2/17 Ruby PMPS 88/+1.5 80/+3 69

Yesterday I had to give Cerenia again to Ruby as her eating slowed down again. The Cerenia did not seem to help, as we had the same situation this morning, so gave her ⅛ tablet of Mirtazapine as the last dose of ¼ tab seemed to be too much. Waiting for Ondansetron to arrive in the mail from an online pet pharmacy where the price was cheapest, even with shipping. Hoping that works better than Cerenia.

Mariette noted yesterday that Buddy and Ruby seem to be having the same problem with dosing. We are on our 5th cycle of .25 and her numbers don't seem to be going any lower. Was lurking on @Mariette's thread yesterday, and wondered if I should also follow @Marje and Gracie 's advice to her to hold Ruby's dose for a week and see. Ruby's number's aren't terrible, they're actually really great, but I keep hoping I can nudge her towards remission. I am also prepared, however, for the probability that it may never happen. Any thoughts would be appreciated!

 

I’m glad you are getting ondansetron. Have you ever tried cyproheptadine as an appetite stimulant? I prefer it as it can be given twice a day and just a sliver worked. Less side effects. Mirt was meowzapine for Tiffany and didn’t last long enough. I hear the transdermal mirtaz is better.

 

I'm wondering today if I should try to push Buddy up to 0.5. See if I can push him a bit lower. But then I stress that it might be too much for him in the day time. Buddy's night time numbers are the problem. It looks like Ruby's night time numbers are a bit better than Buddy's right?

I honestly don't see any effect of 0.25 on Buddy. His numbers are the same as when he wasn't getting any insulin a month ago. (if you disregard the food I'm giving him to bring down AMPS)

If I don't see the insulin changing anything in Buddys numbers it makes no sense to keep him on it. So I feel like I either need to push it higher - to 0.5 or I may as well pull him off it.

Maybe some cats want to run a little higher naturally? We saw Simba wanting to run super low recently on this forum. So maybe cats just naturally have different numbers where they want to settle?

Also I wonder if the teeny tiny dose changes which are great for reducing, are maybe hindering us a bit for increases. That their bodies just compensate somehow.

I measured out my insulin doses this morning so I can see the difference in dose amount. I can already tell the 0.1u I measured off looks too much compared to the 0.25u. But that's the problem with these tiny doses too. We're dealing with an imperfect world of air bubbles and manufacturing imprecision and the tiny doses seem to require scientific instruments to be accurate

 

Are you both using digital calipers?

 

Busy day, but quickly, yes, I am using calipers to measure out the .25, but the calipers are too narrow for my BD syringes when I get down to .1 so I eyeball that to just a hair before hitting the plunger stopper. @Mariette's amazing photo above is pretty much my experience with the drops as well.

 

I haven't tried cyproheptadine but I am going to call the vet tomorrow and ask him for a prescription as the mirtz makes Ruby a little too loopy although it does last for about 4 days in her system somehow.

 

I have calipers but to me the larger problem is air that gets trapped under the needle. I can sometimes sit there for 10 minutes redoing the dose, discarding syringes, and still have to live with a stubborn bit of air. Any air at this small a dose makes caliper measurement a bit of a moot point.

 

Yeah I have the same issue. I also end up eyeballing most of the time. I find I can be more reliable looking at the distance between the little nubbies on top of the syringe plunger and the top of the syringe barrel.

 

I struggle with bubbles every day. I draw about a half unit or even 1 unit, locate the bubble, pull the plunger down a bit more so that the air coming into the syringe merges with the bubble, and then flick the syringe until the now larger bubble is below the needle and then push it out. Then I measure out the dose with the calipers. Super fiddly!

 

I hope the Mirtz helps Ruby's appy pick up. Sending prayers.

 

Hope Ruby surfs safely and you can get the meds you need for her Have a wonderful day, Katherine!

 

Afternoon Katherine, I hope the ondanestron works better for Ruby.
I hope she surfs safely today. Have a nice day Katherine and give her kisses ♥

 

Yep, I have nightmares about air bubbbles! Also I flick the air bubble to the bottom as well to try and suck up the little bubbles there. But I always have some tiny stubborn ones clinging to the plunger as well as one larger one below the needle. As I push the air out a bubble always get trapped in the syringe cavity leading to the needle. It might be a design 'feature' of this type of syringe (sarcasm).

