Questions - Lantus just isn't doing the trick

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SHK

SHK

Member Since 2012
Thank you in advance for any advice, stories, anything you can give me. I'm pretty desperate right now. I am failing EQ and it is a terrible feeling. I'm grasping at straws; he is not improving. :sad: I know all cats are different, but I'm learning mine is very different (I like to call him special).

Question for PZI users - were you ever on Lantus but switched to PZI? What were the reasons, and did your cat do better?

Question for non-Lantus users (Humulin, etc.) - were you ever on Lantus but switched to something else because Lantus wasn't working for your cat?

Background: We've gradually upped the Lantus dose (via regular conversations w/Vet; I fax him my spreadsheet each week) and were at 6u yesterday, and I dropped EQ back down to 5 this morning. He is in the 300s, steady as a rock, with a few dips into the high 200s. His symptoms (increased drinking, massive pee clumps) have not subsided since his diagnosis 6/7/12. We're doing everything else right - zero carb wet food, lots of extra water, as much BG testing as my schedule allows, regular ketone testing (negative). I have next week off, so we'll be going to the vet (UGH, it stresses him out so much, but I need to test him to see if he has an infection or anything that could be making it hard for him to respond to the insulin). I even bought strips that test for leukocytes and specific gravity, before realizing that they're not good indicators of a real infection unless the urine sample is completely sterile. Live & learn.

I had a brief conversation with a vet in another city yesterday. She has never seen or treated EQ, but based on my spreadsheet, she suggested asking my vet if he thinks a different type of insulin - PZI - might work. I need to educate myself on different types of insulin, but want to hear from those who have switched. This is the reason for my post. I'll post this in the PZI forum as well. Hopefully that's ok.
 
PZI or Levemir- PZI is a short insuln, Lev is a long acting insulin like Lantus.

You might also consider it might be something else besides the insulin. Acromelegy or insulin auto-antibody (IAA) could be the culprit- or EQ could just be a high dose cat, in which case you just have to raise to get past the resistance and then it will drop.

You can do blood draws for the tests for the first two at the vet- add it to your visit to save $. I've added a file that is my cheat-sheet for acro stuff- where to send the tests, a little about it, I printed it off and gave it to my vet to look over.

It is a hard thing to find out about your cat but it makes it easier once you know.
 

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There are many factors to consider. For one, could your Lantus be ineffective? Maybe it was bad when you got it or maybe it wasn't stored properly or handled properly. Have you been to the Lantus insulin support group? There are stickies there on how to handle the insulin.

PZI is fine, but for my own cats I wouldn't use it any longer. Over the years I've used several types of insulin and for me, I like the Levemir which is close to Lantus but since I'm not always graceful and have dropped vials in the past I prefer the Lev because it's a little more sturdy. I've found that my cats use a little less Lev than they do Lantus.

When I had PZI cats they were more prone to pancreatitis flares. One also got headaches. I could tell because his fur above his eyes looked scrunched when he had a head ache. Lantus or Levemir are smoother, they don't have the big curves where a kitty might start high, go low for a few hours and then swing back up. With the L insulins the curve is more gentle and my cats don't seem to get cranky from the swings with the other insulins.

This is only my opinion, please see what others have to say. I'm not a vet or an expert.
 
I see that you're feeding Instinctive Choice cat food, which I'm not too familiar with. Is it dry or canned food? [EDIT--I see that it's canned]. Do you have the as-fed values for this food obtained from the manufacturer? I see that you have listed it's 0% carbs, and I'm wondering how you got that value--is that dry weight or % of calories? If that value is dry weight, than it may not be as low carb as you think. Some cats can be extremely carb senstive, so if it's in the 5-8 % carb range you might want to switch to something in the 0-4% range (percent calories, not dry weight).

