's lol. But even on VIN everybody now talks about the importance of high protein/low carb diets for diabetic cats (all cats really but baby steps I guess).
I'm taking Jeckle in to have another UA and culture done to rule out any underlying issues. He just had that done at the beginning of the month but what the heck, better be safe than sorry.
I have been hesitant to home test because I was afraid. Sometimes I would get blood right away and sometimes it took a few pokes. Very stressful! Well for me, Jeckle is like a rock - he's the best cat ever!!!! I've recently learned about the rice sock trick and it truly works even if you use barley instead of rice. And Jeckle actually likes the warmth against his ear.
I'm leaning towards diet change and will tackle that slowly. What's best, replace the wet w/d with new food first and leave kibble down? Then gradually increase wet amount? I don't want him to become hypoglycemic. How drastically do you reduce the insulin dosage?
I agree that he may be getting too much insulin. Maybe there is somogy effect after all? But he always responds well for the first week after an increase and then slowly falls back to drinking more water and begging more. Overall, however, he feels better, has lots of energy, is bright and alert, and his urine output is normal (tight balls). But he won't gain weight (or muscle back for that matter). I'm telling you, he's an enigma.

I think we'll know if it's an insulin problem in a couple of days. He received fresh insulin tonight.
Next will be food. Having to reduce the dosage to accommodate the lower carbs may solve the "too much insulin problem".
So there may be hope.

I was always told to do a curve 10 to 14 days after an insulin increase to give the insulin time to work. Spot checks are less useful because they can greatly fluctuate. I truly didn't expect a reading of 511 this morning. We were both relaxed and it was an easy poke. Should I curve him more often?

 

[Julie and Honey]

I just saw your pic, very cute.

At that high of a dose it is highly recommended testing at home. We usually do a minimum of testing before am and pm shots and also mid cycle. Lantus “usually” is lowest around 6 hours after shot. It is good you have done some of testing. You can find advice here on testing too. It gets easier, just make it a calm experience and be patient and give lots of (low carb) treats and talk calmly to your cat. I never thought my cat would come over to get tested, but she does now. Freeze dried salmon apparently is well worth getting her ear poked

Also it is important with Lantus you keep to every 12 hours as much as possible. If you are very early it acts like a dose increase, if you are very late it can act like a dose reduction.

Reducing to low carb can reduce glucose considerably and insulin dose will likely need to be reduced in conjunction with changing food and there is a possibility he needs a reduction of insulin anyway. There is a way to reduce to low carb food gradually to avoid a huge drop in blood sugar.

I had the same issue trying to find the healthiest food that is low carb and I spent at least 20-30 hours and could not find anything I was 100 percent happy with. If you are familiar with Dr. Lisa’s food list, it is recommended to use a food with less than 10% carbs, many people here use 5% or less. That chart will also list higher carb foods, just check the carb column and make sure it is not more than 10%.

With other gastro issues, I am hoping someone with similar issues has some suggestions for a food that will work. I do remember xantham gum can cause intestinal upset in some cats, so I would try to stay away from anything with that.

I am tagging @Wendy&Neko. She has a lot of experience with Lantus and may be able to add some suggestions on where to go from here. I am newer here and have learned a lot, but am by no means an expert.

 

[Wendy&Neko]

Hello and welcome. Dealing with IBD and diabetes can be a challenge, but been there, done that. As have a number of other people here. There are quite a few off the shelf commercial canned products with unique proteins and low carb. Even more selection if you add raw food to the possibilities list. The website https://www.ibdkitties.net/ has a lot of good information on food. First a couple questions about the IBD. How was it diagnosed? Did you have an endoscopy or surgical biopsy done? Which probiotic are you using? I'm using Visbiome, a probiotic specifically for IBD.

My girl was on budesonide, and it did not impact her blood sugar numbers. I think that's a bid ECID (every cat is different), though budesonide's effects are probably better than the prednisolone alternative.

As for dose, your kitty may or may not be on too high a dose. It could be too little. Dry food definitely is a factor, plus some cats just need more insulin than others. For reference, my girl had two secondary conditions (acromegaly and insulin auto antibodies) which means she needed to get up to 8.75 units. We've seen cats on over 5 units of insulin drop down to a lot lower and even nothing when the dry food is removed. One of the reasons we say any change in carb of food fed should be done gradueally.