I'm using Monoject. It was the only half unit marked 29G syringes I could find. I need a slightly fatter needle because Buddy's skin is tough.

 

You'll have a couple of options once the ondansetron arrives. You can use that on its own OR you can use that and cerenia together. I sure hope that ondansetron and cyproheptadine will work out better for Ruby!

 

Ruby's numbers are wonderful! I hope she starts eating properly for you again soon though.

I had to hold the dose for Gremlin a LOT! I even eventually got him down to a single drop but could never take him off that drop as his BGL would immediately ramp up. It drove me insane being so close to remission but not able to get there! Now I wish it was still like that... I do hope that Ruby WILL go into remission for you. I have no suggestions on how, sorry, I just wanted to say about holding the dose.

 

I just took a look at Buddy's numbers and his day time does look perfect! I'd give anything to have numbers like that for Ruby.

Wow, Laura, you have been at the FD dance for a long time. I see those OTJ attempts on Grem's spreadsheet. In a way, your experience makes me feel better. I see all of these kitties going into remission and it looks so easy and WONDERFUL, but Ruby is sick, and will probably get sicker as time goes on, and I'll have to give her as much insulin as her little body needs. She will let me know. In the meantime I'll go up and down the dosing scale for as long as necessary.

I'm looking forward to the arrival of the Ondansetron so I can see how Ruby reacts to it. The big question though is why she's not eating on her own. Is it possible that subQ fluids might be making her feel badly?

 

Yep, it's been almost five and a half years! Though he did go into remission early on and then relapsed. He developed other health issues which is quite possibly why he never went back into remission, even with all those amazing lows. Last year his health declined quite a bit and he's been all over the place ever since. I'm glad you feel better from seeing Grem's struggle to reach remission again. It just doesn't happen for them all!

If Ruby doesn't make it into remission, I hope she at least stays well regulated! It's so much easier for everyone. And a well regulated kitty on a low dose gives you slightly more freedom. Not as much as remission but it's still good!!

 

You've done such an amazing job at taking care of Gremlin with all of the things he has going on in addition to your own health struggles. You're lucky to have each other. Thanks for the pep talk, Laura. I really appreciate it!

 

Hi Katherine just stopping by to check on you and Ruby today. Ruby is doing so well! I know what you mean about keep wanting to push the envelope, nudge just a leeetle bit more and hope kitty responds. Pearl is sick, too (I don't think I know what Ruby has got going on aside from FD?) and it's hard for me to be prepared that my road to get to remission might take longer (or not at all) than other kitties. I am also trying to learn to relax and rest when the dose is going well (you know, get some sleep!) and be content where I am at - that is hard for me.

 

I agree...it would be great to know what is causing the symptoms and try to address that rather than just treating the symptoms. I don't know enough about subQ but I thought that was supposed to make them feel better. I really don't know though.

 

Sorry, I didn't mean to direct the question re: subQs to you, Lyla, just more generally out there to the world in a rhetorical way...

 

Ruby was diagnosed with early CKD last month. She had a high SDMA result a few months ago and her Creatinine was a little high on her last blood test. I am concerned that her inappetance is the CKD progressing rapidly. She also possibly has IBD or SCL but I have not asked for a biopsy yet to figure out which one it could be because until a few days ago she seemed to be doing really well, but I have a feeling that her vet will probably recommend that as a next step.

The reason why many of us are here is the hope for remission for our kitties. I don't think it's unreasonable to wish for it and work towards it, especially for those of us for whom the pandemic has offered a unique but limited window of opportunity to nurse our kitties back to health.

 

If you want input on the biopsy thing, let me know. I've been to specialists for this before, and learned from them that IBD/SCL is treated the exact same way, and that biopsy will only confirm a diagnosis, not necessarily altar the medications. Steroid plus Chlorambucil (chemo drug) are standard, with just IBD (yes still the chemo drug if steroid alone doesn't curb symptoms) or also with SCL. That knowledge has saved me a lot of heartache. What did ultrasound show?

