10/14 Oberon PMPS 398/1.6, 1.25U R, +1 373, +2 345, +3 306, +4 290, +5 314

Yesterday: Nice long slide into the blues; vet reports no anemia https://www.felinediabetes.com/FDMB...163-4-146-5-148-6-136-test-more-sleep.236809/

My husband wasn't able to test Oberon at +9 or so; Oberon was seriously cranky and bitey. So I don't know what happened between the 136 at +6 and 165 at AMPS. My guess is that he dipped a bit lower but stayed over 100 or so, but who knows?

In any case, no R this morning, so Oberon gets a bit of a break from all the hourly poking. Ketones are nice and low, too. So I can skip fluids, but he'll get his second dose of Veraflox later today. I may go back to bed for a bit.

 

A break all around ! Hope you get some sleep and Oberon does as well.

 

Nice blues. Yay for low ketones. Enjoy your btb.

 

So much for back to bed (had to wrangle other household members)... and there's that bounce I was expecting. 287 at +2. Maybe today's the day to think about doing a mid-cycle R trial? I'd love to keep him from hitting the 400s...

 

Yesterday, he was pretty close to where he is today at this time after his insulin & he stayed pretty even throughout the day.

I am no expert but I personally would see if he stays even again today. I know he started lower today vs yesterday pre shot, but given that he didn’t go higher already (to suggest a bounce) I would want to see if he holds steady again today vs rising.

 

I'll see where he is at +6. Yesterday he was at about the same BG as today at ~+2/+3 but he was heading down, and the dip was slower than usual. This looks like his usual pattern of bouncing up quickly (~120 points in 2 hours just now) after hitting blues and greens for a while. I'm thinking that if he gets some R early in the bounce it might keep him from going quite as high as he usually does, and maybe keep the ketones at bay.

 

That +6 will tell you a lot. I’m hoping he is done rising and onset will hit and keep him steady. Maybe just maybe?

 

314 at + 4 and 384 at +6.25, so definitely still rapidly climbing. I just gave him 1.25 U of R and I'll check him hourly to see how that goes.

 

I am sorry and hope the R brings him back down. I was keeping the faith....

How is he feeling today? Back to normal? No crouching?

 

Definitely seems better. He was meatloafed under the chair (one of his favorite spots) this morning, but more relaxed later. Right now he's eating like mad.

 

No meatloafs! Not allowed!

One thing that you may want to do, if you can, is limit his portions—smaller mouse meals vs going for it with a larger meal!! It definitely helps when there is any underlying issues with the intestines, pancreas and liver.

 

He's a grazer... eats small amounts constantly. It's partly because he's a food snob. As soon as it dries out a little he refuses to eat it unless I either wet it down or top it with a bit of fresh food.

 

.......the book has arrived

 

Perfect!

 

We don't need another meatloaf cat around here. I'm so glad Oberon is relaxed and eating well.
And I'm excited to see where he R takes him now. I hope it brings him back to those lovely blues he was in.

 

A few interesting insights from the Chapter on Acromegaly (HST) written by Drs Niessen and Scudder out of UK:

New Insight- not always associated with external features, or with difficult to control DM or DM at all.

However, due to the research the “overall message” coming from studies over the past decade, they now propose that feline HST should be ruled out “in any cat as a possible cause of its diabetes mellitus.” : estimates are 1 in 3 to 1 in 5 have underlying HST

They have actually now discovered that in non DM cats, cats with HCM-like disease with thickening, later life-onset snoring, CNS issues—that the disease states are actually triggered by underlying HST.

Now, what I found interesting within the section pertaining to “Diagnosis”.

The plasma IGF-1 is the primary test but it looks like the factor range they use is different than what your was:

>1000 ng/ml in diabetic cats (they note that this arbitrary cut off is likely high, increasing specificity while decreasing sensitivity of IGF-1 assessments.

The recommendation is lower values (600-1000 ng/ml) are “also, in principal, abnormal & should at the very least be followed up up if encountered.”

“At the start of developing HST and especially since these cats are not intrinsically prone to become diabetic (unlike a cat with primary DM) the excess GH will be countered by the pancreas simply synthesizing and secreting more endogenous insulin. This is initially possible, given the fact that there is no B cell dysfunction in most cats with acromegaly. Furthermore, at the start of exogenous in insulin therapy after diabetes mellitus has occurred, the combination of exogenous insulin, subsequent lowering of blood glucose and reduction of glucose toxicity effects on B cells can improve endogenous insulin synthesis and even enable temporary remission.”

