9/29 Oberon BG/ket PMPS 368/6.0, +3 360/6.8, +5.25 326; dexa results

ER vet says if he's eating and looking ok he doesn't need to come in right away. The internist will be in soonish and he's going to get in touch with her and have her call me. I'm going to hopefully grab a little more sleep.
 
JaxBenji said:
Good luck Lisa & Oberon :bighug: Sending lots of love :bighug:
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carfurby said:
Sending prayers. :bighug::bighug::bighug::bighug::bighug::bighug::bighug:
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Thanks! Holding steady (5.5) at AMPS. BG is up to 352, but I'm less concerned about that. When the internist calls, I'm planning to talk to her about possibly using Humulin R alongside Lantus. I know Wendy has some experience with that, but probably won't be here until later. Anyone else ever use this procedure?
 
Lisa & Oberon said:
Thanks! Holding steady (5.5) at AMPS. BG is up to 352, but I'm less concerned about that. When the internist calls, I'm planning to talk to her about possibly using Humulin R alongside Lantus. I know Wendy has some experience with that, but probably won't be here until later. Anyone else ever use this procedure?
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Did you ever get the IGF and IAA done? @Marje and Gracie know about using R and one other though I can't remember who. I never went the R route. Ollie didn't have ketones, but had glucoses that just didn't budge, they had me go different route. Did not know of the acro yet.
 
Olive & Paula said:
Did you ever get the IGF and IAA done? @Marje and Gracie know about using R and one other though I can't remember who. I never went the R route. Ollie didn't have ketones, but had glucoses that just didn't budge, they had me go different route. Did not know of the acro yet.
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Got blood taken for IGF, IAA, B12, Cushing's test, senior panel + T4, etc. yesterday, so we're waiting for results.

BG is back down a bit (330) and ketones are about the same (5.9). The vet tech called to see how he was doing and I asked enough questions that she said she'd have the vet call me back. So now I'm waiting for that... I'm about to ditch a work meeting so I can shower and be ready for my class at 11:15 (naturally this is my long teaching day).
 
Do you have fluids, maybe give some to help get those ketones down. They haven't found what's causing them yet, are they sure there is no infection somewhere? Teeth, uti, gallbladder? How about blood cultures, maybe there is a blood infection.

Since they are ongoing, I would have everything at home to start right away as soon as they start creeping up.

If you have any lab reports, get copies and post them. Tag Marje, she great at interpreting them.

Just saw above post about the igf and iaa.
 
I've been giving him soupy food all morning; he isn't coming and asking for food but when I put it in front of him he goes right for it. He pretty much licks it dry and then I have to wet it down again. (This is normal for him.)

He's on Baytril as a "just in case" but so far the only full dose he got was at the vet on Friday. He's fighting it a lot. I got about ⅓ of a dose into him last night (crushed, in syringe).

Fluids daily (100 ml) since Friday; I'll give him today's early, after my class. I have enough for tomorrow and then I need to stock up. I'm going to get a +4 check in a few minutes, and then I have class until 12:30. (Pretty much guarantees that that's when the vet will call back, of course.)
 
OK... talked to the vet. Urine culture was negative, but we'll continue with Baytril in case there's infection elsewhere. Dexa results were annoyingly equivocal. Probably not Cushing's, but she couldn't be sure. Other results are still pending.

She said to call if he starts vomiting or refusing food, and keep doing fluids, etc. She's also very familiar with the Lantus + Humulin R protocol and is willing to guide me through that since I'm monitoring him so closely, but wants to wait a day or so to see what the new Lantus dose does first. (She mentioned some different versions of Humulin, too, that weren't familiar to me.)
 
The acro and iaa tests could be awhile. The igf is only run on Wednesday with vets getting results on fridays. So if sample didn't get there for tomorrow run, it will be another week. IAA I think is done any day.
 
Olive & Paula said:
The acro and iaa tests could be awhile. The igf is only run on Wednesday with vets getting results on fridays. So if sample didn't get there for tomorrow run, it will be another week. IAA I think is done any day.
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Good to know, thanks! Hoping to get the regular senior panel back today. Also, I told her I needed more fluids after tomorrow and she offered to call it in to my regular vet (15 min away instead of 35), and said to also ask them if they have a pill gun for the Baytril.
 
Do you have Humulin R? I can help with dosing. You can get it (I think) fairly cheaply at Walmart pharmacy. Do phone around, there is also Novolin R - same thing, different brand. It should cost under $30 for a vial, but some places charge a lot more. I don't know where to purchase in US.

What time zone are you in, and what time is shot time? Typically we start R slow and build up, and usually start at preshot time. Though if you had R now, that might change things.

Marje is away travelling, not sure exactly when she'll be back.

