Newly Diagnosed, switch to Lantas or PZI, why?

[Pogen]

~I posted this Newly Diagnosed... on the Main Forum and the PZI board yesterday. I am posting here to introduce myself and also because I am going to see my primary vet this Monday and I was told that she would prescribe Lantus, since they have run out of PZI. So, barring any obstacles Taser should begin Lantus on Tuesday. I have a few questions at the end of this post. Thank you for any suggestions and/or information~


Newly Diagnosed, switch to Lantas or PZI, why?
 
Our beloved Taser (tuxedo cat), a 7 year old neutered male had a DKA on Dec. 6, 2012. He was with the vet for 5 days and stabilized. Likely due to Pancreatitis and an infection (based on lab results).  I took him to my secondary vet who treats dogs and cats since my primary cat vet was not available. Leading up to this episode/crisis, Taser had been drinking a lot of water and sleeping by the cat bowls – but we did not appreciate the possible implications of this change in behavior. After bringing Taser home, my secondary vet did a BG once a week for two weeks. His first BG on 12/14/12 was 250 and his second BG was 300 on 12/18/12. On 12/28/12 they did a fasting BG at 9:30 am and his BG was 386 and 439 on my Relion Confirm glucometer. So Taser was prescribed Humulin N (NPH), 1 unit bid.  When I asked why he selected this brand of insulin, the secondary vet mentioned that it was cheaper. When I left the office I read some of the printed materials regarding the pros of using Lantus vs.NPH,  I called the secondary vet’s office and spoke to the front office suggesting that I was willing to pay more for the non-cheaper insulin. She spoke to the vet who said he was more comfortable using NPH. I have a 10 ml vial of HPN. When the vet called to see how Taser was doing the following day I mentioned to him that a majority of people seem to be using Lantus vs HPN on this website. He said that when it first came out it was the latest and greatest thing and that now there was not much difference according to the latest info from conferences. I asked him which insulin, Lantus or HPN, would give the best chance of remission in cats and his response was that “insulin is insulin”. I then asked him if he would change me over to Lantus if I chose and he said that he would.
 
During the time prior to Taser’s official diagnosis of diabetes, I checked the web and this site and proceeded to prepare for a Diabetes diagnosis.  We now have 15 cats (all but 1 are rescues). They are free rangers. We had fed them wet friskies, mostly gravies, shredded and pates, and mostly Costcos maintenance dry cat food. My wife used to give some of the cats, whiskas pouches and meow mix as treats. We are now phasing out these treats.  We stopped the dry food, kept the friskies pate, and added some fancy feast low calorie. I am trying to digest all the information about the types of insulins and the impact of different diets, but feel like I’m going crazy with all this new information. Now I feel like I’ve been “killing them (the cats) softly” for the past 12 to 20 years with the food we had been giving them. 
 
Today is Taser’s seventh day on HPN and I have finally decided to switch him over to Lantus. I called my primary vet, who overall has managed our cats quite well to see if I could see her sooner than Monday’s scheduled appointment 1/7/13. I discovered that she uses PZI for her Diabetic cats. My understanding is that PZI needs to be formulated and is not readily available. At this point I am not to comfortable changing to Lantus with my secondary vet (who is great with dogs), but I will if I must. I’m comfortable with my primary vet, but am concerned about PZI formulation. I want to do what is best for Taser long term. Any suggestions or advise?   Thank You!

1. Does anyone clean their vials with alcohol prior to withdrawing insulin? If not, why?

2. Having used HPN for 8 days now, does that decrease any chances of remission?

3. I did a curve yesterday and am posting the numbers. I am new at this and I am not following protocol yet, but I would just like to share my results. Also, I do not plan to increase his NPH dose since I will be be given a prescription for Lantus hopefully, on Monday. What I noticed with the curve is that his BG nadir is at about 3-5 hours. This is a short window of relief for Taser so I can see why no one likes to use this insulin. I would prefer a longer steadier nadir.

4. Taser’s First BG curve. I did the first test at three hours after his morning dose instead of two hours. I took a 2 hour test after his evening dose to more or less get an idea if his nadir might have started earlier than 3 hours. As I mentioned above, I am using a Relion Confirm Glucometer. When I compared my Relion meter to the vet’s venous sample the Relion value was 15% higher than the vet’s. I can divide my BG value by 1.15 to hopefully get something comparable to the vet’s. Listed are the BG values of my 1st curve using the Relion Confirm numbers.

10:00 am AMPS 417 / 1 unit NPH
1:00 pm 242
3:00 pm 245
5:00 pm 321
7:00 pm 392
9:00 pm 340 / 1 unit NPH
11:00 pm 277

5. Is it preferable to purchase a 10 ml vial or the syringes of insulin? Can I purchase just 1 syringe or do I have to purchase the package? I frequent Costco and Target. Are these the best places to purchase the Lantus?

6. Thank you all for any advice or suggestions!

 

[Marje and Gracie]

Welcome to our board. I have to disagree with the vet who said "insulin is insulin".

NPH is a harsh, quick acting insulin. Lantus is the gold standard insulin and offers the best opportunity for Taser to go into remission. Lantus and levemir are long acting insulins and the goal is to have a fairly flat BG in normal numbers. Prozinc is a medium duration insulin. I believe it is difficult to get PZI but I asked one of our most knowledgeable PZI members to pop on here to tell you about that.

