Saoirse's Spreadsheet - Feedback Requested

Status
Not open for further replies.
Critter Mom

Critter Mom

Member Since 2014
Hi all,

Saoirse and I have been going through a challenging time since I last posted.

Saoirse's now completely on low carb food. It was a real struggle at times to get her to eat during the (somewhat abrupt) transition from that infernal w/d Dry, and the hot weather here really isn't helping her appetite, but it has been worth it. There was an immediate and dramatic improvement in Saoirse's numbers and they have continued to improve. She still needs coaxing (and a sprinkle of Fortiflora sometimes).

Saoirse's Caninsulin dose is down from 3 IU BID to 0.5 IU BID. I transitioned her initially onto Purina DM canned while I hunted around for something to help her digestive system. I started Saoirse on Bozita Sensitive Diet & Stomach formula on 22 July and her numbers have improved further. Also, her abdomen is much more svelte now. Her coat started shedding like crazy but now it's starting to shine again.

I'm delighted at the improvement in Saoirse's numbers, but also getting increasingly nervous about the unpredictable magnitude and variation in post-dose BG level drops on Caninsulin. Her nibs dropped to 3.9mmol/L (70mg/dL) at nadir today (thankfully without the hangover effects she suffered after the two earlier very, very steep drops). At PS this evening, her BG was only 8.7. She also vomited up a hairball just before her insulin dose was due (thanks to the most enthusiastic bouts of grooming she has exhibited in a good while). I spoke to the vet and we agreed that it was OK to withhold tonight's dose and check her BG again in the morning.

I've finally got Saoirse's spreadsheet done (link in signature). I'd be very grateful for comments on how Saoirse's doing so far. Any advice about dosing of Caninsulin when numbers get lower would be extremely welcome, particularly as there can be such wide variations in the drops from peak to nadir.
 
You'll want to update your signature to adjust the note on insulin dose, or omit it since it can fluctuate.

Since Caninsulin (aka Vetsulin) is a U-40 insulin, you may find it useful to use a U-100 syringe for dosing, with a conversion factor. The difference between the insulins is the concentration of units per mL. A U-40 insulin has 40 per mL vs a U-100 which has 100 units per mL, so its 40% as concentrated. To convert the U-100 syringe marks to the U-40 dose, you just multiply by 0.4.
Syringe mark * 0.4 = U-40 dose
0.5 * 0.4 = 0.2 units
1.0 * 0.4 = 0.4 units
1.5 * 0.4 = 0.6 units
2.0 * 0.4 = 0.8 units
2.5 * 0.4 = 1.0 units
 
Are you still using the AlphaTrak meter?

If you are, that 70 is really close the the line where we'd suggest reducing even further, so BJM's suggestion of using the u100 syringes and converting is probably going to help you out

If you're using the AlphaTrak, please put it in big bold letters in your Signature (I'd even make it a different color so it really stands out) It's important that we know which meter you're using
 
Thanks to you both for replying.

I'm using the Alphatrak 2 glucometer. I did put the insulin and meter types in the cell at the top of the 'Notes' column in Saoirse's spreadsheet, but didn't think to put it in my signature. I've updated my signature with both suggested changes.

I get the idea of using conversion charts in principle but never having seen a U100 syringe before my brain is struggling to accept the logic. How do the U100 syringes differ from U40 syringes physically?
 
The difference between U-100 and U-40 syringes is the number of units marked per mL.
This matches the insulin concentrations of 100 units vs 40 units per mL.

If you remember from math class, to get the X% of something, you can multiply the whole thing times the percentage.
Ex 40/100 * $1.00 = $0.40.
 
Hi Aine,

I would actually suggest that you reduce the dose a smidge, because there is little margin for error at the moment, and you are seeing an improving picture for Saorise: Her insulin needs are consistently decreasing. And Caninsulin can drop fast.

U100 syringes are quite different to the Caninsulin syringes. I use .3ml U100 syringes and compared to the Caninsulin U40 syringes they seem lighter, smaller (very narrow barrel by comparison to the U40's), and you will probably find that the needle is finer.

As BJ said, Caninsulin has 40 units of insulin per ml. In a U100 syringe you would find that one unit of Caninsulin looked much 'longer and skinnier' than would be the case in a U40 syringe. The markings are more finely calibrated. And this would enable you to measure small doses more easily as long as you are using the correct conversion. There is a chart here that you can print off: http://www.felinediabetes.com/insulin-conversions.htm

If you put one unit of U40 Caninsulin into a U100 syringe it would show a measurement on that long skinny barrel of 2.5 units (though of course it would still be one unit of Caninsulin, because Caninsulin is more dilute).
If you wanted to measure, say, .2 of a unit of Caninsulin it would show as .5 in a U100 syringe. Measuring .2 of a unit of Caninsulin in a U40 syringe is difficult to do. But measuring .2 of a unit of Caninsulin in a U100 syringe is easy peasy!

