complicated case – underweight w/steroid-induced FD & IBD (tentative – cannot do biopsy to confirm)

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kxk34

Member Since 2022
UPDATED (2/14): This thread was initially created when Fuzzy was having a few days of inappetence after an outlier day where her BG dropped suddenly very quickly. The issues with appetite/eating described below have since resolved. Fuzzy's appetite returned to normal on Friday and the past few days have been good for her :)

After her big BG drop on Tuesday the vet said she got pretty bad diarrhea at the office (my guess is it might have been from the stress/syrup because she is sensitive to anything new) and when she's had liquid diarrhea in the past it's taken her 1-2 days to bounce back to normal so it looks like (hopefully) that is all that happened in this case. She also had blood work checked at her appointment last Thursday and there were no immediately concerning changes to any abnormalities

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This is going to be a pretty long post and I apologize for that, but I'm getting really worried about Fuzzy and I'm not sure how to proceed and am just in general very sad and scared that we're nearing the end if this continues...

Yesterday morning Fuzzy had a noticeably smaller appetite than usual, but was still excited to eat breakfast and did not act too finicky with her food. She did not each much after her insulin shot and as I posted here yesterday her BG dropped very fast and to a much lower level than we've previously seen. We suspect that it might be because she did not eat enough beforehand given the reduced appetite, but are not entirely sure if that was the only factor or what. We took her to the vet after giving her some syrup because she dropped from 89 to 76 within 15-20 minutes and we were scared of her dropping further and becoming hypoglycemic. When they tested her at the vet she had a value of 112 which they attributed to the syrup beginning to kick in. They said we could bring her home or she could stay there for the day and they could administer glucose if she dropped again and needed stabilizing. At the time, we thought it seemed like the safer move to leave her there but now I'm not so sure. She arrived there between +3.5 and +4 and left sometime shortly after +8 and looking at the readings they took there, it looks like her BG levels increased throughout the afternoon even as she would usually be reaching nadir which seems most likely was due to stress of being there since they said they were unable to get her to eat while she was there.

When she got home from the vet a little after 3 PM she immediately seemed very hungry and ate a good amount, but mostly wanted her dry food which is a bit unusual. She seemed pretty worn out from the day at the vet and fell asleep a while after that and when we woke her to up to try to get her to eat she was not really feeling it and we did not want to risk another episode like what happened in the morning so we did not give her the PM dose of insulin. We did test her a couple times during the night just to check how she was doing and she was in the 300-399 range both times.

This morning her AMPS was 323 which is the lowest we've seen from her (her AMPS has been all over the place so this was not a crazy outlier or anything like that, it just happens to be the lowest it's been). Unfortunately, her appetite was even worse than yesterday. She seems to be refusing her wet food entirely and is only interested in the dry food. We were able to get her to eat a little less than 1/4 of a cup of dry food and did not feel comfortable giving her the morning dose of insulin because of her strange inappetence and lower AMPS given what had happened the day before. We kept trying to encourage food all morning thinking we could always shift the cycle times if need be, but she just kind of nibbled here and there. The only point during the day that she ate a good amount and seemed to have a more normal approach to her food was directly after we gave her subQ fluids around 11:30 am ET. Tonight she is similarly refusing her dinner. All day she has acted really turned off by the wet food. We even tried offering her Fancy Feast and baby food like she used to get before we had to switch her to hydrolyzed food for IBD and even that stuff did not tempt her. She would normally get her insulin around now, but she's currently not eaten enough or acting interested in eating enough that it seems like we'll be able to follow through on that (at least not on time anyways, unclear how the night will progress).

We're getting really scared about where this is headed and we're not sure what could have sparked this downturn since the lessened appetite seemed to start before the incident yesterday. I am scared what happened yesterday might have been stressful enough that her IBD is causing problems, but I don't know how to make it better. She had cerenia both yesterday and today. The odd thing is usually she eats a good bit of food then wants to go snuggle in the living room on the couch, but today sat in the kitchen a lot like she usually does when we've picked up her food during the pre-PMPS period when she gets fussy about wanting to eat. There were a few times when I took her from the kitchen to hang out with me in the living room and she went back to sit by where she usually gets her food, but every time she did not eat more than a bite or two when we tried to encourage her.

This is really scary because this is exactly how she behaved all throughout the fall as we were trying to figure out what was wrong with her appetite and had not yet diagnosed her IBD (this period ultimately led to that diagnosis). There were so many weeks that were just like today where she would just sit in the kitchen by where she gets her food, but not eat more than a bite or so at most when encouraged. During this period she was getting cerenia daily in addition to mirataz near-daily. The mirataz most of the time just seemed to make her kind of manic and restless, but did not do much to help get her to eat at all. Weirdly, she randomly started eating normally without the mirataz/cerenia after a day at the vet where she had been in for some fasted blood work and then her appetite improved a great deal when we started giving her the hydrolyzed food, with exception of a 2-3 day period during the transition to it where she had bad diarrhea and seemed to feel very sick. The notes from the vet yesterday did say that she had diarrhea there, but it is unclear whether that was the sort of diarrhea-type stool we see regularly since starting her on the hydrolyzed food or if this was worse than that (possibly from the syrup). If it was the latter type it seems possible that could be what's going on to make her appetite worse if she's still not feeling well, but we don't know.

We've tested her urine with ketone strips twice today – both negative for ketones. We've also checked her BG several times – all were in the pink/red. Is there anything else we need to be checking or doing to ensure that she is safe while unable to give her insulin and only getting her to eat a few bites of food here and there? I'd also be curious if anyone has any theories as to what could be going on with her.
 
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I'm sorry if I overlooked it but could pancreatitis be a possibility? My cat had it last month and one of his first symptoms was wanting to eat but refusing to touch his normal food.
 
I'm sorry if I overlooked it but could pancreatitis be a possibility? My cat had it last month and one of his first symptoms was wanting to eat but refusing to touch his normal food.

