Initial treatment for a diabetic cat?

Re: Initial treatment for a diabetic cat?

Martin Atkinson — Mon, 11 May 2015 09:56:39 GMT

[quote user="jamie winstone"]When I first qualified in 1982 I treated Diabetic cats with Insuvet PZI and achieved good results with few complications at a cost that was achievable to nearly all owners.[/quote]I think you have to define 'good results and few complications'. All things are relative and what the eyes can't see the heart doesn't grieve about. I'm even more of a dinovet than you jamie and that's the way we were taught to do it. I bet that they were poorly controlled and didn't live for more than 2 years post diagnosis. With modern insulins, regular testing and dietary control my diabetic cats will die of old age before they have a complication due to their DM. It may cost the owners more but what price are you going to put on the cat's welfare?

'My real question is-Is insulin Glargine significantly better than the PZI I am now using'? Just ask yourself if Pimobendam is better that HT&S and millophyline pills and maybe you have your answer.

Re: Initial treatment for a diabetic cat?

jamie winstone — Sun, 10 May 2015 17:53:54 GMT

Unfortunately with all aged anecdotes the precise complications are hard to specify.

To summarize, diabetic control was more difficult and client expectations were not achieved.Normally this meant that animals were persistently hyperglycaemic due to my low initial starting dose of Caninsulin. This would be verified with a glucose curve which often would show high glucose levels.

Many of my clients will only allow a minimal number of glucose curves in close succession and then, for whatever reasons, become more and more reluctant to repeat this procedure unless benefits were seen.

I am only too well aware that 2-3 poor outcomes does not suggest firm evidence but they leave quite a profound effect within the practice.

My real question is-Is insulin Glargine significantly better than the PZI I am now using?

Jamie

Re: Initial treatment for a diabetic cat?

Christina Smith — Sun, 10 May 2015 17:26:00 GMT

I can on add that IMO the least intervention the better. And don't try for perfection. If blood glucose drops, STOP

Re: Initial treatment for a diabetic cat?

Kate Richardson — Sun, 10 May 2015 15:35:21 GMT

[quote user="jamie winstone"]Then Caninsulin came onto the market as a licensed competitor and diabetic failure in cats seemed quite frequent for varying reasons, the most common one was the owner discontinuing treatment due to repeated complications which caused perceived distress and would then become a good reason to call it a day.[/quote]

I'm interested- what complications did you have?

Re: Initial treatment for a diabetic cat?

jamie winstone — Sun, 10 May 2015 00:39:28 GMT

When I first qualified in 1982 I treated Diabetic cats with Insuvet PZI and achieved good results with few complications at a cost that was achievable to nearly all owners. The only repeated problems were to do with people mis-dosing due to the inaccuracy in injecting 2-5 units of insulin . This was sorted by diluting the insulin with sterile water 1:4, allowing the average dose size volume to be more manageable.

Then Caninsulin came onto the market as a licensed competitor and diabetic failure in cats seemed quite frequent for varying reasons, the most common one was the owner discontinuing treatment due to repeated complications which caused perceived distress and would then become a good reason to call it a day.

In other words, in my practice, diabetes needs to be improved and controlled quickly and as cheaply as possible. This has led me to always use an off-license PZI product which is then diluted with owners picking up a prediluted bottle at about monthly intervals.

I really do not think we have had any issues of infection or of insulin inactivity due to mishandling or this dilution procedure.

Just like any treatment that I have used successfully for years I am reluctant to change but am intrigued to know if Glargine is seen as better than PZI and if not, why not use a product that many people would be more familiar with.

Jamie

Re: Initial treatment for a diabetic cat?

Kate Richardson — Sat, 09 May 2015 17:01:08 GMT

Indeed

Re: Initial treatment for a diabetic cat?

Evelyn Barbour-Hill — Sat, 09 May 2015 15:58:31 GMT

[quote user="Kate Richardson"]

So I think it would be hard to use cascade to justify using glargine over caninsulin initially on the basis of there being

'no suitable veterinary medicine authorised in the UK to treat a condition'

[/quote]

The delightfully debatable crux of the problem lies within the interpretation of the word "suitable"

Re: Initial treatment for a diabetic cat?

Kate Richardson — Sat, 09 May 2015 12:15:58 GMT

[quote user="Martin Atkinson"]

[quote user="Kate Richardson"].....definitely start insulin asap..... Start with 0.5units per kg BID, [/quote]I presume you're advising starting with Caninsulin Kate. I put my comment in about starting on Glargine as a little bit of a red rag waving. However, some other endocrinologists I have spoken to have suggested privately that perhaps all cats should start on Glargine but they can't recommend this officially because of the cascade. Given that it is believed that remission can be achieved in 80-90% of newly diagnosed cats using Glargine combined with a low carbohydrate diet because of the improved glycaemic control it seems that there is good justification to bust the cascade. I'd be interested in your views on this.