The L insulins work by establishing a depot ...in different ways..but a depot. The first several shots you give establish the depot and then the kitty starts using the insulin in each shot. With the L insulins, we have a starting dose and then we dose primarily on the nadir with some consideration given to the preshot. We shoot consistently every 12 hours and follow a specific protocol that is the only one based on scientific research and published in a veterinary journal.

Humulin N and Prozinc are dosed based on the preshot and your doses may change. Yes, cats who have been on Humulin N or Prozinc and switch to lantus or levemir can go into remission.

I highly recommend lantus. In this forum, we follow tight regulation as it is the best way to get your kitty not remission; the tight regulation protocol is the one I referred to that is based on scientific research. Not all of our members in this forum follow tight regulation but we are a close group and an active and very supportive forum where you will find some of the most knowledgeable people regarding feline diabetes.

Most of us buy the pens instead of the vial. The pens come in a 5-pack but some pharmacies will sell them individually.

Please let us know how we can help.

Edited to add: you don't need to clean the vial with alcohol. You can dry out the rubber that way.

 

[Pogen]

Thank you Marje and Gracie for responding to my post. your information is very helpful. I've always wiped vials prior to withdrawal so I was surprised to see that it was not being done. Now I will not feel guilty when I do not use an alcohol wipe. So thanks for adding that to your response. What should I expect when I see my primary vet for a prescription of Lantus. Will they keep Taser for a couple of days or do you think he will come home with me? Where do you purchase your Lantis? Do you buy one at a time or is it packaged only? How much should I expect to pay for a vial, syringe, or group of syringes of Lantus? Where is the best place to purchase Lantus?
Thanks

 

[Marje and Gracie]

They don't need to keep him. They might want to do a curve but if you are home testing, it's a waste of your money. When you are ready to start giving lantus, post in Health or this forum and you can get help.

The typical starting dose for lantus is .25u per kg of the kitty's ideal weight. If the cat is underweight, it's .25u per kg of the cats weight.

My kitty is on levemir but I bought lantus at Costco where it appears to be cheapest if you have a Costco member or pharmacy card. Lantus is more expensive than levemir and the last time I bought lev, it was $194.00 for five 3-ml pens. Lantus is probably a little over $200.00 for the five pens. Vials are less...probably $130.00 or so for a 10ml vial but for most of us, it is more cost effective to use the pens.

Some hospital outpatient pharmacies may sell the pens individually for around $40 but I couldn't find one in Tucson that did and impost pharmacies won't split the packages. But they last a very long time if handled properly.

 

[KPassa]

Glad to see you're switching off the Humulin. Lantus is a great insulin because you only have to give shots twice a day. Not sure for dosage level, but the Lantus mantra is to "start low, go slow."

1. No, I don't wipe it down. I keep my vial in its original box in the fridge, so I'm not too worried about the top of it getting dirty. If it does, then maybe I'd wipe it down, but doing it twice a day I think is a bit of an overkill.

2. Remission is based on the cat's pancreas being able to recover enough to produce the right amount of insulin on its own. Lantus is a great insulin that helps keep BG numbers stable and low enough to help in the pancreas's recovery, so if anything, this should improve chances of remission. That being said, it's advisable to not expect your cat to go into remission otherwise you might be setting yourself up for frustration. Yes, many cats do achieve remission, but a more realistic goal is to get his numbers stabilized, which also increases chances of remission.

3. Check here for instructions on how to create a google spreadsheet to record Taser's numbers to share with us. If you want, you can also give the link to your vet so they can monitor Taser's progress. You might also want to create a profile about Taser and his history.

4. Don't worry about how accurate your meter is vs. the vet's. All meters have about a 20% variance, so you're never going to have the exact "true" BG number regardless of which meter you use. It's better to consider the glucometer as a guesstimate of his BG numbers, i.e. 325 means he's in the low 300s, 375 means he's in the high 300s. Most people here use human meters (the test strips are so much cheaper!) and the protocol is also based off of numbers from human meters.

In regards to nadir, here is an example of a typical Lantus curve:

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

However, please keep in mind every cat is different (ECID). Data collection will offer you a better picture of YOUR cat's response to either of these insulins.

5. I use a vial simply because I didn't know about the pens when I first purchased it. IIRC, it cost me about $100 for the vial I bought from CVS or Rite Aid (can't remember which one now) and it can last up to 6 months refrigerated (even though they say it's only good for a month). The pens, however, can last till expiration date if they haven't been used yet, so it's usually cheaper in the long term since you're less likely to lose as much insulin due to degrading potency. As mentioned above, a lot of places may even sell the pens individually, which also helps save on cost.

It's important to note that you do NOT want to use the pen needles; just the regular U-100 syringe. Depending on the size of your cat, as Marje and Gracie mentioned, the starting dose is generally not more than 1u. Increases are usually done in .25u increments, so it's a good idea to get syringes with 1/2 unit measurements on them. If you already purchased syringes, then it's not a big deal; you'll just have to eyeball it better.

6. Since you're already testing at home, there's no need for your vet to keep him to "get him regulated" or do a curve. First, most cats experience hyperglycemia at the vet's due to stress so any "regulation" done at the vet's is going to be based on higher BG numbers than normal, meaning an increased chance of hypo once he comes home because he's on too high a dose. Second, since Lantus is a depot-type insulin, the first few days aren't going to really mean anything as that depot is being created. And finally, I have seen on here quite a few vets who are clueless as to how Lantus works vs. other insulins and will base dose increases/decreases on pre-shot numbers instead of the nadir! If your vet happens to be uninformed about how Lantus works, this could also create a potential hypo event.