Kind of mad the internist did a dexa test instead of UCCR. :mad: Oh well, water under the bridge. I haven't seen any other kitties get dexa test first and now we know to strongly not recommend it as first test if Cushings being ruled in/out.
 
Olive & Paula said:
Ask if baytril can be given in the fluids. Then you can give through the port in the line.
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I asked about injectable Baytril and she didn't want to because it can be irritating and he's already getting so many other injections (Pepcid, fluids, Lantus). But we didn't talk about adding it to the fluids, so maybe I'll bring that up. I think the ER vet didn't think I'd be doing fluids for that long.

Wendy&Neko said:
Do you have Humulin R? I can help with dosing. You can get it (I think) fairly cheaply at Walmart pharmacy. Do phone around, there is also Novolin R - same thing, different brand. It should cost under $30 for a vial, but some places charge a lot more. I don't know where to purchase in US.

What time zone are you in, and what time is shot time? Typically we start R slow and build up, and usually start at preshot time. Though if you had R now, that might change things.

Marje is away travelling, not sure exactly when she'll be back.

Kind of mad the internist did a dexa test instead of UCCR. :mad: Oh well, water under the bridge. I haven't seen any other kitties get dexa test first and now we know to strongly not recommend it as first test if Cushings being ruled in/out.
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Eastern time (New Jersey, but I don't have the Humulin yet; she wanted to wait and see how the next day or so goes at the new Lantus dose. I'm hoping CVS has it; it's right next door to me.

Yeah, if I had it to do over and thought about it a little more in advance, I might have suggested that we not give a steroid to an unregulated ketotic cat... fingers crossed that he'll just settle back down once the dexa is gone. (Half-life of 36-72 hrs, apparently.)
 
Humans use R all the time, so most pharmacies should have it, but their might be price differences. Eastern time, but what time is shot time? Just trying to translate that to my time in Pacific.
 
OK, so I won't be helping at AMPS time. :p Will see if there is someone on the east coast who can help with that. We typically have someone on line with you the first couple attempts. First test, we suggest you get a +1, +2, +3, and +4 after shooting R, so that has to work for you as well. The goal is to learn how R works in Oberon. +2 is typical onset, +4 typical R nadir (note: my girl didn't like being typical :rolleyes:). You only want R to lower the BG about 100 points over it's duration. It is used to nudge the BG down, to give the Lantus a better number to work with. Too big a drop causes a bounces which defeats the purpose of giving R to lower the BG. And that also means you don't want the Lantus (or Levemir) nadir to coincide with the R nadir. And you don't want to shoot R in a bounce breaking cycle. There are more guidelines - I'll stop there for now. It's more important to learn when not to use R, than when to.
 
Wendy&Neko said:
OK, so I won't be helping at AMPS time. :p Will see if there is someone on the east coast who can help with that. We typically have someone on line with you the first couple attempts. First test, we suggest you get a +1, +2, +3, and +4 after shooting R, so that has to work for you as well. The goal is to learn how R works in Oberon. +2 is typical onset, +4 typical R nadir (note: my girl didn't like being typical :rolleyes:). You only want R to lower the BG about 100 points over it's duration. It is used to nudge the BG down, to give the Lantus a better number to work with. Too big a drop causes a bounces which defeats the purpose of giving R to lower the BG. And that also means you don't want the Lantus (or Levemir) nadir to coincide with the R nadir. And you don't want to shoot R in a bounce breaking cycle. There are more guidelines - I'll stop there for now. It's more important to learn when not to use R, than when to.
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OK, thanks! I don't even have the prescription yet, so the earliest I would be starting would be tomorrow evening, and that's assuming the vet agrees that we should start it now. How is the dose determined?
 
Not all places do you need a prescription for R. For dose, we start low, go slow. We'd start with either 0.1 or 0.25 units, and see how that goes. Eventually you build an R scale, that tells you how much R to give based on BG at the time, plus time of cycle. Sometimes you give R at the last half of the cycle, to slow the rise and start the next cycle with a nicer number. But not where we start.
 
Morning data (from title): BG/ket +9 311/5.6, AMPS 352/5.5, +2 330/5.9, +4 356/5.3, +6 347/5.8, +10.5 381

Still stuck in the mid 300s, but still eating. He's already gotten his fluids and Pepcid for the day, so all that's left is the Baytril (wish me luck) and monitoring until bedtime.
 
Now that I have a minute... here's the results from the dexamethasone suppression test. Oberon's results (ug/dl): baseline 3.1, 4 h 1.1, 8 h 1.4. Interpretation: Normal: values under 1.4 at 8 h. Hyperadrenalcorticism: values above 1.4 at 8 h. Annoyingly, the test doesn't say how to interpret if the value at 8 h is exactly 1.4. Is that positive, or not?

