5/11 Oren; AMPS=570;PMPS=415; pancreatitis

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Megan & Oren

Megan & Oren

Member Since 2015
Yesterday

black morning to match my mood. Could this be a bounce, from pink?? perhaps the damn insulin is losing potency. No floaties or threads, but haven't I heard/read that it does get less potent w/ time?
I know Wendy has said a new pen didn't seem to make any difference, but I thought I'd read in other condo's that people do sometimes reduce dose when starting a new vial or pen?

I will be getting a new bottle today or tomorrow. The first one is very low anyway. It's so bloody expensive though, following that expensive vet visit and now probably a dental. :(:blackeye:, and I don't think I should wait for the extra time to get it from Canada this time around...
 
Megan, I was told that you don't reduce the dose with a new vial/ pen. You just don't want to increase on it, just in case the old insulin HAS lost some potency.
I hope Oren decides to come down soon!
 
finally talked to the vet. Of course, she called while I was in the pharmacy getting the Lantus, so it was hard to take any notes. Hence I'm writing this down now while I can try to remember.
He has pancreatitis. She is prescribing Bupe for pain for about 5 days(even though he isn't showing much, I know that they hide pain extremely well), a probiotic to sprinkle on his food and strongly wants me to switch his diet to the canned DM prescription food; says the Fancy Feast although high in protein and low in carb, is too high in salt and other things, and difficult to digest making it not good for pancreatitis...

I also finally got what should be his ideal weight, no other vet has told me that before. She thinks he should be 9.5 or 10 lbs and he is currently just under 9, so she's calculating calorie consumption based on that to advise me how much to feed. Says he can keep getting the cooked chicken too. At least for 3 wks, she wants to follow this regime, recheck bloodwork just for the pancreatitis and go from there. Really doesn't think the IAA test is necessary, didn't even go back to acromegaly; I think she feels the pancreatitis is the cause of the higher BG.

She is NOT on board w/ the protocol (she claims she read it finally). She claims she consulted w/ an internal medicine specialist specifically. Biggest issue seems to be agreeing on what is "too low" because of the meter variance. Her comfort level for low numbers is 60s or 70s and doesn't appear to want to budge on that one. Her STRONG suggestions if we are to continue to work together is that I adjust dose according to her thinking. I should do a 12 hr curve every couple of weeks, layoff the daily multiple checks, except for maybe 3-4 days after whenever a dose change happens( i said I would NOT give up pre-shot tests no matter what). She does approve of the home testing at least, for the curves. Once the pancreatitis is resolved we'd talk about a dental.

I can't get any of this going till tomorrow evening, as it's too late to get the stuff today, except I do have the new lantus. Another client of hers (the guy that actually recommended me to her) cat was diagnosed about the same time as Oren, and is now in remission; She got as high as 7 units a day (3.5/shot) and this vet claims, the diet switch was a big factor in her remission and Lantus. If she had her way, Oren would be on the DM canned forever... but wants me to agree to it for 3 wks. at least for now.

I am so blitz-krieged right now that I just feel like I don't know where to turn. I could smile and nod about the Lantus dosing i guess, but really, all of this is too much to deal with. Did I give him pancreatitis by feeding fancy feast? Have I been under feeding him thinking he was supposed to be about a 9 lb cat? I'm overwhelmed and at this point I don't have the energy to fight against something when I don't have sufficient knowledge myself. I can't see how she is making suggestions based on ill-malice or complete lack of experience etc. But just because she hasn't heard of this protocol, doesn't make it invalid. And everyone here also has a wealth of knowledge and experience too. Many have advised me to go one way or the other, because of this conflict. All I can see clearly right now is that Oren hasn't done great so far, and I just want to do right by my kitty. I've noticed a small tremor in his front legs, which has actually been present on and off for a while now. No idea if it's some mild neuropathy or related to anything else. He's more vocal recently, maybe because he's hurting.
So, for 3 wks, at least, I'm trying her way. Starting tomorrow night, the diet switch, meds, probiotic and a dose of 4U of the new Lantus.
 