I have not had a chance to look to see if a PIIP assay is actually available, but they have found that “medium serum PIIP concentrations were five times higher in HST cats with secondary diabetes compared to cats with uncomplicated diabetes mellitis.” “There was also a significant correlation between serum IGF-1 and PIIP”. They are thinking it can be a useful part of the screening panel to reliably diagnose HST without imaging (they say imaging most likely won’t be used in the future and should not rule out HST currently if it’s done and nothing is seen).

The chapter does go on to describe some interesting treatment options in depth.

I wanted to share this initial info before I move onto the “Unstable Diabetic” written by Drs Rand and Gottlieb. The chapter includes underlying diseases like HST, pancreatitis, as well as info on rebound hypoglycemia, lack of duration with an insulin & the key to figuring out what is going on by using a CGM. That dang CGM recommendation keeps showing up !

 

That paper came out in 2015 on a very large scale study. They were trying to eliminate acrocats from another study so got to accidentally discover this. They found cats on as low as 1 unit with acromegaly. And yes, there have been cats with increased IGF-1 who do not yet have diabetes. It is thought to be a later stage condition. Neko's first signs of acromegaly (I found out later) were 6 months before her FD diagnosis. There have also been caregivers who have tested siblings of acros and found them positive for IGF-1, but no FD. Side note, in another paper of Niessen's I saw him mention that only 35% of HST cats had visible signs on diagnosis.

Like BG's, European measures of IGF-1 use a different scale than in North America, hence the "possibly greater than 1000" as their measure of positive of HST. IGF-1 numbers can also change over time as people who have had subsequent tests have noticed. A study done by Dr. Vanessa Woolhead also at Royal Veterinary College, found that initiation of exogenous insulin can change results. Hence a guideline to wait at least 73 days after starting insulin therapy before testing. She found that in a study of 200 cats, 9.1% of them changed from <1000 to >1000 after those 73 days. That added to the 19% that had initially tested over 1000. So a third of the ones ultimately positive didn't show up on the early testing. I think Oberon's blood draw for IGF-1 test was closer to 60 days. Sorry, should have suggested you wait a couple weeks, but I think there were other things happening at the time.

I agree on the comment on not using imaging. When I was at Colorado State University with Neko for SRT, they had seen some cats with no tumour seen on CT, so had to move to MRI. And at the time, even one cat with symptoms and higher IGF-1 that didn't even show on the MRI. They still treated, though obviously harder to target with radiation properly.

 

This is actually not from a single paper. It is actually what the authors for the particular chapter in the first feline dedicated Endocrinology textbook published 2/2019 wrote and actually cited that based on all of the research that has been done over the past 10 years it is what they recommend.

With respect to the values, again, it is what the authors for the Chapter of the textbook are recommending vets follow when testing to catch it earlier and prevent health issues later.

They did state MRI is more sensitive than other imaging but they are not saying not to do it at this point but that in the future it most likely won’t be needed because more specific hormone testing will hopefully be available.

There obviously is even more information, including all the cited sources in the textbook. If you are able to purchase it or get it through the library I highly recommend it. All the top endos contributed to various chapters with some fascinating new information Re diagnosis, treatment .....all things feline endo .

 

I think Wendy's point about the scale is just that the textbook is using ng/ml, and my lab results are in nmol/L. We'd need to know the conversion to see how their recommendation would affect the scale used here. Definitely thinking about that book... maybe an early holiday gift to myself.

I think I'm declaring my midcycle R experiment a success. Normally after a big dip his BG skyrockets into the 400s over the next couple of cycles. Some ups and downs for the past few hours, but it looks like the R is successfully fighting the spike. (I assume that since I just gave R midcycle I shouldn't do it again at PMPS, right?)

 

That is awesome news ! Fantastic! I’m excited!

What is funny is that I personally had no point, stance, opinion whatsoever about any of it and am just literally taking some information from what is now the go to text for feline endo, written by the top endos in the US and world today, and passing it along in case any of it helps . In the meantime, I was wishing I could send copies of ALL the pages....because it’s AWESOME !

I say Santa DEFINITELY comes early this year & Amazon Prime yourself the book ! I was pleasantly surprised by pricing given that I have some medical textbooks which broke the bank !