Thank you for your response! While we were trying to diagnose this same sort of behavior in the fall Fuzzy had ultrasounds and special bloods tests done that did not indicate pancreatitis was an issue so I'm hoping that is still the case.

It honestly could be a flare up of her IBD since she's been like this before. It's just very odd to have it happening now given how hungry she must be without getting her insulin so I'm not sure what to make of it and am worried about her being at risk for ketones if she does not eat enough to get her insulin soon :/
 
Thank you for your response! While we were trying to diagnose this same sort of behavior in the fall Fuzzy had ultrasounds and special bloods tests done that did not indicate pancreatitis was an issue so I'm hoping that is still the case.

It honestly could be a flare up of her IBD since she's been like this before. It's just very odd to have it happening now given how hungry she must be without getting her insulin so I'm not sure what to make of it and am worried about her being at risk for ketones if she does not eat enough to get her insulin soon :/
Taz's pancreatitis came out of nowhere but I recognized the signs and kept insisting that he be checked for it, even though the vets kept telling me he most likely didn't have it. 4 days in the vet's and almost $6,000 later, he came home and we had to syringe feed him, while shoving numerous pills down him, AND starting insulin. It was a very stressful few weeks. My heart goes out to you and I hope you find answers quickly so your baby can feel better.
 
Taz's pancreatitis came out of nowhere but I recognized the signs and kept insisting that he be checked for it, even though the vets kept telling me he most likely didn't have it. 4 days in the vet's and almost $6,000 later, he came home and we had to syringe feed him, while shoving numerous pills down him, AND starting insulin. It was a very stressful few weeks. My heart goes out to you and I hope you find answers quickly so your baby can feel better.

Wow I'm so glad that you knew about it and could advocate for him. I'll ask about it tomorrow when we do blood work at the vet. Thank you!
 
Poor Fluffy. It is always stressful when they don't eat.
I would suggest it might be pancreatitis too. Did Fluffy get any anti-nausea medication at the vet.
You need to be careful if you aren't giving her insulin and she isn't eating because that's how DKA happens. Perhaps consider syringe feeding. I guess you can talk to your vet about it tomorrow.

I hope Fluffy feels better soon and gets his appetite back.:bighug:
 
I would also make sure you get some antinausea medications as eating is really important.
I would also get a bottle of Ketostix and test the urine for ketones…..oops I see you tested for ketones..great!
Are you skipping any doses of insulin? It looks as if you may be skipping the last couple of doses. This is not a good idea, especially when she is not eating. A half dose should be ok as cats that are fasting for an operation are given a half dose of insulin. Insulin is used in the body for more than just helping metabolise the food.

The blood tests for pancreatitis are a snap fPL which will tell you she’s/no or a spec f PL which will tell you a number a to have severe it is. They are not routine blood tests.
 
If you are hometesting, a fructosamine test is a waste of money.It might make the vet feel better because they seem to understand fructosamine tests more than they understand hometesting.
I see you are giving cerenia…maybe ask for some ondansetron…it is better for nausea then Cerenia and can be given 8 hourly
If she will only eat the dry at the moment…that is fine. The most important thing is that she eats something. My kitty Sheba, how used to get pancreatitis, would only eat dry food when she started to eat again. So I let her until she went back to wet, which she always did.
1/4 cup of dry is a fairly good meal I think….I haven’t given dry for years but from what I remember 1/4 cup would be enough to give a dose of insulin.
Not eating and not giving insulin are two of the three ingredients for the recipe for DKA so please make sure you give at least some insulin and get an antinausea medication that works so she will eat. If she does have pancreatitis she will need subQ fluids, pain meds, and anti nausea meds.
 
Poor Fluffy. It is always stressful when they don't eat.
I would suggest it might be pancreatitis too. Did Fluffy get any anti-nausea medication at the vet.
You need to be careful if you aren't giving her insulin and she isn't eating because that's how DKA happens. Perhaps consider syringe feeding. I guess you can talk to your vet about it tomorrow.

I hope Fluffy feels better soon and gets his appetite back.:bighug:

Thank you! The blood work she got today at the vet did not show any abnormalities consistent with pancreatitis so I'm hopeful that is not it. She takes cerenia as needed for nausea. Thankfully she ate food after we heated it up today so she got insulin this morning :)
 
I would also make sure you get some antinausea medications as eating is really important.
I would also get a bottle of Ketostix and test the urine for ketones…..oops I see you tested for ketones..great!
Are you skipping any doses of insulin? It looks as if you may be skipping the last couple of doses. This is not a good idea, especially when she is not eating. A half dose should be ok as cats that are fasting for an operation are given a half dose of insulin. Insulin is used in the body for more than just helping metabolise the food.

The blood tests for pancreatitis are a snap fPL which will tell you she’s/no or a spec f PL which will tell you a number a to have severe it is. They are not routine blood tests.

She did not get insulin yesterday because of her appetite (unfortunately we are at 1u of insulin and the syringes we were given would be difficult to measure less than 1u so we did not want to risk it since the vet did not advise). Thankfully today she ate readily once we heated up some of her wet food so she got insulin this morning (:

She got a test like that previously, but the vet did not want to put her through additional blood draws since she did not think it seemed likely based on the regular blood work we got done today.
 
It is possible to draw up less than 1 unit of insulin. As you are using Prozinc, which I do not use, I will ask @FrostD to look in.
If your kitty is not eating and you don’t give insulin, there is a real risk of ketones forming which can lead on to DKA. It is good you are testing for ketones but if this happens again I would look at giving a smaller dose, not skipping. You could try practicing drawing up a 1/2 unit. @FrostD are there 1/2 unit syringes for Prozinc?
 
Do you have a preference on needle length? For example I dislike the 1/2" needle, I feel it's too long. I prefer the 5/16".