As for the CKD, what was her CREA? You might need to do another Chem panel to check her kidney progress if you feel like something is going on. I will say, though, having many cats with CKD, inappetance goes with the territory. If Mirtazapine isn't doing the trick, try Cyphroheptadine - I think Elise mentioned it above?? I'm hopeful the Ondansetron will help. BTW what was your Cerenia dose?

You may have had these conversations with lots of peeps before me, if so please don't worry to respond I know it can be wearing to talk about medical issues a lot (believe me, oyy my little Pearl!) but it is possible for Ruby to live a long and happy life with CKD so take heart. I will be thinking of little miss Ruby and you

 

@Mariette I disagree that Buddy looked the same without insulin as he does now. His BG looks so much better now. He was having some really high PSs.

Katherine....my suggestion for Mariette to hold Buddy’s dose for a week was in regard to reductions. Unless he drops below 50, she would hold the dose for a week and, as long as he was in BGs mostly below 100, she would reduce the dose. Buddy has been at his dose ten cycles tonight.

You just increased Ruby’s dose so you’d hold her dose 8-10 cycles (unless she earns a reduction within those cycles) and see how she does. If she’s cruising along in solid green, we’d count seven days from the increase and, if she stays mostly below 100, then you’d reduce. But if we see more BGs like that 134 (maybe treat response?), we would increase. Of course, if Buddy starts throwing out BGs that are a bit higher, we also might need to increase.

The “hub” on the Monoject syringes has always been an issue. It’s why I quit using them. Great photos, Mariette, of the drops and syringes.

 

The ultrasound showed a thickening in her small intestine. Would love to pick your brain about the biopsy, as the peeps on the Feline SCL board won't even engage with me unless I'm committed to getting one, but was also told that I can go ahead without one and treat with Chlorambucil and a steroid alternative (I forget what that is, the steroid would knock Ruby out of regulation). So I'm caught, but I can't afford a biopsy right now.

Her creatinine was 2.4 in January, up from 2.1 a month before. My vet recommended doing another panel in March after a course of subQ fluids which is being administered by a vet tech who comes to my home who is a character out of a Martin Scorsese film.

 

One word about steroids. Gracie had a biopsy and they diagnosed IBD only. Then the sample was sent to UC Davis for a PARR and conclusion was “mild anemia”. The IM specialist we were seeing was not a fan of budesonide even though that is what I wanted. The pred caused Gracie to have heart issues (and she was only on it a few days) and then I think it was also instrumental in her spontaneous bowel perforation. I found out later that pred can do this.

It has also come to light that the PARR tests might produce false positives for SCL. If I had it to do over, I’d skip the biopsy and just proceed with treatment with budesonide. If that did not help entirely, I’d probably look at using chlorambucil. I was in the process of slowly changing Gracie back to a raw diet by making balanced homemade cooked. All of that is JMHO.

 

Budesonide is not a systemic steroid and is less likely to affect the BG.

 

The reason I increased Ruby's dose was because she wasn't dropping into that sweet spot of being between 50-80 all the time. Should I have waited until she properly earned a reduction to a drop dose before expecting that range of numbers?

Thank you for relaying your experience with Gracie. This is something I needed to hear today, as I was very anxious about putting my sweet Ruby through a biopsy. Am grateful to know that budesonide is less likely to affect BG. I will talk to my vet about how to proceed tomorrow.

 

Agree 1000% with the Budesonide and going straight to treatment. That is also what we used for Cricket with great success. It is considered to be the safest steroid you can use with respect to the blood sugars. You could start there and see how she responds, and consider the Chlorambucil in time after she is on the Budesonide. That is my advice. Thickened intestines are pretty common for IBD, and the vets will always say possible SCL because they have to (and because they can't rule it in or out) - but that is what they say to everyone. The treatment can really help. Cricket lived 6 years on it, and flew over the rainbow bridge for something totally unrelated!

 

Gosh, I am so happy I brought this up! I have known about the ultrasound results for a while now but kept it to myself because I didn't want to put Ruby through the biopsy procedure and because I would have to go into major debt as a consequence. I could not handle being judged to be a bad cat mom. But in the last week, her unwillingness to eat on her own has scared me. Thanks for sharing your experience, Margaret. You and Marje have made my night.

