Insulin Glargine in cats

Re: Insulin Glargine in cats

Martin Atkinson — Wed, 03 Nov 2010 16:26:25 GMT

[quote user="KathW"]

Yes, Did test for HyperA as well - that was negative so went on to do Insulin resistance + acromegaly tests.

Did they say anything about the research that the RVC are doing into acromegaly? I've found flyers that talk about submitting bloods but it looks as though it would lead on to visit to London + poss treatment + further monitoring after and we are too far from London for that.

The cat seems to have "done better" on glargine (although blood glucose levels stayed around 20) and the caninsulin certainly didn't last v long before blood glucose levels shot up again so We'll probably keep on glargine for now (just about to start a new bottle) and reasses later. There is info from New Zealand that says g;argine wi'll last several months if kept in the fridge (anyone tried that?)

[/quote]

The lecture was by David Church from the RVC so it was from the horse's mouth and mention was made of the research but not of ongoing recruitment of patients unless I was asleep at that point! I am a fan of Glargine now as well - I haven't had the courage to use it much beyond a month yet but were you in on the discussion regarding getting the Lantus pen refills? They're 3ml cartridges so there's a lot less wastage and have a rubber membrane that you can draw from using a standard insulin syringe. I get mine from NVS as a special order. I had considered the pens themselves as you can just dial a dose and inject but they only work in 1iu increments so as my Lantus cats are on fractions that wouldnt be of any use.

Re: Insulin Glargine in cats

KathW — Wed, 03 Nov 2010 14:22:36 GMT

Yes, Did test for HyperA as well - that was negative so went on to do Insulin resistance + acromegaly tests.

Re: Insulin Glargine in cats

Martin Atkinson — Wed, 03 Nov 2010 11:10:29 GMT

I was beginning to think I knew everything there was to know about DM in cats then went to a lecture at London vet show and learned that acromegaly is very much common than previously suspected and insulin 'resistant' DM is one of the most common manifestations long before anatomical changes are seen (just to complicate things also learned that plantigrade stance may be due to HAC 2ndry to the same pituitary tumour). Apart from radiotherapy ever increasing does of insulin is the only way to deal with the DM, but have you done any tests for HyperAC? Under the circumstances it may be better to consider reverting to Caninsulin as is will cost the client less.

Re: Insulin Glargine in cats

KathW — Tue, 02 Nov 2010 20:01:34 GMT

[quote user="KathW"]

Last dose of Glargine was Friday eve. No injections since. Cat fed as usual on same amts food etc.

Sunday 5.30 pm glucometer test - 16.9

Today (tuesday) had cat in to do a curve.

Glucometer 8am -before fed was 20. Then fed main portion of morning ration as normal.

2 hours later(10am) 24

12 noon 24

1.30 pm 22.

I've left the surgery now now but we will do a couple more tests later today.

What's puzzling me is that whatever dose we give if this cat's glucose seems to stay around the 20 mark - apart from that sunday teatime one (done at home by the owner).

It's weight today is 4.7kg - same as a month ago. It looks brighter. Mouth looks great after the dental. It's coat looks a lot better at the moment lot less moulting and general scurfiness/grease. Also it is walking with less of a plantigrade stance. Owner reports it seems possibly a bit less thirsty but will eat ++ whenever fed and eats all up at once. In the surgery it doesnt seem v thirsty/doesnt drink. Eats whatever fed as soon as food hits it's disch.

[/quote]

Update on above cat. Six days without glargine and still am blood glucose around 20 mark. Cat still wants to eat++ as soon as sees food but now more polydipsic than when on glargine.

Further tests done and end result: :-

ACTH test - normal

Insulin Antibodies 3.4 (mildly increased at >2)

Insulin Like Growth Factor 1 >2000ng/ml (result above 1000ng/ml consistent with acromegaly.

Cat has some respiratory stridor but no (as yet) large body size head/paw enlargement, cardiac signs (on auscultation) central neurological signs.

