? Advice Sought: Euthyroid Sick Syndrome / Non-thyroidal Illness Syndrome

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Critter Mom

Critter Mom

Member Since 2014
Saoirse's recent bloodwork showed low thyroid levels. In addition to her blood levels being low, she is showing some clinical signs of hypothyroidism (including hair coat condition poor/shedding; signs of tyrosine deficiency (coat is rusted); lethargy; inactivity; weight gain; low mood; elevated cholesterol).

Saoirse has chronic pancreatitis (well-managed now) and the vet specialist has indicated that the thyroid issues are related to same. However, I am sitting here and looking at many of my girl's clinical signs regress back to where they were before starting insulin treatment last year and I'm not one bit happy about it.

When Saoirse was receiving insulin, she was active (tree-climbing, able to jump onto counters), groomed with appropriate frequency (grooms very little now); was spontaneously playful (little or no interest in playing now); had a svelte abdomen (now distended again); and her hair coat was kitten-soft, glossy, and black as the ace of spades.

Saoirse has some abnormalities in her liver (detected on scan). Her liver labs are at the high end of normal - vets not overly concerned at the moment (treating with milk thistle/SAMe supplement - labs much improved over lab work done shortly after diabetes Dx last year).

Saoirse also has early stage II CKD (BUN in line with high protein diet; Creatinine just slightly above high end of reference range but trending downwards without any specific CKD treatment; no protein in urine; specific gravity c. 1.02). Saoirse is eating well (already takes ondansetron and famotidine for pancreas issues).

Diabetes-wise, Saoirse's numbers have slowly trended upwards since suspension of Lantus treatment (from low 5's to about 7, with some peaks going outside regulation (some 8s, occasional 9s, 11s). Without careful dietary management (mini meal feeding to produce frequent pulses of insulin) I think her BG levels would be going outside the euglycaemic range more frequently.

NB - The coat rusting and deterioration in other clinical signs started almost immediately after Saoirse's insulin treatment was suspended. Since becoming diet-controlled Saoirse has been, on average, running in the higher part of the normal range.

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Now that the background info's in place, I'd like to ask members for some help / advice:

1. Any advice on day-to-day aspects of Euthyroid Sick Syndrome would be very much appreciated.

2. Is anyone treating their cat for ESS? If so, I would greatly appreciate it if you would share information and experience you have on treatment/management techniques for this condition.


My understanding is that vets are not keen on treatment interventions for ESS so I'm trying to learn more about what's possible. It's eating me up inside to see Saoirse sliding backwards like this. (((Saoirse)))

EDITED TO ADD:

The feline specialist that examined Saoirse in March detected a slight gallop heart rhythm but structurally her heart was OK when they examined it (can't remember whether it was an ultrasound or an x-ray). Saoirse's blood pressure was taken recently at home - 140 systolic (normal range 135-170). No protein in her urine last time I tested it a couple of weeks ago. (See Weight/Urinalysis tab in her Labs below for further details.)

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As a human with thyroid issues that fell into the "normal reference range" for years, I can sympathize. I was sick for about 3 years before anyone would treat me. The concern in treating early thyroid or ESS is that over treatment with thyroid hormones can cause cardiomyopathy long term, specifically, cardio hypertrophy. What doctors (and probably vets) fail to remember is that -not- treating thyroid disease leads to heart failure, and is probably much more common than hypertrophy. I can't begin to count how many heart failure patients that were hypothyroid that I've seen and I always wonder. If her thyroid tests are low, then supplementation is warranted. Blood tests are required fairly regularly to tract supplementation.

The problem falls in the research (which is probably lacking in cats). In humans, they don't have good disease studies relating to the thyroid levels. Therefore, when labs designed tests for levels, they simply did a bell curve, and if you fell under the main curve, you were "normal". "Normal" and disease-free are not the same thing. If you did the same statistical analysis with weight and our current population, the normal weight would probably end up being twice as much as healthy weight, and healthy weight would probably be outside the curve. It makes no scientific sense.

