Switching insulin - Is my Vet doing it right?

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Lacy

Lacy

Member Since 2020
Hi everyone. Saff was previously on Lantus (Glargine) with no luck. Her numbers stayed high consistently no matter what the dosage. We had gradually increased all the way up to 5 or 6 units twice a day. Her weight improved on Lantus, but she was still starving and drinking excessively all the time. The Vet decided not to increase anymore and switch her to Vetsulin. She is currently on 4.5 units twice a day.

What I'm seeing now is exactly what y'all said would happen with Vetsulin. I'm seeing her numbers drop to a normal range midway through the cycle, then spike up before her next dose because the insulin just isn't staying in her system for a full 12 hours.

- It's important for me to note that I believe the Lantus didn't work because we still had her on Purina DM 10% carbs. It wasn't until I switched her to foods 3% or under that I saw any improvements and this was after her switch to Vetsulin. With that said, I cannot say for certain that she would respond better to Lantus now with the diet change or if she just responds better to Vetsulin when it's in her system -

When the Vet made the insulin switch, she had us stop all insulin for 3 days before starting Vetsulin at 1 unit twice a day. Saff really struggled during those 3 days and in the beginning low dose of Vetsulin. My question is if it is necessary to have that 3 day break? Her numbers skyrocketed and she was having many accidents around the house. I know she needs to switch to a longer lasting insulin, so what do you recommend in terms of how to make that switch?
 
I also wonder how fast you were increasing on Lantus and by how much. Were you going up at .25 increments as we recommend here or by 1 unit per vet’s orders? It’s possible to pass right through the ideal dose if it’s the latter. I think most experienced members here would suggest you start the new insulin at 1 unit and increase gradually from there. Starting high gives you almost no place to go and sometimes cats need less insulin not more.
 
Well I'm no expert but thats a new on on me. Keeping ANY diabetic away from insulin is dangerous. 3 days is an incredibly long time for a kitty cat. wth? Even if its a switch of insulin type. That said I'm no insulin guru.
sigh I dont understand your vets logic. :confused:o_O:facepalm:
 
Some questions, Lacy:

1. Are the vet readings the only ones that were done for Saff when she was on Lantus?

2. What dose of Lantus did the vet prescribe when Saff first started treatment on Lantus?

3. Do you have a history of the adjustments made to Saff's Lantus dose while she was on it, along with the dates those adjustments were made?

4. What was the size of the final Lantus dose Saff was receiving before she ceased treatment with that insulin?

(Sorry if I've got anything wrong but from your spreadsheet it looks like you had not yet started home testing during the time when Saff was receiving Lantus.)

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Re the gap between ceasing Lantus treatment and starting Vetsulin, Lantus is a depot insulin so there would still have been some of it in Saff's system for a while after stopping it. The vet was taking that into account when the switch was made as giving Vetsulin in addition to the remaining Lantus in the depot might have taken Saff too low.

It's impossible to comment on whether so long a delay was necessary because there's no visibility in Saff's spreadsheet of her Lantus dosing or her BG levels just before treatment was stopped.

A better approach might have been to run a full curve on Saff before ceasing the Lantus and determining a possible token dose of the Vetsulin to tide her over. You should also have been advised to monitor Saff for ketones during that period.

If only those mid-cycle tests were considered during Saff's Lantus treatment it is possible that she just wasn't receiving the correct dose. For a start, all those vet office readings were very likely to have been temporarily elevated due to stress. If that was the case, then the vet may have been prescribing too high a dose of Lantus. (Too much insulin can result in numbers being driven higher.)

As you have already observed, Vetsulin has notoriously short duration of effect in cats. It may be possible that Lantus wasn't being dosed correctly, it may be that Saff just didn't get on with it. Should it turn out that the latter be the case, there are other, longer-acting insulins that might be better to try than Vetsulin.


Mogs
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Critter Mom said:
Some questions, Lacy:

1. Are the vet readings the only ones that were done for Saff when she was on Lantus?

2. What dose of Lantus did the vet prescribe when Saff first started treatment on Lantus?

3. Do you have a history of the adjustments made to Saff's Lantus dose while she was on it, along with the dates those adjustments were made?

4. What was the size of the final Lantus dose Saff was receiving before she ceased treatment with that insulin?

(Sorry if I've got anything wrong but from your spreadsheet it looks like you had not yet started home testing during the time when Saff was receiving Lantus.)

-----------------------

Re the gap between ceasing Lantus treatment and starting Vetsulin, Lantus is a depot insulin so there would still have been some of it in Saff's system for a while after stopping it. The vet was taking that into account when the switch was made as giving Vetsulin in addition to the remaining Lantus in the depot might have taken Saff too low.

It's impossible to comment on whether so long a delay was necessary because there's no visibility in Saff's spreadsheet of her Lantus dosing or her BG levels just before treatment was stopped.