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many of us have had our vets try to push hill's on us.... mine did too....
and fortunately, she's not in control of what I feed.
hill's spends tons of money on vet research.... so all the vets think their food is necessary.... but hill's isn't good quality...
and vets only get a few hours of dietary during their training... and it's for all species.... cats aren't usually their top priority....
and hill's is expensive.

you did not cause anything feeding ff... the only issue with it is so many of them are way high phosphorus.

You are correct... those here , some being here for many years, live and breathe fd 24/7....
there is so much experience here.

from reading other condo's, it's pretty obvious that there are so many vets who don't even understand how to dose lantus
by the advise they give.
It helps if you can remember that you pay her for her advice but that doesn't mean you have to do what she says.
It should be a partnership and you get to decide.
and any vet who says it's my way or the highway, well , I take the highway.
I've had several rheumatologists for myself tell me that I will take the medications they want me to take.... and I always get up ,
leave, and say no.


You hold the needle.
and sometimes the best revenge is when you can show how well your baby is doing..... against what they recommended.
I just nod with some of it.... and walk away.
the best diet for a diabetic kitty is the one they will eat. Most cats only eat the hill's stuff for a couple of days before turning away.
I'd be telling her I got some from a friend and she won't eat it.
the vet will probably hush from that.

just mho.


so
question....
are you giving anything for neuropathy?
read the symptoms on this page

Is it really tremors? or just weakness?
 
I don't think she's recommending hills, I think it will be Purina DM canned... but I'll know for sure tomorrow when i go to pick it up. He's not having difficulty walking, and definitely not hock walking. Just noticing sometimes when he's standing still, his little front legs get a bit 'wobbly'? not constant..
 
I found this in a document of a roundtable discussion on pancreatitis
http://www.idexx.de/pdf/de_de/small...ine_pancreatitis_roundtable_discussion_us.pdf
...
Robertson:
One disease mentioned earlier that often develops secondary to chronic pancreatitis in cats is diabetes mellitus. It is important to recognize if diabetes is present or develops in these cats, so that it can be managed appropriately. This usually requires insulin therapy, at least in the short term. However, the
diabetes in these cats may be transient and as the pancreatitis resolves, the diabetes may also resolve.
Managing these cats can be challenging.
Forman:
I agree. The pancreatitis is also a common contributing factor in insulin resistance in diabetic cats. (emphasis mine)
Williams:
Even if the diabetes mellitus is not caused by the pancreatitis per se destroying islet cells, the presence of inflammation in the pancreas can make diabetic cats more difficult to regulate and stabilize. Also, in rare cases chronic pancreatitis can lead to concurrent exocrine pancreatic insufficiency and diabetes mellitus, so that treatment with pancreatic extract supplements as well as insulin is required.
Steiner:
I think that it is pretty much agreed upon that pancreatitis and diabetes mellitus often occur together.
Managing the pancreatitis may alleviate the need for insulin therapy. I think that is quite significant for the cat and the owner.
 
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((((Megan)))) I'm so sorry you are getting conflicting advice. :bighug::bighug: I've been there. My vet also thought I didn't need to test for IAA and acromegaly but said she'd humor me. But it took a lot of talking.

Many people try DM and find their cats grow tired of it. You could always say you tried it and Oren didn't like it. There are many commercial options besides Fancy feast if you want to try better quality food. Not sure DM qualifies as better quality.

It's your choice on dose, but if you do lower the dose, please don't hold it long. I've seen several people lower the dose on vet's advice. Then glucose toxicity sets in and you have to go even higher. 3 weeks, maybe even 3 days might be too long at 4 units. For ease of mind you might want to try it - I understand that.

As for the other client at the vet, I've seen lots of cats here do a diet switch, even to Fancy Feast, and go into remission quickly. For some of us though, that's not the hand we've been dealt.
 
i'm not in favor of any of the prescription foods.... and I saw you said purina dm.... i apologize. I now call all the vet can foods hills.....
just mho ....

does he seem to be in pain when you push on his elbows, or shoulders?
generally the way to confirm arthritis is with xrays....

i'm wondering if he doesn't have something neurological so hopefully someone who has dealt with that will see....
if not, maybe ask about that in the subject heading later.
 