My biggest concern for you though is before you switch insulins, I would try dosing Lantus as outlined the attached protocol and article below (which I would print and share with your vet). There is a more user-friendly explanation outlined here: http://felinediabetes.com/FDMB/viewtopic.php?f=9&t=1581. This method has an 84% remission rate in cats when started within 6 months of diagnosis, and keep in mind that the high effectiveness and remission rates with Lantus are only valid if you're properly following the protocol. With Lantus, dose adjustments are based on the daily nadir, or the lowest number of the cycle. Since you aren't collecting this number, you don't know if the dose is too low, or too high. Can you get some daily mid-cycle checks (about 6 hours after the shot)? This can be in either the AM or the PM cycle, so if work prevents you from getting it during the day (like if you can't get home during your lunch break), you can get it at night. When Bandit was on Lantus, I got a test before bed at 10-11pm, and I set an alarm to get the nadir test at 1am (shots were at 7am/pm) M-F every night and went right back to sleep, and did curves in the AM cycle on the weekends. It seems like a pain, but you adjust to it quickly and that small amount of effort is 1000 times worth getting your cat's BG under control and likely off insulin.

When a cat's BG drops too low, its liver releases glucose into its bloodstream, which works to keep BG high for up to 72 hours (we call this rebound, or "bouncing"). That means if you're not getting daily nadirs, and only an occasional nadir every week or so, you're not likely going to catch that low number which is causing the rebound, if that's what's going on.

I would strongly urge you to follow the recommended dosing protocol for Lantus before switching insulins. If rebound hyperglycemia is your problem (and this is very common when the dose is raised too fast based on preshots only), then switching insulins is not going to help at all. We recommend getting mid-cycle checks for all insulins, because the mid-cycle numbers are the ones that tell how the insulin is actually working in the cat.

6u is a very high dose if your cat is eating a low carb, canned diet and does not have a high-dose condition (which at this point I would probably get tests for as well), so I would make it a priority to eliminate the possibility of rebound hyperglycemia.

Dosing protocol: http://www.uq.edu.au/ccah/docs/diabetesinfo/link4.pdf

Article:
 

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I think there's a fundamental issue involved with how you're dosing (or you vet is advising your to dose). With both Lantus and Lev, dose changes are NOT based on your pre-shot numbers. Because both Lantus and Lev are long-acting, depot-type of insulin, dosing is based on the lowest point in the 12-hour cycle (i.e., the nadir). It looks like you're basing your dose increases on the pre-shot values. What this means is that you need to get at minimum, one test during both the AM and PM cycles. It is entirely possible that your getting a test result over 300 at pre-shot, EQ drops to the 40s at nadir and then bounces back to the 300s by the next shot time. Based on the pre-shot numbers, you'd be increasing the dose. Based on the nadir, you'd be decreasing.

If you look at 11/2/2009 on my cat's spreadsheet (the link is in my signature and you'll need to click on the tab at the bottom), you'll see that Gabby went from 400s at pre-shot to the 40s and back to the 400s. The kind of bounce I've described is entirely possible.

You also need to be feeding a low carb, canned food diet. You also noted that you suspect a UTI. This can also effect BG levels. Any infection or inflammation, whether it's from a UTI, pancreatitis, or gingivitis or other dental issue can raise BG numbers.

As for a comparison of Lantus to other insulin, you may want to share this journal article with your vet:

While this is a study with a small sample, more of the cats on Lantus went into remission compared with PZI or Lente insulins.
 

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Most noticeable on EQs ss is the lack of numbers at mid-cycle.
As has been already mentioned, you need to know what's happening during those 12hrs between the shots.

If you were to do a curve on a day you are able, maybe on the weekend, test every 2 hrs and see how the insulin is affecting EQs numbers.
If you see that the numbers stay up in the 200s and 300s, with a small bit of a drop around the middle, then your dose is likely not high enough.... and no, I don't believe that dropping back to 1u as may be suggested is a great idea.
If you see that EQ is dropping really low around the middle or some spot between the 2 shots, say you are seeing a big drop and then EQ is going high again, then you may start thinking about dropping that dose down because it's likely too much insulin.

So, without seeing what happens to the numbers after shots, you will not know if you are close to the right dose, or if you passed it days ago.

Many people cannot test much during the weekdays, with work and all, but it's important to get a before bed test as cats go lower at nite, and then see if you can do a curve or two on the weekends.

