? Simon update re Toujeo - advice please

[Yvonne & Simon]

Thanks all for your advice regarding my cat Simon who had been prescribed Toujeo insulin by my vet.

After struggling with trying to stabilize his BGs with this for a week, I just was not comfortable in what I was seeing. At one unit of the Toujeo, his BG would gradually increase through the next 12 hr period into the 20's (360 in US mg/dL).

At 2 units, although he never went low, I felt that his BGs were dropping too quickly and that I could not trust continuing to give this dose to him when his BGs went from 22 (400) to 12 (216) a couple times overnight. And on one day from 17 (311) to 7 (149).

My feeling was that one unit of insulin was not enough but that 2 was too much. So ultimately, I wonder if he only seems to need about 1 1/2 U?. However, as several of you pointed out, this Toujeo insulin cannot be titrated in that fashion because you are limited to the full one unit increments administered by the special pen it comes in.

I talked to my vet today, and explained what was happening, and she agreed with my observations and my suggestion that we change to Lantus so we have a bit more control and ability to provide smaller dose increments.

Because his BG was 21.2 (378) tonight, I elected to give him 2 units of the Toujeo as his PM dose. If he holds to his previous pattern, this should drop him to about 12 (200) by morning (fingers crossed!).

FWIW, I decided to continue on with the Toujeo for tonight, since I feel I at least have an idea of what it will do. Didn't think that making a change to a new insulin for the PM dose would be a good idea. So plan to make the change to Lantus tomorrow morning.

Since the number of units of Toujeo and Lantus are supposed to be equivalent, I am planning to give him 1 1/2 U of the Lantus tomorrow morning, assuming his BG are in about the 12 (200) range. Does this sound like a reasonable plan?

I have updated his spreadsheet. Also added comments. Am embarrassed to admit, I didn't actually see that column until tonight!

 

[Bron and Sheba (GA)]

Hi Yvonne,
I see you have said Simon was lethargic today and vomited. Have you tested for ketones at all?
If not I think it would be a good idea to do so as he is unregulated and has the lethargy and the one vomit.
You will need a bottle of Ketostix which you can buy at any pharmacy. Then you need to collect a urine sample and test it for ketones. Follow the directs on the bottle. Anything above a trace is of concern so let the vet know.

I think it is a very good idea to swap to Lantus. You will have more flexibility with the doses.
You could start at 1 unit or 1.5 units. It will take 6 cycles at least for the depot to fill and for you to see the full effect of the dose. Stay with the dose for at least 5 days in the beginning unless he drops under 90 (for SLGS) or 50 (for TR).

 

[Diane Tyler's Mom GA]

Glad you are switching to Lantus, in your signature could you also add switched to Lantus and the date.
Also on you SS for this mornings AMPS you have 21.4 in the US sheet could you please put in the correct BG. Thanks . I think you will like Lantus
Did you get the the U-100 syringes with the half unit markings?

 

[Yvonne & Simon]

Hi Yvonne,
I see you have said Simon was lethargic today and vomited. Have you tested for ketones at all?
If not I think it would be a good idea to do so as he is unregulated and has the lethargy and the one vomit.
You will need a bottle of Ketostix which you can buy at any pharmacy. Then you need to collect a urine sample and test it for ketones. Follow the directs on the bottle. Anything above a trace is of concern so let the vet know.

I think it is a very good idea to swap to Lantus. You will have more flexibility with the doses.
You could start at 1 unit or 1.5 units. It will take 6 cycles at least for the depot to fill and for you to see the full effect of the dose. Stay with the dose for at least 5 days in the beginning unless he drops under 90 (for SLGS) or 50 (for TR).

Thanks for your help. Good thought about checking for ketones. I'll have to get some strips.

I think that his vomiting is more than likely due to his IBD (with associated history of vomiting) which is what landed us in this whole pickle in the first place. He was started on Budesonide in January which was just enough steroid to make him hyperglycemic. It has since been stopped, but my vet has warned me that his vomiting will likely start up again, in which case we'll have to explore treatment options for the IBD.

So far, I am happy with the Lantus and feel very relieved that we've changed him to that. The Toujeo just wasn't working for him at all.

 

[Yvonne & Simon]

Glad you are switching to Lantus, in your signature could you also add switched to Lantus and the date.
Also on you SS for this mornings AMPS you have 21.4 in the US sheet could you please put in the correct BG. Thanks . I think you will like Lantus
Did you get the the U-100 syringes with the half unit markings?

Hi Diane. Thanks for your assistance.
I have changed my signature to reflect the changes. Thanks for the reminder. I have also fixed the SS and made all of the additions for today. Have also added his labwork to it too.

I feel quite relieved now we have him on the Lantus, and am already very pleased at how his BGs are reacting. There is a much more consistent trend and decrease of them now.

I am using the 3/10th mL insulin syringes with the 1/2 unit markings. Luckily I just happened to have them on hand as we use them for our horse breeding business (needed for processing semen for shipping). I am a bit surprised as I actually find them easier to inject with and to get the fur out of the way, as I can see right where it goes in, as opposed to with the pen which obscures the injection site.

I have purchased the 3 ml Lantus cartridges and am using one of them as a vial (also have the pen for it as well).
Question about their use. Unlike with a vial where one injects the same volume of air as liquid to be withdrawn to equalize the pressure in the vial, I am not doing this as I imagine there should not be any air injected into a pen cartridge. Does this sound correct?

