1/21 CRYSTAL PMPS 353 +2 248 + 3 288 +6 270 / RVC update

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suki & crystal (GA)

suki & crystal (GA)

Member Since 2014
Hi everyone
Well, we bit the bullet last night and went with a whole unit increase to 15.5. I must admit I was very nervous, just need to get my head around these big figures, but amazingly she went down at +2 to 248 and carried along nicely until bedtime, big cuddles for the clever little girl. Don't know whether it's my imagination or just wishful thinking on my part but she seems generally much better in herself, she was buzzing last night (after a very quiet day) and is in good form this morning, paws crossed we are on the right track. Thank you all for your support and especially to Suzanne, Wendy & Julie for giving me the push that I needed.

I contacted the RVC London again with a couple of questions (I think you can work out what I asked by the reply) and here is Dr Niessen's student's reply:

Q: I asked about using R insulin in conjunction with either Lantus or Lev:

"We have not recommended combinations of short and long-acting insulin types to our cats, so I do not have experience of that approach. We believe that feeding a lower carbohydrate diet will reduce the post-feeding hyperglycaemia, but I don’t know a study describing that. I will put an abstract about feeding cats different carbohydrate / fat / protein combinations at the end of this e-mail.

There was also a recent abstract at a congress in America describing short-acting insulin with longer insulin type in dogs. The addition of a shorter acting insulin improved blood glucose control, but not by much (this abstract is also below).

With regard to the change from glargine to determir, each cat will respond to each insulin type differently, so it is difficult to have hard and fast rules. A study assessing blood concentrations of the different types of insulin showed on average most cats needed 30% less determir than glargine, but the response of each cat varied quite a bit (graphs from that study are also below). Both insulin types seem to have similar remission rates in similar groups of cats, but controlled studies directly comparing these types in diabetic cats in a clinical setting have not been performed.

A recent study has suggested another type of drug, pioglitazone, might increase insulin sensitivity. This has not been used in the diabetic cat yet. A similar drug called exenatide has been used in diabetic cats. The drug appeared to cause some side effects, mainly intestinal, and may have improved response to treatment. This was performed over 16 weeks and we don’t have longer-term information yet.

So, to answer the question would an insulin change or addition of other drugs help, I am not sure. Long term use of some of the newer drugs needs to be assessed before it can be recommended.

Q: Is it possible to get an IAA test done at the RVC?

We do not perform insulin antibody measurement at our hospital, and we do not use this as a test even at an external laboratory. I don’t know of a UK laboratory offering this test commercially.

It would be great to hear how Crystal is getting on and we can help where appropriate."

(The attachments are quite long and mostly about nutrition. If anyone is interested in seeing them let me know but I I don't know how to add a link either, sorry.)

So, I will just have to carry on as best we can without the IAA test being done. I will probably switch to Levemir once my current Lantus pen runs out but depending on what happens over the next couple of days.

Suki & Crystal
 
FWIW, members here have used a short acting insulin in combination with a longer acting insulin for quite some time. In fact, this is a fairly common practice when managing cats who are in the hospital with diabetic ketoacidosis. It's referred to as using a basal insulin (the long-acting insulin such as Lantus) with a bolus (short acting) insulin. It is very common practice with humans.

One thing to keep in mind... You are in touch with a PhD student. She is advising you based on the research literature that she is familiar with. I doubt that she is doing a lit search for each of your questions. In addition, her knowledge is based on the literature not on practical application. There are many situations where a drug is used in a particular way even though that is not what the manufacturer or a regulatory agency indicated it's use is for. As an example, we use Lantus with cats. The manufacturer and the Food & Drug Administration (FDA) in the US do not state that it is for veterinary use. We use it in an "off label" manner.
 
Good point Sienne, there is nothing to beat tried and tested practical use by experienced carers, I am taking all my advice solely from this site now as my vet has zero experience with acromegaly. The main reason why I contacted the RVC in the first place was to try to get the IAA test, but I took the opportunity to ask for their view on a few other points while I was writing anyway. I had hoped to hear from Dr Niessen himself, who I think we all consider to be one of the best experts around, but unfortunately wasn't so lucky.
 
Hi Suki - sorry for the late reply which you won't get until tomorrow now. I did talk about using R to the internal medicine specialist at Colorado State University where I took Neko to SRT. They were very familiar with it but thought it might not be appropriate for Neko at that time. I didn't use it mostly because there was no one around to help me at that time, who had experience with R and a high dose cat. In hindsight, it would have been a good tool to use at the time, to reduce some of Neko's most wicked bounces.
 
interesting reply from the RVC. it's too bad that you can't get the iaa test done - when a cat is only iaa the dosing strategy is aggressive to stay ahead of the antibodies. But . . . it is what it is, so we'll plow on without that information.

I was nervous about using R at first but really found it to be fantastic. I liked it a lot. Didn't use it all the time, but it was available when i needed it. I'd encourage you to give it a try when it's convenient for you. I was just reading last night about the benefits of using a bolus (R) insulin in a cat with a high dose of insulin. If I understand this correctly, they are saying that using a faster acting insulin that is effective at bringing down the blood sugar can help improve insulin resistance, ie, make the cat more sensitive to insulin overall. I think. You can read it and see if that's what you get from it too.

Insulin Resistance and Hyperinsulimia
PULSATILE INSULIN MINIMIZES DESENSITIZATION—
Studies comparing continuous versus pulsatile administration of insulin have further supported the hypothesis that continuous hyperinsulinemia can cause insulin resistance. In healthy subjects, pulsatile delivery of insulin had a more robust hypoglycemic effect than continuous delivery (19–21). This phenomenon has also been shown in subjects with diabetes (21–23) as well as in an animal model of diabetes (24).
​
 
Wendy and Julie, thanks for looking in, I feel so sad having just read about CoBb, I shall miss him and my thoughts and prayers go out to Suzanne.
I will make the change to levemir first I think and get used to that but it certainly sounds as if R is a good tool to have and it's definitely worth giving it a go. What would I need to ask my vet for next time I visit?
 
First thing is to find out if you need a prescription for R in France. You do not in the US or Canada. I don't need a prescription for any insulin in Canada, and I just switched to Levemir without involving the vet.
 
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