Lantus is a fine insulin, I prefer Levemir myself, but without any numbers, you cannot say that Lantus is not doing the trick.... Once you see more numbers, you will have a better idea how EQ is doing and what you need to do next.
 
I don't normally offer dosing advice because I don't feel as though I know enough to dole it out, but by increasing in .5 unit increments, it could be possible you have missed EQ's "sweet dose" meaning that dose that is just right for him, not to high, not to low .. again, that's just something I noticed on the SS, not saying that is the reason he is so high, or that you aren't seeing lower numbers .. also, not every cat has those perfect non diabetic numbers in the first two months .. you'll see by looking at random SS on the lantus forum that many cats in the first two months bounce all over the place or are stuck on those higher levels .. mocha was on insulin (lantus) for nearly two years before she leveled out ...
 
I will give you my experience with my Tonis. I adopted him an as untreated diabetic. I first started using Lantus since my other cats were on Lantus. With the first shot I got a good response and then really nothing. I got up to 4 or 5 units bid with little drop. I then switch him to Levemir. Still no good results with up to 8 units bid. I had some N left over from Twiggy. I got a good drop with N. I ended up with 4 or 5 units of N and 8 units Levemir bid. With that I could maintain his BG below 150. These results are not at all typical but it worked for Tonis.
 
Did you try posting this in the Lantus forum? Also wondered how your kitty is doing? I'd love to hear what your vet had to say.

I am going through the same thing right now with Tiggy I think - numbers seem flat and unresponsive even though I am slowly increasing the insulin and have fingers and paws crossed I will hit the right dose soon since I am up at 4IU BID today. See my SS. His urine is still high BG but around 3.5IU I started seeing less clinical signs ie less drinking and peeing even though the BG levels really didnt change. And his stools are pretty soft still. So sounds like our babies may be going through the same thing?
 
Thank you for all your responses, and the reading material. In answer to some of the questions:

1. The wet food (Instinctive Choice) information comes from the Janet & Binky chart, zero carbs, as fed; it's listed under the "Other" section toward the bottom. EQ has been on this food for three years (long before his diagnosis), with water added to it at each feeding (distilled and/or filtered). He used to eat a little low carb/grain free Fancy Feast, but since the DX, I have not fed him any variation on the Instinctive Choice.

2. I cannot follow tight regulation protocol due to my schedule, so I have been trying to follow the general guidelines section in the link provided by Julia & Bandit. I've been rotating injection sites too.

3. Most days it is impossible for me to get daily mid-cycle numbers in the daytime - I work over 40 minutes away from home. There is no one else to help. While I am on vacation right now (and on weekends) I am trying to get mid-cycle numbers as often as possible. If you look at the times I was able to get any in-between numbers on my spreadsheet since the diagnosis, you'll see that they are rarely a great deal lower than the pre-shot numbers. There is no doubt in my mind that EQ's numbers have ever dropped below 200 at any given time in a cycle. But I will start setting an alarm for the middle of the night to get numbers then as well.

4. I have driven myself crazy wondering if I did something to render the Lantus ineffective in the beginning, but I don't think so. I'm pretty careful with it. But then again, it's my first bottle. I did ask a couple of the pharmacies if they could order the pen refills for me and they all said no. The cheapest pharmacy only sells the pens in packs of 5 for over $200, and will not break them up to sell individually.

Question - if I do get a new bottle of Lantus, and the old one is ineffective (how would I even know?), by how much should I drop the first few doses to ensure we don't have a hypo episode?

We'll be headed to the vet this week to test for infection (urine or dental, although he just had quite a bit of dental work and cleaning done in January). Thank you to hmjohnston for the link to your acrocat page. I will ask about Acromegaly and IAA testing as well.
 
Did you look at Tiggys SS? It's really similar, although Tiggy is yellow instead of pink, his numbers are flat with a very small dip . I can see a small dip in EQs consistently too, so I think the insulin is working, just not enough.

and I am not surprised he is still showing sugar in his urine, the renal threshold is 180-270 so you will see urine sugar in any BG above that.

