6/9 Copernicus AMPS=420

I hope you get some good answers from the IM vet. If you can't afford radiation therapy or surgery (both very $$$) you should push for cabergoline.

When he gets home, Copernicus is overdue for a dose increase. He needs to find those yellows again. If he's only seeing 300 and above, increase every 6 cycles.
 
Im not doing brain surgery on this cat. We are going to start cabergoline. The MRI is the most sensitive but the most expensive and then they would need to still do a CT anyway if we moved forward with radiation. Also crazy expensive. They said the cabergoline is a capsule made by their in-house chemist. She said the liquid isn't as stable. She also was going to hold his dose since he is starting this medication. Something tells me you are going to tell me something otherwise??
 
Krista & Copernicus said:
Something tells me you are going to tell me something otherwise??
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So true! Cabergoline doesn't work right away. It's cumulative. He's in such high numbers that I'd really like to be seeing at least upper blues before you slow down in anticipation of cabergoline working. And get those ketones down, which requires more insulin. Is the cabergoline to be given every day or every other day? Every other day (EOD) takes even longer to take effect. But can be a good idea, at least to start, for cats with a sensitive tummy.

FWIW, almost no one gets an MRI for the radiation therapy, and only then if the staging CT doesn't find anything. Neko had SRT twice and never had an MRI.

What are they charging for the cabergoline? Wedgewood compounders was a popular source here.
 
His ketones have been below 1 except for that one off. I don't know the cost until I pick it up tomorrow. I'm worried about the capsules getting stuck in his throat since he hard swallows. It's every 48 hours. And his BGs are over 400 today. Not sure how I will justify going against medical advice and them not telling me I am welcome to get advice elsewhere bc that comment has already been made from other vets and then I don't hear from them if I don't do what they tell me to.
 
Can the capsule contents be mixed into his food? That is the advantage of the liquid. I agree that capsules can be tricky, you don't want anything bigger than a size 4 capsule. Acros can have thickening in the pharynx, you have to watch for larger objects.

You are the closest to Copernicus, you see him every day. You are the customer, you have to advocate for him. He should be doing more than sleeping and eating;
 
He hasn't had much quality of life since this all started. Are we just delaying? Not all cats can be saved. Radiation can cause blindness, hypothyroidism, neurological complications but so can having high BG like this all the time. I also would have thought he should see some sort of positive response to these increases, especially 9, but he isnt. I'm not even getting the low 300s on this much insulin.

I really don't want to start crushing meds into his food and changing the flavor since he is eating so well. But I will have to see the size of the capsule and make a determination.
 
Wendy&Neko said:
Can the capsule contents be mixed into his food? That is the advantage of the liquid. I agree that capsules can be tricky, you don't want anything bigger than a size 4 capsule. Acros can have thickening in the pharynx, you have to watch for larger objects.

You are the closest to Copernicus, you see him every day. You are the customer, you have to advocate for him. He should be doing more than sleeping and eating;
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Do you have a resource for tissue growth in the throat that I can read? I will Dr. Google but I know you are a good resource so thought I would ask. Something I would like to educate the resident on
 
If the acro tumour is actively growing, which it looks like with Copernicus, you have to keep more aggressively increasing to get him into better numbers. I have see acros on much higher doses than Copernicus. Not saying he will get to much higher doses, but you do have to stay on top of increases. One of the vet techs on this board many years ago said "be the tank, the tank always gets where it's going". You WILL get to a dose that moves Copernicus and gets him to feel better, but not by sticking with doses that aren't doing it for him. 9 units is still a relatively small dose for an acro. I lucked out that Neko maxed out at 8.75 units, just before we went for SRT. Her tumour was tiny.

Jackson, currently posting here, seemed to have a good reaction at 15 units. See how on March 12 he saw greens on 8 units, then not again until April 20th on 13 units. Take a look at his spreadsheet.

See Figure 2 in this article: Feline Acromegaly: An Essential Differential Diagnosis for the Difficult Diabetic also the text before the figure.

I have yet to see a cat undergoing SRT go blind or have neurological complications, though untreated acromegaly can do that as the tumour grows. A small percent of cats go hypothyroid, but that is treated with a simple pill each day. I think cabergoline is an excellent option. It wasn't available for us so it was SRT or nothing at the time.

Try giving the cabergoline in a liquid treat like a puddle of Churu.
 
I will read all of that. Thank you. Back to the MRI, it sounds like not all tumors show up on CT. So how do they know where to aim the radiation if not all tumors are visible? And this vet made it sound like cabergoline had low success rate? And how can an unregulated cat fast and go under anesthesia without going into DKA?
 
Most places just use a CT scan to plot the tumour. MRI only if nothing seen on CT, which is a small percent. When I went to CSU they even had one case where tumour didn't show on CT or MRI but they did radiation anyway because there were a lot of acro symptoms. They just radiated the entire pituitary gland. Which is tiny.
Krista & Copernicus said:
And this vet made it sound like cabergoline had low success rate?
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Depends on your definition of success. We've seen maybe half dozen cats go off of insulin, but more important, most see reduction in dose and better QOL. Does the vet have experience with cats on cabergoline, or is he just quoting from the small study (5 cats) by the Royal Vet Clinic which is unfortunately getting too many views? The South America study had much better results numbers and much larger number of cats in their study.

