8/11 Ruby AMPS 252/+4 202/+7 243/+10 300/PMPS 262/+3 206

[Katherine&Ruby]

Yesterday.

Increased Ruby's dose to 2.25 units today and not too happy about it. Wondering if Ruby's increasing insulin need will influence the oncologist to introduce chlorambucil finally. She's showing no symptoms of distress aside from higher BGs and is acting quite herself. Nervous to change much now that us humans will be home less often to monitor, but life can't stop. Will be home with her half the day, then I have in person meetings to attend.

Hope everyone has a beautiful day.

 

[carfurby (GA)]

 

[Tomlin]

Hi Katherine

Overall, the increase with the glucose with more time being treated with the drug, BID dosing compared to what you experienced with QD dosing & the dosing of insulin being required to manage the glucose at this point is not abnormal/unusual at all. Keep in mind that the effects of Pred on glucose, if there is going to be an effect, increase with time exposed to the drug. As a result, it is not unusual to see less of an effect early on in treatment with respect to insulin resistance vs 2-3 months into treatment. Based on the data and the clinical symptoms being under control, I personally would be more inclined to attribute the rise in glucose levels you are seeing with 1) the increase in time she has now been treated with Pred and 2) the move to BID dosing of the Pred vs concluding that the inflammation is not being managed. Now, if 1) her symptoms were not being managed or only partially managed (not to say it is completely out of the realm of possibly that there may be some low level inflammation still existing), & 2) there was an increase in glucose & you had not started the drug recently & also moved to BID dosing, I would be more concerned that inflammation is a problem.

Again, it is not an official, large study in cats, but within the human literature, BID dosing resulted in increased glucose overall throughout the 24 hour period vs QD dosing, but again, lowered the level of the glucose of the peak or spike with the Pred after it was given. I experienced the same with T—-higher glucose after each dose vs a period of higher glucose in one cycle followed by a return to lower glucose and a need for less insulin for the 2nd half of the cycle. Despite the Pred having a biological effect long after you give it, there is at least a break for the body, to some extent, when it is given QD vs BID.

I am sure you will run it by your team who has worked with many cats with SCL/DM and have seen the glucose levels and they will have some thoughts as well . One other thought/option you can try to test the whether the QD vs BID dosing is contributing to what you are seeing for Ruby is go back to QD dosing and see if the glucose returns to the pattern/lower glucose similar to where it was before. Keep in mind, it may still run a bit higher because of the amount of time that she has now been on the Pred vs during your previous QD dosing. I know this may be a challenge due to your work schedules, but I wanted to at least throw the idea out there as one trial and error/info gathering possibility.

Rubs to Ruby and Olive !

 

[Diane Tyler's Mom GA]

Afternoon Katherine, I hope the increase helps and curious to see what the oncologist thinks about it whether or not to start the chlorambucil. ♥

 

[Katherine&Ruby]

Hi Katherine

Overall, the increase with the glucose with more time being treated with the drug, BID dosing compared to what you experienced with QD dosing & the dosing of insulin being required to manage the glucose at this point is not abnormal/unusual at all. Keep in mind that the effects of Pred on glucose, if there is going to be an effect, increase with time exposed to the drug. As a result, it is not unusual to see less of an effect early on in treatment with respect to insulin resistance vs 2-3 months into treatment. Based on the data and the clinical symptoms being under control, I personally would be more inclined to attribute the rise in glucose levels you are seeing with 1) the increase in time she has now been treated with Pred and 2) the move to BID dosing of the Pred vs concluding that the inflammation is not being managed. Now, if 1) her symptoms were not being managed or only partially managed (not to say it is completely out of the realm of possibly that there may be some low level inflammation still existing), & 2) there was an increase in glucose & you had not started the drug recently & also moved to BID dosing, I would be more concerned that inflammation is a problem.

Again, it is not an official, large study in cats, but within the human literature, BID dosing resulted in increased glucose overall throughout the 24 hour period vs QD dosing, but again, lowered the level of the glucose of the peak or spike with the Pred after it was given. I experienced the same with T—-higher glucose after each dose vs a period of higher glucose in one cycle followed by a return to lower glucose and a need for less insulin for the 2nd half of the cycle. Despite the Pred having a biological effect long after you give it, there is at least a break for the body, to some extent, when it is given QD vs BID.

I am sure you will run it by your team who has worked with many cats with SCL/DM and have seen the glucose levels and they will have some thoughts as well . One other thought/option you can try to test the whether the QD vs BID dosing is contributing to what you are seeing for Ruby is go back to QD dosing and see if the glucose returns to the pattern/lower glucose similar to where it was before. Keep in mind, it may still run a bit higher because of the amount of time that she has now been on the Pred vs during your previous QD dosing. I know this may be a challenge due to your work schedules, but I wanted to at least throw the idea out there as one trial and error/info gathering possibility.

Rubs to Ruby and Olive !

Thank you, Amy, for all of this. What you say makes a lot of sense. I think the pred has done its job to quell any inflammation. I suppose my question is if there is any benefit in having Ruby experience green numbers for a cycle and then high ones another on QD dosing or if it would just make her feel bad. I would much rather keep her on BID dosing and be increasing her dose so that she is euglycemic in both cycles, but I may be chasing after a ghost, especially if as you say the longer she is on steroids the more insulin resistant she becomes.