I can't tell you why this is happening, I am still struggling with the same issue with Tiggy but I would be interested to see what the vet says. I just bought a new vial of insulin myself and I am going to try it on Tuesday when I can be home to monitor him so I will let you know how it goes. ...
 
BTW I did a quick analysis of your AMPS and PMPS and if you look at the trendlines, both show a slow but gradual decline - see attached graph. So that has to be good news!
 

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Wow, thank you so much for that, Wendy. I guess I was on the right track, but after reading some posts that I might be giving him too much insulin, missed the sweet spot, etc., I dropped him to 5u about 7 days ago. When you don't know if you're doing the right thing, and you get responses like that and you get scared and react, you know? But I think (hope) I just have a high dose cat and I have to figure out what that dose is. The more I think about it, the more I wonder if he has been borderline diabetic for quite some time.

So anyway, dropping him down one unit apparently was the wrong choice. Last night I woke up around 1am and he was like a lump and difficult to wake (not like him), so I suspected a hypo even though he's never been low enough that I've seen symptoms. Other than lowering the dose, I haven't made any changes to his routine/food/etc. I took him into the bathroom and he woke up and tested at a whopping 469! He was at 335 pre-PM shot. Today was a whirlwind so far, 418, then 362, and now 415 pre-PM shot.

We went to the vet today. Got a full panel of bloodwork including thyroid, and a urinalysis - will get some results tomorrow and the rest later this week. Vet suspects dental or urinary infection and put him on Baytril (he has pukey issues with Clavamox) for seven days. His teeth are full of tartar again, despite having a deep cleaning and extraction just seven months ago. But vet said unregulated diabetes can wreak havoc on the teeth too with all of the sugar in his saliva secretions. She also detected a slight heart murmur. And she said she doesn't think his current food is allowing for enough protein, even though it is zero carb as fed. So I looked it up on some of the spreadsheets, and noticed the phosphorus is kind of high too. I was so engrossed with the carb count that I didn't even think about the phosphorus or protein! So much to know, so much to research. You think you're doing the right thing, but jeez... poor little guy, what next?

After we get the results, I'm going to buy a new bottle of Lantus too. Heck, there's only a quarter left in the first bottle.

P.S. I see Tiggy had some pretty low numbers today!
 
SHK said:
Thank you for all your responses, and the reading material. In answer to some of the questions:

1. The wet food (Instinctive Choice) information comes from the Janet & Binky chart, zero carbs, as fed; it's listed under the "Other" section toward the bottom. EQ has been on this food for three years (long before his diagnosis), with water added to it at each feeding (distilled and/or filtered). He used to eat a little low carb/grain free Fancy Feast, but since the DX, I have not fed him any variation on the Instinctive Choice.

2. I cannot follow tight regulation protocol due to my schedule, so I have been trying to follow the general guidelines section in the link provided by Julia & Bandit. I've been rotating injection sites too.

3. Most days it is impossible for me to get daily mid-cycle numbers in the daytime - I work over 40 minutes away from home. There is no one else to help. While I am on vacation right now (and on weekends) I am trying to get mid-cycle numbers as often as possible. If you look at the times I was able to get any in-between numbers on my spreadsheet since the diagnosis, you'll see that they are rarely a great deal lower than the pre-shot numbers. There is no doubt in my mind that EQ's numbers have ever dropped below 200 at any given time in a cycle. But I will start setting an alarm for the middle of the night to get numbers then as well.

4. I have driven myself crazy wondering if I did something to render the Lantus ineffective in the beginning, but I don't think so. I'm pretty careful with it. But then again, it's my first bottle. I did ask a couple of the pharmacies if they could order the pen refills for me and they all said no. The cheapest pharmacy only sells the pens in packs of 5 for over $200, and will not break them up to sell individually.

Question - if I do get a new bottle of Lantus, and the old one is ineffective (how would I even know?), by how much should I drop the first few doses to ensure we don't have a hypo episode?