 

The paper I mentioned was a summary paper, about previous studies, paper linked here. It and links to other papers in this post. Acromegaly - the basics I have a bunch more, just haven't posted them all yet. Sounds like what is in the acro section of the endo text is in snippets of many other papers. But could be easier to read summarized in one place. Even though that book came out in 2019, the recommendation to test difficult diabetics has been out there several years before then.

To convert:
ng/ml to nmol/L divide by 0.131
nmol/L to ng/ml multiply by 0.131

The R experiment did seem to work well. I'd see what he does in the next couple hours before deciding on R or not at PM. At some point you should do a PMPS without R after doing it mid cycle, just to see what the after affects are.

 

PM shot is in 30 minutes... I think if he's decreasing from his +10 (314) I'll skip it, but if he's coming back up significantly I may do it. His bounce is probably still in progress.

 

Wendy-

To be clear, the recommendation is that ANY cat diagnosed with feline DM vs the older thought process that you screen cats with difficult to control diabetes. “The argument has been made that since it is generally accepted to screen for urinary tract infections (UTI) in feline diabetics (prevalence estimate 12%) it seems only logical to also recommend screening newly diagnosed diabetic cats for the presence of HST/acromegaly (prevalence estimate 18.32%) . Given the tremendous implications on optimal treatment method, potential for diabetic remission, and prognosis, each new diabetic cat should be assessed doe this underlying condition.”

It is not “snippets” from previous studies to make up a chapter. It has extensive, latest info, new diagnostic, treatment options etc.. Maybe get the book . A lot of helpful information!!

Back to your thread Lisa! Let me know if you get the book and I hope you enjoy it as much as I do.

Best with tonight’s dosing!!

 

398 at PMPS... guess the R wore off. I'm going to do another round this evening. (Ketones still low, 1.6. Bet they'll be higher tomorrow, though.)

 

Sorry but really great news about the ketones! I am going to keep my optimism and hope and pray you are wrong about them increasing . No higher ketones and NO meatloaf positions......tell him if he must do a pose he needs to choose a yoga position instead.....Namaste!

 

Morning data for reference: AMPS 165/1.4, +2 287, +4 314, +6.25 384, 1.25 U R, +7.5 379, +8 342, +9 359, +10 314

Ketones seem to lag behind BG numbers by a cycle or so. When he has a dip, ketones come down, but then when he pops back up they go right back up again. I'm hoping that if R can help keep the BG numbers down ketones will also stay lower. Having said all that, while I'm paying close attention to his numbers, so far he hasn't shown any tendency to go from ketosis to ketoacidosis (fingers crossed, knock wood, anti-jinx, and all that). I hope it stays that way.

 

Hmm, PM R is showing a little more action.

Out of curiosity, how is his weight trending?

 

I was just thinking that I hadn't checked in a little over a week. 11.7 lbs just now, so pretty much stable for the past couple of months. His pre-Dx weight last year was around 13-14 lbs and he definitely still feels thin to me, but he's not losing more weight. (Weight at Dx in Dec 2019 was 10.2 lbs and was the main thing that brought us to the vet.)

 

Wow, 290 at +4 (likely R nadir). Down 108 points from preshot. Interesting. I'll grab one more check before I go to bed later.

Wondering whether the R is different enough from Lantus that the antibodies don't bind as tightly. Or maybe we're just getting to an effective dose of R + L.

 

Or you are seeing some delayed antibody action. IAA kitties or even some others, show action the cycle following R. Might be the mid cycle R talking too. But I agree, don't want to change the R much. Next experiments might be varying the R amount a bit based on preshot, to get a bit of a scale going. You'd do the same for any mid cycle R.

Good to see his weight is staying stable.

 

Good points. And the R effect is also overlaid on whatever else is happening; it didn't appear to do much in the mid cycle because it was fighting a big spike. Maybe in this cycle BG would already have been coming down a bit.

I just looked back at Black Kitty's R scales; I assume I would do something similar but lower doses/smaller increments. I've been giving 1.25 in the 300s range, so would I maybe try out 1.0 in the 250-300 range and 0.75 in the 200-250 range? What's the target drop I'm aiming for (or target nadir, if that's a better way to gauge things)?

 

Maximum drop over the first four hours should be 100 points. I would avoid shooting under 250 at this point in time. And under 300 it would depend on the circumstances. The only time I shot R that low was if I knew a bounce was on it’s way.

R mid cycle did a lot today - it capped the bounce and brought numbers down mid cycle where normally they'd be going up.