Hold the 1U for now because of those greens a few days ago. I'm going to come back to this later tonight and brainstorm
 
Ok few thoughts:
- seconding the ondansetron suggestion, that has always worked better for me for nausea.
- Mirataz only works if nausea is gone, otherwise it just makes them pissy (I would be too). Sometimes that's enough to get them over the hump. Other things that can help are tuna water (without the onions or celery, etc) or probiotics sprinkled on too, even some crushed up dry food or freeze dried treats.
- did they do a weight check today?
- I forget, is she on anything for the IBD? Pred, budesonide, etc? Probiotics, prebiotics? Or just the diet for now?

The dry food is contributing to the wonkiness, it's most important that she eats anything at this point, I'm just pointing that out if you're trying to make sense of the numbers.
 
Do you have a preference on needle length? For example I dislike the 1/2" needle, I feel it's too long. I prefer the 5/16".

Hold the 1U for now because of those greens a few days ago. I'm going to come back to this later tonight and brainstorm

We just have the needles that the vet provided for us so I'm not quite sure what the specifics are or our options there. If I recall correctly we actually went with the ProZinc over the Lantus because the vet she was seeing said that it would be easier if we needed adjustments smaller than 1u, but maybe she meant in addition to the 1u? I'm not sure.

I'm glad that you think holding the dose there for now is advisable. I was thinking we should hold the dose there for now too. Before this drop, I was originally thinking we needed to increase as soon as possible, but now I'm a little confused on how to think about the way this affects Fuzzy. She dropped so fast the other day... that morning her appetite seemed decent, just less than usual, and she still ate enough food that my partner thought it would be fine without hesitation but then it really wasn't... :/ the vet wanted to hold off to reassess next week anyways so we just agreed to that for now since we don't know what her appetite is going to do these next few days at this point since her blood work today showed low phosphorous and low calcium and the vet said that can sometimes indicate absorption issues which could be from the stress of Tuesday worsening her GI inflammation :/


Ok few thoughts:
- seconding the ondansetron suggestion, that has always worked better for me for nausea.
- Mirataz only works if nausea is gone, otherwise it just makes them pissy (I would be too). Sometimes that's enough to get them over the hump. Other things that can help are tuna water (without the onions or celery, etc) or probiotics sprinkled on too, even some crushed up dry food or freeze dried treats.
- did they do a weight check today?
- I forget, is she on anything for the IBD? Pred, budesonide, etc? Probiotics, prebiotics? Or just the diet for now?

The dry food is contributing to the wonkiness, it's most important that she eats anything at this point, I'm just pointing that out if you're trying to make sense of the numbers.

We ended up being able to get her to eat by heating up her wet food (I don't know how we didn't think of this yesterday because we've done this before and it's worked sometimes).

She weighed 3.67 lbs today (they checked in office but we also weigh her frequently at home).

She is on a few different things for IBD, but we are going to be making some adjustments because we have been unhappy with some aspects of her treatment. She is currently on prednisolone and metronidazole, in addition to being on the hydrolyzed diet. She gets a probiotic on her food (I believe it is called proviable) and she gets b12 shots every 2 weeks and a b-complex shot every week. She also sometimes gets a potassium supplement as a gel depending on what her levels look like.

Our vet just returned from maternity leave so we discussed making a few changes based on our experiences the past few months. The first change was to her prednisolone dose and the second change relates to her food. Fuzzy was getting 5mg pred daily, but we reduced that today to 3/4 of a 5 mg tablet. I'm really not comfortable with the calculation used for the starting dose of her pred (4.4 mg/kg/day) and she's lost weight since the dose amounts were calculated without any adjustments to the dosing made. She's also clearly had negative side effects from the pred (diabetes, muscle wasting, hair loss), plus accelerated weight loss and no noticeable improvement beyond mostly maintaining the improvement initially shown after she started eating more consistently and started getting vitamin b-complex and b-12 injections. So I want her tapered to a lower dose of the pred.

Regarding her food, we spoke to our vet about how Fuzzy only started getting diarrhea regularly when we made the switch to hydrolyzed food and was not a symptom we ever saw before the evening we made the switch. Fuzzy really likes the hydrolyzed food so we've been hesitant to change anything given how picky she can get but it's not great for her diabetes and it's been stressful seeing continuing diarrhea written as a justification for not reducing her pred dose week after week when we are very confident that the diarrhea is not actually attributable to her IBD... our vet said that if it coincided with the change then we should work on starting to transition her to other food so we plan to do that. We are going to look into getting a novel protein to add to her diet so hopefully we can find her a wet food she really likes so she goes back to gravitating less towards her dry food.
 
Ah ok thank you for refresher.

Did she have an endoscopy at any point to confirm IBD vs SCL? I think I asked when you first joined but I've forgotten. I'm guessing she's not exactly ideal candidate for that right now. Have you discussed possibly starting something like chlorambucil? Since youre doing everything you can to treat the IBD and not seeing results, I'm wondering if it may be SCL (although pred is recommended first line of defense for that anyway).

The metronidazole is curious, I thought that is mostly for SIBO? Does she have that? Since she's on it long term, are her liver values still ok?

I don't think food is the only explanation for that low the other day; it factors in sure, but with everything else she has going on it's all contributing.

When you get a chance, and I realize this asks a lot - in the remarks column can you note when she gets the pred (I e. @ PS, +10, whenever you give it) and then any food changes (carb % and wet/dry is most helpful - so things like 1/4 cup 30% carb dry or things like that). Dose changes for meds, timing changes for meds, even things you don't think would affect BG. Because she is such a complicated case, it helps to have anything and everything.

I am torn. Because it really appears she needs more insulin, but that green really doesn't leave you any room. So my first order of business is trying to figure out if anything else influenced that - med timing, dose, food - keeping in mind it may not have been that day, it could have been something in the few days prior.

An insulin like Lantus would likely be better for her, but I suspect you'll still see the same wonkiness due to food and the other underlying issues - just perhaps muted a bit.
 