Certainly has started to maintain (increase?) body weight despite poor glycaemic control.

So looks as though it could be acromegaly. Won't be having a brain scan.

I'm thinking of doing a fructosamine test to see what the result is on the high glargine dose and then looking back at past results with a view to reducing the glargine dose to the lowest that gives "best" control looking at thirst, weight, general demeanour, etc.

Any other thoughts or ideas?

Re: Insulin Glargine in cats

Kate Richardson — Wed, 20 Oct 2010 09:53:33 GMT

[quote user="Jillian Hall"]But why this cat is not PUPD I do not know[/quote]

Does the cat go outdoors? If so may just be drinking away from home? I have one diabetic cat who has no observed pupd, so was quite surprised to diagnose with DM, but diabetic she is. Makes it difficult to monitor on clinical signs obsrved by owner, so have to rely on weight, glucose curves and fructosamine, but clinically she is very stable and happy.

Re: Insulin Glargine in cats

Martin Atkinson — Mon, 18 Oct 2010 09:27:27 GMT

[quote user="Jillian Hall"]

I've got another odd diabetic case, possibly a candidate for Glargine??

It had been on PZI for some time when under treatment by another vet. He had gradually crept up to 9iu BID based on high frutosamines. The clients had tried at home BG curves and failed. It came to my practice when it had an episode of hypoglycaemia when in a cattery. The insulin dose was halved adn then later stopped. The fructosamine after a week off tx was 440 but the cat was brighter than he had been for some time, and no sign of PUPD or PP. Since then I have had him on m/d (or Royal canine diabetic, can't remember which). The fructosamine levels have crept up agin to the 600's however the cat is still very bright with no PUPD or PP. It has however been losing weight more rapidly than I would like (it was 8kg in June, it's now 5.8kg, certaintly not underweight). Initially I was quite confidently saying to the owners that we would treat the symptoms not the blood test results but Im starting to worry he's going to come in suddenly ketoacidotic. I was thinking of trying an oral hyopglycacemic as a halfway point before starting injections again, but have warned the owner they aren't much good for most diabetic cats. They aren't keen on risking another hypo any more than I am.

I haven't done a BG curve as with a fructosamine of 620 I can't see it saying anything other than high. But why this cat is not PUPD I do not know. Any thoughts? And do I hold out and treat the symptoms rather than the numbers?

[/quote]

Sounds very much as this was a chronic Somogyi effect on the original treatment. Unfortunately fructosamine will still go up even when overswinging so it isn't a reliable guide at that stage. This cat certainly sounds as though it needs some treatment. Oral hypoglycaemic drugs are rarely much use in cats but I have one nicely stabilised on them from the outset (I found glibenclamide better than glipizide). It is supposedly easier to get them on oral medication if they've been in remission with insulin first then relapse, especially glargine, but I've not found that yet. You could try orals with your cat Jillian as it hasn't gone DKA yet but if that isn't successful, if the cat hasn't been on Caninsulin bid yet - that may be a better bet initially rather than glargine as it is 40iu/ml which is much easier to titrate than 100iu insulin. Start with a minimum dose as it is better than nothing and shouldn't cause the cat to go hypo. I don't have much faith in diabetic diets and tend to put all my DM cats on moist kitten food so they're getting a high protein/low carb diet, however I confess to not having tried the latest generation of diabetic diets.

Re: Insulin Glargine in cats

Jillian Hall — Sun, 17 Oct 2010 11:57:17 GMT

I've got another odd diabetic case, possibly a candidate for Glargine??

