What to do about prednisolone induced diabetes?

My cat Vivian, 10.5 years, has been taking 5 mg prednisolone daily for three months to  treat large intestine inflammation. A biopsy did not show lymphoma but it is not completely ruled out. The pred has helped firm up her stool much of the time but not always, and she still has a small amount of blood at the end of the bowel movement. She began drinking and urinating a lot in the past 1-2 weeks, and Saturday she tested positive for diabetes with blood glucose at around 350. My vet consulted a specialist yesterday, one who had seen Vivian this winter for the IBD. The specialist recommends insulin to control blood glucose, and also agreed that if I start her on chlorambucil  (which I have been asking about for a while) I may be able to taper pred. Agh! Insulin is a huge commitment!!

Does anyone have experience with a cat who became diabetic as a side effect of pred and went into remission when pred was tapered, without insulin? I can't take the cat off pred completely (I don't think) because it has helped normalize her stool, so I assume reduced inflammation. Is it possible tapering to a smaller dose would bring blood glucose back down? I will if I have to but I REALLY don't want to put this cat on insulin. Related experiences requested.

A good place to ask is on the Feline Diabetes Message Board. They promote tight regulation and species-appropriate feeding to help manage the diabetes.

Steroid- induced diabetes can reverse when the steroids are removed. But it seems from my quick search that the steroids don't cause the diabetes, they are a tipping point.

I don't know what you feed your kitty, but just understanding contributing factors to the development of diabetes may help you make some decisions here. I'd also like to note that species-appropriate feeding (very low carb diet, no kibble) can also help control the IBD, and sometimes put IT in remission. So managing the diabetes with diet (though you must work with insulin initially to control the BG!) may also benefit the IBD.

The FDMB: http://www.felinediabetes.com/FDMB/

General feline diabetes info: http://www.catinfo.org/?link=felinediabetes

More information - all of which include discontinuing the steroid and treating the problems with other methods:

http://www.catster.com/lifestyle/cat-diabetes-steroids

http://www.endocrinevet.info/2013/01/steroid-induced-diabetes-in-cats.html

You've really been unlucky with the pred. My chf cat was on quite high doses of it, and I had a long talk to my vet about potential problems. She said cats generally tolerate it very well, and pred inducing diabetes is uncommon. I agree with LDG - the pred was likely the final straw that tipped her over. I'm so sorry you're in this position. I'm not able to offer any additional advice. I really hope you can get it under control soon

So I had a conversation with Vivian's vet, and she convinced me that Vivian stands the best chance of remission if insulin is started right away, to be followed by tapering pred when I get chlorambucil to supplement the pred. She said she thinks the insulin will be temporary, however, one never knows for sure. She said the insulin she recommends, glargine, would be $100 per bottle - turns out the pharmacy charges $375 per bottle, and it will expire long before the two to six months it would take to use the whole bottle. I'm in sticker shock.

I have checked out websites for diabetic cats, but I'm crazed right now trying to figure out what to do. Does anyone treat their diabetic cat with an insulin that costs less than this? To me this seems an outrageous price!

Wow, I had no idea that insulin was so expensive! I've met a lot of diabetic cats and boy that just shocks me. Whereabouts are you - in the States? Surely there's a less expensive insulin out there.

I live in Vermont

Cat Pal said:

 
She said the insulin she recommends, glargine, would be $100 per bottle - turns out the pharmacy charges $375 per bottle, and it will expire long before the two to six months it would take to use the whole bottle. I'm in sticker shock.

I have checked out websites for diabetic cats, but I'm crazed right now trying to figure out what to do. Does anyone treat their diabetic cat with an insulin that costs less than this? To me this seems an outrageous price!

Click to expand...

Lantus (glargine) is a great insulin to use Yes, it's expensive but well worth the cost. Tip on how to save money: instead of the 10 ml bottle buy the box of SoloStar pens instead. Each pen is 3ml and since there are 5 pens in the box, that is at least a 5 month supply you have on hand. A pen can last to nearly the last drop. Use the pen just like the bottle. You do not use it the way a Human diabetic would. The cost of the box is only slightly more than the 10 ml bottle. If you're not sure if you need an entire box, ask the pharmacist if they can sell you just one pen. I know that people on the FDMB board have been able to buy one pen at a time. Ask over on the FDMB board for more tips on how to save on insulin and other diabetic costs.