If you can get a spreadsheet set up that Julie referred to, we'll be able to help you figure out where to go next with the dose. Don't get my started on Symogyi - that's an old vet's tale. And yes, something they used to all be taught. It's been disproven for kitties on longer lasting insulins that are increased safely.

The insulin depot needs around 6 cycles to build. You don't need to wait more than a week to do a curve. Get a test before each and every shot (AM and PM), plus random spot checks where you can. A test a night before bed is really helpful because many cats go lower at night. We dose based on how low the dose takes the cat, so catching those lows is key.

Take a look at the yellow starred Sticky Notes posted at the top of the forum. Keep asking questions, we love to help here.

 

[Julie and Honey]

Thanks Wendy.

I also forgot to mention getting ketone urine test strips would be a good idea. You can get these at Walmart or any pharmacy. Good idea to check for ketones.

 

[tabbylvr]

Hi Wendy,
Thank you for helping!

First a couple questions about the IBD. How was it diagnosed? Did you have an endoscopy or surgical biopsy done? Which probiotic are you using? I'm using Visbiome, a probiotic specifically for IBD.

At this point, he's only had an ultrasound that showed mild/moderate inflammation, no pancreatitis or acid reflux. My cat that passed away last year from lymphoma had several ultrasound, an endoscopy (upper and lower) and was diagnosed with small cell lymphoma. He was put on Budesonide and Leukeran. Both meds were tolerated very well. 4 months later he started to feel unwell and was switched to Pred. Initially Pred was avoided because of HCM. 5 months later I had to put him to sleep - every single lymph node in his body was swollen, the largest over 5cm. To this day I feel like something was missed because the scope only gives limited options of biopsy collection and one part of the intestine cannot be accessed at all. I am definitely a little jaded. I don't think I'd do another scope. If anything then surgical biopsies.
So far Jeckle hasn't responded to any IBD treatments. Metronidazole only worked for a few days while on it then soft stools again. Budesonide didn't improve stool quality. He did test positive for c. perfringens enterotoxin and has been on Tylosin bid for weeks. I just recently reduced it to sid. Stool quality comes and goes. Fortiflora has minimal impact on stool quality. I've been using Dr Mercola complete probiotic because it also has s. boulardii in it - no significant impact either. Sigh. At least he's feeling well and doesn't seem to be bothered. We will be repeating the ultrasound in April.
I haven't heard of Visbiome! I will definitely give that a try!!!!

I have tried making my own raw food following catnutrition.org and Anne was very very helpful. Jeckle, however, didn't like the food and vomited no matter which protein was used.

As for dose, your kitty may or may not be on too high a dose. It could be too little. Dry food definitely is a factor, plus some cats just need more insulin than others. For reference, my girl had two secondary conditions (acromegaly and insulin auto antibodies) which means she needed to get up to 8.75 units.

I assume the inflammation in his body has something to do with him not being able to regulate. What surprises me, however, is that his numbers were initially lower and have gone higher with every dose increase. They definitely got higher on w/d. I have no problem giving more units if he needs them. But I'd like to see his numbers go down to feel like we are making progress.

Although my vet told me that diet at this point is probably only about 10% of the problem, I decided to make some changes. I went back to the DM canned food and am adding Metamucil to it to add fiber. I still have the w/d kibble down but I'll get the DM kibble delivered middle of this week. I decided to go with DM for now because it has the lowest carbs (7% in canned and 18% in kibble). It's a start. Jeckle is so skinny and really needs the calories. With his high numbers his body is just burning everything away and urinating everything out. W/d has only about 9% fat and 37% carbs in the kibble. It's very low calorie and I feel he needs calories. Fortunately for me, Jeckle prefers canned and will only nibble on dry! I also chose DM because even the canned is very calorie dense. Eventually the plan is to switch to an even lower carb canned food and get off the kibble (although his brother may always need a kibble crutch to maintain his weight).
I was hoping to see a reduction in his numbers but so far no luck. I checked his BG Saturday am and pm - 425 and 488. I did it wrong, however, and checked it after feeding before insulin. I really don't know why I did that! I know it should be PRE feeding and insulin, duh! This morning I tried to use his right ear - I had 2 left hands and the coordination of a newborn baby giraffe . I could feel him getting impatient and decided to wait until later.

I'll be taking him in on Tuesday for bloodwork, ua with culture (I don't think he has a UTI but it needs to be ruled out), and a glucose curve. So far his numbers have been similar whether I did it at home or at work and since he has to go anyway might as well do it there.