Re: Insulin Glargine in cats

Martin Atkinson — Wed, 13 Oct 2010 16:35:43 GMT

I now use Alphtrac which is calibrated for dogs and cats. It correlates well with the Vetscan but reads 3-4mmol above the Ascencia Breeze. This under-reading with human glucometers is to prevent users getting too hypoglycaemic before they decide to do something about it. I think it just confirms that you should treat the patient not numbers and so long as they are not hopelessly hypo or hyper-glycaemic with wildly fluctuating curves, if they're clinically stable then they're probably OK. One of my cats on Lantus has a nice flat curve hovering just above or in top end of normal all day while another is fluctuating between 15 and 10 but if it goes higher it is in DKA if it goes lower it goes hypo if stressed. I think they're both stabilised in their own ways

Re: Insulin Glargine in cats

Rosie_Skinner — Wed, 13 Oct 2010 16:35:39 GMT

When I worked in Australia earlier this year, they only used glargine in the practice and I was informed that 'nobody uses caninsulin because it doesn't work'. I haven't found caninsulin to be quite that useless, but the glargine certainly worked nicely in the cases I encountered who were on it and in my ketoacidotic, cushingoid maltese responded very well to it!

Re: Insulin Glargine in cats

Bob Russell — Wed, 13 Oct 2010 14:35:12 GMT

[quote user="Michael Woodhouse"]

[quote user="Bob Russell"]This morning we had 19.8 (Accu) and 23.1 and 24.6 for the G pets from the same sample at the same time. Yesterday from different dog 19 (Accu) and 25.3 and 28.6 for G-pets. In house vetscan 21.6, was done a bit later in morning!!![/quote]

The other thing is to read the instructions and see what kind of blood the meters want. We use a human meter (Medisense Optium, that will measure ketones as well as glucose - good for cows) and got some funny readings from fl ox yellow tubes, but the readings were close to the external lab on wither fresh blood or EDTA samples. Just because the lab wants a yellow tope doesn't mean the meter will like it. Worth checking.

To be honest, so long as the glucometer gives a indication of the BG, does it really matter if it's really 19.8, 23.1, 24.6 or 21.6? So long as it's a reasonable ball park figure what you do won't change much?

[/quote]

Absolutely - that's why I increased the insulin dose anyway but my concerns are when the dogs are better stabilised. These were all taken from the same sample and tests performed within moments (other than the vetscan one).

I am concerned that there is such variation between individual machines even same make but different batches of strips. It is hard enough getting the beggars stable sometimes without worrying about the consistency of the strips!!

Re: Insulin Glargine in cats

Michael Woodhouse — Wed, 13 Oct 2010 14:17:07 GMT

Re: Insulin Glargine in cats

Bob Russell — Wed, 13 Oct 2010 10:45:37 GMT

A bit of a diversion from the original post - what machines are you using to measure the glucose?

We have an Accu-chek (human) and have used it for years. We have also got two g-pet (Woodleys) and these have annoyed me by just reading Hi (in early stages of stabilisation) whereas the Accu gives a figure.

We have two 'new' diabetics and I have been rather surprised to find all three give different readings. I know the Accu tends to indicate a 1-2 point underestimate compared to lab - possibly a built in safety thing to reduce the likelihood of humans going hypo but the G-pets read a lot higher.

This morning we had 19.8 (Accu) and 23.1 and 24.6 for the G pets from the same sample at the same time. Yesterday from different dog 19 (Accu) and 25.3 and 28.6 for G-pets. In house vetscan 21.6, was done a bit later in morning!!!

This all looks far to hit and miss to me so bright ideas please!!!

Re: Insulin Glargine in cats

Martin Atkinson — Wed, 13 Oct 2010 09:50:48 GMT

I would say if the glucose level had been stable around the 20's and is slowly rising then its time to re-start insulin at the dose previously suggested. Its easy to panic into changing things too quickly and unless your hand is forced then try and last out for 5 days between changes. I would repeat biochem & electrolytes as this may give a clue as to what may be causing the leg weakness and an early warning for impending DKA i.e. raised liver enzymes, acidosis indicated by raised Cl in relation to Na and of course K levels and a CBC to look for a stress or inflammatory leucogram. If you can get urine you should check for ketones as well if you don't have the olfactory gift.