Levemir is a similar insulin to Lantus and also costs about the same. The FlexPens are typically used instead of the bottle.

Other insulins that also have good results are BCP PZI and ProZinc. Both of these are animal-specific insulins so you can only get these from the vet. I'm not sure about the costs of these. Your vet can request a free 5ml bottle of BCP PZI for you. The link is at the bottom of the BCP PZI web site.

Humulin N is cheap but does not work well for most cats. It hits hard and the effect doesn't last long. I would avoid this insulin.

I was able to buy one Lantus pen from the pharmacy and am using it with the corresponding insulin syringes sold to me by the vet.

Still very expensive to get started, but cheaper than a whole vial of insulin that will expire long before Vivian could use it all, even if she did need it all.  Vivian's vet recommends NO other insulin besides Lantus, so that is what I got, for a large price. The hope is that she can taper from the pred to the extent that the diabetes goes in remission. In order to be able to taper from pred I have started her on chlorambucil Mon-Wed-Fri, which hopefully will take over the job of addressing her large intestine/colon disease. It's all so very complicated. Vivian has had four doses of insulin, minimum dose, and seems to be doing well with it. I think I even notice less urine in the litter box already, if that is possible. I have to either bring her to the clinic for a day for a blood glucose curve, or purchase and learn how to use a glucometer PDQ so I can do it myself next weekend, if it can wait that long. Right now I am relying on keeping an eye on her behaviors, which are good, and the amount pee in the litter box, which seems to be down, of course in addition to ongoing poop patrol. I think we're in for a long haul, hoping for the best for Vivian. Anyone have a an IBD/lymphoma cat who was able to come off pred with chlorambucil? That's the goal. Thanks for tip on Feline Diabetes site, I have asked a lot of questions there and gotten some thoughtful responses.

Hi,

Just a few questions here.

What food was your cat on prior to the diagnosis?

What did your cat weigh prior to the diagnosis?

I have three cats on prednisolone and im terrified they will develop the same problem. How did you know your cat had developed diabetes?

My cats are on the drug long term which makes me very nervous, even though I have heard the pills are better than the injection safety wise.

Sarah Ann

My cat Vivian has been eating Hills DD, switched from Hills ID several months ago to address her loose stool with blood. The food had no effect, nor did metronidazole or B12. After a biopsy that was not conclusive of lymphoma even though ultrasound images and symptoms are consistent with it, I began treatment for IBD with prednisolone three months ago. Vivian's weight had already gone down from 13 to about 10 pounds, and has not changed significantly since then. She is quite a long cat, so with this weight she is actually quite skinny. You can feel the bones beneath her skin by touching and petting her,  though this does not seem to concern the vet. Vivian has lost a lot of fur, also probably a side effect of pred, which I guess accentuates her thinness, also hair shaved for ultrasound has been very slow to grow back. I knew something was wrong when I began to see a large volume of urine in the litter box, and to investigate which cat was producing it, there are two in the household. Paying very close attention, I could see that Vivian was making lots of trips to the water bowls and the litter box, which began to be soaked with urine within a day or two. It happen rather quickly. If you use clumping litter, which I do not, I suppose you would see an increase in clumps. Some people weigh their litter box so they know how much heavier it gets (with pee) on average between cleanings. I don't do this and relied on knowing what it usually looks like after one and two days. The amount of urine Vivian has been putting out would have been hard to miss, as she is really saturating the litter. Besides drinking and peeing, weight loss, poor coat and body condition, the cat is often hungrier than usual. I do know that Vivian's appetite has been good throughout her ordeal and she sometimes cries for the wet food as I am preparing it in the a.m. and p.m. - something she didn't do before, but canned food is also a switch in the last few months. Increased hunger can be a side affect of pred AND a symptom of diabetes, so tough call...She gets about 1/5 can of food plus 1/4 cup of kibble twice a day. 

People have commented and I have heard them - "IBD, diabetes cats should eat only canned food" - I haven't quite got there yet. I'm feeding 2 cats who have eaten dry prescription food for 10+ yrs.