Unfortunately, hypothyroidism is a mimic of many other diseases and difficult to pin down when labs are "normal" or close to it. Other hormonal issues can contribute to symptoms you see. Low level adrenal insufficiency has the closest symptoms to thyroid disease, and are often co-morbid. Cushings can also mimic symptoms. Lack of insulin can alter the metabolism because exogenous insulin has some effect on growth hormone receptors (IGF and others). You may be seeing effects from kidney disease (anemia? electrolytes?).

Do you have copies of recent and older lab results for reference?
 
Thank you for responding, Meya.

Here's a link to Saoirse's Labs. (Not very tidy - it's a work in progress. Should be shareable. Let me know if you have access problems.)

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Re the CKD, I joined Tanya's group recently. Saoirse's food isn't the greatest phosphorus-wise, but it's the only thing she can eat reliably that doesn't hurt her digestive system. (Spent 10 months trying to find one - although she did relatively OK on Smilla kitten food when she was receiving Lantus.)

Our vet wants to see Saoirse a smidgen lower phosporus-wise. The group experts looked at Saoirse's labs and think she only needs a tiny bit of support, if any, at the moment. I'm giving her a miniscule dose of aluminium hydroxide binder in one meal each day (1/16 of an Alu-cap) and I'm going to get more labs done in a few weeks' time to see how that's impacting her numbers. (She can't take Ipakitine because of the soy (allergic) and we got nowhere with Pronefra as it upsets her GI tract/pancreas.)

There's only one thing of which I'm sure: Saoirse was looking and acting youthfully on a microdrop of Lantus once a day. Her numbers started trending upwards within weeks of suspending Lantus treatment, her pancreatitis symptoms got worse, the abdominal distension returned, her fur started rusting, and she started losing muscle mass again. It is only a diet change and careful feed scheduling that has held her remission at all, and even at that she's spending significant amounts of time every day above 7.2/130 (Alphatrak).

I wanted to reinstate a 'maintenance' SID microdose of Lantus months ago but got no support from the vets. They're waiting for her to start spilling glucose into her urine, and I'm really very, very unhappy about that.
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So the labs don't show too much you aren't already aware of, the abnormal kidney/liver values which appear to be stable. The MCV and MCHC are measure of the size and hemoglobin concentration of the red blood cells, and are abnormal, but your hgb and hct are in the normal range. I'd keep an eye on these, as anemia is common in CKD.

Its interesting about the B vitamins, I assume you began supplementing. Are you supplementing just b12 and folate, or b-complex. Since these all are water soluble, I'd imagine that it wouldn't be surprising if she's deficient in more than those two.

I'm not sure in cats, but in CKD the other deficiency that causes morbidity is vitamin D deficiency. The kidneys activate vitamin D, and CKD can lead to low levels. In addition to calcium/phos balance and bone health, vitamin D is thought to play a role in a whole host of disease processes. I was able to find some research in cats, but I'm sure there is more. It might be worth getting a test if one is available in cats. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430519/

The only lab you had done for thyroid is thyroxine. Thyroxine is the inactive form of thyroid hormone. Again, I don't know in cats, but some humans have trouble converting thyroxine (T4) to triiodothyronine (T3) so getting both hormones tested is worthwhile. Since these are both highly protein bound, the free hormone tests are more specific. I'm unsure the exact test that is more specific for cats, there are a few thyroid tests available.

The aluminum hydroxide binder is not the binder of choice for long term. Aluminum is neurotoxic and does build up in the system over time.

As for the vets, I'd say if she was doing better on the microdose, I really don't see any harm in doing that. You probably don't even have to do twice a day as there are residual effects of lantus for 24-48 hours. There are other things insulin does besides lower the blood sugar. It acts as growth hormone (both suppressing and agonizing various systems) and influences other hormone balances via the pituitary. It also changes receptor density of various hormones on the cells.
 
Thank you so much, Meya, for reviewing my girl's labs.

I've been doing my research and found studies that showed endogenous insulin as being influential in CKD (e.g. http://www.the-scientist.com/?articles.view/articleNo/29298/title/Insulin-is-key-to-kidney-disease/.)

