Abbott-sponsored diabetes presentation

[k9diabetes]

I was fortunate to get to attend a presentation last night on managing canine and feline diabetes by Dr. Dave Bruyette, an internal medicine specialist in LA who does a lot of work with endocrine disorders. The audience was mainly veterinarians and technicians, who received CE credit, and Abbott was there selling the AlphaTrak meter to them.

So there was a strong emphasis on home blood glucose testing in the presentation, which was very encouraging.

Among the interesting topics to me was a detailed description of precisely how canine and feline diabetes differ. They may have the same name but that's about as far as the similarities go.

Dr. Bruyette described a protocol used by Dr. Rand in Australia with cats that involves a four or six week period of very intensive testing (8 times a day 6 days a week) combined with Lantus insulin, which works very well in cats, and the high-protein low-carb diet to drive their blood sugars quickly down below the renal threshold, which in cats is higher, somewhere around 270, and maintain to there with as little fluctuation as possible. Dr. Rand, according to Dr. Bruyette, is achieving remission in better than 90% of the cats treated with this protocol if the diabetes is caught earlier rather than later. Eventually, they go off insulin and stay on the high protein, low carb diet and theoretically can be diabetes free indefinitely. This is because cats' islets cells do not die unless they go untreated for long periods of time. And the studies are showing that a basal type insulin like Lantus does a far better job of inducing remission than insulins that provide more ups and downs in the blood sugar.

He made a clear distinction between that type of diabetes in cats and diabetes in dogs, which is an autoimmune disorder in which the islet cells are destroyed, making dogs permanently insulin-dependent diabetics. This is also why oral medications can be used in cats but not in dogs. But his general feeling is that the oral meds are not the first best approach as you can very likely get a cat fully into remission with the insulin and diet change and then mainly just need to keep them at a healthy weight.

I was sad to see, when Dr. Bruyette asked how many start with Vetsulin in dogs and how many with NPH, not one person said they start with NPH. At the end of the talk, someone asked about a starting dose for Lantus for a 70 pound dog going through three vials of Vetsulin a day. At which point I asked if they had ever tried NPH. They hadn't. The speaker was of the commonly held opinion that NPH would disappear by fall and I challenged that assumption, saying that they have to give six months notice before discontinuing it and I've been hearing about its demise for four years now. So I hope I planted a seed to take the claims often made by marketers of Vetsulin that there's no point in using NPH since, they say, it will be gone any day now.

Not that I think NPH will stay forever. But it's a great insulin, especially in larger dogs, and even if we have it only six more months, that's six months of inexpensive, easy diabetes treatment for that 70 pound dog. One concern was expense and Lantus certainly wasn't going to help there, although at least it would be a smaller volume of insulin.

I heard much discussion among people during the break that they just didn't think they could get owners to test and they didn't even know how to tell them to do it at home. Dr. Bruyette emphasized after the break that it's a thoroughly manageable task for most pets and to check k9diabetes.com and Abbott's website for assistance! (I talked to him briefly during the break and told him about the videos on home testing at the site) He puts all cats on home testing if they will tolerate it and the owners are willing.

An Abbott rep claimed that UCD's vet school endocrinologists have come around to supporting home blood glucose testing in the past year. Will do a little research later this week and see if I can substantiate that. I told them that Nelson's presentation at WSAVA 2007 discouraged it. Also told them I didn't routinely use the AlphaTrak because it is too expensive for frequent use. They included a survey in the packet on what would make participants more inclined to use AlphaTrak and I again stated that the cost of the meter and especially of the strips was prohibitive for frequent testing.

So it was a very interesting night... discouraging on some fronts in that so few are using NPH and how many vets and techs felt home testing was difficult. But they were there and they were hearing that it's not only possible but much easier than they think and far more useful than they may realize.

Also, Dr. Bruyette asked that vets never make a dosage adjustment based solely on a fructosamine test. That a higher result on the fruc test tells you something is causing a loss of blood sugar regulation but not WHAT is causing it. So if the fruc test shows regulation is fading or failing, you need to do a curve to see what's actually happening with the blood sugar and investigate things like UTIs, etc. before choosing how to tackle the problem. Very good advice in my mind.

Natalie

[Soaphie & Sydney's Mom]

Very interesting! Thanks for sharing!

[Patty]

Oh Natalie!
I'm so glad you were able to go...and he endorsed your website! That's wonderful. Glad you got to give some feedback on the AlphaTrak.

My mom is a pharmacist. She hasn't heard of NPH being discontinued yet either. Hopefully still a rumor. That's sad that all start off with Vetsulin. I think N is an easier starting place for most.