Sorry, but more reading: Quality of life and response to treatmentin cats with hypersomatotropism:the owners’ point of view This paper suggests that people giving cabergoline were pretty happy with it. Travel and cost are real factors for surgery and radiation therapy. One of the researchers posted here collecting survey responses.
Krista & Copernicus said:
And how can an unregulated cat fast and go under anesthesia without going into DKA?
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If the vet is using modern protocols for diabetic cats undergoing anesthesia, they can eat until early morning, and have about 1/3 of their breakfast and 1/2 dose of insulin. More details in the second post here: Info on Dental Procedures (including pictures) It's about dentals, but the second post is about anesthesia in general. If kitty gets high numbers, the clinic should be monitoring blood sugars, and can give a bit of R (Regular) or fast acting insulin to bring down the numbers.
 
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Wendy&Neko said:
Most places just use a CT scan to plot the tumour. MRI only if nothing seen on CT, which is a small percent. When I went to CSU they even had one case where tumour didn't show on CT or MRT but they did radiation anyway because there were a lot of acro symptoms. They just radiated the entire pituitary gland. Which is tiny.

Depends on your definition of success. We've seen maybe half dozen cats go off of insulin, but more important, most see reduction in dose and better QOL. Does the vet have experience with cats on cabergoline, or is he just quoting from the small study (5 cats) by the Royal Vet Clinic which is unfortunately getting too many views? The South America study had much better results numbers and much larger number of cats in their study.

Sorry, but more reading: Quality of life and response to treatmentin cats with hypersomatotropism:the owners’ point of view This paper suggests that people giving cabergoline were pretty happy with it. Travel and cost are real factors for surgery and radiation therapy. One of the researchers posted here collecting survey responses.

If the vet is using modern protocols for diabetic cats undergoing anesthesia, they can eat until early morning, and have about 1/3 of their breakfast and 1/2 dose of insulin. More details in the second post here: Info on Dental Procedures (including pictures) It's about dentals, but the second post is about anesthesia in general. If kitty gets high numbers, the clinic should be monitoring blood sugars, and can give a bit of R (Regular) or fast acting insulin to bring down the numbers.
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This is all doom and gloom:

Feline Acromegaly - WSAVA 2015 Congress - VIN

But this statement scares me the most:
Some patients treated with high doses of insulin unpredictably and inexplicably become sensitized to the effect of the insulin, resulting in hypoglycemic crises. The timing of the insulin sensitization and occurrence of hypoglycemic episodes was extremely variable. In one study, several acromegalic cats were euthanized after experiencing hypoglycemic comas

The life spans after treatment aren't significant . :(
 
Any 2015 paper is pretty much out of date regarding treatments now. Royal Vet Clinic does the most hypophysectomies of any place and has a lot more data on outcomes now. Cabergoline was just started being researched in 2015, and the paper would have been written before then. SRT has become a lot more available now. I had to drive 3 days to get to Neko's treatment. Obviously a lot of people couldn't travel that far then. In 2015, most people didn't treat other than insulin.

Regarding the concerning statement, remember that not everyone home tests. Relying on periodic visits to the vet for a "curve" would be even more dangerous with high doses. Even cats on lower doses pass from hypos now with no home testing.

Neko lived one week short of 5 years as a diabetic. Many of our acrocats are older cats and also get other conditions. Of a few acrokitties that were around in Neko's time, two passed from totally unrelated cancers. Neko had kidney disease, heart disease, and small cell lymphoma when she passed. Not sure which one did her it, probably a bit of each. But for the majority of her life as a diabetic, it was a pretty good life. Once I got her into reasonable BG numbers.

Every acrocat is completely different in what the journey will be going forward. All you can do is try to give them as good a QOL as you can for the time they have. Remember, cats live for the moment, they don't worry about tomorrow.
 
I agree with everything Wendy said.

Lots to add, but for now I’ll focus on the MRI/CT question.

Tubby was one of the “interesting” (cough) acrocats who had microadenomas rather than macroadenomas — the “micro” indicating that they so small they couldn’t be visualized on CT.

I was initially told we had to wait until we could visualize the tumors before we could do SRT. We lost a year as a result, which I regret (that’s a story for another day). Then I was told they could do an MRI and “marry” the results to the CT to determine target areas. Ultimately, they said the CT was adequate and that they’d just “zap” the entire pituitary.

Like Wendy, I know of no one who did an MRI.

Interestingly, despite having microadenomas, Tubby tested clearly acro on the IGF-1 and had a lot of physical symptoms of acro, including tissue overgrowth that affected his breathing, enlarged internal organs, overall enlarged body features, a large flat spot on the top of his head, and a protruding lower jaw. The breathing improved notably after SRT.

Finding a good dose will likely make Copernicus feel better (Tubby always looked like he had a hangover in high numbers). I would follow Wendy’s advice on the dose increases. It may feel like a lot of insulin, but a cat needs however much he needs.
 
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