6/27 Henry WC. AMPS 336 ket: 1.1 +1 312 +2 238 +3 186 +5 167 +6 163 ket:0.3 +8 167 +10 182 +11 193

Previous condo: https://felinediabetes.com/FDMB/threads/6-26-henry-wc-pmps-252-2-303.265099/

Well, I'm really hoping for a better day today. Ketones are back up to 1.1... Consuming tissue he really can't afford to lose. Just gave 1.75uL & 0.1uR

He ate 2 cans of FF back to back this morning and finished the 3 partial ones I had left out for him overnight. The subQ fluids he got last night really seemed to help.

Does anyone know if IBD or lymphoma (the 2 suspected causes of his intestinal wall thickening) can cause him to not absorb nutrients as readily? I'm feeling bony parts of his skull and hips I've never felt before. Just another reason ketones scare me so much. He doesn't have the tissue needed to make them. I'm afraid his body will start "eating" his heart muscle and other vital organs soon if it's not already occurring.

 

Wow, what a struggle. Was he producing ketones that whole time?

I understand this. I was just looking at the only BG reading I have on him before his FD Dx (taken the same day as his Dx) and it was 336, so he could have very likely been living in the red for a long time. The R really muddies the data and makes it hard to assess a baseline. Under the normal condition of FD I can see this as absolutely being the best way forward. In cases like Henry's where rapid ketone production causing DKA and secondarily consuming what little body tissue he has remaining (to me) the R is a lifeline, which yes, best avoided (edit: and used sparingly), but at this point I don't see how it can be avoided but only try to use it as sensibility as possible.

Thank you for your comment Sandy

 

It can, though it is hard to say what is diabetes, what is possibly IBD or lymphoma, or potentially something else. Certainly don't intend to beat a half-dead horse, but another reason to have a more in depth conversation with the vet about those findings.

As you know my cat has a working SCL/IBD dx that we cannot confirm (I can't even do ultrasound because he's so fractious he would have to be anesthetized). His poop has been pale, smells different, and sometimes diarrhea, and he had coat changes (bleaching, he's a black cat), which is what led me to bring him in. The TAMU GI panel JL mentioned is what helped point us to SCL/IBD, and it leans more towards SCL but is not definitive diagnosis. My personal approach was going to be novel protein first, if that didn't help after some time then I was going straight to prednisolone as recent research is showing it as the first treatment for SCL and would also help IBD, then after some time likely attempt chemo if all else failed. His hyperT dx put all that on hold, needed thyroid under control first as that's more life threatening. But pred is contraindicated for heart problems, budesonide wears on the liver, it's just a lot to consider.

To Wendy's point yesterday, some caregivers/vets prefer to go straight to chemo if they know it's an SCL/lymphoma dx and not waste time on novel protein or a steroid. We have had cats go into SCL remission on pred alone (@Katherine&Ruby )...but pred is likely an unwise choice with Henry's current state as it affects BG. Also to Wendy's point we are not vets, and you are in complex territory that really needs an IM vet, likely an oncologist, and possibly others.

I would also be asking about food. I don't know whether it is best in his situation to prioritize low carb and perhaps high protein, or higher calorie, etc. Novel protein can't hurt if you can get the right nutritional profile, but you run the risk of him not eating it. And it's more important that he eats.

This was a lot of thinking out loud. I've been trying to meter how much information I give because you have a lot on your plate but you are asking questions that I don't want to ignore.

Site a lot of use for IBD reference - https://www.ibdkitties.net/

Specific page on IBD vs lymphoma - https://www.ibdkitties.net/ibd-or-cancer/

 

Got my fingers crossed for a yellow shortly.

Absolutely. A large number of cats with GI issues can be deficient in B12. Next time Henry is in at the vet, it'd be a good idea to get a GI panel blood test done. If the B12 is low, it can be supplemented, usually injections. B12 orally isn't absorbed as well. But you also don't want to give B12 without a test showing the need, cause there is some thoughts that excess B12 is good for cancer.

Unpublished research is the only what I've heard about. If you've got a link to published peer reviewed research showing it's a treatment by itself, I'd love to see it.

A short novel protein trial is fine, but the complicating factor is that some cats (including the one snoozing on my couch who has been in SCL remission for 4 years), can have both IBD and SCL. Novel proteins help if IBD is present, but don't do away with the small cell lymphoma. SCL does not go into remission on pred alone, but pred can definitely help symptoms for a period of time. Until it doesn't. It can also mask the progression of SCL until it becomes a lot harder to treat. Treatments for the two conditions are different, which is why knowing what you are dealing with tells you which direction to go in. That's why I was hoping for more details on the ultrasound that seemed to have vanished from the report. Again there can be hints in an ultrasound. Neko could not have a proper diagnosis due to her heart conditions but her ultrasound pointed more to the likelihood of SCL.

An internal medicine vet is a better choice than an oncologist. Henry has several issues, IM vets are great at balancing multiple conditions and prioritizing. Many IMs treat IBD or SCL. The other Henry issues are beyond that of an oncologist unless they are double ticketed. In the three cats I've had with SCL, none went to an oncologist. Though Neko's IM vet consulted with an oncologist, who suggested too high a dose of chlorambucil. Which I told the IM was too high, and subsequent blood work proved me right. So I'm kind of down on them. I belong to a SCL online group that is occasionally helped out by an IM vet who has treated hundreds of these kitties.

 

Wendy, it sounds like they’ve already sent blood to TAMU for a GI panel — fPLI/fTLI/folate/cobalamin. Still awaiting results, I think.

John, the cobalamin value is the B-12 Wendy mentioned. It’s often low in cats with GI impairment. Injectable B-12 (cyanocobalamin) is the go-to and TAMU has an established protocol. It’s inexpensive and easy to administer (I use my insulin syringes).