I'm curious to know more about the 70 pound dog and Lantus. I know you brought up N as an option and benefits for that particular owner. But, in general, learning more about Lantus in dogs is always something that interests me. Ali doesn't have the traditional carbs and I've wondered how she would do on it to make her curve a little gentler.

Regarding the break discussion that the vets didn't think they could get people to test...I do hope they start giving their clients the benefit of the doubt. It wasn't brought up to me at diagnosis at all and took me 3 vets before I found someone willing to help me try. Even then, he wasn't helpful and I learned how online.

Also very glad Dr. Bruyette addressed not changing insulin dosage based on fructosamine tests!

Thanks for the review. Maybe there's hope for the colleges to get on board.
Patty

[We Hope]

The day a pharmaceutical company gives the insulin you're using the ax is based on finances, either because they feel they're not selling enough vials of it or because there's a desire to move everyone along to a newer product, which may not be better for everyone.

There were still 500,000 or more users of bovine insulin when the decision to discontinue it was made. GE insulin was still new and in patent at the time; people were paying a lot more for the in-patent product than for out of patent beef insulin. Some opted to switch to porcine--that was also out of patent.

Fast forward a bit to each pharma offering analog insulins, which are still under patent; the various patents on GE insulin expired a few years ago for both major companies selling them in the US. We still have made little to no progress regarding FDA approving generic GE drugs, so there's no possibility at present that another company might decide to produce the GE insulins.

As the switches to analog insulins continued, all porcine insulin had to go along with GE Lente and GE Ultralente insulins in 2005. So it's not unheard of for them to be discontinuing a GE insulin; Novo discontinued their L and UL in 2003, Lilly in 2005.

When they "get to" your insulin, FDA requires a six month notice of the drug's discontinuation be given and that's it.

People who want or need either bovine or porcine insulins now have to import them from a UK based pharmaceutical company who makes them.

What's really sad is that there are more and more diabetics with two and four feet and less insulin options for them all.

Kathy

[k9diabetes]

I most often hear vets thinking that the home test must be done either on the ear, which doesn't work well with dogs (and owners find scary as ears are so sensitive), or with a syringe in a vein. So I can see why they think it would be too difficult or intimidating for owners. When they can see much better, easier ways to test at home in videos, etc., I think that will help.

They were surpised that I had a video of a cat being tested on my website but I told them why - if someone sees a cat being tested, they will be encouraged to test their dog! (it is an extremely mellow cat... nothing like mine...)

As far as Lantus goes, the few studies or comments I've seen are not encouraging as it just does not always work in dogs and it often does not provide the flat basal type of insulin response that it does in cats and people.

So there would be no harm in trying it in any dog as long as monitoring is very carefully done as I've seen Chris and one or two other cases where the metabolism of Lantus was extremely erratic. For Chris it was a rollercoaster of very high and very low blood sugars, screaming up and down very sharply.

Chris would have been in very grave danger if we had tried Lantus without home testing blood glucose.

So definitely did not work for him. Betty's Monk, on the other hand, does great on it. It's just one of those things that the only way to know if it will work is to try it.

And it too is very expensive, another drawback. It also generally has to be given twice a day.

[eyelostit]

Interesting Nat, my first vet never mentioned home testing at all, don't know if my 2nd would have cuzs I was already testing. The new vet has the alphatrak.

They need to promote home testing, and know that NPH can be used and to have some compassion for pet owners regarding expenses, they are trying damn hard to take good care of their pets, especially the newly diagnoised, I can just imagine how many pets are put down because they don't get the correct information or with hearing from the vet the expense they will incur with having to use Vetsulin as if that were it.

Then again there are the vets who tell people the dog will have a hard life, and owners but the pet down, as far as I'm concerned Niki's been happy as a clam all these years and eats better than I do.;)

[pgcor]

Hi Natalie!

I haven't been on for awhile - no excuses, just old and tired of working! I still read here whenever I can though.

I wanted to ask you what would happen if NPH "went away"? Pip has done so well on that. What other insulin is there like it?

Just the thought of going through another re-regulation with Pip is sickening! Personally, I don't want to go back to Vetsulin because it stopped working for Pip. Plus, it's not as easy to get as the Humulin.

I hope I haven't confused my insulins again...I can never seem to get that straight for very long.

