i know i'm a broken record, and i guess everyone is sick of this, but i am really worse off than before. What really kills me is I attached the Roomp/Rand paper as a PDF, and i excerpted bits of it in my email, and she's claiming she wants to charge me for reading the paper I supplied? I also had the SLGS pasted in after the body of the email, it wasn't even an attachment, as well as the part of the spreadsheet covering the dose change (with my notes)
for the record, here is what i sent her. I think there was a failure of basic reading comprehension on her part to start with.
Dr. XXXX
I'm writing this because I feel we are still having difficulty communicating in person and I think part of that is due to your time constraints in the office(completely understandable!), and my awkwardness in handling myself in an escalating situation.
I think I can better try to express myself in writing, so I'm at least going to try! Let me start by saying I
do not want to be in an antagonistic relationship with you, quite the contrary, I need a partner and an advocate, someone who can help me navigate the myriad issues associated with this terrible disease. However, I was thrown off by your resistance to the Tight Regulation protocol and I get very flustered in a situation where I feel I'm being put on the defensive and I don't explain myself very well. I would hope we can both agree that we both have Oren's best interest in mind and want for him to be as healthy as possible? I am not meaning to come across as doubting your training, but I would hope any doctor, human or veterinarian would remain open to discussing different treatment strategies and work to find the best fit for everyone.
I hope to address some of your concerns with actual cited data rather than my sputtered, poorly expressed answers.
Per your concern on the use of human glucometers
Journal of Feline Medicine and Surgery (2009) 11, 668e682 doi:10.1016/j.jfms.2009.04.010
Intensive blood glucose control is safe and effective in diabetic cats using home monitoring and treatment with glargine
Kirsten Roomp BSc, MSc1, Jacquie Rand BVSc, DVSc, DACVIM2*
...
”Values obtained using human-use whole blood glucose meters are up to 30-40% lower in the lower end of the glucose range (hypo- and normoglycaemia) than plasma-equivalent meters calibrated specifically for cats and measurements obtained from serum chemistry analysers. This is assumed to be because the distribution of glucose between red blood cells and plasma in cats is substantially different from human beings (7:93 for cats and 42:58 for human beings).33,34 Therefore, if this protocol is being used together with measurement of blood glucose concen- tration using a glucose meter internally calibrated for feline blood, or using a serum chemistry analyser, it is recommended that approximately 1.7 mmol/l (30 mg/dl) be added to target glucose concentrations used in this study that are in the lower range. For example, instead of aiming for a blood glucose concentration of 2.8e5.6 mmol/l (50-100 mg/dl), aim for 4.4e7.2 mmol/l (80-130 mg/dl) when using a meter calibrated for feline use or a serum chemistry analyser. Importantly, this protocol has not been tested and shown safe for diabetic cats only monitored once every 1-2 weeks at a veterinary practice. It has only been shown safe when combined with home monitoring of blood glucose concentration a minimum of three times daily.”
SOURCE:
http://www.thecatclinic.com.au/medical-and-health-info/blood-glucose-monitoring-at-home/
”...
Measurement of blood glucose concentration (BG) is usually the best method of determining the correct insulin dose for diabetic cats. Stress hyperglycaemia occurs commonly when cats visit a veterinary surgery and can result in the wrong dose of insulin being selected. Thus, the stress-free environment at home is the best place to measure a cats BG.
Most human glucometers are very accurate at measuring cat blood. We prefer the Accu-Chek brand which can be purchased from any chemist for approximately $60...”
Document compiled by a longterm member on FDMB:
“In general, a human glucometer will read 30-40 percent lower than a pet-specific glucometer. At the low end of values, that difference is approximately 18 points. At the high end of the scale, it really doesn't matter. If the test is high, its high and you take the appropriate action based on the insulin you are using. If there is another medical condition affecting the glucose levels, you treat that condition and adjust the insulin...
...An important note about glucometers: The FDA allows glucometers to be sold which read within 20% of what a lab test might get. This means that any test represents a range of possible values.
Ex. A test value of 100 mg/dL means the glucose could be anywhere from 80 to 120 mg/dL.