"Prednisolone is a culprit in causing diabetes in cats, but may just be the tipping point in cats who were on the verge of becoming diabetic already" - this could be true, but I am hoping that by tapering pred and replacing with chlorambucil I can bring her blood glucose back to normal, eliminating the need for insulin AND still addressing intestinal trouble. Such a complicated balancing act.

My other cat Willis was on pred for two weeks to address chronic rhinitis/sinusitis and he ended up getting super sick. Presumably the pred suppressed his immune system enough to allow some sort of acute infection to take over, and it raised his liver enzymes far above normal. The liver enzymes came back down and the acute respiratory illness was treated with long term antibiotics; we continue to search for a safe effective treatment for chronic rhinitis. 

Of note is the fact that fewer cats react adversely to pred than dogs, lots of people treat their cats with pred long term without obvious harmful side effects. So my cats are among (the minority?) who reacted poorly I guess. As I have learned more about pred I have learned that it may be ideal to give it only every  other day so it doesn't completely take over the job of the adrenal glands, allowing them to atrophy.

My vet has had me giving it to Vivian every day for 3-4 months, because Vivian really needed something to treat the intestinal inflammation and resulting symptoms. We were going to re-examine that and decide what to do next right around now anyway. Since her GI symptoms are not completely resolved, chances are good that I would have proceeded to chlorambucil even if diabetes had not happened.

Depending on how you dose your cats you might consider the same. The thing is, if they are sick enough, they need something to address their sickness and you have to weigh the risks and advantages.

If pred addresses their symptoms and has no apparent side effects, chances are it's ok to continue, lots of folks do. If you're really concerned, you can ask your vet about pred alternatives. They are out there. Vivian was quite sick and needed something to address inflammation, pred helped, unfortunately it also hurt. It's a very tough situation. 

If you are super scared of this happening to your cats, have their blood glucose tested, it's a simple blood test, quick results, relatively inexpensive - by the time cats are drinking and peeing a lot I guess the situation has already progressed a bit. I probably should have had Vivian tested earlier, hindsight it 20-20. Hope this helps. As I said, I knew these risks existed, thought they were minimal and chose to give Vivian the pred because she needed it.

.

Cat Pal said:

 
I was able to buy one Lantus pen from the pharmacy and am using it with the corresponding insulin syringes sold to me by the vet.

Still very expensive to get started, but cheaper than a whole vial of insulin that will expire long before Vivian could use it all, even if she did need it all.  Vivian's vet recommends NO other insulin besides Lantus, so that is what I got, for a large price. The hope is that she can taper from the pred to the extent that the diabetes goes in remission. In order to be able to taper from pred I have started her on chlorambucil Mon-Wed-Fri, which hopefully will take over the job of addressing her large intestine/colon disease. It's all so very complicated. Vivian has had four doses of insulin, minimum dose, and seems to be doing well with it. I think I even notice less urine in the litter box already, if that is possible. I have to either bring her to the clinic for a day for a blood glucose curve, or purchase and learn how to use a glucometer PDQ so I can do it myself next weekend, if it can wait that long. Right now I am relying on keeping an eye on her behaviors, which are good, and the amount pee in the litter box, which seems to be down, of course in addition to ongoing poop patrol. I think we're in for a long haul, hoping for the best for Vivian. Anyone have a an IBD/lymphoma cat who was able to come off pred with chlorambucil? That's the goal. Thanks for tip on Feline Diabetes site, I have asked a lot of questions there and gotten some thoughtful responses.

Click to expand...

Lantus is the insulin of choice for diabetic cats Definitely ask questions on the Feline Diabetes Lantus specific board for in depth tips on how to use the insulin. I know there are members there who have steroid-induced diabetics who were able to get the cat off insulin fairly quickly and manage both the diabetes and the other health issues pretty well.

It's cheaper and much more accurate to do your own blood glucose curves at home. Stressed out cats at the vet office will often have elevated blood glucose levels. There is a bit of a learning curve but once you get into a routine and figure out what works best for your cat, testing and giving insulin takes under a minute to do.

Is the dose 1 unit twice a day? That's a good dose. Some people even start at 0.5 units. It's hard to eyeball that on a regular whole unit marked syringe but there are special half unit marked insulin syringes that will make life a lot easier.