Pam

[BaileyBear]

I'm so glad you had the opportunity to attend the presentation. Kudos to you for being such a wonderful representative for those of us caring for diabetic pets! I hope many of them visit this site and see just how easily most families can learn and adjust to BG testing and how much out pets benefit! :)

As far as NPH is concerned, I'll be heading back to my rubber room if it's discontinued anytime soon. Bailey feels so great right not and I would hate to see him fall out of regulation while switching to something else. With all of the initial costs involved in diagnosing a diabetic pet, possible prescription food switches, infections, monitors & testing strips, more frequent vet visits, etc - I'd be very concerned that more owners would have their pets euthanized, or take them to already overwhelmed shelters, if you add expensive patent covered insulins to that tab. I know the bottom line is financially motivated, but it still sucks. :(

Aren't there enough human diabetics who use NPH to make it worth it to them to still produce it? I just assumed there was a big market for it since Walmart chose to strike a deal for the ReLion labeled version. :confused:

Maybe if the makers of AlphaTrak are successful in spreading the word to vets that home BG testing is extremely beneficial to diabetic dogs, then demand for the AlphaTrak will increase and the cost of strips will start to come down. I for one would definitely purchase an AlphaTrak if the cost of the test strips were more in line with other monitors. ;)

[Fishslayer]

Aren't there enough human diabetics who use NPH to make it worth it to them to still produce it? I just assumed there was a big market for it since Walmart chose to strike a deal for the ReLion labeled version.

Of course. But why have "enough" when you can have "more?"


Rick

[We Hope]

Since this is an insulin made for humans, the "cues" will come from there. From 2003-2005, 5 of them were gone--all three pork insulin and the two GE Lente family ones left on the market.

Lilly seems to have a "stock" statement for their discontinuations; it always begins with, "after thoughtful consideration", then you plug in the name(s) of the discontinued insulins. The further statements they made re: discontinuing Iletin II Lente was that the few vials they were selling were being sold to people with diabetic pets; they said the same thing when Iletin II R and NPH, Humulin L & U had to go.

http://www.diabeteshealth.com/read/1998/10/01/1297/parting-causes-great-sorrow---beef-pork-insulin-users-prepare-to-switch/?section=204

Here you see there were about 300,000 people using the 90% bovine, 10% porcine Iletin I insulins when the "thoughtful consideration" message went out for them in 1997. Ironically, when I got to this page, I was greeted by two ads for Lilly, telling me how I can get a free 5-pack of Humalog (analog) pens. Back when their disposable pens were new (about 2003), the offer was being made for both Humulin and Humalog pens.

Novo began an agreement with WalMart for ReliOn in 2000; my understanding is that every so often, the contract does come up for renewal.

http://www.childrenwithdiabetes.com/d_0j_20r.htm

What was really strange to see was their discontinuation of Novolin L & U in late 2003. At the time, Novo had a contract with the US Department of Defense to supply insulins for our service people and their families. While a civilian couldn't beg, borrow or steal any Novolin L or U after the end of 2003, Novo kept production of them going until February/March of 2004, to meet its contractual agreement with DoD.

Not so long ago, it was only people whose diabetes was dependent on insulin who were the human users of it. Today it's not unusual to see someone whose life doesn't depend on insulin but who has diabetes using at least some insulin to help control it.

They are selling more insulin, no doubt about it, because the minority of people with diabetes are those who must have insulin to survive; the others, the majority, are T2. So for many years, one's insulin sales were only to those who literally wouldn't live without it; a small number of people with diabetes. The "big 3" insulin producers choose to emphasize their patented analog insulins because that's where the money is.

Those who use insulin pumps currently have 3 choices of insulin for them--Humalog, Novolog, or Apidra. The specially buffered pork and GE R insulins (chemical added to it to keep it from clogging the infusion set tubing) of the Velosulin type are gone.

Anyone with little to no prescription drug coverage would feel the bite also, because they're probably buying and using these insulins for themselves. So you get "moved on" whether you like it or not or whether it's the right choice for you or not because of decisions made by the 3 major insulin producers.

Kathy

PS--People with diabetes have the same complaints you do about the cost of test strips because while the message to them is test, test, test, most insurance companies will only cover X number of strips a month for them to do that.

[k9diabetes]

I don't think there's any question that "some day" NPH will go away. But I don't think that should be used as an excuse not to use it now! After all, it works extremely well AND is very affordable.

We will get at least six months notice of its demise and at that time people using it can stockpile a number of vials. They are good through their expiration date unopened. This is what many folks did when Humulin L, which also was a very good insulin for dogs, was discontinued. They bought up bottles and stored them carefully in the refrigerator and were able to go on for quite some time after it was no longer manufactured.

And then if it comes down to it and you have to switch insulins, you find whatever works best and move forward!

Much of the "imminent demise" of NPH has been promoted by the sales reps for Vetsulin as a way to convince vets to use it. It's a shameless tactic and I was really sad at the lecture to see how effective they have been in convincing veterinarians of this.