Ex. A test value of 200 mg/dL means the glucose could be anywhere from 160 to 240 mg/dL.
For any 2 tests, they may be considered equal if they overlap, ie. if 1.2 * low value is greater than 0.8 times the high value
Ex given two tests with the same meter, 280 vs 310, can they be considered the same?
1.2 * 280 vs 310 * 0.8
336 vs 248
Yes, the 2 tests may be considered the same.”
Per the Tight Regulation Protocol
I first learned of this approach from the The Feline Diabetes Message Board at
www.felinediabetes.com. This is a wonderful online resource of hundreds of lay people with a huge amount of experience in the day to day treatment of this disease, and many others. It has been a source of great support and information, and really a lifeline after being thrown in the deep end after diagnosis. Many of the users there successfully follow one of two modified protocols developed out of the Roomp-Rand paper. One is the tight regulation and the other is called Start Low, Go Slow. I suspect that this approach may be more in line with your preferred dosing schedule, as well as comfort level. I have attached this at the end of this email, for your review.
The TR objective is to try and keep a cat in healthy range as much as possible to try and facilitate healing of the pancreas and possible remission. It is an admittedly aggressive approach, and does require a lot of commitment. I understand that you, and many other vets feel uncomfortable supporting this treatment protocol. In fact, many FDMB members have had similar discussions with their vets, and a common theme is that most vets feel uncomfortable promoting this for a number of reasons: most vets can't be accessible, as people are on the FDMB, at nearly any time night or day for people who are faced with lower numbers, they can't be sure who will be committed to the testing and learning when to feed and when to do the next test and so, for safety's sake, they are more conservative. They understandably, don't want to be the cause of a hypoglycemic cat. FDMB members stress safety first and commit to staying with someone if necessary to handle a situation. It is also been observed that Lantus, even using the TR protocol, tends to not result in clinical episodes of hypoglycaemia, both by FDMB members, and as stated in the Roomp-Rand article:
“...In human patients, clinical hypoglycaemia is reported to be less common when using glargine compared to intermediate-acting insulin.28,29 This is thought be associated with glargine’s consistent insulin action over 24 hours compared to a sharp peak of insulin action which occurs with intermediate-acting insulin. Based on the very low frequency of clinical hypoglycaemia observed in this trial and another trial in cats, it appears that glargine use in cats might be similarly advantageous.7 The frequency of biochemical hypoglycaemia reported in our study was likely over estimated because blood glucose concentrations were measured using whole blood glucose meters designed for human-use, which give readings that are 1-2 mmol/l (18-36 mg/dl) lower than measurements using automated serum chemistry analysers calibrated for feline plasma.30... “
Another member stated that her vet (she lives in NY) told her Cornell University Veterinary now recommends the TR protocol for all their newly diagnosed cats, and they seem to have an approach that takes into account the life/treatment balance. They offer a simplified version at diagnosis while their clients are learning to test and shoot, and then after the first 10 days they work with each client to create a modified version based on what their lifestyle will allow. They also make themselves available 6 days a week (24/7 in an emergency) for email and phone consultations to take dosing questions. I'm hoping to get a copy of their protocol when she returns in a few weeks for a follow up visit for her kitty.
I myself have concerns that I would always be able to put in the work necessary to stay on top of things following TR protocol. I can only argue that I wanted to give Oren the best chance of remission, but now that I'm nearly 5 months into treatment, I know that it is becoming less likely the longer we get from diagnosis. I think the TR or the SLGS protocols are a good place to start and give a structure and guideline to follow. But reality dictates there has to be some flexibility to make it work. The first goal is getting Oren regulated, then well-regulated, then hopefully tightly regulated. If remission happens...fantastic! If not, Oren is much better off being as tightly regulated as possible, rather than being just at or below a somewhat ambiguously defined standard of renal threshold. In any case, I just can't see how this is not a better approach then shooting a fixed dose for weeks at a time w/o home testing pre-shot at least, to catch what is going on. So many variables affect blood glucose levels on a given day, let alone across several. I would never be comfortable with shooting blind and will continue to test him several times a day when possible. Conversely, with your concerns about hitting numbers that appear to be uncomfortably low, I feel like I have good knowledge and support from the forum, to handle such situations, by steering with various kinds of foods (higher carb levels etc.) and also would not ever endanger him by shooting a low number if I know I can't be there to monitor him.