For values above 1.4, there's a followup to distinguish pituitary-dependent hyperadrenalcorticism (PDH) from adrenal tumor: Cort less than 1.4 at 4 h is consistent with PDH, and if cort at 4 or 8 h is less than half of baseline that's also consistent with PDH. Oberon's values meet both of these criteria (1.1 at 4 h, and less than 1.55 (half of 3.1) at both 4 and 8 h. So IF his 1.4 at 8 h counts as hyperadrenalcorticism, his results are consistent with PDH.

Just to complicate things, I just looked up the test on the company's web site and the interpretation is slightly different there. Same bit about <1.4 and >1.4 as above but leaves out =1.4. But then "Cortisol levels less than 1.0 ug /dl 2 – 6 hrs post-dex and greater than 1.4 ug/dl 8 hrs post-dex supports PDH." So based on that he barely misses the criteria for PDH.

TLDR: Looks like he's on the borderline for PDH. Not sure yet what to do with this info; I'll wait until we get the rest of the results in.
 
I'm sorry Lisa, I'm trying to follow, but this is way out of my experience zone...I can try and Google a little?! :p:bighug:

How's our fella doing with ketones lately? That I have some minimal thoughts about :bookworm:
 
Christie & Maverick said:
I'm sorry Lisa, I'm trying to follow, but this is way out of my experience zone...I can try and Google a little?! :p:bighug:

How's our fella doing with ketones lately? That I have some minimal thoughts about :bookworm:
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Oh, I've been all over Google this evening with this. For now I think I'm not going to stress about it, and discuss it with the vet when we have the fuller picture. I'm just annoyed that the criteria don't specify what it means when the cat is right on the cutoff.

Ketones are still high (6.0 at PMPS) and I'm still pushing food and fluids. The vet says so long as he isn't refusing food or vomiting he doesn't need to come in. I'm really hoping he starts to come down soon because I'd love to get some real sleep. (Last night I was up until 1, told DH to test at 4 and wake me if ketones were up. They were and he did. Back to bed after consulting with the ER vet. Up at 7 for Lantus. Back to bed. Up at 9 for good. 4 hours of Zoom lecture, plus more testing and stuff. I'm totally baked.)
 
He's lucky to have such caring people in his life :bighug:, hoping you can catch some sleep tonight. You are doing all the right things, and it sounds like he is feeling okay through it all. I'm still quite perplexed about those continued elevated ketones.
 
I'm pretty convinced that the ketones right now are largely the result of the dexa test. Which doesn't mean they're not a concern, but hopefully it means they'll resolve as the dexa wears off. (dexa half life 36-72 hrs...) Just have to keep it from starting to spiral out of control.
 
I'll be filing that in my memory banks, crazy though, those numbers....ugh. I'm so glad it isn't really phasing him, but I really want to see a lower number tomorrow ;)...tell him I'll be looking for improvement. Extra chin scratches for Oberon, what a gorgeous boy.
 
Wendy&Neko said:
Start reading page 335 of this article. Also see the table 5 on page 337 for interpretation of results. Note that cat results are different than dog ones.

Which is why having R in the toolkit would be helpful.

Paws crossed you get some catch up sleep tonight.
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Wow, thank you! Downloaded it, and I'll read that tomorrow. Sleep soon, after I make one more attempt to get the Baytril into him. (Didn't get the pill gun yet.) BG was 326 just now. Paws crossed it's the start of a dip now that he's on his 3rd cycle at this dose.
 
Prayers for a dip! I know you said West coast.....one thing you can ask your IM to do is consult with an endocrinologist specialist, either through the U they studied at Or through another U. I am not sure how close or how far you are to UC Davis but they have quite a few of the top endocrinologist IM/PhD vets based there. Some of these diagnosis are tricky. I know one vet out of UC Davis wrote an article (https://www.dvm360.com/view/feline-facets-cushings-disease) & stated that the Dex test can be an issue with unregulated DM (false positives) however, there is so much to these diagnosis sometimes (timing of the test etc) that the IMs who have gone on to sub specialize within endo are incredibly helpful and the best in figuring it all out.
 
Tomlin said:
Prayers for a dip! I know you said West coast.....one thing you can ask your IM to do is consult with an endocrinologist specialist, either through the U they studied at Or through another U. I am not sure how close or how far you are to UC Davis but they have quite a few of the top endocrinologist IM/PhD vets based there. Some of these diagnosis are tricky. I know one vet out of UC Davis wrote an article (https://www.dvm360.com/view/feline-facets-cushings-disease) & stated that the Dex test can be an issue with unregulated DM (false positives) however, there is so much to these diagnosis sometimes (timing of the test etc) that the IMs who have gone on to sub specialize within endo are incredibly helpful and the best in figuring it all out.
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Thanks! I'm actually on the east coast (Wendy is west coast), but with everything happening over Zoom these days location doesn't really matter anymore! Good article. The false positive issue is really interesting, because it suggests that this borderline result we have could actually be negative.
 
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