[/quote]

I agree the evidence does suggest that Glargine is a superior insulin and I have treated cats successfully with it. However I have also treated cats successfully with Caninsulin and achieved good control including remission. So I don't feel I can say without a shadow of doubt that I should jump straight to glargine without trying caninsulin first if we are talking about cascade regulations. I wouldn't hesitate to switch to it if I wasn't achieving glycaemic stability, but I do have concerns about dose accuracy due to it being 100iu/ml and we are talking tiny doses in cats.

So I think it would be hard to use cascade to justify using glargine over caninsulin initially on the basis of there being

'no suitable veterinary medicine authorised in the UK to treat a condition'

That doesn't mean I am a fan of the cascade system in small animal veterinary medicine, far from it.

Re: Initial treatment for a diabetic cat?

Luca Poddighe — Fri, 08 May 2015 16:35:54 GMT

Should I say that 'It's a kind of magic!'

Re: Initial treatment for a diabetic cat?

Martin Atkinson — Fri, 08 May 2015 15:36:12 GMT

[quote user="Luca Poddighe"]I was told by a rep that it wasn't to shake but to mix gently as it damages the crystal of insulin..[/quote]Its all a load of tosh, shaken or stirred it makes no difference, keep it in the fridge or not, use it beyond 28 days, makes no difference it still works.

Re: Initial treatment for a diabetic cat?

Luca Poddighe — Fri, 08 May 2015 15:12:53 GMT

[quote user="Stephen Courtney"]By the way, does everyone know that you are now supposed to SHAKE your caninsulin vial vigourously before drawing up the insulin? It's in the data sheet![/quote]

Have they changed something in the composition? I was told by a rep that it wasn't to shake but to mix gently as it damages the crystal of insulin... I suppose it is important.

Re: Initial treatment for a diabetic cat?

Stephen Courtney — Fri, 08 May 2015 13:04:28 GMT

Braden I agree totally about the Cascade in this issue, but almost all vets in the UK wander around wringing their hands saying they can't use glargine because of the cascade. which is in my opinion a flawed attitude that simply gives the VMD a psychologically taller pedestal to stand on. Totally unnecessary in my mind!

Re: Initial treatment for a diabetic cat?

Braden Collins — Fri, 08 May 2015 10:16:21 GMT

[quote user="Martin Atkinson"]

[quote user="Stephen Courtney"] I took it that a unit of soluble insulin will drop blood glucose faster and further than a unit of lente will, and lente will drop faster and further than PZI and PZI will drop faster and further than glargine. So as insulin a last longer their hypoglycaemic effect drops.[/quote] Can't argue with that but this lack of sudden drop and overall steadier state without peaks and troughs because it is protein bound is why you have better control and a greater chance of remission with Glargine so it is a bonus not a downside.

[quote user="Stephen Courtney"]And I still don't understand why people feel the cascade prevents them from choosing glargine as a first choice given that it is not an equivalent product to caninsulin.[/quote] Totally agree. There is enough evidence even in this thread to justify it as first choice for cats.

[/quote]

From the VMD website: http://www.vmd.defra.gov.uk/pdf/vmgn/vmgnote13.pdf

The principle of the Cascade is that, if there is no suitable veterinary medicine authorised in the UK to treat a condition, the veterinary surgeon responsible for the animal may, in particular to avoid causing unacceptable suffering, treat the animal in accordance with the following sequence, in descending order of priority:

I think if you can argue that Caninsulin is not suitable you're good to go with another type of insulin.

Re: Initial treatment for a diabetic cat?

Martin Atkinson — Fri, 08 May 2015 09:33:15 GMT

[quote user="Stephen Courtney"]Problem is i have Caninsulin the fridge, glargine needs ordering...and U40 is easier to handle than U100[/quote]Opposite here, we have some Lantus pen vials in the fridge that need using! But as I also previously noted the U100 presentation can be an issue with margin of error with very low doses. The pen seems like a good idea but can only be set to single units and some of my cats needed fractions of units to ideally stabilise.

This is one occasion when some enterprising company can make a useful contribution by formulating a U40 veterinary Glargine rather than just licencing a human product we already use as route to profit via the back door of the cascade!

Re: Initial treatment for a diabetic cat?

Stephen Courtney — Thu, 07 May 2015 20:57:48 GMT

Tortuous - but we get there in the end!

Problem is i have Caninsulin the fridge, glargine needs ordering...and U40 is easier to handle than U100

By the way, does everyone know that you are now supposed to SHAKE your caninsulin vial vigourously before drawing up the insulin? It's in the data sheet!

Re: Initial treatment for a diabetic cat?

Martin Atkinson — Thu, 07 May 2015 16:44:02 GMT

Re: Initial treatment for a diabetic cat?

Stephen Courtney — Thu, 07 May 2015 16:18:47 GMT

I took it that a unit of soluble insulin will drop blood glucose faster and further than a unit of lente will, and lente will drop faster and further than PZI and PZI will drop faster and further than glargine. So as insulin a last longer their hypoglycaemic effect drops. And I still don't understand why people feel the cascade prevents them from choosing glargine as a first choice given that it is not an equivalent product to caninsulin.

Re: Initial treatment for a diabetic cat?