A better approach might have been to run a full curve on Saff before ceasing the Lantus and determining a possible token dose of the Vetsulin to tide her over. You should also have been advised to monitor Saff for ketones during that period.

If only those mid-cycle tests were considered during Saff's Lantus treatment it is possible that she just wasn't receiving the correct dose. For a start, all those vet office readings were very likely to have been temporarily elevated due to stress. If that was the case, then the vet may have been prescribing too high a dose of Lantus. (Too much insulin can result in numbers being driven higher.)

As you have already observed, Vetsulin has notoriously short duration of effect in cats. It may be possible that Lantus wasn't being dosed correctly, it may be that Saff just didn't get on with it. Should it turn out that the latter be the case, there are other, longer-acting insulins that might be better to try than Vetsulin.


Mogs
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I do not have the home readings from her time on Lantus. Only the readings from the vet. I did have a Freestyle Libre on her during the Lantus time, but I lost all the data from it. What I do know is that the readings were always over 400 no matter what dose or stage in the cycle.


On the Lantus dosing - my vet started at 1 unit twice a day. She increased her by 1 unit once a day. So for example, Saff started on 1 unit in the morning and 1 unit in the evening. She was then increased the next week to 2 units in the morning and 1 unit in the evening. Then, increased to 2 units morning and evening. This continued until she was on 5 units twice a day. There was never a half or quarter increase. We stopped at 5 units and made the switch to Vetsulin.


I believe my request to the Vet will be to switch back to Lantus, starting with 1 unit twice a day. Then when increases are made, I'll do them by .25 instead of the full units she is suggesting.
 
On the .25 increases when needed, is it recommended to increase the dose by .25 on both cycles? So an increase in the morning and evening doses. The seems to make more sense to me.
 
Lacy said:
She was then increased the next week to 2 units in the morning and 1 unit in the evening. Then, increased to 2 units morning and evening. This continued until she was on 5 units twice a day. There was never a half or quarter increase. We stopped at 5 units and made the switch to Vetsulin.
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There's no way of knowing for certain, but I think the 1 unit dose increases do open up the possibility that a good dose might have been skipped over. In such cases numbers tend to stay high and flat.

The 2 units AM / 1 unit PM lopsided dosing of Lantus won't have helped matters either.

Another general note: if a cat is on too high a dose of one insulin and then makes the switch to another insulin where the starting dose is based on the dose of the first insulin, the cat may actually wind up starting on too high a dose of the new insulin as well.

I'm tagging @tiffmaxee and @Chris & China (GA) to ask them whether they could give their view on what information you have available and to ask them to suggest a safe and effective plan of action for you.

While it is possible that ineffective dosing may have brought you to this point, it must also be noted that some cats have 'high dose' conditions and there's the possibility that Saff might be a cat that needs more insulin.

In the absence of BG data, all we can fall back on as a guide for Saff's time on Lantus is to look at her clinical signs. Was there ever a time when Saff seemed to feel and act better during the period she was on Lantus? For example, was there a time when there might have been any subtle changes after a particular dose change when she:

* started drinking less water / peeing less?
* started drinking more and peeing more?
* had better/poorer bladder control?
* had an appetite more like that of a non-diabetic cat?
* started to regularly show signs of getting hungrier?
* started regaining weight she had lost, or started losing weight after a dose increase?
* started to show improvements/deterioration in coat condition?
* started to be more energetic/lethargic?

I'm trying to help you zone in on whether there were a series of improvements after initial diagnosis and whether at some stage Saff may have started to 'go backwards'. If you could identify such a period and let us know how her Lantus was being dosed at that time, it might give us a better picture to work with.

In the meantime, if you and your vet do reduce the insulin dose, for safety it is vital to test Staff daily for ketones, especially as she seems to be running in such high numbers at the moment. If you don't already have some, you can pick up the ketone test strips anywhere they sell diabetic supplies. Here are some information resources to help you:

Testing Your Cat for Ketones

Tips for Collecting Urine Samples

Keeping fingers and paws crossed that you can get Saff onto an effective dose of the right insulin really soon.


Mogs
.
 
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Lacy said:
On the .25 increases when needed, is it recommended to increase the dose by .25 on both cycles? So an increase in the morning and evening doses. The seems to make more sense to me.
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Lantus works best when it is dosed consistently, i.e. the same dose administered twice a day, 12 hours apart.


Mogs
.
 
Hi. I agree with the others about increasing in 1 unit increments as well as uneven dosing. It can cause a cat to bounce around a lot going from hi to Lo. I’m not sure that 1 unit would be the correct starting dose. It probably will be too low a starting dose. . Would you follow TR with the switch? Are you feeding any dry food? I don’t know if f the Meow Mix is canned or dry.
 