In the latter stages of Saoirse's Lantus therapy I used SID dosing effectively since she naturally ran lower at night and that kept her numbers in the TR healing range ( <=7.2mmol/L). Based on Saoirse's clinical signs, I think that tiny drop of Lantus was doing much more for her than regulating her blood glucose levels. Saoirse was a different cat on insulin. She looked really, really healthy at the end of last year. Alert, active, playful, body and coat condition excellent. Our main vet was absolutely gobsmacked at the difference in her after she started Lantus treatment. He could not get over how much younger she looked. Her quality of life was much better when she was on it, too.

I do want to get a full thyroid panel done at her next test in addition to the full workup on everything else.

Saoirse was showing signs of tyrosine deficiency when Dx'd for diabetes last year - her coat was badly rusted, but that completely resolved with insulin treatment. The rusting was the first really obvious change when Lantus support was suspended. It's not related to the change in food brand - happened on the Smilla I had been feeding her when treating with Lantus.

I'm supplementing B complex at the moment, Meya. There isn't much B12 in the product I'm using so I've also got some Zobaline on order but I think it's stuck in UK customs at the moment. After Saoirse had her scans in March, she had post-shaving alopecia. The fur started to regrow when I started supplementing the B complex, but it doesn't look 'right' if you get my drift.

Depending on Saoirse's phosphorus level results from the next set of labs I may skip the binder if her numbers have improved. (I am concerned about the aluminium toxicity.) I'm looking at getting a consult with Dr Pierson to see if she can design a diet for Saoirse that she'll eat consistently but which is lower in phosphorus: it really would be the best way forward for her, given that her phosphorus levels are quite stable; they just need a bit of a tweak downwards and it would be much better to do that with diet.

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I can't thank you both enough for your input on this. I've been stalling and stalling for months now over whether to start her back. I have an unopened cartridge of Lantus (refrigerated - well within expiry date) and I'm worried about not getting another one. It's not a decision I've been able to make alone. Thing is I've not read anywhere here about anyone else following a similar course of treatment.

My thoughts are that I should get our vet to examine Saoirse and get another set of labs done in a fortnight or so, then trial her on a Lantus SID microdosing regimen. If her clinical signs improve, then maybe our vet will be more supportive? I will have BG data to show I can keep her safe. What do you think?

It is killing me inside seeing Saoirse gradually return to her pre-Dx condition and doing nothing. She looked - and acted - amazingly healthy at Christmas just after her Lantus treatment.

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Just a question about the rusting of the fur. If the color change is along the back, and tail base this might be oxidation of oils when there is an overproduction of oils (stud tail). Depending on her coat color, the oxidation could have a yellow, green-ish or orange-ish appearence. Flakes of dried oil might be visible. Stud tail can happen when there is a change in the production of androgens. In a spayed/neutered cat, the adrenal glands produce estrogen and testosterone in addition to cortisol, so it could indicate changes in adrenal function. Not sure where this fit into the clinical picture.

Tyrosine deficiency will be pretty even color change, or could represent a pituitary change in the production of MSH or melanin.
 
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There's just no better proof that you're doing the right thing than to show positive clinical signs....if you have a sick looking cat now, and the only change you make is to restart the insulin and she returns to a healthy looking cat, I don't know how your vet could argue
 
Meya14 said:
Just a question about the rusting of the fur ...
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It's pretty much uniform, Meya, with the exception of the fur on her head and neck (where she can't groom). It looks like the reddish-brown colour a black cat goes in summer when the sun has bleached some of the colour out. No flecks other than an occasional tiny trace of dander.

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Chris & China said:
There's just no better proof that you're doing the right thing than to show positive clinical signs....if you have a sick looking cat now, and the only change you make is to restart the insulin and she returns to a healthy looking cat, I don't know how your vet could argue
Click to expand...

That's my plan of attack, Chris. I don't like 'going rogue' but I feel I have to do something. There is only one Saoirse.

I pray that it will be enough...
 
The even color change then would be related to melanin, perhaps tyrosine deficiency, but not necessarily. The pituitary may not be producing the melanocyte stimulating hormone. It could be an indicator of overall pituitary dysfunction. The MSH is very closely related to the ACTH (for cortisol) and TSH (for thyroid) and have some overlap in function. It's an interesting observation if you also think there are thyroid issues.

