Charlie: High triglycerides and DM?

[Sarah & Charlie-cat]

Kinda just thinking out loud, I guess.

Got a partial report back from ISU vet (attached), minus the part I am most interested in-- the ultrasound. Not really sure why they would send it without that since it would certainly provide more information to the working theories, including what was communicated to me when I picked him up, that his duodenum is corrugated, which appears to be indicative of quite a number of things, including cancer and pancreatitis

In the report, in our appointment, and on the phone, the resident was adamant, that Charlie's high triglycerides are exacerbating or causing pancreatitis and he must be put on a low-fat diet. Specifically Hills W/D dry, which is 37% carbs and has rice, corn, wheat, and powdered cellulose in it. I am not opposed to low fat, but I'm unclear why that needs to be high carb. It isn't like human cookies from the low-fat fad in the 1990s that turned out to be stupidly high in sugar. And I am open to figuring how to reduce his inflammation through diet. They thought I changed his diet too much.

But I'm pretty sure he was just eating rabbit from Mid-March until mid to late April, which would be at least 6 weeks. He did well on that, throwing it up twice, from my notes. We did seem to have some good numbers in there before his DKA in mid-May, including a bunch of dose reductions under SLGS.

I did add in raw duck and turkey, and eventually, chicken because rabbit is expensive. He seemed fine on any of these until we hit the A/C out/potential infection from no one telling me how often I needed to change his fluid line/ possibly bad food. The only thing we haven't really tried to add back is fish.

Since that episode in July, he's seemed generally fine, but stupid high numbers that just don't seem to come down. Although he certainly bounced last night from being under 200 briefly, which I could see on the Libre.

His regular vet recently noted his high triglycerides and said that was to be expected with his diabetes.

I've been trying to find studies to make sense of this...
One noted that in healthy cats, those "on a high-protein diet had significantly higher serum cholesterol and triglyceride concentrations, yet lower fructosamine concentrations than baseline measurements." And overweight cats " had lower cholesterol and triglyceride concentrations on a high-protein diet than cats representing other BCS groups." (Berhman, C.F. et al. 2022, Influence of high-protein and high-carbohydrate diets on serum lipid and fructosamine concentrations in healthy cats. Journal of Feline Medicine and Surgery 24(8) 759–769). They conclude that both findings need further investigation... Charlie was overweight. He's probably put back on enough weight to be a little overweight at 15lb.

I found an older piece that suggests that hyperglycemia not hyperlipidemia causes beta cell dysfunction and loss (from 2009).

This one suggests that cats with sustained high BG develop high triglycerides ahead of developing ketones, although the high level they cite is 29 mmol, which is in the 500s for us weirdo Americans. https://doi.org/10.1016/j.ygcen.2013.04.029

Another suggests that there is a link between pancreatitis and diabetes and that control of diabetes in the case of pancreatitis is "brittle" due to variations in inflammation (Davison, L. J. 2015, Diabetes mellitus and pancreatitis – cause or effect? Journal of Small Animal Practice (2015) 56, 50–59). That certainly rings true for me. Just before everything fell apart in February trying to get him off the pred, his diabetes was much better controlled and on very little insulin. This piece appears to largely be a review of the literature and the linkages between hyperlipidemia and diabetes seem largely to come from human studies that suggest a linkage between fats, and obesity, and inflammation.

Needless to say, they do not want me to feed raw (I have been trying to get him on cooked, he was not into home cooked with EZ complete before his crash in July, but he's been doing well on Fetching's lightly cooked food). I'm open to cooked, but I'm not open to corn, rice, wheat, and cellulose.

Anyway, not sure where that leaves us but its shot time so we're gonna go do that.

 

[JL and Chip]

In my experience, it usually takes longer to get the ultrasound report (radiology reviews the images, report has to be transcribed and reviewed/approved/finalized, etc). Did you specifically request that they send it to you? Some vet hospitals will give you the discharge papers but won’t automatically send you the more technical reports unless requested (most clients don’t understand them).

If you have questions, you can call the vet to inquire as to status or go directly to Medical Records to see if the ultrasound report is on file yet.

Have you had a GI panel run on Charlie? I’m specifically referring to the Texas A&M University (TAMU) GI panel that looks at fPLI, fTLI, folate, and cobalamin. Blood gets sent off to TAMU for testing and analysis. If not, I’m somewhat surprised they didn’t suggest it.

Did ISU suggest any reasons for the fur loss and crusty ears? The pred, perhaps? They probably think it’s an issue secondary to steroids or whatever is going on with him metabolically, but most university vet schools do have the option for dermatology consults if needed.

Does Charlie have any issues with diarrhea or constipation? I’m curious about the color and consistency of his stools as well.

If he did well on rabbit, I might be tempted to go back to that and give it another try to see if things settle down. The general wisdom I’ve heard from numerous IM vets is that cats with chronic pancreatitis are less sensitive to fat content of their diet than dogs (for which it’s a bigger consideration). Of course every cat is different.

My own Charlie was also a complicated case; he too was put on steroids for IBD, which triggered diabetes, and he too suffered from chronic pancreatitis. Fortunately he never went into DKA, but it took a lot of digging and testing and time to get him somewhat stabilized, so I feel your angst. Was budesonide ever suggested instead of pred? Its effects are supposed to be more localized to the GI tract (whereas pred tends to have a more systemic effect) and so has less of an impact on BG for many cats. Just something to consider if you haven’t already.

