SmallestSparrow
Very Active Member
I’ve been given some good advice in the past from @tiffmaxee and @Wendy&Neko and @Diane Tyler's Mom GA (and others I’m blanking on bc I haven’t slept more than a hour a day for a week—many thanks to you all and I hope for more wisdom because I’ve spent the last 48 hours crying and unable to eat for fear I’m killing my poor cat.
I need help figuring out a good dose and soon before he tips into DKA. Because the ER won’t intervene until he’s solidly in DKA, no tuning him up K-wise until then.
For anyone who doesn’t know, Methos has a right adrenal tumor overproducing both cortisol and aldosterone, each of which causes insulin resistance. He has abnormal pancreatic enzymes and spec fpl over 50 since Jul (tested three times since then). We assumed pancreatitis but the US is cyst vs tumor. He also has two probably benign liver tumors and cysts vs something else going on in the right kidney. He was on Vetoryl 10 mg twice a day (which should block some cortisol and to a lesser degree aldosterone production. There’s no good guidance for the use of Vetoryl for cat adrenal tumors, and ACTH stim tests aren’t really designed to follow felines on Vetoryl but it is what it is. Our best guess has been it’s less effective as time has gone on but we’ve probably got him on as much as we should risk—too much and there’s the risk of addisons. Plus non-dose related there’s the risk of adrenal infarct (and addisons)
In theory you don’t use ALDACTONE (spiranolactone) with Vetoryl as both block aldosterone, so can cause hyperkalemia. but he needed both to prevent pretty severe hypokalemia. This has been a complicated balancing act (hence my mantra of “no green, ever, no need to involve the adrenals and liver”. (Since the left adrenal is atrophied and as far as I know the right is one big tumor, along with the liver tumors)
You can see from his spread sheet he went up as high as 3.5U of Glargine because he really wasn’t doing anything on lower doses. But once there he started having his nadir several hours past the following PS (evidenced by his BG decreasing for several hours after eating and skipping a shot). And a handful of low (for me) PS numbers so we started back down in search of a number that would give a decent nadir without me poking his ear every hour for ten hours and feeding him until he was too full to eat the next cycle.
Unfortunately he continued to be unpredictable in his reaction to insulin and started losing weight despite better BG numbers. When he was found to be hyperkalemic I was afraid we’d gone too far and stopped the Vetoryl and ALDACTONE for 48 hours. He had a low for him/me cycle immediately stopping the meds as they cleared his system. After that his number have been horrible, he’s developed ketones 0.8, and it all persists despite restarting the Vetoryl 10mg BID and half of the ALDACTONE (12.5 mg once a day as opposed to BID) with a temporary bridge of 1/4 potassium tablet a day because he’s hypokalemic again. And we increased him back from 2.5 to 3U. Needless to say I’ve worried about potassium in both directions from all the meds, plus intracellular shift with increased insulin dose. He’s still not hungry and still losing weight. His BG remains unpredictable and haven’t been helped by me giving smaller doses but again, not eating, low potassium. And me in the library with him holding a bottle of K tablets in one hand and insulin in the other thinking I’d never have a human patient handle this at home
my vet is brilliant and compassionate and has bent over backwards to help me. She does not believe in quarter units, and she feels his dose is probably 3 but she’s agreed we can try him at 2.75 (I think a couple of you have said before that he may do better at that). I suspect she agreed more to treat me than methos. I’ve cried nonstop in her clinic my last three visits.
I’m afraid to not give him enough insulin because of the ketones—should I just be giving 3 and then pumping him full of MC food—I’m not crazy about that, the MC food is junk, but if it’s best then ok. Or is the issue 3U is too high and he’s bouncing, and if so is 2.75 right? And is there a good time to reduce the amount? I’m planning on tomorrow am unless his BG is 450 again.
edit: for that matter maybe I should increase: since he’s only getting 12.5 of spiranolactone once a day now it could be he’s going to be more insulin resistant.
I need help figuring out a good dose and soon before he tips into DKA. Because the ER won’t intervene until he’s solidly in DKA, no tuning him up K-wise until then.
For anyone who doesn’t know, Methos has a right adrenal tumor overproducing both cortisol and aldosterone, each of which causes insulin resistance. He has abnormal pancreatic enzymes and spec fpl over 50 since Jul (tested three times since then). We assumed pancreatitis but the US is cyst vs tumor. He also has two probably benign liver tumors and cysts vs something else going on in the right kidney. He was on Vetoryl 10 mg twice a day (which should block some cortisol and to a lesser degree aldosterone production. There’s no good guidance for the use of Vetoryl for cat adrenal tumors, and ACTH stim tests aren’t really designed to follow felines on Vetoryl but it is what it is. Our best guess has been it’s less effective as time has gone on but we’ve probably got him on as much as we should risk—too much and there’s the risk of addisons. Plus non-dose related there’s the risk of adrenal infarct (and addisons)
In theory you don’t use ALDACTONE (spiranolactone) with Vetoryl as both block aldosterone, so can cause hyperkalemia. but he needed both to prevent pretty severe hypokalemia. This has been a complicated balancing act (hence my mantra of “no green, ever, no need to involve the adrenals and liver”. (Since the left adrenal is atrophied and as far as I know the right is one big tumor, along with the liver tumors)
You can see from his spread sheet he went up as high as 3.5U of Glargine because he really wasn’t doing anything on lower doses. But once there he started having his nadir several hours past the following PS (evidenced by his BG decreasing for several hours after eating and skipping a shot). And a handful of low (for me) PS numbers so we started back down in search of a number that would give a decent nadir without me poking his ear every hour for ten hours and feeding him until he was too full to eat the next cycle.
Unfortunately he continued to be unpredictable in his reaction to insulin and started losing weight despite better BG numbers. When he was found to be hyperkalemic I was afraid we’d gone too far and stopped the Vetoryl and ALDACTONE for 48 hours. He had a low for him/me cycle immediately stopping the meds as they cleared his system. After that his number have been horrible, he’s developed ketones 0.8, and it all persists despite restarting the Vetoryl 10mg BID and half of the ALDACTONE (12.5 mg once a day as opposed to BID) with a temporary bridge of 1/4 potassium tablet a day because he’s hypokalemic again. And we increased him back from 2.5 to 3U. Needless to say I’ve worried about potassium in both directions from all the meds, plus intracellular shift with increased insulin dose. He’s still not hungry and still losing weight. His BG remains unpredictable and haven’t been helped by me giving smaller doses but again, not eating, low potassium. And me in the library with him holding a bottle of K tablets in one hand and insulin in the other thinking I’d never have a human patient handle this at home
my vet is brilliant and compassionate and has bent over backwards to help me. She does not believe in quarter units, and she feels his dose is probably 3 but she’s agreed we can try him at 2.75 (I think a couple of you have said before that he may do better at that). I suspect she agreed more to treat me than methos. I’ve cried nonstop in her clinic my last three visits.
I’m afraid to not give him enough insulin because of the ketones—should I just be giving 3 and then pumping him full of MC food—I’m not crazy about that, the MC food is junk, but if it’s best then ok. Or is the issue 3U is too high and he’s bouncing, and if so is 2.75 right? And is there a good time to reduce the amount? I’m planning on tomorrow am unless his BG is 450 again.
edit: for that matter maybe I should increase: since he’s only getting 12.5 of spiranolactone once a day now it could be he’s going to be more insulin resistant.
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