We'll be headed to the vet this week to test for infection (urine or dental, although he just had quite a bit of dental work and cleaning done in January). Thank you to hmjohnston for the link to your acrocat page. I will ask about Acromegaly and IAA testing as well.
Click to expand...
1. you can feed the fancy feast again if you like.
2. you don't need to rotate injection sites.
3. you don't need to go crazy on the testing, setting alarms, etc. Most people are away from home, working Monday - Friday or some sort of schedule, and they cannot do all sorts of testing, so just do what you can.
Test before am shot, then before pm shot, and finally, get a before bed test. Those are the 3 most important daily tests.
Then on the weekends or some day off, you can do a variation of a curve, say test every 2 hrs between 2 shots.... a couple curves on a weekend should be more than enough to give you an idea how the dose is working.
Don't worry about TR if you think it's multiple tests 24/7; just test when you can, OK?
4. I think in the US, you need to have your vet write your rx to say vial or pens or cartridges; you may have been told no to the refills as your rx is for vials/bottles. Ask your vet for an rx for pens because in the long run, pens will be cheaper for you. Also, if the bottle is bad, that's alot of money wasted but if it's just one bad pen, you are out 3ml instead of 10ml, and you can just crack open a new pen.

It looks like your trial to drop down by 1u to 5u did not go over too well. I hope you get some results from the AB and also the b/w results. I guess you will go back up to the 6u and hold till you see how the numbers settle.
 
I think the vet is on the right track. Our other cat Bailey also is diabetic (see my profile although I dont have an SS for him), he had an ear infection which we treated and his BG got a lot better. He has bad teeth too and we and the vet reckon that the once we fix those and any infection, it should make the BG any better. Our vet says he finds you can usually drop insulin by 1IU if not more, after a dental.

Also I agree on the wet food, I wonder about it being so low carb - I wonder if you can go too much the other way ie too low.. but dont quote me on that. Most people here seem to feed Wellness which I have switched Tiggy too now although he gets some of the low carb fancy feasts too (cheap!).

Lastly, I wonder if he has high numbers because he bounced down at some point around 8pm last night.. cos he shot up quite fast after that. Are you still on vacation this week? Can you test tonite at say 7.30pm (+2) and 9.30pm (+4)? Be interesting to see where he goes from here...
 
Thank you Blue & Wendy. I can't tell you how appreciative I am for your feedback

No, the trial lowering by one unit did not go well. The vet said there's no need to raise back to 6u until we're done with the course of antibiotics, but... I'm going to be watching those 400s like a hawk.

I am on vacation the rest of the week, thank goodness. If this was happening while I had to work, I'm not sure how well I'd handle it.

I just did a +2 test, and it's only dropped by 5 points. Will test again at +4 and add to the spreadsheet if I'm not on the forum then.
 
interesting.. Keep testing when you can. AMPS, +6 and PMPS is good. +6 tends to be the nadir, and its that which they base dose changes on here. Hard to do when you are working during the day but maybe you can also do one right before bed (someone else suggested) which will get you closer to that +6 time.

If you see a yellow number pop up ( you seem to get one every few days) I would test 2 hours after that to see if it drops down further or if it goes back up. If it drops down, I would test again in a few more hours.

We are looking to see how low he could be getting.
 
SHK said:
Thank you Blue & Wendy. I can't tell you how appreciative I am for your feedback

No, the trial lowering by one unit did not go well. The vet said there's no need to raise back to 6u until we're done with the course of antibiotics, but... I'm going to be watching those 400s like a hawk.

I am on vacation the rest of the week, thank goodness. If this was happening while I had to work, I'm not sure how well I'd handle it.

I just did a +2 test, and it's only dropped by 5 points. Will test again at +4 and add to the spreadsheet if I'm not on the forum then.
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I think you want to increase the dose while EQs numbers are high and he is on AB for a possible infection.
If the AB do start to work on some infection, you will see a drop in the BG numbers. There is no need for EQ to be up in the high 300s and 400s while the AB take effect. For all you know, there is no infection, and after a week, you will still have the high numbers.
Better to raise the dose now because you are aiming to get under 240 and you are nowhere near that number.

Those 400s are too hard on the body; go back to 6u or at least 5.5u.

ETA: Because you will be around to watch the numbers, it would be better if you go back to the 6u dose and you can always lower if you see the numbers improve later in the week.
 