Re: Insulin Glargine in cats

KathW — Tue, 12 Oct 2010 22:21:22 GMT

6pm on glucometer reading back up a bit to 25.2

Martin do you think it would have gone higher say up to around 28 or 30 or just "High" on a glucometer if this cat was needing more insulin and the glargine stopped 3 days ago?

We could probably do an morning 8am fasted reading in a couple of days time whilst keepin the cat off insulin a few days more.

Re biochem + electrolytes, they'll have been done when the dental was done I'm pretty sure but i can check .

Thanks, Kath

Re: Insulin Glargine in cats

Louisa Huntington — Tue, 12 Oct 2010 20:24:32 GMT

Out here in Canada my boss will only use Glarginein cats .. BID and has great results - i have 2 cats on it now which are doing very well.

Re: Insulin Glargine in cats

Martin Atkinson — Tue, 12 Oct 2010 17:05:59 GMT

This is exactly what was happening with my cat on Caninsulin which is now beautifully stable on 0.75iu glargine bid for a 4kg cat. Three whole days days may not be enough for a chronic overswing to settle but I think it shows you that it wasn't being underdosed otherwise the glucose would probably have gone up. If you can't wait any longer I'd probably re-start the Glargine at 0.25iu/kg and reasess every 5 days. Don't forget it may be stressed in-clinic which may push up the glucose. What I've found interesting is running an Alphatrac parallel with an Ascencia glucometer. The Alphatrac is reading 3-4mmol higher on each test, This makes we wonder that when I had animals beautifully stabilised on a standard glucometer i.e. starting around 10 and reaching a nadir of mid-upper normal before returning to around 10 twelve hours later that now I'm getting higher readings on the Alphatrac whether I'm being too pedantic about chasing numbers. Regarding the plantigrade stance have you run biochem and electroytes recently? Finally I've had the same issue with owners going away leaving an unstable diabetic cat and offered to keep them here just at the cost of boarding during the week with them going home for the weekend for the carer to administer the insulin if capable. That way you can sneak in a few more tests and have peace of mind and what does it really cost you? - a bit of cat litter and a couple of pouches of cat food.

Re: Insulin Glargine in cats

KathW — Tue, 12 Oct 2010 16:40:55 GMT

Last dose of Glargine was Friday eve. No injections since. Cat fed as usual on same amts food etc.

Sunday 5.30 pm glucometer test - 16.9

Today (tuesday) had cat in to do a curve.

Glucometer 8am -before fed was 20. Then fed main portion of morning ration as normal.

2 hours later(10am) 24

12 noon 24

1.30 pm 22.

I've left the surgery now now but we will do a couple more tests later today.

What's puzzling me is that whatever dose we give if this cat's glucose seems to stay around the 20 mark - apart from that sunday teatime one (done at home by the owner).

One other thing it was on glargine bid but at night the cat got it's evening ration around 7-8pm and no other food left down all night . If the owner did give any food later - to leave it down for grazing on the cat would just gobble it all straight up so it doesn't get any moreapart from a few kibbles at bedtime.

Owner goes on holiday in 4 days time for 2.5 weeks and cat at home with older children so I need to decide what to advise for the next few weeks when re testing the cat will be difficult but possible.

Re: Insulin Glargine in cats

KathW — Fri, 08 Oct 2010 08:39:25 GMT

Owner did a glucometer test last night at 11.30 pm after 8pm glargine inj. Glucose was 15.9.

I'm seeing her today so will reasses the cat and suggest we try stopping everything for a few days and then re testing as Martin suggested.

Watch this space!