Martin Atkinson — Thu, 07 May 2015 14:25:39 GMT

[quote user="Stephen Courtney"]so yes I've used it , and nothing you have said explains to me why vets feel they cannot use glargine as a first choice insulin in cats if they wish - it isn't the same as caninsulin, so I don't see why Cascade needs to be an issue, if you want to use this type of insulin for clinical reasons, then you can. [/quote]I realised I'd misunderstood your previous post as opining that you couldn't understand the fuss about why people would want to use Glargine and was going to amend my reply but thought I'd wait until you responded in case I hadn't! However, I still can't see what this supposed divergence of 'potency' is given the starting dose is the same as with lente insulin and you are more likely to get cats into remission with Glargine it sounds more rather than less 'potent' if you are going to use that word. Its a bit like saying one antibiotic is 'stronger' than another. They are just different.

Re: Initial treatment for a diabetic cat?

Stephen Courtney — Thu, 07 May 2015 13:08:08 GMT

FYI the speaker was Anne Della-Maggiore on 10th April Hall 4 0830-0915 and 0925 to 10.10

i don't know this series of lectures are also going to be available as video, but she was great and had a lot to say about how this insulins work, and how the relative potencies of the various insulins varies.

generally longer acting insulins are weaker, shorter acting e.g. soluble, are stronger.

the exception is Detemir, which is very long acting but of equivalent potency to Caninsulin.

Re: Initial treatment for a diabetic cat?

Richard Carter — Thu, 07 May 2015 13:07:40 GMT

taken one of my 14 year old burmese patient off all insulin 2 weeks ago after 4 years injecting - were down to 1/2 iu oid (caninsulin in this case) and blood glucose today 5.5mmol/l. Message trying to say - cats are not small dogs. This is type 2 not type 1 DM and just a small amount of insulin constantly may be more important than short duration, high efficiency insulin

Re: Initial treatment for a diabetic cat?

Stephen Courtney — Thu, 07 May 2015 12:57:24 GMT

[quote user="Martin Atkinson"]

[quote user="Stephen Courtney"]Glargine and can insulin are not equivalent products - glargine is a much longer acting insulin, and also not as potent. so i don't really understand why people tie themselves up in knots over glargine![/quote]Have you actually tried it Stephen? I don't know where you got that information from.

The starting dose is similar to Caninsulin but maintenance dose is actually less in most cases. Like any insulin there is a range of duration of action - it is quoted as 12-24 hrs so take your pick but we know cats metabolise insulin more rapidly so the ones I had on it were on twice daily dosing the same as Caninsulin, The control is much more stable and you see a much flatter curve without the peaks and troughs you see often with Caninsulin and there is less danger of causing a Somogyi overswing.

The downsides are that it is 100iu/ml so there is a greater margin for error with small doses and you can't dilute it, plus it genuinely needs to be refrigerated and chucked a month after opening so cost may be an issue but this can be largely overcome by using the pen cartridges instead of bottles. Other than that it is the almost perfect product for cats. That's why people get their knickers in knots over it.

[/quote]

According to the Diabetes lectures at BSAVA this year, the lecturer stated that glargine is a long acting insulin but less potent than Caninsulin. there is another called Detemir that is same potency as caninsulin but also longer acting than glargine. The podcasts are about to become available, feel free to have a listen.

She gave a range for glargine of 1-9 units per cat, usually twice a day - as it is less potent than caninsulin this makes sense and explains why my fat pancreatitis diabetic cat with IBD isn't responding to glargine at 3.5 units twice a day....

so yes I've used it , and nothing you have said explains to me why vets feel they cannot use glargine as a first choice insulin in cats if they wish - it isn't the same as caninsulin, so I don't see why Cascade needs to be an issue, if you want to use this type of insulin for clinical reasons, then you can.

Re: Initial treatment for a diabetic cat?

Richard Carter — Thu, 07 May 2015 09:39:04 GMT

just been a discussion on this topic on ISFM (FabCats) - glargine won as initial treatment for cats - length of action giving sid injections a realistic chance of remission, lower doses needed, less of a swing of glucose levels so less chance hypoglycaemia etc

Re: Initial treatment for a diabetic cat?

Martin Atkinson — Thu, 07 May 2015 08:57:34 GMT

Re: Initial treatment for a diabetic cat?

Stephen Courtney — Wed, 06 May 2015 23:32:13 GMT

Glargine and can insulin are not equivalent products - glargine is a much longer acting insulin, and also not as potent.

given that they are not equivalent products and have different indications personally i feel all you need is to be able to clinically justify your choice in order to prescribe it, quite legally, under current cascade rules.

We all apply same logic to other product groups e.g. antibiotics - if I need erythromycin, i can use it, regardless of the fact that there are veterinary licensed antibiotics available as well.

so i don't really understand why people tie themselves up in knots over glargine!

Re: Initial treatment for a diabetic cat?

Emily Rainbow — Wed, 06 May 2015 21:50:15 GMT

Another interested in glargine following a good talk at BSAVA. Currently got a couple of cats on it that I've failed to stabilise on caninsulin (not lasting long enough) and having done some research it seems a shame to not jump straight to it.