Well, he's on the upswing. :( +4 number is 418. I'll be shooting at 5.5 or 6u tomorrow morning, most likely.
 
Really it's more kinda flat, 410-418 is all in the range of error of the meter. I wonderif it's somogyi. Some people of this forum don't believe in it, but somogyi in theory is a big drop followed by high flat numbers which can last for 3 days. We will see what happens! He was at the vet today too so that could have affected today's numbers though as well . Anyway i agree with Blue i think take him back to 6 again and see what happens, and keep measuring!
 
RE: somogyi:


You will also see high numbers and sudden drops low in cats positive for IAA.
I have not heard of true examples of somogyi, using Lantus, I don't see it.

ETA:
http://www.tillydiabetes.net/en_6_protocol2.htm

Be aware that experimental studies in human diabetics over the last 15-20 have rejected the existence of the Somogyi effect (sometimes also called rebound). In cats, no studies have ever been done which properly demonstrate that such a phenomenon exists. Therefore, adjust the dose as described above, focusing on the nadir: don't do so-called rebound checks, as they only lead to unnecessary (and unhealthy!) hyperglycemia.
 
I'm so thankful that you're sticking with us, Wendy & Blue. EQ and I appreciate it greatly! I feel less hopeless, and that's a big step up. Hugs!

Very interesting about the Somogyi. I'm hoping he's not IAA. As far as I know, EQ hasn't had any low drops yet (of course I can't test every hour, but I've never seen him with symptoms of hypo, except yesterday and that turned out to be hyper). The vet didn't seem to think the IAA test was necessary until we finish the course of antibiotics and get the bloodwork back for the other tests. I hope the antibiotics do the trick and we don't get any more bad news with the bloodwork. Wish us luck!

I had plans to wake up at midnight and test, but I slept through the alarm. We had a 384 pre-shot this morning. A little better. I bumped him to 5.5; I have to be away from home part of the morning, and will take him to 6 tonight while I am home.
 
When you get your blood work please pay attention to the electrolytes like potassium. The episode you had last night, the lethargy that was difficult to wake but BG was high. Low potassium can be caused by too much insulin. I'd also want to check on ketones, do you have ketone urine sticks? The vet hopefully checked that too.

Also curious about that thyroid level the vet checked. Hyperthyroidism can cause slight heart murmurs.

Regarding insulin, I would ask the vet for a script for the pens, written "Five 3ml Solarstar Lantus pens"

In the States you can't get cartridge refills, actually I'm not sure Lantus has them in Canada anymore either. If you get the script for the pens, at a local pharmacy it could be expensive, but you can purchase through Canadian drugstores online or if you are really pressed for cash, perhaps others on FDMB may want to buy a pen or two off of you when you get your order. Even if you bought them locally, they would be cheaper than the vial in the long run because you can usually use the pen til the end whereas with the vial you often end up tossing it before it's finished.

As for how to tell if Lantus is bad, the only time I've ever come across a bad vial of Lantus it smelled like lobster. The bottle was in bad shape and the odor was unmistakable.

I'm not a lantus expert or vet, this is simply my personal experience.
 
All of us know how hard it is, our cat is not feeling well, looking lousy, and those numbers we got are horrible.
But that's in the beginning, when we are getting used to what needs to be done, and our cat is adjusting to changes in the body.

Watch for changes in EQ first.... you will start to see those glimpses of EQ feeling better and more like before. Less urine, weight loss stopped, coat improvements, all the small little signs that will let you know your efforts are making a difference. Sure, the numbers take some time for some cats, and you won't see much of a change until you are around EQs good dose, but just keep at it. EQ is better than before you started.

Look to EQ for progress in his recovery, and the numbers will happen in time.
 
Too many 400s to be comfortable with yesterday, but no 400s yet today. Talked with the vet, still waiting on urinalysis. Added Cowboy Cookout to current food for a little more protein. Day 3 on Baytril and acidophilus - no diarrhea yet (cross your fingers!).

Picking up a SoloStar pen tomorrow; Walmart sells them by the pen instead of making you buy the pack of five. Will see if a new batch of insulin has an effect.

Thanks again!
 
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