 

[Tomlin]

I may be chasing after a ghost, especially if as you say the longer she is on steroids the more insulin resistant she becomes.

I want to clarify—-it is a change you will see with the start of the Pred & within the first few months of starting treatment vs it being a problem that will continue to worsen & never level off if that makes sense? That would be scary if there was no end. There are obviously some cats who have issues with controlling their glucose with a steroid, but for the most part, most cats diabetes is able to be well managed with insulin. I believe I shared with you that Dr Lidbury, who works with Dr Steiner at TAMU, actually shared with my vet and I that he has had cats with inflammatory issues being treated with Pred & their DM was better regulated than patients with the same issue not taking Pred—because it is addressing the inflammation that causes the insulin resistance.

The QD/BID is going to depend on insulin dosing strategy. If you are locked into same dose of insulin both cycles, then you are probably better off keeping the Pred BID and then dosing the insulin to flatten the cycle the best that you are able to. You are going to find the right dose . T has days where he is flat both cycles & on the days where there is an increase due to Pred it is a climb hours into the cycle and it is only for approx 3-4 hours and it comes back down, so he it isn’t spiking and then dropping . He’s steady. As you know, we do not keep the dose the same for the cycles so that is how we are able to accomplish that level of regulation with him using QD dosing. Based on all the trials we did, our Pred and insulin dosing produced the best results for him. It may not be the best for Ruby. Again, some trial and error to figure it out.

It is great to read that she is feeling good & that picture of her from the other day was beautiful. Her eyes were so bright and full of life!! You are doing a great job. I know you will find the dose of insulin that works best for her. You are by no means chasing a ghost! I just wanted to mention the initial insulin resistance piece. It doesn’t hit all cats the same—if it is going to happen, it can happen over a few month while others get hit with it within weeks sometimes. Fortunately, Ruby came into the treatment with the advantage of a well working pancreas thanks to how well managed she was !

 

[Katherine&Ruby]

I want to clarify—-it is a change you will see with the start of the Pred & within the first few months of starting treatment vs it being a problem that will continue to worsen & never level off if that makes sense? That would be scary if there was no end. There are obviously some cats who have issues with controlling their glucose with a steroid, but for the most part, most cats diabetes is able to be well managed with insulin. I believe I shared with you that Dr Lidbury, who works with Dr Steiner at TAMU, actually shared with my vet and I that he has had cats with inflammatory issues being treated with Pred & their DM was better regulated than patients with the same issue not taking Pred—because it is addressing the inflammation that causes the insulin resistance.

The QD/BID is going to depend on insulin dosing strategy. If you are locked into same dose of insulin both cycles, then you are probably better off keeping the Pred BID and then dosing the insulin to flatten the cycle the best that you are able to. You are going to find the right dose . T has days where he is flat both cycles & on the days where there is an increase due to Pred it is a climb hours into the cycle and it is only for approx 3-4 hours and it comes back down, so he it isn’t spiking and then dropping . He’s steady. As you know, we do not keep the dose the same for the cycles so that is how we are able to accomplish that level of regulation with him using QD dosing. Based on all the trials we did, our Pred and insulin dosing produced the best results for him. It may not be the best for Ruby. Again, some trial and error to figure it out.

It is great to read that she is feeling good & that picture of her from the other day was beautiful. Her eyes were so bright and full of life!! You are doing a great job. I know you will find the dose of insulin that works best for her. You are by no means chasing a ghost! I just wanted to mention the initial insulin resistance piece. It doesn’t hit all cats the same—if it is going to happen, it can happen over a few month while others get hit with it within weeks sometimes. Fortunately, Ruby came into the treatment with the advantage of a well working pancreas thanks to how well managed she was !

Thanks, Amy. When I contacted Ruby's oncologist a few weeks ago, I presented two scenarios: different dosing of insulin or BID dosing of the pred. She opted for BID dosing. Is Tomlin on Lantus or another depot insulin? How would that work with carryover, overlap, and overall duration if you're giving two different doses of insulin over a 24 hour period?

 

[Tomlin]

He is on Lantus & the duration of action & consistency of the Lantus works well for him & it is consistent to the point that we are happy with how he does with it. He falls right into the average with how long it takes the Lantus to be metabolized, so for T, it works out very well. If there is a day in which there is a more significant effect on his glucose for a few hours, we’ve got him dosed so that he doesn’t drop too low before that happens or as that effect dissipates at the end of the cycle, yet the dosing manages the potential spike. That was a balancing act! We then have the cycle where he does not get the Pred and therefore, the insulin requirement is less so we dosed that based on his nadir as well. Fortunately, I had the the help, expertise & vast knowledge of his endo who does a lot of the studies to determine how the various insulins are actually metabolized in cats. That was extremely helpful and beneficial for T.

 

[Our Dolly Girl (GA)]

Hi Katherine. Good luck with the increase, so happy to hear Ruby has been feeling good. Sending healing prayers and lots of hugs for all of you. Please let Olive know I haven't forgotten about her