Ok I actually can't find the shorter needles. So what you want to look for is U-40, 0.3cc with half unit markings. Gauge does not matter. There's a lot of options and price shopping so unfortunately I can't be of much help with links. I used the Ulticare ones for a long time and really liked them. Advocate Pet Test has awkward markings. CarePet , BD, and Monoject are some other popular ones.

Just send us a link to ones you are thinking about and we can review for yoi
 
Hi! So sorry about the delayed response. The big scare last Tuesday and associated concerns the rest of the week put me a good bit behind on work so I got tied up trying to catch up on a some things. I’ve tried to quote your last reply in pieces so make it easier to follow my response, but if this is not the preferred way to approach that please let me know so I can refrain in the future.

Ah ok thank you for refresher.

Did she have an endoscopy at any point to confirm IBD vs SCL? I think I asked when you first joined but I've forgotten. I'm guessing she's not exactly ideal candidate for that right now.

Unfortunately she did not. By the time we were investigating potential gastrointestinal issues she was already in poor enough shape that there were concerns about her ability to handle anesthesia. We also would have needed to take her to a referral center elsewhere in the state and up until last month she used to get intense car anxiety (including crying, vomiting, defecating, drooling, gas, etc. even while medicated and on short drives) so we were worried the combination of the journey + her poor body condition and health issues would be too hard on her. Unfortunately, she is currently in much worse condition than she was back then (in terms of her body condition) so at this point anything requiring anesthesia is off the table unless her circumstances change.

I’ve uploaded images of the results of her Texas A&M GI panel, VDI Lab Feline GI Lymphoma Panel, and the consult report from the abdominal ultrasound she got in November here: https://imgur.com/a/WRqfzKR

Have you discussed possibly starting something like chlorambucil? Since youre doing everything you can to treat the IBD and not seeing results, I'm wondering if it may be SCL (although pred is recommended first line of defense for that anyway).

We had originally discussed trying chlorambucil if she did not show improvement, but both vets who Fuzzy saw while our vet was on leave thought that it might be much for her to handle at this point in time (and the vet I trust more of the two seemed confused and concerned that it was even on the table given her condition and poor general prognosis). Based on that, I’m really not confident she’s strong enough to handle that and I want to make sure we need to go there first before doing so.

I’ve been doing a lot of research and thinking about where we are with her IBD treatment and how we got here and have come away feeling weird about it all because it really is hard to say whether everything we thought we were doing was really effective in the way it was carried out initially (if that makes sense). As I've mentioned previously, the situation with her vet being on leave at the time put us in a tough spot and we have been really dissatisfied with the way that things played out with the one vet who treated Fuzzy most frequently during her regular vet’s absence. So while we're doing all these things and not seeing results, it seems pretty clear there are some real caveats to that conclusion because of how everything transpired. At this point I almost feel like we need to try to alleviate some of her iatrogenic problems (like her diabetes) to get a better idea of her ability to gain weight while that is less of a complication because honestly the timing of everything didn’t leave us much room to actually do that before she likely developed the diabetes.

Both timing issues that complicate our understanding of how she’s responding to treatment have to do with the two things I’ve mentioned previously that we were really not comfortable with regarding the vet’s instructions.

The first was the insistence that we switch her to a hydrolyzed diet without a transition period. This occurred over Thanksgiving week. This made Fuzzy very sick for a few days (though I realize now after looking into it more recently that we’re lucky it wasn’t a whole lot worse). After a couple days of bad diarrhea, she had a poor appetite and did not poop much for another day or so and then when she perked up finally her poop was still often closer to diarrhea in color and form than to how it was previously. We were told this could happen sometimes and we didn’t think it would be a bad thing since it was from food we were told would help her as opposed to disease progression. We realized this was an error in how we were thinking recently when we noticed on her chart that the vet referenced a time she had diarrhea at the office in her justification for not adjusting her pred or taking her off the metronidazole. This was frustrating for us, because we had raised concerns about her poop to the vet at the time because she had never had poop like that before we made the change and we were told that this could be due to her IBD worsening (which seemed implausible).

After one conversation with our normal vet last week, she said clearly it is not agreeing with her and that Fuzzy should be transitioned off. We only made one change to her diet so far, which was to just mix some of her old dry food in with the hydrolyzed dry food (so it’s about 30/70). Every poop she has had since making that very minor change has been fully formed to an extent we haven’t seen since November and is more normal in color than it has been since then as well.

The biggest issue of all is that we were very much pressured into putting Fuzzy on the pred right away. We weren't against doing it, we just wanted to give her a chance to try a new diet and to see if the first set of treatments we'd started helped the situation at all. This is where the metronidazole comes in (more on this below). She was initially prescribed metronidazole with the hope that it would help with inflammation and that the combination of metronidazole + changing her diet would be enough for her to show improvement without the addition of a steroid. Unfortunately, we were pressured to go directly to the pred and ultimately caved to that pressure only 9 days after Fuzzy had started to get adjusted to eating the hydrolyzed food.

Looking back at our log of her urination/drinking habits, we now suspect that she may have developed diabetes from the pred around December 19th because she went from peeing about 4-6x daily before that date to about 8-13x daily and there is a marked increase in her water consumption as well. If that is the case, then it means that she may have only on been on the pred for 10 days before her condition became more complicated by diabetes. This is very disheartening given that the whole reason we were pressured to put her on the pred was because of her desperate need to gain weight and my understanding is that it is unlikely she will be able to do so while her diabetes is so poorly controlled. I’m also concerned that the higher dose of pred she was on before was really driving her muscle wasting because of the timing of everything.

The metronidazole is curious, I thought that is mostly for SIBO? Does she have that? Since she's on it long term, are her liver values still ok?

Fuzzy was initially prescribed the metronidazole with the hope that it would help reduce inflammation and help us get her to a better weight without needing to put her on a steroid, but the vet continued it even after starting the steroid on the rationale that it is often used when diarrhea is an issue. Realizing that this was still the explicit rationale after the last few appointments is what prompted us to re-evaluate the food issue because we suspected (and have now confirmed) that the issues with her soft poop was from the food and not her IBD symptoms.