Would you like me to send you some U100 syringes to play with...? I can pop some in the post to you so you can see the difference. Just PM me if you're interested....

@BJ, the only thing I remember from my maths class was staring out of the window and watching the 6th form boys playing football (soccer) outside in the field. Utterly mesmerising. (Hormones, eh..?) :oops:

Eliz
 
Thanks to you both for the additional info. I am cool with the maths side of it (always good at maths - no sixth form boys to distract me :shock: ), it's just the physical syringe thang that my brain was struggling with. Eliz, your description of the U100 syringes was really helpful. :-D

Our main vet called today to discuss how Saoirse is doing and he's really pleased with her progress. He commented on how valuable the regular home testing has been in aiding Saoirse's treatment. I've asked him about the U100 syringes and although it is not something they normally do at the practice he's happy to support me in switching to the different syringes in order to manage Saoirse's decreasing insulin requirements. I was sad to leave our old practice, but I'm thrilled that our new vet is in our corner and so on board with supporting me in making good decisions about Saoirse's treatment.

As you say, Eliz, the Caninsulin drops are a major problem now. Saoirse has developed a pattern of looking for food anywhere from +1.5 in every cycle now: I assume that this is the Caninsulin kicking in. It is getting harder and harder to know if it's safe to give her the dose. This morning she was at 11.1 AMPS with a nadir of 4.5 at +3. She's eating better since the weather cooled a little, but there's no guarantee of how big or small a drop will come from any particular dose. Oh, for a gentler insulin...

Eliz, thank you for the link to the conversion chart and your kind offer of some U100 syringes to trial. Will drop you a PM.
 
Critter Mom said:
...Oh, for a gentler insulin...
Click to expand...
Aine,
Is there any chance your vet would prescribe you a gentler insulin because of those steep BG drops..? (Hypurin PZI, Lantus or Levemir....?) UK vets vary enormously in their attitudes to prescribing alternative insulins, but many will prescribe alternatives under the 'cascade system' rules.

Eliz
 
Hi Eliz,

I've made tentative enquiries about whether Saoirse could be prescribed a different insulin. Unfortunately her main vet was on holiday at the time. The vet I asked said that they only prescribed a different insulin if the Caninsulin didn't work. I asked why and he said that Caninsulin was regarded as the safest insulin.

I'm caught between a rock and a hard place at the moment in that Saoirse is responding to the Caninsulin, but it is no longer the "safest" option for her because of the drops. I think her pancreas still needs support, but the Caninsulin is just too harsh (and it shows in her bearing: she's not as perky when it is acting on her system). Also, I think I home test much more than other clients so her numbers support the effectiveness of Caninsulin therapy but I don't think the vets are placing enough emphasis on the steepness of some of the BG drops in judging whether or not it is the right insulin for her. One of the nurses told me that many of their clients with diabetic pets don't home test at all so they may not be used to working with a barrage of data such as I'm able to give. The current practice view could well be that Caninsulin is working extremely well for Saoirse (in that her BG is within regulation thresholds most of the time) and that I have no grounds for requesting a change to a gentler insulin.

Is there anywhere that you recommend where I could find out more about the cascade system so that I might be able to build a case for switching Saoirse to a gentler insulin that I could then discuss with our vet?
 
Does your country require a prescription to get insulin for humans?

If no, is Lantus or Levemir available? Either of those are very gentle in onset.
 
Hi BJM,

To the best of my knowledge, human insulin requires an Rx in the UK. Viovet UK sell Lantus, Hypurin and PZI insulins (you need to phone them about the latter) but they all need an Rx from the treating vet.
 
Another dicey BG drop today with less than 0.5 IU Caninsulin: 10.5 AMPS down to nadir of 3.8 at +3 (on Alphatrak 2).

I've got some 0.3ml 100 IU syringes on the way. Hopefully they will be here tomorrow, but I think they're only going to be a stop-gap.

I consulted with my vet again this evening, and we agreed it was best to skip Saoirse's PM dose this evening on safety grounds. He agrees that the huge drops are a major problem going forward. Given that Saoirse has responded well to Caninsulin and her new diet, he is going to explore avenues to get a more dilute formulation of Caninsulin for her in order to edge her closer towards possible remission on the "known quantity" rather than switching insulin type when it might not be necessary, and when her response to a new insulin might not be as good. If that doesn't work out, he will look at prescribing a different insulin.