My biggest concern of all that you've said is the drop in dose from 6.25u to 4.0u - and then minimal testing so you won't even know what's happening. If you opt to decrease his dose, please, please, please test him twice a day for ketones. They can develop quickly and if left untreated can move into diabetic ketoacidosis - a crisis.
 
I'm not really planning on not testing a few times a day, I will definitely do preshots, and probably a few mid cycle tests as I've been doing. She doesn't need to know that I am. As for the doseage decrease, I believe her fear is that this dose had dropped him too low. And now if the pancreatitis has been 'elevating' his insulin needs, I can almost see her point. The problem is, until he's had a few doses of Bupe for pain control, and perhaps the inflammation subsides a little, he probably does need the extra. So of course I'm not going to not test him at all... still, it's so hard to know the right course.. He is still eating very enthusiastically, and not vomiting...
 
When I was in the process of leaving our vet of 25 years with Punkin and looking for a new one, I went to one that specializes in cats. The young woman vet that I saw was probably in her 20's and she made it very, very clear that she would be in charge of his dose. In other words, she was new at being a vet and she needed to control things. I just said thank you and went to another vet who had 2 diabetic cats of her own. By that point Punkin had been diabetic for at least 6 months and I had a good handle on what I was doing. We also had the acromegaly diagnosis by then, which added a whole other thing to become educated about.

The second vet didn't practice Tight Regulation, didn't even test her cats at home. She ran them to the clinic if they had hypo symptoms and put them on a glucose drip. I thought my system was better than hers, LOL - punkin never needed intervention by the vet for anything "ordinary" to do with diabetes. I don't know if you have another vet option or not, but I wanted a vet that would be my partner and who would also respect the information that i brought from FDMB. She'd never seen a cat with acro, so it was smart of her to be open to the research I brought from here.

Many diabetic cats have pancreatitis - it's common. Punkin had one acute episode and the vet said then she thought he likely had chronic pancreatitis. As the pancreatitis settles down it's possible that his insulin dose needs may decrease, but you don't need to decrease the dose in advance. It's not a sudden healing that suddenly makes a cat overdosed. If you're hometesting, you'll catch the change and will reduce it appropriately.

If your current dose had been achieved inappropriately, without methodical increases to the dose based upon the nadirs at each dose, then there might be reason to suspect that his dose is dropping him low and he's bouncing from it. But you've followed the dosing guidelines and increased appropriately. That is your assurance that this is an appropriate dose, that it is how much he needs, and that he's not overdosed.

You didn't cause any of this, so take that burden off of your shoulder. To the contrary, you were observant, got Oren tested when he became sick, and are treating him more thoroughly than probably 90% of cat owners would ever do. You should feel very good about being so competent of an advocate for your little sweetheart.
 
simply put, how do i argue with her that the doseing guidelines I've followed are appropriate, when she doesn't believe in the protocol? I offered to send the actual published journal article, and she showed little interest. She simply believes that the increases I've made have been too much, too soon. And I don't think she'll change her mind on it. So, with her wanting to recheck him in 3 wks (or me having to walk away now, and find ANOTHER vet to pick up from this point, w/ new testing etc), transfering records again etc., I don't know what else to do except lie about how I'm dosing him.

Perhaps the SLGS method would be more to her liking; slower adjustments in the dose changes...

I guess I can try to argue that the expense of the recent testing, a new bottle of Lantus and now an expensive prescription food is not tolerable (and that isn't far from the truth); i need commercial food alternatives or something. And i suppose there is a chance Oren won't like it (though so far, I've never found a food wet or dry he didn't like...). I can't find much in the way of specifics for diets for pancreatitis; the biggest concern seems to be make sure they're eating something. And he is. Supposedly high protein, low fat, low carb, 'low residue', (I don't know what that means.) It is apparently trial and error to find the right food. She seems to swear by this DM canned for helping both conditions. No one else is giving me definitive alternatives, just bad mouthing the prescription foods (though I definitely have seen some people say the Purina DM canned is ok). Fear not, I will NEVER go back to dry.