I’ve also read more about metronidazole since she was first prescribed and am increasingly uneasy about her staying on it much longer given the limited evidence that it does much beyond what a steroid accomplishes when used together and the risk of neurotoxicity, especially since Fuzzy had noticeable neuro symptoms from nutritional deficiencies during the fall. However, because the first priority was lowering the pred dose given the diabetes situation, etc. our vet did not want to make more than one medication change at once so that it would be easier to assess how Fuzzy does at lower doses of pred.

So far her liver values have not worsened on blood work except that she has an elevated ALT value which the vet told us they see a lot in cats who are on pred. Her liver is something that I have been worried about for a while because the ultrasound consult had mentioned a few things about it that sounded concerning to me (but the vet said that it wasn’t anything we could worry about at this point in time).

I don't think food is the only explanation for that low the other day; it factors in sure, but with everything else she has going on it's all contributing.

When you get a chance, and I realize this asks a lot - in the remarks column can you note when she gets the pred (I e. @ PS, +10, whenever you give it) and then any food changes (carb % and wet/dry is most helpful - so things like 1/4 cup 30% carb dry or things like that). Dose changes for meds, timing changes for meds, even things you don't think would affect BG. Because she is such a complicated case, it helps to have anything and everything.

I am torn. Because it really appears she needs more insulin, but that green really doesn't leave you any room. So my first order of business is trying to figure out if anything else influenced that - med timing, dose, food - keeping in mind it may not have been that day, it could have been something in the few days prior.

We actually have been adding notes to each cell in the spreadsheet with that sort of information, but I didn’t realize when we started that there does not appear to be a way to make those notes viewable on the shared version published to web so I need to go through and try to figure out the best way to record the same information but so that others can view it as well. I probably will not be able to until Tuesday or so unfortunately but I will try to get that sorted as soon as I can.

Thank you so much for taking interest in this and for being so willing to review her information and help us. We really appreciate it.

An insulin like Lantus would likely be better for her, but I suspect you'll still see the same wonkiness due to food and the other underlying issues - just perhaps muted a bit.

If Lantus would be better for her we’d certainly be open to going that route instead. The only issue is if our vet wants to try to tweak her ProZinc dose first.

I am honestly very worried about Fuzzy’s BG remaining as high as it’s been for much longer.

She had an intermittent plantigrade stance at home for a while during the fall that improved with weekly B12 injections, but we recently moved to once every two weeks (per the vet’s instructions) and I’ve noticed the last few days that when she does get a plantigrade stance it seems worse than it was previously so I’m concerned about potential diabetic neuropathy… but to be honest I’m still a little confused on the specifics of how that potential complication arises and whether we can improve the situation day-to-day before achieving more controlled diabetes overall so I could be wrong..

It also just feels like we’re letting too much time pass without making adjustments after being so lucky to catch this development when we did. After losing over two weeks to the vet dragging things out (first wanting us to stay at once a day for some reason, then wanting to hold the 1u dose for a week after the pm dose was added) it feels like every day we don't try to adjust things we're wasting precious time and worsening her odds of turning things around... But at the same time I’m nervous to tweak the dose at home myself after being told to wait given what happened last week and not understanding exactly how to avoid a drop like that going forward.

If there is any other information that would be helpful for you to consider that would be included in her patient history chart from the vet, please let me know and I will get that together as well. Thanks so much for looking over her values, etc. — I really appreciate it.
 
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I'm going to tag @Katherine&Ruby and @Wendy&Neko because they are much more well versed in this (IBD, pred, antibiotic, etc than I am). To make it easy for them, can you summarize the supplements, meds, doses, and frequency in a short list?

From what I understand, if she were my cat - I would discontinue the metronidazole. I don't see the point, which truthfully is why I asked about it. Antibiotics mess with gut flora so I really don't think that's helping anything.

Truthfully I would keep the pred, though you do say she's having side effects. I'm not entirely convinced those are from pred, but the two ladies I tagged would know better than I. Prednisolone should not be affecting liver that much I don't think (Prednisone would, because liver has to metabolize it to usable prednisolone). Budesonide, the other usual option, is more heavily metabolized in the liver. I can understand the concerns about chlorambucil. Again, tagged ladies will know more.

It is true her FD isn't helping things, but unfortunately for you it's a fairly complicated case. You cannot treat one vs the other, they are all intertwined. The priority is treating whatever she has going on GI - wise. We adjust insulin last to account for everything else, at this point I wouldn't care what medications she needs, we can work around it with insulin.

I'm not sure why those green numbers happened, but it's been too long since then in high numbers. You have a choice here - if it were my cat, I'd increase to 1.5U and keep a very close eye on her, meaning +2 or +3 tests every cycle, this will allow you to catch any big dives early enough to prevent low numbers. A larger increase does carry a fair amount of risk at this point, which is why I'm saying those tests need to be done. Realistically, if that same odd drop happens again, she could end up in 30s or 40s if you aren't testing to prevent it, we absolutely do not want them in those numbers. I'm also assuming you have hypo kit and plenty of spare strips.

You could conservatively go to 1.25U but given her weight and other challenges, there's the risk of neuropathy (already happening but treatable) and ketones/DKA by taking the slow and steady path. I do not think she would survive DKA. I would still do the +2 or +3 tests every cycle. If the odd drop happens again, she'd probably end up in the 50s if not caught. Still safe number but don't want her lower.

I'm sorry I don't have a clear answer for you, but hopefully it's enough for you to choose the best option for your situation.
 