Vivian is taking 0.5 U of insulin twice a day, 5 mg prednisolone once a day and 1.8 mg chlorambucil M-W-F. Hoping to get her off the pred, or at least reduce enough to bring down BG. I have to teach myself to take her BG so I can make an insulin curve Sat., or if I can't, bring her to the clinic Mon., b/c it needs to get done. Good to know there are insulin-induced diabetes success stories. I have reached out on Feline Diabetes but so far have not caught the attention of anyone in a similar situation to Vivian's -

thanks!

Cat Pal said:

 
Vivian is taking 0.5 U of insulin twice a day, 5 mg prednisolone once a day and 1.8 mg chlorambucil M-W-F. Hoping to get her off the pred, or at least reduce enough to bring down BG. I have to teach myself to take her BG so I can make an insulin curve Sat., or if I can't, bring her to the clinic Mon., b/c it needs to get done. Good to know there are insulin-induced diabetes success stories.

Click to expand...

One thing to know about Lantus is that it takes a few days for a dose to "settle" (start working on blood glucose levels). Lantus works on an "insulin depot ". I think you could try for a curve on Saturday. The most important times to test are right before insulin in the morning, one  around 6 hours later, and right before the evening insulin shot. Three numbers won't tell too much so try to get at least two more tests in when you can. 2 hours after the morning insulin and 8 or 10 hours after insulin are good times.

Cat Pal said:

 
I have reached out on Feline Diabetes but so far have not caught the attention of anyone in a similar situation to Vivian's -

Click to expand...

One thing that helps to get the attention of FDMB members is to be specific in the subject of your message, such as " Need help from others with steroid-induced diabetics" instead of a general "Newbie needs help". I think you can edit your post to change the subject. Once you do that, you can bump up your own thread to the top of the board.

Great information, I wasn't clear about when to do first morning test for curve, thank you.

I changed the title of my post in Feline Diabetes to include the language 'steroid induced'. It's possible if people have steroid induced diabetics who went into remission they don't follow the board any longer, or as much. I wouldn't. Vivian has been on Lantus for a week, so that should be long enough to get I curve I think. I'm going to teach myself about BG testing today, will use myself as guinea pig - gah!

One thing that makes me nervous about BG testing on Vivian is that she is already a bit freaked out by new meds, the way she feels on chlorambucil and our efforts to get her to eat. We've actually lost her to new hiding places a couple of times and had to dig her out of spots for treatments, it's been hard for everyone, human and feline. Can't imagine how she'll react to getting stuck in the ear every couple of hours, but will try. If she's doing reasonably well on chlorambucil after a week (today's dose will be a week), we will start a taper of the pred.

Any experiences tapering 5 mg daily pred? I would imagine it's a slow process after three months on it.

thanks again!

Cat Pal said:

 
Great information, I wasn't clear about when to do first morning test for curve, thank you.

Click to expand...

Typical routine is test, feed, give insulin. I always tested and gave insulin while my cat (now GA) was busy stuffing his face with food For testing in between times, I was able to just test him without a food reward. He was pretty laid back about being poked multiple times daily. I could even test him while he was sleeping. There's a great spreadsheet template on the FDMB site to track your cat's blood glucose levels.

Did your vet give you a no insulin blood glucose number? This is the cut off number in which no insulin is given. It varies for every cat but FDMB generally recommends no insulin under 150 mg/dl. If you get a number under that, you would feed the cat as usual, re test the blood glucose level in about half an hour, and if the level has gone over 150 give the usual amount of insulin. If the level is still the same, it's best to skip giving insulin unless you have been doing the diabetes routine for awhile and have the blood glucose data to back up giving a reduced insulin dose.

Cat Pal said:

 
I changed the title of my post in Feline Diabetes to include the language 'steroid induced'. It's possible if people have steroid induced diabetics who went into remission they don't follow the board any longer, or as much. I wouldn't.

Click to expand...

Those people may be hanging out over in the Community forum so you may need to post there and ask for people to look in at your thread. Is this your post? There are a few responses there. Larry and Kittens is an old timer (been on the board for years) and always has good advice. You may also want to post in the Lantus specific forum. Sometimes people with former steroid induced diabetics and who used Lantus hang out there.

I no longer post on FDMB. I stayed around for awhile after my cat passed away and entertained the Lantus users at that time stories about my new crazy hyperactive Aby