Insulin causes a lot of changes to pituitary feedback and other hormones in the body. A lot of these changes aren't even really studied yet. The endocrine system is really still a mystery of medicine. I'd think if she did better on the insulin this probably has something to do with it, and why not put her back on?
 
There's one subtle difference I did notice when Saoirse was on insulin. Her saliva was a different consistency. The insulin affected so many things. Saoirse's mood and sociability were much better, too.
 
Áine....you've been around this board long enough to know pretty much all of us are "going rogue" when it comes to our sugarcats!!

That's why the "smile and nod" way of dealing with some of our vets recommendations is suggested so much!....There's also the "hmmm...that's interesting! I'll think about that!" way of dealing with them!....LOL
 
I've done a fair bit of that meself, Chris. :D Our main vet was inclined to raise a tactful eyebrow over some of my choices; for example my choice keep Saoirse tightly regulated on Lantus treatment until there was irrefutable evidence that her pancreas was working; and also my home testing frequency (that old chestnut ... ).

What worries me is that, assuming renewal of Lantus therapy works, once my cartridge is gone that I won't be able to get another Rx.

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You'd have to scavenge friends, neighbors, co-workers, etc and see if anyone will give you their leftovers if not available OTC in the UK. Not ideal. Wish it was OTC here too like in Canada.
 
I would hope if you can show positive clinical signs that the microdose is improving her QOL, that your vet wouldn't deny you another script

But at 1 drop per day, that cartridge should last you a good long time, so we'll cross that bridge when we come to it! Like Meya says, keep your ears open for friends, neighbors, etc. that might be able to help you out if it comes to that
 
Not OTC here, Meya.

Chris, what would a ballpark figure be for longevity of a properly refrigerated pen cartridge once the seal is breached for the first dose?

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We've seen them last as long as 6 months, but the key is to watch the numbers...if they start to trend up and there's no reason for it, then it's time to consider the insulin.

My last pen pooped out at about 4 months
 
Thanks for the guides, Chris and Meya.

If the Lantus is going to make a difference to Saoirse's health then there should surely be sufficient changes to her clinical signs to convince the vet of its benefits? What do ye think?
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Chris & China said:
I might even take pictures...document as much as you can and it'll make your case stronger if it does end up making a difference
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That's a brilliant idea, Chris. After Saoirse was diagnosed last year, I couldn't take pics of her progress because my camera phone went pear-shaped. However I now have a shiny new tablet thingy. I can document any changes pictorially using that. Excellent. :)
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Aine, I don't have any advice to offer but I'm sending lots of hugs and healing thoughts for both you and Saoirse. I'm so sorry to hear she's having these problems! Wish I could help more.
 
Aine, this hug is for you :bighug: And here's one for your sweet kitty :bighug: I don't have anything else to offer you that could be helpful. Let me know when you need a refill of this Rx and I'll gladly send it along. :D
 
there was a vet at our clinic who didn't want me to restart insulin and I was prepared to give her false info....
inflate the numbers...
they knew I wouldn't pay for a curve or leave my cat at the clinic.
Fortunately there was one vet there that pretty much was willing to try whatever I wanted to.
but othoh, success of treatment probably speaks louder and you should be able to get lots of time out of your vial.

@Critter Mom
I will happily try mailing you all of Shadow's methyl b12... pm me your address.
I will label it something like cat toys or clothing...
either it will make it thru or not....

Sending hugs....
 
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@rhiannon and shadow (GA) -

Thank you so much for sharing your experience, Rhiannon, and for the suggestions and much-needed hugs. Also for the offer of the B12. The postal gods must have heard you: I got the note for the customs charge through the letterbox earlier today so I'll have the stuff I ordered by Wednesday. I really appreciate your kind offer very much. :bighug:

(And sorry for taking so long to reply. Been trying to get to this thread all day.)


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Bless you, you are certainly going through it!! you have been there for me so much, and my thoughts and hugs are with you to. It certainly seems a no brainer to start the Lantus again, trust your instincts you are a great mum and you know best!!! IT WILL BE OK XX
 
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