Hi Kaitlyn & Gideon,

I'm really sorry that you have found yourselves here with Fuzzy. There's a lot of history to digest, but I'll tell you about my experience with pred, diabetes, and small cell lymphoma. My Ruby was diagnosed via endoscopy. I had searched high and low for a way to diagnose IBD versus lymphoma without surgery, but it was the surest way for me to know what the diagnosis was as Ruby was nearly in remission and I did not want to give a steroid unless I was absolutely sure what she had. Since Fuzzy's state is so fragile, I can understand why you chose to treat inflammation. It's too bad your vet did not allow you to do a food trial first, though I did that by switching to homemade raw food from commercially prepared wet food like Weruva, and it still did not improve Ruby's appetite because she had SCL, not IBD. Once her SCL was diagnosed and she went on prednisolone, her diabetes became unregulated within 2 days, going from a dose of a single drop of Lantus insulin to now 3 units. I have no regrets though about putting Ruby on pred, as 6 months after starting it, her intestinal inflammation was completely gone, she's gained weight and is eating well most of the time. I thought I could get my life back if I could get her into diabetic remission, but I'd much rather continue giving the pred and the required insulin to battle the increased blood sugars than watch her suffer.

A great resource for dealing with IBD in cats is the Raw Feeding for IBD Cats Facebook group. I have followed a lot of their advice over the last year with regards to Ruby's diet change and learned a great deal about feline nutrition, though I have realized that they don't understand very much about feline diabetes at all.

I looked at Fuzzy's labs and radiology reports. Sadly the bloodtest that was done is not very accurate, and the only surefire way of knowing if it's IBD or SCL is via biopsy. You can still change his diet to a novel protein (Ziwi Peak makes some good ones that are low carb) to see if that helps. You can sprinkle his dry food on the canned to encourage him to accept it as food. He could probably benefit from a raw food diet--it's more nutritiously available, easy to digest, and you can choose meats that have more fat in them to help him gain weight like duck. Your first priority right now though is to get him to eat anything at all.

Prednisolone is the best treatment for IBD. From what I understand, cats usually gain weight while on it, not lose, so it could possibly be the diabetes causing his weight loss. Basically what happens with diabetes is the body loses its ability to absorb sugar into the cells, so it turns to the body's store of fat and muscle as a source of energy. By giving Fuzzy insulin, you're helping the cells get access to the carbohydrates he gets from his food, and in the process he should be able to gain back some weight.

I learned much of what I know about GI disorders in cats from @Wendy&Neko, so hopefully she will chime in.

Hang in there. :bighug:
 
Diet doesn't make a difference if a cat has SCL, unless of course the cat has both IBD and SCL. Yes, it can happen. I wouldn't keep feeding a food that causes diarrhea. If you can get fluffy on a low carb wet food or raw, it will help the diabetes. And if you can find a novel protein he likes, that might help the IBD too.

Prednisolone doesn't automatically cause diabetes. I've had a couple cats on pred now, and it didn't increase their blood sugars much. Neither were diabetic.

These posts are really long. Any chance you could come up with a short list of priority questions?
 
I'm going to tag @Katherine&Ruby and @Wendy&Neko because they are much more well versed in this (IBD, pred, antibiotic, etc than I am). To make it easy for them, can you summarize the supplements, meds, doses, and frequency in a short list?

From what I understand, if she were my cat - I would discontinue the metronidazole. I don't see the point, which truthfully is why I asked about it. Antibiotics mess with gut flora so I really don't think that's helping anything.

Truthfully I would keep the pred, though you do say she's having side effects. I'm not entirely convinced those are from pred, but the two ladies I tagged would know better than I. Prednisolone should not be affecting liver that much I don't think (Prednisone would, because liver has to metabolize it to usable prednisolone). Budesonide, the other usual option, is more heavily metabolized in the liver. I can understand the concerns about chlorambucil. Again, tagged ladies will know more.

It is true her FD isn't helping things, but unfortunately for you it's a fairly complicated case. You cannot treat one vs the other, they are all intertwined. The priority is treating whatever she has going on GI - wise. We adjust insulin last to account for everything else, at this point I wouldn't care what medications she needs, we can work around it with insulin.

I'm not sure why those green numbers happened, but it's been too long since then in high numbers. You have a choice here - if it were my cat, I'd increase to 1.5U and keep a very close eye on her, meaning +2 or +3 tests every cycle, this will allow you to catch any big dives early enough to prevent low numbers. A larger increase does carry a fair amount of risk at this point, which is why I'm saying those tests need to be done. Realistically, if that same odd drop happens again, she could end up in 30s or 40s if you aren't testing to prevent it, we absolutely do not want them in those numbers. I'm also assuming you have hypo kit and plenty of spare strips.

You could conservatively go to 1.25U but given her weight and other challenges, there's the risk of neuropathy (already happening but treatable) and ketones/DKA by taking the slow and steady path. I do not think she would survive DKA. I would still do the +2 or +3 tests every cycle. If the odd drop happens again, she'd probably end up in the 50s if not caught. Still safe number but don't want her lower.

I'm sorry I don't have a clear answer for you, but hopefully it's enough for you to choose the best option for your situation.

Thank you for your response. I have to check with my partner ab a few things related to her treatment, but I will add a separate reply with that short summary to the thread later today once I have the full list of her medications and supplements with their dose/frequency.

There are two things I should clarify about my concerns about the pred and my intentions with that going forward.

My goal is definitely not to get her off of the pred entirely, but more to get her tapered to a lower dose. Everything I’ve read concerns me about how high her starting dose was (4.4 mg/kg prescribed when she weighed 4.4 lbs). I just want to see if she shows improvement at a dose somewhere closer to the range of 1–2.5 mg/kg with the hope that at a lower dose the good the pred does will outweigh the bad, which we cannot confidently say it does currently (more on this below). But to be clear, if there is any indication the tapered dose is too low we will not hesitate to increase it again.