Critter Mom said:
There's no way of knowing for certain, but I think the 1 unit dose increases do open up the possibility that a good dose might have been skipped over. In such cases numbers tend to stay high and flat.

The 2 units AM / 1 unit PM lopsided dosing of Lantus won't have helped matters either.

Another general note: if a cat is on too high a dose of one insulin and then makes the switch to another insulin where the dose is based on the dose of the first insulin, the cat may actually wind up starting on too high a dose of the new insulin as well.

I'm tagging @tiffmaxee and @Chris & China (GA) to ask them whether they could give their view on what information you have available and to ask them to suggest a safe and effective plan of action for you.

While it is possible that ineffective dosing may have brought you to this point, it must also be noted that some cats have 'high dose' conditions and there's the possibility that Saff might be a cat that needs more insulin.

In the absence of BG data, all we can fall back on as a guide for Saff's time on Lantus is to look at her clinical signs. Was there ever a time when Saff seemed to feel and act better during the time she was on Lantus? For example, was there a time while Saff was on Lantus when there might have been any subtle changes after a particular dose change when she:

* started drinking less water / peeing less?
* started drinking more and peeing more?
* had better/poorer bladder control?
* had an appetite more like that of a non-diabetic cat?
* started to regularly show signs of getting hungrier?
* started regaining weight she had lost, or started losing weight after a dose increase?
* started to show improvements/deterioration in coat condition?
* started to be more energetic/lethargic?

I'm trying to help you zone in on whether there were a series of improvements after initial diagnosis and whether at some stage Saff may have started to 'go backwards'. If you could identify such a period and let us know how her Lantus was being dosed at that time, it might give us a better picture to work with.

In the meantime, if you and your vet do reduce the insulin dose, for safety it is vital to test Staff daily for ketones, especially as she seems to be running in such high numbers at the moment. If you don't already have some, you can pick up the ketone test strips anywhere they sell diabetic supplies. Here are some information resources to help you:

Testing Your Cat for Ketones

Tips for Collecting Urine Samples

Keeping fingers and paws crossed that you can get Saff onto an effective dose of the right insulin really soon.


Mogs
.
Click to expand...


The only improvements we saw on Lantus was that she did gain some weight. She looked much healthier, but did not seem to feel better. She continued drinking too much, peeing too much, and was constantly starving. Her numbers were consistently high.

In the switch between Lantus and Vetsulin, she lost weight fast.

On the low doses of Vetsulin, she deteriorated and had little control over her bladder. After we gradually increased to 4.5, she started to improve. She is drinking a little less than before. But not yet normal. She has not gained as much weight as I would like, she is still starving, but does have more energy.

I did a lot of work on getting a diet that I believe is helping. I've seen that with the numbers and her energy levels. I am giving her a little more calories than I usually would based on her ideal weight calculations. Just to help with her appetite and need to gain some weight.
 
No wonder she didn't do well on Lantus, that is the weirdest increase method I've ever heard. :confused:

I would give Lantus another try. Altering the dose between morning and evening cycles AND increasing too fast never gives the depot a chance to stabilize. Lantus craves consistency, from the dose itself to the 12-hour mark.

If Saff is underweight I would not restrict food until she's back to where she needs to be, and that may take a while.
 
Saff's last weigh in was 8.5 lbs two weeks ago and she really should be around 11 lbs to be considered a healthy weight. I'm looking into Levemir now. I still have some Lantus left and I wanted to see how that goes with slower dosing increases.
 
Lacy said:
Saff's last weigh in was 8.5 lbs two weeks ago and she really should be around 11 lbs to be considered a healthy weight. I'm looking into Levemir now. I still have some Lantus left and I wanted to see how that goes with slower dosing increases.
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Just weighed her on my scale and she is currently 8.8 lbs.
 
Lacy said:
Saff's last weigh in was 8.5 lbs two weeks ago and she really should be around 11 lbs to be considered a healthy weight. I'm looking into Levemir now. I still have some Lantus left and I wanted to see how that goes with slower dosing increases.
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Did you ever notice any occasion Saff getting even more hungry during the middle of a cycle when she was on Lantus (really, really ravenous or being exceptionally intense about demanding food)?

Even if it was only an intermittent occurrence it would be helpful to know.


Mogs
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So I see why you were thinking 1.0 unit BUT the dose used on the prior insulin needs to be taken into consideration. It’s going to take time for the depot to build and with high numbers you risk insulin resistance. I need to read more but no way would I think it’s wise to start with 1.0.
 
Critter Mom said:
Did you ever notice any occasion Saff getting even more hungry during the middle of a cycle when she was on Lantus (really, really ravenous or being exceptionally intense about demanding food)?

Even if it was only an intermittent occurrence it would be helpful to know.


Mogs
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Click to expand...