 

[Bron and Sheba (GA)]

Thanks for your help. Good thought about checking for ketones. I'll have to get some strips.

I think that his vomiting is more than likely due to his IBD (with associated history of vomiting) which is what landed us in this whole pickle in the first place. He was started on Budesonide in January which was just enough steroid to make him hyperglycemic. It has since been stopped, but my vet has warned me that his vomiting will likely start up again, in which case we'll have to explore treatment options for the IBD.

So far, I am happy with the Lantus and feel very relieved that we've changed him to that. The Toujeo just wasn't working for him at all.

Have you tried Slippery Elm Bark Powder for the vomiting?

 

[Diane Tyler's Mom GA]

Hi Diane. Thanks for your assistance.
I have changed my signature to reflect the changes. Thanks for the reminder. I have also fixed the SS and made all of the additions for today. Have also added his labwork to it too.

I feel quite relieved now we have him on the Lantus, and am already very pleased at how his BGs are reacting. There is a much more consistent trend and decrease of them now.

I am using the 3/10th mL insulin syringes with the 1/2 unit markings. Luckily I just happened to have them on hand as we use them for our horse breeding business (needed for processing semen for shipping). I am a bit surprised as I actually find them easier to inject with and to get the fur out of the way, as I can see right where it goes in, as opposed to with the pen which obscures the injection site.

I have purchased the 3 ml Lantus cartridges and am using one of them as a vial (also have the pen for it as well).
Question about their use. Unlike with a vial where one injects the same volume of air as liquid to be withdrawn to equalize the pressure in the vial, I am not doing this as I imagine there should not be any air injected into a pen cartridge. Does this sound correct?

With using the lantus pens, I just draw up the dose needed, I have never seen any air bubbles, After drawing what I need I will just
Give the syringe a couple of flicks with my finger

 

[Diane Tyler's Mom GA]

https://felinediabetes.com/FDMB/thr...-low-go-slow-slgs-tight-regulation-tr.210110/

Have you decided which method you will be doing
Here is the link about it
If you are not sure about anything you know you can always ask or tag someone

 

[Wendy&Neko]

Good luck with the Lantus. The method for drawing from cartridges is slightly different. You are correct that you don't need to inject air. More details and a video in this post:
Insulin Care & Syringe Info: Proper Handling, Drawing, Fine Dosing We've also seen people say their cats are happier with syringes than pens - you also don't need to hold them in there.

Just a FYI, my girl went on budesonide for her GI inflammation, and it made no difference to her blood sugars. Each cat is different though.

 

[Diane Tyler's Mom GA]

Good luck with the Lantus. The method for drawing from cartridges is slightly different. You are correct that you don't need to inject air. More details and a video in this post:
Insulin Care & Syringe Info: Proper Handling, Drawing, Fine Dosing We've also seen people say their cats are happier with syringes than pens - you also don't need to hold them in there.

Just a FYI, my girl went on budesonide for her GI inflammation, and it made no difference to her blood sugars. Each cat is different though.

Thanks @Wendy&Neko I really didn't understand her question about the air

 

[Yvonne & Simon]

https://felinediabetes.com/FDMB/thr...-low-go-slow-slgs-tight-regulation-tr.210110/

Have you decided which method you will be doing
Here is the link about it
If you are not sure about anything you know you can always ask or tag someone

Hi Diane
I have read over both protocols but I haven't decided what method to try. Frankly, he has been so all over the place, I am just trying to keep my head above water. It is all so much to take in!
He is so labile right now, I am just trying to get his sugars down, but to keep him safe. I am really worried about making him hypoglycemic.

He has had a huge drop in his BS today, and I am wondering if I am now dealing with the effects of the steroids having cleared his system. I have put an emergent post up, requesting dosing advice for tonight actually.
Argh!

 

[Yvonne & Simon]

Good luck with the Lantus. The method for drawing from cartridges is slightly different. You are correct that you don't need to inject air. More details and a video in this post:
Insulin Care & Syringe Info: Proper Handling, Drawing, Fine Dosing We've also seen people say their cats are happier with syringes than pens - you also don't need to hold them in there.

Just a FYI, my girl went on budesonide for her GI inflammation, and it made no difference to her blood sugars. Each cat is different though.

My vets were quite mystified, and understandably very disappointed about his becoming so hyperglycemic on the Budesonide. She (the cat specialist) weighed the pros/cons very carefully before starting him on it. He had one episode of stress induced hyperglycemia 2 yrs ago where his BS was checked during an office visit and was found to be 33 (594). I monitored him very carefully after that, and they came down on their own after three days. And have been normal since.
However this made me very cognizant of the fact that he was likely pre-diabetic so needed to be monitored carefully. I have been checking his BS monthly since then. All normal.

He responded really well to the Budesonide and his vomiting stopped on it. He was only on the full dose of it for 5 weeks. By the fifth week was acting overtly diabetic.
As I understand, if his intestines were quite inflamed, they may have been quite "leaky" allowing the Budesonide to go systemically. Very disappointing as otherwise he did well on it.
So once we get this BS thing under control, we'll have to go back to the drawing board and figure out how to deal with the IBD thing. She wants to try chlorambucil next but I am worried about it's anorexic effect as he is a super fussy and rather poor eater.