Thanks, Kath

Re: Insulin Glargine in cats

Martin Atkinson — Thu, 07 Oct 2010 16:25:28 GMT

The fact that the glucose is rising after the insulin injection rather than initially falling on that dose screams of a chronic overswing to me. I would be inclined to stop everything for 3 days then do a curve with no insulin, I think its the only way to find out, fructosamine can be a poor guide because it will be high if its being under-dosed or it its overswinging. For sure the cat may go DKA but so long as you act swiftly it won't die however if its overswinging and decompensates in the middle of the night then it could die of a hypo. Are you sensitive enough to smell low levels of ketone?, because I've found that is an invaluble gift to be able to predict that an animal is about become clinically ketotic before it does. Don't forget that glargine should give a fairly flat curve so you wont see big peaks and troughs once its stabilised unless its overswinging. If the glucose levels continue to go up after a break then you will know you need to re-start at a higher dose, if it comes down then re-start at 0.25iu/kg and gradually work up doing a curve every 5 days or so. Its unlikely to currently be pancreatitis if it is eating and bright but don't forget PLi levels will fall to normal after a few days anyway. I have stopped trying to chase perfect numbers and accept that I'm never going to perfectly stabilise some patients, you've got to contend with how reliable owners are at giving the insulin, check their technique again even if they did it perfectly to start with and make sure the injection site is varied. Don't forget the cat can get stressed in the clinic and will push up the glucose and some clients stress their cats doing tests at home.Sometimes you have to accept that if the patient looks well, is eating and drinking and behaving normally than it is probably OK despite the numbers. Sadly there is no simple answer, we're all on a learning curve here and your experience will be as invaluble to me as mine is hopefully to you.

Re: Insulin Glargine in cats

KathW — Thu, 07 Oct 2010 10:35:30 GMT

Hi,

I've finally found the time to compose a reply!

Started the cat on glargine in june2010. Starting dose was 1 unit bid. Each time I have increased the dose it's been by one unit. I have always waited at least 5 days after a dose increase before re checking the blood glucose and then increasing the dose again. As per the papers I have read once the cat was on glargine I did a curve a few days later and after that checked the morning glucose pre glargine injection ( or the owner has sometimes borrowed a glucometer - alpha trak - and done it at home). The info I had then said if morning pre inj blood glucose was above 12 mnol/litre then increase the dose by 0.5-1 unit. Pehaps a 1 unit increase each time was too much?

I can't find the info I used at the time but I'm sure I read that as it's so long acting then it does tend to last 24-26 hours plus and so the glucose may fall a bit further after the 7-8am glucometer reading. I'm also sure I read back in May/june that with glargine you can leave longer time intervals between readings for a curve.

Perhaps that's incorrect? Anyway a "curve" done 6 days after staing glargine at 1 unit bid was

8.30am glucose 15.2 ; 12.30 pm 20.1; 4.30pm 23.7; 7.30pm 23.9:

Morning glucose around 8am before glargine injection and 5-6 days after a dose change have been 21.3 22.8 18.8 - always around 20 never lower than 15.

The last curve I did was when the cat was on 7 units bid but unfortunately was only done until mid afternoon. Then 8am glucose was 24 (then glargine inj) and it went down to 20.4 at 11.30 am (having been measured hourly to then to see if there was a carry over from the evening inj) up to 24.1 at 1.20pm and down to 20.9 at 2.20pm then up to 22 units at 3.30pm.

The cat grazes all day on small amts of dried food given every few hrs by the owner as it is always asking for food.but has a "meal" with each injection. This is high protein low CHo but the owner only changed to this in the last few months as well.

After a month on glargine we did a dental and yes the dental disease is now fully resolved. We have checked a few times for UTI - always negative.

I've asked th Owner to do a glucometer reading as late on in the evening as she will and hopefully that will be done this week. 24 hr hosp isn't an option for monitoring as we don't do our own on call.

I haven't checked bloods for pancreatitis Martin. Perhaps I should do that as well.