Civvie Patty is eating Friskies pates, so I suppose I could try those? Vet thinks FF is not easily digestible, and too high in salt.

ARRRRRGGGGH. just too much. I'm wiped
 
If I could get mine to eat this and only this, I'd go with http://www.instinctpetfood.com/cats


I have a picky eater. She was originally a friskies canned eater and I'm going back towards that brand too. now that she's got ibd,
ff seems to aggravate it.

I'm not trying to frustrate you.... so sorry if I did/am. ( I probably still have a little pent up frustration from my own recent vet experience)

it does sound like the slgs would be more to her liking because the low threshold is higher for dose changes.
Perhaps you can use it as a bargaining chip....for compromise.
I recently had one of the other vets at our multivet practice try to butt in on food for mine and she wouldn't even listen .
She was also trying to change medications that were working and gave me some that aggravated the condition.
I now ask for the one I prefer who works with me instead of trying to control everything.

I would lie to her about dosing .... and keep it where it is.
just for the reason Julie said:
My biggest concern of all that you've said is the drop in dose from 6.25u to 4.0u - and then minimal testing so you won't even know what's happening. If you opt to decrease his dose, please, please, please test him twice a day for ketones. They can develop quickly and if left untreated can move into diabetic ketoacidosis - a crisis.
Click to expand...
 
Megan & Oren said:
simply put, how do i argue with her that the doseing guidelines I've followed are appropriate, when she doesn't believe in the protocol?
Click to expand...
Ask her what protocol or guideline she uses, and where was the research done to support it. Was the research published in a veterinary journal? The answer is probably no. She does know you are using a human meter and not a pet one? Setting a lower limit of 60's/70's makes sense for the pet meter.

I agree to disagree with Neko's regular vet about food all the time. I feed Neko raw food. At least the vet didn't try to sell the prescription food when I said I was feeding low carb wet. I started out feeding the Wellness Chicken/Turkey which are low carb (and several others here feed), but switched to raw when the civie got cystitis and his vet (a different one) recommended raw as something they both could eat. A major criteria for me was a food both could eat, as Neko pushes the other cat out of his bowl. Neko's acupuncture vet, who is also a regular vet, recommends raw food. The Wellness in the tall cans is quite economical. I've seen a number of people here also feed Tiki cat or Merck options. Dr. Lisa's food chart lists a lot of low carb options.

rhiannon and shadow said:
I would lie to her about dosing .... and keep it where it is.
Click to expand...
One of the frustrating things about diabetes is that a dose that worked at one point can stop working. If you were following TR, I wouldn't keep Oren on this dose any longer, I'd increase. He's only gotten to high greens and that was over 10 cycles ago.
 
I feel for you, Megan. There isn't anything about this that's easy, and then to have the vet giving you grief and wanting to control everything would be overwhelming. All I can say is what i would do/did. The choice is always yours.

When I look at Oren's ss, it looks to me like a high dose kitty. He had only one green cycle until after you passed 5u. If I were a betting person, I'd bet there is iaa involved. Notice how when you increase the dose, he gets to better numbers once, and then the dose stops working almost immediately. That is a hallmark of iaa.

On 4/30, you increased from 5.25u to 5.75 - he had one green cycle and then never again on the 5.75u. He even got down to the 50's on it, but after that first cycle, the lowest he got was in the 100's.

On 5/6 you increased to 6.25u and again, he got to green soon after the increase. This time on the 2nd cycle of 6.25u, but now it's been 5 days since that barely green test and he hasn't gotten back under 100 again.

With acro, the dose can just keep going up but that initial response to the dose is more a "symptom" of iaa. With acro a dose might work for quite a while, but if the tumor ramps up production of its insulin-like growth factor then you have to go up in dose again.