Thank you so much for your time and help

Nadine

 

[tabbylvr]

If so, you can save over 60% getting Lantus from Canada.

I found a coupon online (a Lantus card actually) that gets me either a 10ml vial for $99 or a box of 5 pens for $149 with 10 refills. Is it even cheaper in Canada? I thought that was a pretty good deal.

 

[Julie and Honey]

I found a coupon online (a Lantus card actually) that gets me either a 10ml vial for $99 or a box of 5 pens for $149 with 10 refills. Is it even cheaper in Canada? I thought that was a pretty good deal.

Those are good deals, but if you try to get discount from Lantus, you are attesting to the fact that the insulin is for a human, not an animal. Some people have tried this, many pharmacists will not accept it if they realize you are getting for an animal as Lantus is not intending that discount for pets.

The best I have found for one pen at Walgreens with a specific prescription discount card was $80 (regular $94). I am in Illinois and out 5 pharmacies, Walgreens was the only one that will split a box of 5 pens and sell just one. I will be ordering from Marks in future, just got first pen at Walgreens due to the $15 discount and no shipping and did not want to wait.

The vial will likely get thrown out before you use it all unless on high dosage (vial has 1,000 units). Insulin if refrigerated will last 6 months, most people will never use that in 6 months.

The pens are more economical because each contains 300 units and are usually dated out a couple of years, so last longer as long as refrigerated. Once you start using a pen cartridge (best to draw with syringe from cartridge for more precise dosing) that will last you up to 6 months, so normally less waste than vial.

Marks prices

Vial is $110 USD
5 pens are $165 USD

Add temperature controlled shipping at about $25

Allow 7-10 days for delivery to US as it needs to clear customs and gets delivered by US Postal service.

Here is their site, they are helpful if you want to call them with any questions, you can email them a photo or scan of the script from your vet. They are not open on the weekends.

https://rxcanada4less.com/search.php

 

[Julie and Honey]

Was any dosing advice given here since it seems doses may have been increased before adequate data gotten? If dose increases were only made by looking at curves, mostly at vets, increases may have been made too soon because those numbers can be artificially elevated due to stress.

 

[tabbylvr]

Those are good deals, but if you try to get discount from Lantus, you are attesting to the fact that the insulin is for a human, not an animal. Some people have tried this, many pharmacists will not accept it if they realize you are getting for an animal as Lantus is not intending that discount for pets.

For what it's worth, Walgreens had no problem accepting it knowing it was for my cat Maybe that could be helpful for other people in the future.

If dose increases were only made by looking at curves, mostly at vets, increases may have been made too soon because those numbers can be artificially elevated due to stress.

Yes, the dose increases were made based on the curve results. Curves were done both at home and at the vet - the numbers were high regardless (actually lower at the vet). I set up the spreadsheet with tomorrow's starting date (a little OCD here, sorry) and will track AMPS and PMPS. I won't be able to track midday values except for Sat, Sun, and Thu due to work. I see the signs of "high numbers" though - begging and increased drinking. Mostly in the am and pm when the numbers would be highest. I am hoping switching to DM will bring his numbers down but, as Wendy pointed out, with other underlying issues he may just require more insulin than other cats.

 

[Sienne and Gabby (GA)]

If you've not seen the Raw Feeding for IBD Cats website, I'd recommend it. Even if you opt to not give Jeckie a raw diet, their information on supplements, managing nausea/vomiting, diarrhea, etc. is excellent.

Lisa Pierson, DVM's site on feline nutrition has an excellent section on transitioning a cat from a dry to canned food diet. This is the section on transitioning.

 

[Wendy&Neko]

If you have any data from the last two weeks, it’ll help us help you if you can enter that in the spreadsheet.

As for testing, are you out of the house for 12 hours? Many people arrange their schedule so they can get a +2 before they leave for work. That is enough to give a hint what is happening. If you can’t get an out the door test, in the door can help if there are still a couple hours until PMPS. Plus you have the entire night time cycle to gather data. A test just before bed is a good one. Many cats go lower at night and we determine how to change doses based on those lows.

DM kibble is still really high carb food. Almost any kibble is no good for cats, even more so for diabetic ones. There are also several low carb novel protein canned or raw options available commercially. And there are some premixes good for making your own cat food, which means even more novel protein options. Lamb and duck are usually higher calorie.