Thanks,

Kath

Re: Insulin Glargine in cats

KathW — Thu, 30 Sep 2010 22:24:52 GMT

Hi, Sorry I've had 2 busy days - today's being a 450 mile round trip to deliver student to uni. Long day tomorrow too but will add reply with more clinical info Saturday (unless I'm lucky tomorrow) Thanks for the replies so far, sorry I should have put more facts in at 1st.

Re: Insulin Glargine in cats

Martin Atkinson — Wed, 29 Sep 2010 18:01:56 GMT

Good to hear from you Henry. I've only used Glargine in 10ml vials from NVS but at £35 it isn't particularly expensive. Your method sounds interesting so I may inquire about it. Because of the way Glargine works we're not supposed to dilute, decant or keep for longer than 1 month once opened and I'm fairly anal about that at the moment but wonder if I will become a bit more blase in the future - I have used some soluble insulin in desperation that was 5 years out of date but it still worked.

Re: Insulin Glargine in cats

Henry Jubb — Wed, 29 Sep 2010 15:49:08 GMT

We buy Lantus from Centaur in 3ml vials which I believe are cartridges for some kind of injection pen. However they have a rubber plug in the end from which our clients draw up their cat's dose in an insulin syringe. This is economical for the client. Doses are frequently small so 10ml can last for months if not discarded.

Re: Insulin Glargine in cats

Martin Atkinson — Wed, 29 Sep 2010 10:23:02 GMT

I'm pleased to report my cat is now stable on 1.25iu Glargine bid and we never found any clear-cut contributing factors although pancreatitis remains the most likely, time will tell if she goes into remission or remains a very rare juvenile diabetic. Be aware of interpreting the persistantly high fructosamine as meaning inadequate control it could be reflecting a chronic somogyi effect and keep bumping up the insulin could end in a massive hypo. I've reassesed my interpretation of a somogyi overswing now and from expecting it to plummet dramatically then shoot back up, realise that sometimes they don't fall vey much at all other than a fairly rapid onset nadir in 2-4 hrs so your curve with the effect only lasting 6-7 hours may reflect this A 24hrs curve may help to reveal if your insulin is 'piggybacking', if its not practical to hospitalise some owners can be co-operative with a glucometer and ear pricking at home. The maximum recommended dose of glargine is 3iu/kg - but quite what you do if it is genuinely resistant who knows other than to keep increasing it. I don't know that PZI will give you more control than either lente of glargine if they're not working, probably less. You mentioned the cat had dental disease - has that completely resolved and have you eliminated other infections or pancreatits before you get onto more complicated things like HAC (unlikely in a cat) or acromegaly? Quite what you can do to test the Somogyi theory other than risk dramatically reducing or stopping insulin I don't know, when I suspected it in our cat and tried that it just went DKA again.

I now have an older cat on Glargine having found that neither Caninsulin or Insuvet PZI could control it but so far I'm still not getting the nice flat curve you're supposed to and he's dramatically varying between 25 and 4 during the day so I suspect this is an overswing and have reduced his dose, but he has had a flare-up of his chronic URTD which has probably made him more unstable.

Re: Insulin Glargine in cats

Kate Richardson — Wed, 29 Sep 2010 09:53:34 GMT

Hi Kath

A few questions? What dose did you start on? How often did you change the dose and by how much each time? Is it possible that you are overdosing this cat and getting a somorgi effect (which can last for several days)? Have you checked for urinary tract infection?

Might be worth giving the cat a week or 2 off insulin completely to allow things to get back to 'normal' and starting again with a low dose (0.25-0.5iu/kg) and making 0.5iu incremental increases as needed but not more frequently than once per week. Fructosamine is not always reliable so use it but don't hang your hat on it. Use the clinical signs eg weight gain, pupd/appetite and glucose curves if nec and consider getting the owner to try home glucose monitoring if you think the cat and owner are amenable. Also worth rechecking T4 depending on how long ago it was you last checked it, as a robust T4 in the face of other disease always makes me suspicious of hyperthyroidism and may explain some of the pupd/polyphagia and weight loss.