I dont think it will be discontinued tomorrow but even if it is, you could likely get an entire year out of it with some stockpiling - possibly longer - and a year is a long time in the life of a dog.

The loss of Humulin L was huge for dogs. Vetsulin is similar to Humulin L in that it's a lente insulin but with it being human GE vs. pork and U100 vs. U40, it definitely does not work exactly the same as Humulin L and has not always been a good substitute. So it was a very tough transition for Humulin L dogs, who did at least have a choice then of Vetsulin or NPH.

One day at a time - that's all you can do.

Natalie

[We Hope]

When Lilly first opted to discontinue Iletin II Lente, there was enough of a firestorm in Canada to cause a Parliamentary hearing on pork insulin. The Lilly people had to appear to testify. What came from all of it was Lilly's promising cooperation with the Canadian government for the time when they did plan to discontinue their pork R and pork NPH.

At the point of their discontinuation announcement in July, 2005, the UK company Wockhardt/CP Pharma made application to have their Hypurin pork R and pork NPH approved by Health Canada; that would bring this insulin to the pharmacies, as the Iletins were without the need for import permission and importation.

What developed along the road was that the approval for Wockhardt did not go through in the time planned; Lilly expected there would be no Iletin II available by March of 2006.

What was available were vials of it that had passed their expiration dates. Lilly's dating system was for the insulin unopened to be good for two years after it left the factory. Lilly was questioned by Health Canada because of the "gap" between valid dates of Iletin II and the arrival of the Wockhardt products. Lilly's data they presented to Health Canada indicated that an unopened vial of Iletin II would be perfectly safe and potent if it was used with one year of the expiration date on the vial. Health Canada went on record advising people that there was no problem or danger in using the vials which were expired up to a year.

From what they admitted, you can see that you can get a year's extra time from a vial.

Personally know people who have vast stocks of the old Iletins of all types and species who are using them and they are long past the dating. One person purchased a new fridge to store his personal stockpile in. All I can say is that they are doing fine with it. ;)

Kathy

[Fishslayer]

If the drug companies will go on record with "good for one year" I personally would be pretty confident with a 2 year stockpile. Remeber, if they go on record with a figure and one in a million goes south, they can be looking at a big $$$ lawsuit.

Rick

[We Hope]

http://www.hc-sc.gc.ca/dhp-mps/brgtherap/activit/fs-fi/qa_qr_insulin_02_2006-eng.php

Health Canada

Q8: "I will have unused vials of Eli Lilly's Iletin II Regular and Iletin II NPH insulin as of April 1, 2006. Can I use them past the expiry date?

A8: "Health Canada understands that there may be individuals who plan on using Iletin insulins past the labelled expiry date. While Health Canada does not recommend the use of any product past the labelled expiry date, Health Canada has reviewed stability data from Eli Lilly Canada. That data indicates that if the Iletin insulins have been stored properly, the products could be used safely up to 12 months beyond he labelled expiry date."

[BaileyBear]

Of course. But why have "enough" when you can have "more?"


Rick

Sad, but true.

Oh, well - best to be aware and have a plan B for the eventual. I will keep my fingers crossed that NPH hangs around for Bailey's lifetime. But if not, at least I know where to go for advise on what options to try next...after my stock pile runs out, lol. ;)

[pgcor]

I have to risk asking this question and looking foolish, but what else is there if NPH goes away? For Pip there was always only two choices- Vetsulin and NPH. Vetsulin stopped working for him last year.

Aren't the other insulins available for humans more specialized - like fast acting with shorter durations, etc?

[We Hope]

Pam,

The reason for the possible demise of NPH would be because most people are using analog insulins. There are some which are rapid-acting, some which are intermediate-acting and some which are long-acting.

http://petdiabetes.wikia.com/wiki/Analog

This page should give you an overview of the analog insulins; there are wiki pages there for all of them. As you see when you view the time action profile tables, the two intermediate-acting analog insulins Novolog 75/25 and Humalog 70/30 are like speedier versions of Novolin and Humulin 70/30 or 50/50. And you'll see that the rapid-acting ones are faster versions of R insulin.

http://veterinarynews.dvm360.com/dvm/article/articleDetail.jsp?id=463054&pageID=1&sk=&date=

You can also read the article based on the 2007 ACVIM presentation of Dr. Anthony Abrams-Ogg at the link above.

Kathy

[pgcor]

Thank you for explaining Kathy. I can see I need to do a lot more reading on insulins! After almost two years in treating Pip, I still wish this would just go away.

By the way, Pip has never looked as good as he does right now!!!! Some friends stopped by over the weekend and were shocked at how good he looks! I can't tell you how much that means to me!

Thank goodness for folks like you who will understand this disease a lot better than I ever will.