 

So he's had 3 ultrasounds so far, but as far as I know all the findings were the same. I'll call the vet and see if they can't email me all his records. I know in human medicine you can always get your records, not sure it's the same in the veterinary world.

His current attending is an IM (cornell undergrad/CSU vet school). She has made 3 major mistakes with his diabetes case but I think she's competent. The amount of knowledge required to treat such varying disease in cats/dogs/birds, etc. almost seems harder than being a human doctor.

I'll look into the novel protein thing.

Edit:

That is correct. Hoping to have the results tomorrow.

 

Thank you for all that information frostD. I know very little about any of these things, but I am good at learning and researching. Thank you for being a good resource of information & options.

 

I learned the hard way to request copies of all blood tests and ultrasounds etc. I originally just said I wanted them in case I ever needed to go to an ER after hours. It became automatic that I got them after that.

 

I think you own your veterinary records and are supposed to be able to request them. I have mine trained to email me a copy each time of blood work, etc. For the ultrasound report you posted, it just looks like they cutoff part of it in however they gave it to you.

Note, I made an edit to my previous post above which I realized could be read the wrong way. Novel protein diets do not help with just SCL, but can help if kitty has IBD.

 

@Wendy&Neko In an effort to keep out of the red (and thus avoid ketones) I'm curious on your thoughts about modifying the R dosing by doing either or both of the following:

A) Give .1uR if >275 & .25uR if >325
B) Assess & if necessary give dose at PS, +4, +8, instead of the current PS, +6 schedule

That would give a full 4 hours for the R to take effect and wear off, and hopefully keep out of the reds. If not, why? Is it due to not being able to see the nadir for the Lantus?

While this cycle has been good and if the data repeats itself, next cycle should be good too, but I'm worried we'll be back in the reds tomorrow. Thoughts?

edit: I know we had a big drop with the .25uR yesterday, but again I'm having a hard time getting a consistent dose eye balling it and it may have been a bit heavy. I'm now using my analytical balance to be able to weigh the dose. (Ie. 1U weighs ~10mg therefore ~1mg=.1U ~2.5mg=.25U) My balance is very accurate to .1mg (+/- .3 mg)

 

Amazingly, after his 2nd hospitalization for DKA he never had ketone troubles again - a miracle in and of itself. I don’t need to tell you how it feels to be swimming in a sea of relentless pink. For us it went on for months and months after 2 hospitalizations for DKA in 35 days time.
As a matter of fact his second (and last) hospitalization for DKA was on this day, June 27, 2008 …

Exactly.

To get back up to 10lbs he needs to consume about 390 calories per day. A can of FF is probably in the neighborhood of 90 calories

 

@Sandy and Black Kitty Did you see John’s question about R in #10 above?

 

Yeah, @Sandy and Black Kitty I'd definitely appreciate your input on that too.

 

Well, he's been eating about 5 cans per day, so looks like he's right on track for that 390 calories.

 

I think the amounts and BG range are OK to try but not the timing. Shooting R at L+4 could result in unexpected lows due to both nadirs happening at once. I recommend PS and either +6, +7 or +8 for a second bolus if needed.

 

Sounds good, thank you Sandy

 

Hi John, just checking in. Ill be around for the next several hours.
How is Henry? No more vomiting after the vomit at +3?
Have you managed to catch up on sleep?

 

Yes, finally got a (mostly) good nights sleep... In between mixing up +4 and +6 and sticking myself that is. He's doing pretty well tonight. Eating is ravenous as always. No, only the one vomit and he had eaten a bunch, not sure if it may had been because he was a little too full. It wasn't huge tho.

Quick questions: I need to do subQ fluids and Lantus shot at the same time. I was going to put the Lanus in his side instead of his scruff like shown in the sticky post, but I already put it in the scruff. Will now giving subQ fluids in the scruff mess up the insulin dose?

edit: I think another contributing factor to messing up +4 and +6 last night was because it was 6am.

 

I would not put the sub Q fluids in the scruff if you have just given the insulin shot there.
Any reason why you can't wait a few hours to do the sub Q fluids?

 

Well I was going to try and go to bed soon, but I can wait til +2. How long should I wait?

 

You know what... cancel that question, I'm such a dummy. I had measured out the dose and put it in the spreadsheet, but I hadn't put it in the cat yet. Doh. I usually do the spreadsheet last. I'll go ahead with the subQ and put the insulin in the flank. That should be ok, right?

 

I am glad you spotted you hadn't given the insulin. Its easy to happen if you go out of routine.
I think I would wait until +2 to give the sub Q fluids as long as they are in a different spot.

 

OK. I'll wait

 

John, I would get the +2 test first to see if there is much of a drop. If there is I would wait until the BG has flattened out a bit before giving the sub Q fluids because they can sometimes lower the BG further than you want, although ECID.

 

OK, so this is the third time today I've seen that "ECID" and I'm not sure what it means, and google isn't any help. So now I gotta ask "ECID"?

 

Every cat is different.

 

Ahhh, gotcha. Just did the +2 and we're back in the yellow (204), so I wouldn't mind a little drop. I got a (human) Doctors appointment tomorrow, so I should probably head to bed soon. I think I'm going to fill'em up here shortly and hit the hay.

 

Only just back in the yellow.
I would still monitor every couple of hours until nadir if you are going to give the fluids. Can you manage that?

 

Yep, I'm on it. I'm predicting a good cycle tonight, but the next 2 will be back in the red if this trend continues.

 

At +4 we're purrfectly flat no really. the only 2 times I've heard him do some really loud purring was just now and last night both times about 3 hours post subQ fluids. The fluids really seem to make him feel better (or at least act nicer) ... Going back to bed