Whether the pred has really helped much to date it’s hard to say bc she was explicitly prescribed it with the hope that it would help her gain weight by improving inflammation and increasing her appetite. However, the issues with her appetite had already resolved before she even started the pred (this stopped being a problem once she started getting her b12 and b-complex injections at the end of Nov) and it looks like she may have developed diabetes w/in the first two weeks so it is hard to assess the extent to her continued inability to gain weight is due to FD complicating things vs. not responding to treatment w/ pred. Recurrent hyporexia/anorexia, weight loss, and neuro symptoms (believed to be related to nutritional deficiencies) were the only issues that we were having that led to investigating whether there was a GI problem (only sporadic vomiting and never diarrhea otherwise). The side effects that concern me about the pred (in addition to the steroid-induced FD complicating her weight issues) are worsened hypokalemia, muscle wasting, hair loss, and susceptibility to infection (she’s had recurring bouts of thick nasal and ocular discharge at times during the past two months).

The other clarification I have about the pred relates to her liver — I am actually not concerned with the pred affecting her liver at this point in time (at least not as a side effect that informs my thinking about her dosage or anything like that). I only mentioned the pred in that context bc you’d asked about her liver values and the only change was an increase in ALT that the vet told us not to worry about in isolation bc she said it is sometimes elevated in cats on pred. (My main concern about her liver is just that it was mentioned in her ultrasound consult report so it seems like there’s potential for an additional problem showing itself eventually).

Re: the metronidazole, I am inclined to agree about discontinuing it and plan to raise that with our vet at our next follow up appointment (in about 10 days). I just didn’t want to push back on that last visit bc I'd already asked our vet to re-evaluate her colleague's instructions on other aspects of her treatment and that was the only part she wanted to hold off on for now so too much wasn't changed at once. I had actually started to discontinue it last weekend, but (likely coincidentally) the 2nd day after that was that strange drop so I didn't want to mess with it again after that.

Re: the insulin dose increase to 1.5u, I am inclined to agree with you there as well. I have a packed work schedule today so we will likely hold her dose until tomorrow or Wednesday when I can help keep a closer eye on her. We definitely will be diligent about testing at +2/+3 every cycle going forward. We’ve just been torn about when/how often to test at times bc we’ve been uncertain about whether we’re testing her too much bc of our own anxieties despite not changing her dose so any times you advise we routinely check really helps alleviate those concerns. She has gotten very easy to check most of the time. We’ve also continued to test her urine daily for ketones. Fuzzy showing signs of neuropathy really concerns me... just on first glance it looks like there's some indication b12 supplementation might help with the neuropathy issue so we are going to ask if we can go back to giving her that injection once a week instead of every two weeks (we were a little wary of the reduced frequency already anyways).
 
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I have to finish preparing for a meeting I have in a couple of hours, but will respond to everyone's replies (more succinctly going forward) as soon as I'm done with work obligations for the day. I really appreciate everyone's insight and willingness to help.

I also apologize for the lengthy posts... Fuzzy just has a very complicated history with a lot of caveats due to the continuity of care issues related to her vet going on leave just before her diagnosis so it can get a bit unwieldy when there are multiple questions to address in a given reply. I also wanted to answer the earlier replies ASAP given everything going on with her even though I'm a bit overwhelmed with work stuff at the moment (I'm reminded of that quote "I would have written a shorter letter, but I did not have the time" – but truly I will strive to do better going forward)

I also should clarify in case the start of this thread was misleading – Fuzzy is no longer having trouble with appetite. As of Friday she was back to eating normally and just reducing the amount of hydrolyzed dry food by mixing in some of her old food made her poop immediately return to normal (solid and darker in color). I edited the original post with a note to make that clear and updated the title so that it more accurately reflects her current situation.
 
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Ok, DEEEEP breath. :) Fuzzy's situation is complicated, but not beyond what a lot of us have seen or dealt with. I would stop the metronidazole immediately and get S. boulardii with MOS from Jarrows. It's a single strain probiotic with a prebiotic that helps with diarrhea and restoring gut flora. Here is a link to using it: https://www.rawfeedingforibdcats.org/probiotics-for-cats---why-and-which-ones.html. Once the diarrhea is resolved, you can move to a multistrain probiotic. I use the human strength Visbiome. It can be sprinkled on food or added to water or broth and syringed into the cat's mouth.
 
Have you discussed the use of budesonide? It is a steroid that mostly says in the GI tract so it should not have much effect on BG/insulin needs. I have used it in several of my cats, some diabetic, sime not and sy little effect on BG/insulin needs in the one diabetic cat.
 
Thanks for the clarification on the pred dosing. I've only ever dosed 1-2.5 mg/kg. Actually I've lowered it a bit below 1 on current kitty. Your plan to lower makes sense. Note that blood sugars may come down as you taper the pred. I have also used budesonide (on Neko) and it didn't impact her blood sugars. However we have seen some cats for whom it does.
 
Sorry about the delay on this.

Fuzzy's current medications/supplements/etc. and the dose & frequency:
  • Prednisolone
    • 3.75mg (3/4 of 5mg pill)
    • 1x daily (5 PM)
  • Famotidine (Pepcid AC)
    • 2.5mg (1/4 of 10mg pill)
    • 1x daily (5 PM)
  • Metronidazole
    • 31.25mg (1/2 of pill of 62.5mg pill)
    • 1x daily (5 PM)
  • Cerenia
    • 4mg (1/4 of 16mg tab)
    • As needed – no more than 1x daily
  • ProZinc Insulin injection
    • 1 unit SQ
    • 2x daily (7:15 AM/PM)
  • B12 injection
    • .25ml SQ
    • 1x weekly* (Mondays)
      • *had switched to once every two weeks in early January but given worsened ataxia lately we’re going to start giving weekly again
  • B-complex supplement injection
    • .25ml in muscle
    • 1-2x weekly
  • 0.9% Sodium Chloride fluids
    • 50ml SQ
    • a few times weekly
  • Proviable probiotic powder
    • 1 capsule on food
    • 1x daily in AM
  • RenaKare Potassium Gluconate gel (for potassium deficiency)
    • 1/4 teaspoon
    • 1x daily on food
  • Viralys Lysine powder (for feline herpes symptoms)
    • 1 scoop (500 mg)
    • 2x daily on food
 