Saff has been consistently ravenous on both Lantus and Vetsulin. We've had to cover the trash can, keep the sink empty at all times, follow behind our kids like vacuum cleaners. She's even licking off the kitchen counter if she can. This has been a constant since her diagnosis.
 
tiffmaxee said:
I think a conservative starting dose would be 2 units.
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I agree that, given the clinical signs and what dose history is available, a 1IU Lantus dose is likely to be a step too far back. If Lacy could start with the 2IU and then follow TR - even if only for the early stages of a 'reset' - it might be the most speedy and effective way to identify a dose that would work better for Saff.


Mogs
.
 
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tiffmaxee said:
How old is your Lantus? When was it opened and what’s the expiration date?
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I will be able to monitor closely. We are home testing now and I will increase my testing times when we switch.

I feel much better about starting her on 2 units. I feel like going back down to 1 would cause her to be really miserable.

Can someone tell me what TR is though. I can't find that meaning.

The Lantus was purchased and used for the first time in March 2020. The expiration is 05/31/2022.
 
TR is tight regulation. The method I suggest you use. The Lantus has been kept in the fridge? It should be fine. Might have lost a tad of potency but not likely.
 
tiffmaxee said:
https://www.felinediabetes.com/FDMB...-low-go-slow-slgs-tight-regulation-tr.210110/

Some reading. When you have time read all the yellow stickies there. Lots to absorb. I’d print out the only on Handling low numbers.
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I just found this sticky. This is great, I would feel most comfortable following this protocol.

The Lantus has been kept in the fridge. I believe there was one or two nights where we forgot to put it back in the fridge, though. I have a call with the Vet this evening to get her sign off on my decision to switch.

Also, just to be certain. It is okay to make an immediate switch? For example, I gave her 4.5 units of Vetsulin this morning at 9:30. Can I go ahead and switch to the Lantus 2 unit does at 9:30pm?
 
Yes BUT some cats have a strong initial response. It’s quieter on the board that late and you do want to test more often at first to catch the nadir which. Ishtar be as late as 6 hours after injecting. I would start in tge morning but it’s totally up to you.
 
I would. Does 9:30 insulin work for you? You will likely need to set alarms between +4-+7 in the evening at times since Lantus is dosed based upon how low it takes Saff Just checking because if you want a different t time now is a good time to try. If this works for you it’s fine.
 
@Lacy -

Now that you've got a plan of action that involves Saff initially getting less insulin than she is currently receiving, please remember to test her pee for ketones every day for the time being. It's a very important safety measure. (Info links in one of my earlier replies to you.)


Mogs
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Critter Mom said:
@Lacy -

Now that you've got a plan of action that involves Saff initially getting less insulin than she is currently receiving, please remember to test her pee for ketones every day for the time being. It's a very important safety measure. (Info links in one of my earlier replies to you.)


Mogs
.
Click to expand...

Ketones has been one of the things I've struggled to fully understand. The blood glucose monitor does have a ketones notification on the readings. I've seen it once on an extremely high reading and spoke to the vet about it. I have not seen the notification again. I just read a lot on it and believe I understand it better now. I found a store nearby with the urine strips.
 
So, I didn't hear back from the Vet last night. I know they've been swamped and she will most likely call today. I decided to go ahead with TR and start testing her today to get a more recent look at her numbers with Vetsulin. Her preshot AM number today was 145. Which is the best preshot number we've ever gotten. I'm going to see how her readings are today and check back in.
 
tiffmaxee said:
I’m confused. Did you give vetsulin or Lantus this morning?
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I gave Vetsulin. I want to get the approval from the Vet before making the switch. I also want to get a day of solid testing numbers to present to her when she calls. I was surprised by the good pre-shot AM number. I want to see what her numbers are at +3, +6, +9, and preshot PM today. That way we've all got a solid idea of how she's reacting currently. I'll update tomorrow when I've got more information to share. I'm still convinced that Vetsulin isn't lasting long enough in her system, but based on the AM reading, I may need to have more data to confirm.
 
Okay, quick update as I need some help now for sure. Called my Vet back again today and still haven't heard from her. Yesterday I tested at PSAM, +3, +6, +9, and preshotPM while continuing the 4.5U Vetsulin until I got the go ahead from the Vet to switch back to Lantus. Her numbers were more in the normal range than I expected, but climbed to 315 at the PSPM reading. I didn't get a read on her this morning before giving the morning Vetsulin dose (my mistake). I noticed that she wasn't acting as hungry as usual today. She is still eating and drinking, but not yelling at me like usual. I decided to get a read on her at +5 at she clocked in at 37! I mixed a small amount of Caro syrup in her snack and fed her. What should I do next? I'm not waiting for the Vet anymore. The Vetsulin is apparently dropping her numbers too low then they skyrocket back up when it leaves her system. I feel like this is too hard on her.
 
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