 

[Sarah & Charlie-cat]

I will request they be sent to me if they aren't next week. No one even wants to give me bloodwork so I can keep tabs on stuff. It's really frustrating.

He did have a GI panel done in May, a different one that was still sent out that also looked at fPLI, fTLI and folate etc. I didn't really want to repeat it, although that was three months ago now. And certainly, his regular vet can do that and probably not charge me as much. I have no idea why the did the FIV testing, he's been tested multiple times and is negative. Potentially because his regular vet doesn't seem to put his ER records into his regular records... they're record keeping is such a mess.

I think his ears are scabby because I do a lousy job of holding them after I test to stop the bleeding. To be fair, he hates having his ears held more than he does having them poked.

He hasn't been constipated since I stopped feeding him Darwin's turkey. On the Vital Essentials rabbit, they were chalky. Both of those I think probably have too much bone. The last time he was sick in July, he had diarrhea but as a rule, he does not. Last time I caught him doing the deed, brown, solid, except for the very last bit. They look as if the fur is moving in the correct direction, as opposed to in February and March when he was having huge hairballs very frequently, multiple times a week. They're much larger than the other cats' poops, although I don't think any of the other cats come close to eating as much as he does.

I asked my regular vet about budesonide and she said she hadn't had much luck with it.

Yes, my understanding was feline pancreatitis was not as sensitive to fat as dogs. I mean, I can certainly skip duck and pork. Rabbit is generally the least fatty option. There are no good canned rabbit options for low carb. I have one that I keep on hand as a medium-carb food, it has peas in it! Fetching Foods offers a dry matter analysis of their foods: https://www.fetchingfoods.com/detailed-nutritional-analysis/. They also offer it sous vide, gently cooked. He ate that fine. The rabbit is still 15% fat on a dry matter basis. Which is twice as much as the prescription food but also it doesn't have ****ing cellulose in it. It is, however, 300 a month to feed him just that. If I could make cooked food with chicken breasts and Alnutrin with calcium and psyllium husk, that would be great. He doesn't seem to mind Alnutrin but doesn't seem to care for EZ Complete. I also need to get more consistent with giving him his probiotic. I don't know why that one is harder to remember than all the other medicines he gets/has gotten.

 

[Sienne and Gabby (GA)]

The one point I would keep in mind is that most medical professionals (vets and MDs) are very poorly trained in nutrition. They get almost no classroom time on the subject and most of their "training" comes from the sales reps from the pet food companies. The reps can sound very knowledgeable and science based -- well, that is until you ask them what powdered cellulose is. No doubt the resident is subject to such a lack in training. My initial vet was a big fan of "prescription" food for Gabby. We ended up having an argument over the food choice when I brought all of the food back. I asked her what the carb counts were on the canned and dry food she had me purchase. She didn't have any idea. When I told her and then pointed out that Fancy Feast was about 4%, she apologized. They really have no idea.

I have an IBD kitty. Both of my cats get a combination of raw and commercial cat food. The raw is either pork or venison with EZComplete. They get ZiwiPeak venison and Stella & Chewy's raw, freeze dried rabbit morsels. His labs don't typically include triglycerides but his cholesterol has been fine.

I would feed Charlie what Charlie likes and keeps his symptoms at a minimum.

 

[Sarah & Charlie-cat]

I left out the part where the 4th year vet student was not prepared to go 10 rounds with me on how research gets funded and published (tenured professor at University of Nebraska, although in a social science).

Yes, I just wish the rabbit wasn't so expensive. The only food difference before his last flare was the cooked chicken with EZ complete he didn't want to eat. But he might already have been flaring.

 

[Sienne and Gabby (GA)]

FWIW, many cats have GI issues with poultry and beef. My IBD cat can't eat turkey or chicken. None of the over proteins are inexpensive.

 

[Sarah & Charlie-cat]

He's had no interest in raw beef or lamb. Beef liver treats came back up basically whole. So we're skipping those proteins, although he's had some lamb canned food. He also has no interest in venison so I binned that one as well.

I haven't noticed an issue with chicken, it was the last to get reintroduced. If I had to guess, I think fish. He was getting a lot of freeze dried tuna and salmon treats when we started out testing and minnows, and sardines. We have not reintroduced fish. It seems like fish has been added to FF's non-fish flavor pated and I know the Savory Centers all have fish regardless of the flavor. While he loves that food, I've noticed it does have a tendency to come back up.

I'm going to put in an order for some more of the gently cooked rabbit but boy it's pricey. Rabbit does seem to be his favorite and he seemed fine on the gently cooked version so hopefully that will at least stop all the nasty vet comments about how I'm trying to kill him by feeding him a species appropriate food that's as close to what he would eat in the wild as possible. And it's the lowest fat option of the Fetching Foods regular offerings.

 

[Sarah & Charlie-cat]

Finally heard back about the ultrasound. He has... pancreatitis. The first section of his intestines is corrugated. But they didn't really find anything else super notable. His kidneys looked big but they decided since his kidney values have been fine that this was probably just because he's larger than your average cat. She said something about his liver but didn't seem overly concerned about it.

She reiterated she wanted him on a low-fat diet and didn't think his glucose was too high... It was so high when I went to send her the Libre data that it doesn't actually register on the charts and the website shows that he spent 95% of the six days it lasted over 250. I ordered him some cooked rabbit that's 15% fat by dry matter analysis... not as low as the prescription food she was pushing on me, but its 0% carbs and not 37%.