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Hi Kaitlyn & Gideon,

I'm really sorry that you have found yourselves here with Fuzzy. There's a lot of history to digest, but I'll tell you about my experience with pred, diabetes, and small cell lymphoma. My Ruby was diagnosed via endoscopy. I had searched high and low for a way to diagnose IBD versus lymphoma without surgery, but it was the surest way for me to know what the diagnosis was as Ruby was nearly in remission and I did not want to give a steroid unless I was absolutely sure what she had. Since Fuzzy's state is so fragile, I can understand why you chose to treat inflammation. It's too bad your vet did not allow you to do a food trial first, though I did that by switching to homemade raw food from commercially prepared wet food like Weruva, and it still did not improve Ruby's appetite because she had SCL, not IBD. Once her SCL was diagnosed and she went on prednisolone, her diabetes became unregulated within 2 days, going from a dose of a single drop of Lantus insulin to now 3 units. I have no regrets though about putting Ruby on pred, as 6 months after starting it, her intestinal inflammation was completely gone, she's gained weight and is eating well most of the time. I thought I could get my life back if I could get her into diabetic remission, but I'd much rather continue giving the pred and the required insulin to battle the increased blood sugars than watch her suffer.

A great resource for dealing with IBD in cats is the Raw Feeding for IBD Cats Facebook group. I have followed a lot of their advice over the last year with regards to Ruby's diet change and learned a great deal about feline nutrition, though I have realized that they don't understand very much about feline diabetes at all.

I looked at Fuzzy's labs and radiology reports. Sadly the bloodtest that was done is not very accurate, and the only surefire way of knowing if it's IBD or SCL is via biopsy. You can still change his diet to a novel protein (Ziwi Peak makes some good ones that are low carb) to see if that helps. You can sprinkle his dry food on the canned to encourage him to accept it as food. He could probably benefit from a raw food diet--it's more nutritiously available, easy to digest, and you can choose meats that have more fat in them to help him gain weight like duck. Your first priority right now though is to get him to eat anything at all.

Prednisolone is the best treatment for IBD. From what I understand, cats usually gain weight while on it, not lose, so it could possibly be the diabetes causing his weight loss. Basically what happens with diabetes is the body loses its ability to absorb sugar into the cells, so it turns to the body's store of fat and muscle as a source of energy. By giving Fuzzy insulin, you're helping the cells get access to the carbohydrates he gets from his food, and in the process he should be able to gain back some weight.

I learned much of what I know about GI disorders in cats from @Wendy&Neko, so hopefully she will chime in.

Hang in there. :bighug:

Thanks so much for your response. I definitely will look into the facebook group. We were planning to look into adding a novel protein to her diet, but weren't sure which would be best so the duck suggestion is very helpful as well. I'll look into Ziwi Peak.

We are suspicious that the diabetes is complicating her ability to gain weight so we're hoping once we get that better controlled she will improve. We're going to increase her insulin dose her next cycle (assuming there are no issues with appetite in the morning). Thankfully, for the most part appetite ceased to be an issue in November once we started her on b-complex and b12 injections to address nutritional deficiencies. The only time it started to be a concern again was this past week. It improved as of Friday, but she's been wanting her food warmed up this week (we warm up water to add to it) which makes me a little nervous since heat kills some of the nutrients in it (like thiamine) so we're going to talk to our vet about how to compensate for that if this continues.

Ok, DEEEEP breath. :) Fuzzy's situation is complicated, but not beyond what a lot of us have seen or dealt with. I would stop the metronidazole immediately and get S. boulardii with MOS from Jarrows. It's a single strain probiotic with a prebiotic that helps with diarrhea and restoring gut flora. Here is a link to using it: https://www.rawfeedingforibdcats.org/probiotics-for-cats---why-and-which-ones.html. Once the diarrhea is resolved, you can move to a multistrain probiotic. I use the human strength Visbiome. It can be sprinkled on food or added to water or broth and syringed into the cat's mouth.

Diarrhea actually isn't an IBD symptom she has thankfully. She only started getting diarrhea once we switched her diet to all hydrolyzed, but this week we mixed some of her old dry food into her bowl and just switching to a mix made her poop go back to completely normal in color and more solid than it had been since the switch. I will look into the Visbiome and talk to our vet about starting Fuzzy on that probiotic instead. Is there a reason that you do not use the pet version of Visbiome?
 
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*quick note to say boulardii won't work if B12 is low (or hyperthyroidism), I know you were giving the shots but if neuropathy is there i wonder

I've been wondering this too. We did switch to once every two weeks in January so I'm going to see how things are once we go back to once a week and if we're still seeing worsened ataxia by next week's vet appointment I'm going to ask if it's possible to recheck her levels without fasting beforehand and whether we should increase the amount she gets.
 
Have you discussed the use of budesonide? It is a steroid that mostly says in the GI tract so it should not have much effect on BG/insulin needs. I have used it in several of my cats, some diabetic, sime not and sy little effect on BG/insulin needs in the one diabetic cat.
We've mentioned it a few times, but the vet wanted to stick with prednisolone for now and try to taper it and get her better controlled on insulin before considering any larger changes like a switch in steroid.
 
Why the Pepcid?

Visbiome might be a better probiotic than Proviable whose first ingredient is a sugar.
 
Why the Pepcid?

Visbiome might be a better probiotic than Proviable whose first ingredient is a sugar.

We were instructed to start the pepcid at the same time as the pred to protect against ulcers. I definitely will look into the visbiome. I didn't realize that about the proviable (we got it from the vet). It was added after she got diarrhea when starting the hydrolyzed food. Should we discontinue that for now?
 
In the grand scheme of things, I don't think the amount of Proviable you are giving is making a huge change. Just consider switching it out when it runs out.

Pepcid is OK for short term use, might not be the best long term. More info here.
 
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