 

Oh i am so glad to hear this! You are a GREAT cat mom, Katherine! Ruby is lucky to have you (and vice versa ) So, the inappetance is likely nausea (as I think you've already pinpointed). Can be the IBD, the CKD, a number of things. It's not uncommon with either. With Cricket, this happened with us regularly. But if she is not eating, you may need to assist feed via syringe to get her going (my Cricket had bouts of this - it's like they "forget" that food is good for them), so don't be afraid to do the assist feeding. Good you've got the Ondansetron on order. What was her Cerenia dose and what is her weight? It is possible that medication was not the right dose, and did you ever try the injection of Cerenia and if so did that help? You can ALSO add in Pepcid or Omeprazole believe it or not to help with nausea. But try only changing like 1 med at a time so you know what is doing what!!

 

No, you correctly increased so you could try and get rid of the blue BGs. A cat can be on, for example, 2.5u of insulin and be tightly regulated with nadirs 50-80. That range is attained by the correct dose no matter how much that dose might be. Does that make sense?

You’re welcome but that is just my experience. Others might have different ones. Wendy did not go the biopsy way with Neko but just treated the symptoms “as if” Neko had IBD/SCL.

 

I know there are two groups on groups.io that deal with lymphoma. I think it might be the LCL people that are a little nicer but Elise would know. I didn’t have much luck with the SCL group. There is also a great group on FB called Raw Feeding for IBD cats. There are SCL cats there, too.

 

The vet prescribed 4 mg of Cerenia every 24 hours, but Wendy suggested that 2 mg/kg was closer to the correct dose so I'm giving her 8 mg. She weighs 11.7 lbs. Ruby did have an injection of Cerenia the day before her DKA diagnosis last September and it didn't help too much then but she had a lot going on at the same time. I have the feeding syringes at the ready in case I need it but I really hope I don't. How do you know when to syringe feed? When the appy stims don't work? I gave her ¼ tab of Pepcid yesterday when she didn't eat her +4 meal and that didn't do anything.

 

Can't wait to hear how the Ondansetron works - or combination with the Cerenia might be just what's needed to kick-start that effectiveness. The 8mg is the best for her weight from my experience too.

Pepcid will take some time to work, consistency with everything is key. ECID is different about the eating. With Chessie, I will give her up to 36 hours-ish without eating (or just picking at things) before I syringe. Pearl's cap is 24 hours max, since Pearl at her usual healthy self is a strong eater, and she tends to decline rather quickly. You can always start the feedings and then back off when she starts back on her own. I would do maybe 15mls at a time to start, every couple of hours. How long has it been since she's eaten more than a couple bites?

 

I started in Tanya's CKD group and then because Ruby also had a low thyroid result people recommended me to the Feline Thyroid Management Group where members really took apart Ruby's labs and I met the woman who runs the Feline SCL group (I forget her name). She was actually extremely helpful and is the one who told me I could just treat the symptoms rather than do the biopsy if money was an issue, but I have not dared to post in her group. I've been lurking in Raw Feeding for IBD cats but haven't been able to devote the time to figuring out if and how I would do raw for Ruby as I have so many factors to juggle.

 

She's been eating like a champ since this afternoon after I fed her ⅛ tab of mirtazapine. She's actually sitting in front of me right now, staring at me intently in the hopes I will feed her yet another meal this evening. Ruby is a very good eater unlike her sister, my civvie Olive, who is a skinny little cat. When Ruby does not eat, I get very worried, whereas if Olive gets a little finicky I let it go for longer.

 

Yes, so maybe Ruby is a little like Pearl in this respect (Ha! the little gems!) I tend to pay very close attention when Pearl stops eating. I will give her 24 hours but no more to right herself. As long as you have the supplies to syringe feed, that is what matters and you are ready for anything! Glad her appetite is going strong today.

 

YOU have been a gem for me this evening, Margaret. Ruby and I thank you for your care and support. You're awesome.

 

Yes, this makes sense. I'm always afraid of being too aggressive while also, at the same time, concerned about staying at a dose that isn't doing what it needs to do for Ruby. I find it hard to know what the right thing is to do when she hits a number in the 60s every once in a while. Her AMPS numbers are improving, however. Last night I stopped the +9 feeding because of the dose increase. Is that the right thing to do?