I am so pleased I took the plunge and sought out a different vet. I could not be happier with the support our new vet is giving Saoirse and myself. :-D
 
Hi Aine,

Critter Mom said:
he [the vet] is going to explore avenues to get a more dilute formulation of Caninsulin for her...
Click to expand...
My understanding is that Caninsulin/Vetsulin dilution is inadvisable. The following extract is from Caninsulin FAQ's:

"Can Caninsulin be diluted?
Caninsulin is a mixture of amorphous (soluble) insulin and crystalline insulin. The crystalline part is relatively insoluble which is why the insulin activity lasts more than a few hours. Caninsulin has a balance between the amorphous and crystalline parts. If Caninsulin is diluted, this may result in an alteration of the characteristics of the product (pharmacokinetics and Pharmacodynamics) in the animal. In addition, the stability of the new suspension is unknown. Dilution of Caninsulin would constitute off label (extra label) use."
http://www.caninsulin.com/faq-answers-p.asp

And this is from the Vetsulin FAQ's:
"Can Vetsulin be diluted?
No. Vetsulin is a mixture of amorphous (soluble) insulin and crystalline insulin. The crystalline part is relatively insoluble which is why the insulin activity lasts more than a few hours. Vetsulin has a balance between the amorphous and crystalline parts. If Vetsulin is diluted, the balance between amorphous and crystalline parts is no longer 30% and 70%, relatively speaking. The amount of soluble insulin is increased by the aqueous diluent used. This results in an alteration of the pharmacokinetics of Vetsulin. With a larger aqueous fraction and smaller crystalline fraction, there would be a decrease in the crystalline portion responsible for the second peak of insulin activity.
In addition the stability of the suspension is unknown if Vetsulin is diluted. The Vetsulin suspension is optimized to maintain the crystalline portion as a salt. If the water content is increased as with dilution, the solution "looks for a new balance" i.e. it is not stable and the dissolved fraction increases with time."
http://web.archive.org/web/200801200948 ... AQs.html#8

Critter Mom said:
...If that doesn't work out, he will look at prescribing a different insulin.
Click to expand...
That is excellent news that he is willing to do that.
We've had quite a few UK folks here switch from Caninsulin because of the steep drops they've been getting with it (and/or short duration). One member switched from Cansinsulin to Hypurin PZI because of repeated hypos with the Caninsulin.
The longer lasting insulins, Hypurin PZI, Lantus and Levemir, are thought of as 'gentler' because they tend not to give steep BG drops (I expect there are exceptions, as with everything). They are also longer lasting insulins and work on overlap.

Quite a few vets in the UK prescribe Hypurin PZI. That's because there used to be a veterinary PZI and so a lot of vets are familiar with the use of PZI insulins. Some vets favour Lantus. And a few favour Levemir. We see folks on all of those insulins here. Each of the insulins has differing properties/characteristics.

I'm wondering if your vet is unfamiliar with prescribing alternative insulins..? (This varies hugely from vet to vet.)
The alternative will be prescribed under the 'cascade system' rules. And I think it only means that your vet will have to fill out a small form stating why the Caninsulin wasn't suitable, and saying what will be prescribed instead.
The vet can order the insulin in for you or can give you a prescription so that you can get the insulin from a pharmacy (these are 'human' insulins). If you get it from a pharmacy then VAT is payable on medicines for veterinary use. Some folks still find it much cheaper to get insulin from pharmacies than from their vet. (But I get mine from my vet because I know I can be a bit of a PIA at times and want to support him where possible! :lol: )

Another insulin option that your vet might be able to consider is Prozinc. I say "might" because it's not being generally prescribed at the moment in the UK (although it is licensed for use here now). The Royal Veterinary College are doing a remission study at the moment and are trialling Lantus and Prozinc. Prozinc is an insulin from the US that is made for cats. It may be worth your vet giving the RVC a call to find out about availability...

Keeping fingers and paws crossed that things continue to improve for Saoirse!

Eliz
 
Hi Eliz,

Thank you so much for all that background information. You're an absolute topper! I have to email him over her recent BG test results. I think I might send him a copy of the links you posted about the problems associated with trying diluting Caninsulin.

My vet is familiar with prescribing other insulins. He said that they used to use more cat-centric prescriptions before the regulations changed to make Caninsulin the first insulin that should be prescribed.

My BD U100 Demi 0.3ml syringes arrived today. Still in a quandary about whether or not to give her a token dose tonight. Poor wee thing is not in anything like the good form she was in yesterday, even though her levels are relatively low (8.0 / 144 at +29.75, down from 8.8 / 158 at +24). She ate ok last night and early morning, but her appetite is very low today: she's only eaten about 46g of food since her scheduled dose time. Normally, she would have eaten at least 1½ times that by this hour of the day.

What to do next??? Is there anywhere on the FDMB where there is a Characteresitics Comparison / Pro-Con list for different insulin types, perchance? I'd find that very helpful right now.
 
Thanks for the pointer, Deb. I'm finding it very helpful. And there are lots of great links from Michelangelo's page as well. :smile:
 
Status
Not open for further replies.
Back
Top