I think your vet is thinking in terms of a "regular" diabetic cat. I'd ask her how much experience she has working with a cat with a high dose condition. Just tell her that the people on this board who have experience with high dose cats think that it's very possible that Oren has either acromegaly or insulin auto-antibodies or both. The latest research is that 25% or so of diabetic cats have an acro tumor. Ask her if she has ever seen a diabetic cat with pancreatitis that needed that much insulin. We're concerned that decreasing his dose may result in him being in high numbers unnecessarily. Even without decreasing his dose, he's already developed a tolerance for this dose and it's no longer working for him. I agree with Wendy, in fact, I'd be increasing his dose. The trouble with staying at a dose that isn't working is that the cat develops Glucose Toxicity and then it takes increasing even more to bring the blood sugar down. With high dose cats the worst possible thing is to stay at a dose that isn't working - you don't want to end up with a gigantic dose if you can avoid it and staying on top of the blood sugar is the only way to keep the dose size down.

The last thing I want to do is add to your burden, but where would you be if those of us with experience weren't frank about what we see? I hope you've gotten a good night's sleep and feel up to taking this on tomorrow morning. I remember only too well the frustration of having a cat that doesn't fit the protocol, that is difficult to get regulated, and not having a vet that I felt knew enough that I could trust them.

If I were you, I'd tell the vet that I'm willing to try what she suggests after I get negative test results back on acro and iaa. In the meantime, I'd want those tests both done. You'll have the results in a week and those results will be your basis for how to proceed. Surely she can wait for a week for you to do things her way.

Whatever you choose to do, you know we're on your side and will do our best to help you.:bighug:
 
thanks ladies. I totally appreciate the input and support; I just feel being pulled apart by two very strong forces! I am afraid of his higher numbers too lately; and so I think I need to flat out put it too her why does she think that's ok, and yes, has she ever seen pancreatitis cause this high a dose? Not sure I'll get to see her actually today when i go to pick stuff up, probably not. We are supposedly going to stay in touch by email/calls, so I think I'll plan to send her lots of info. that way. WHen they tell me what the food costs for a 3 wk. supply I'll make a decision whether to get it or not. seriously, my finances are straining a bit; and being locked into something i can only get at the vets will complicate my life A LOT in terms of access/cost etc. I will definitely be getting the Bupe and trying this probiotic (which I can't remember what she said it is, some kind of powder to sprinkle on his food). the only good thing is she's not pushing dry food.

ETA; also forgot to mention that the urine culture was negative for a UTI.
 
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A couple of thoughts....

I agree with Wendy's response on how to deal with your vet. Medical decision making should be based on evidence -- research based evidence not conventional wisdom, not because, "I'm the vet." and not because "That's what a specialist told me." Your vet needs to read the literature. If she doesn't base her recommendation for the use of Lantus on the tight regulation protocol, what does she base dosing recommendations on? How does she justify her approach? Does she understand the pharmacology of this tipe of insulin (i.e,. that it's a depot-type of insulin, how it achieves it's long duration, etc.) (And if she had to ask a specialist, maybe that's the vet you ought to be seeing?)

The notion that food contributes to pancreatitis is very old school. The roundtable article that you linked is an excellent resource for understanding pancreatitis. Have you seen Marje's Primer on Pancreatitis? That will help give you more information. DM is a Purina product. It is low carb. However, it's main ingredients are animal by-products. Why pay for a poor quality prescription food when you can buy a human grade food for the same money? I'm really, really curious where your vet is getting her information on the sodium content of DM and other foods. Take a look at the manufacturer's websites -- there's no information there on sodium content. If your vet is so convinced as to the superiority of DM, ask her to provide a print out of the nutritional information for DM along with whatever it is that you're feeding so the two of you can sit down and do a side-by-side comparison. (FWIW, my guys wouldn't eat DM or Hill's MD. That's pretty significant since they are both rather food motivated. As someone once pointed out, why would our cats eat a food that's made of eyeballs and a**holes when they can eat muscle meat?) Oh. And the first ingredient in DM is liver. Cats shouldn't be getting a diet that's high in liver. (They need liver in their diets but not as a first ingredient. A mouse is not composed of primarily liver.)

FWIW, I deal with physicians on a daily basis. Be polite and respectful and ask for the published research that supports their point of view so you can educate yourself. I have access to medical and veterinary libraries. If she can't produce the article, ask her for the reference -- and don't let her scoot around by saying it's in a book. You want published research not a secondary source. I can lay my hands on pretty much any journal article if you want a copy.
 
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