Per His Diet
I understand you feel that the DM prescription food is the way you'd like to proceed, but quite honestly, with the increased cost of all of Oren's care these days, I simply can't afford it on top of all the other costs. I also have a 2nd cat, and feeding them both would really be prohibitive. I'm stretched pretty thin as it is. I would like for you to work with me to suggest appropriate commercial options, if you truly feel Fancy feast is not a good option. High protein, low carbohydrate and even low phosphorus food is available (Friskies Special diet Turkey and Giblets is often recommended). Are you familiar with Dr. Lisa Piersons, DVM food charts maintained at catinfo.org. She has a very informative site discussing feline nutrition and food composition. I also find many references in literature and from people in the message forum that feeding smaller more frequent meals during each cycle is beneficial, rather than solely 2x a day, as it's less stressful on the pancreas. Many people find 4 meals a day works well, the main meals being pre-shot, with 2 additional smaller ones generally in the front half of each cycle. And some people continue to free feed in between the preshot meals. However, I also recognize that there is often a need to experiment to find the right food and schedule. ECID(every cat is different)!!
As you know, I came to you because I'm afraid there may be a secondary, rare condition causing his greater need for insulin, perhaps IAA or Acromegaly. I had wanted the IAA and/or Acro tests done just to rule those conditions out. Of course, It made complete sense to run the blood work and urine culture to eliminate UTI and it caught the pancreatitis before it got too severe, thankfully. However, if you look at his progress overtime, you can see the trend overall has been a dose would hold him for a while, but always seemed to begin to slip into higher ranges. Once 6u is reached, the recommendation is to check for these conditions.
As I feared, with this reduced dose his numbers are climbing even more, as are his water intake and urine output. I am extremely concerned about glucose toxicity and possible development of ketones the longer he stays in these higher BG numbers. Remember, it's not just since the dose reduction (which is now 6 cycles), but it's more like a week of numbers in the 300-500 range. His 14 day average is 335.This is backward momentum, no matter how you cut it.
I know there is more to consider than just the numbers, I try to remind myself to not get stuck there; is he eating? Grooming? Playing? Purring? Pooping normally, peeing 'normally'. Thankfully so far, yes to all those things, though as I noted, an uptick in drinking and peeing has happened in the past week especially. I can read his behavior pretty well now, and know from the litterbox and his demeanor when he is running high. He was backsliding at 6.25u, and it's only been worse since dropping to 4. I don't see any significant influence of more potent insulin from the new vial, even with any lasting effect of the depot from the last dose. He has had just over half his course of bupenephrine, and if there was any pain influence from the pancreatitis contributing to his higher numbers, there doesn't seem to be a noticeable effect yet. Thankfully, his appetite has stayed strong (though I note he eats his fancy feast first, even as it has decreased in proportion, and then eats the DM.) Waiting another 2 weeks of sending him backwards seems unnecessary and potentially unhealthy.
I will reiterate, that I have no wish to be confrontational with you, it makes me extremely uncomfortable and I know it is counter productive. Please don't take offense at me questioning everything, there is such a steep learning curve and I'm trying to soak up as much as possible. I have been extremely stressed and upset this week and I'm trying to reach out. I want to feel that we can work together, and agree to be open to finding the best course of action. I need to be a strong advocate for my beloved kitty. Again, we both want what's best for Oren! I truly thank you for all your efforts and input thus far, and for hopefully reading through all this. Depending on what I hear from you, I want to up his dose this evening. It is optimal for me on a weekend when I can be around to monitor him more closely, and I could even get a 12 hr curve today (as I'm off on Fridays)
In hope of better communication and partnership
Megan
) although a bit of FF was still there. Tonight might be first meal of just DM. 
