I apologize in advance for the novel. Cute pic of Chicamonkey - looks like she doesn't have any facial signs, not uncommon. Good luck with the phone call.
Tell me about Acro IAA cats from your experience.
As I said yesterday, good luck on getting a vet who knows anything about this. Vets, until recently, were taught "this is acromegaly - it's so rare you'll never see it". The research showing just how common it is came out less than 10 years ago. IAA - good luck getting a vet knowing even what that is. Our experience with some internal medicine vets here don't get it.
Read this first, you might know more than the vet:
Acromegaly - the basics
What is IAA- is it self limiting?
Again, you'll likely get a deer in headlights look. I have seen only two papers on it studying how common it is, both on tiny samples. One said it's common, the other said uncommon in diabetics. Our experience here is that it is self limiting over time, about a year.
How do I know if she has a pituitary tumor?
The chances are good she does. A CT scan or MRI may see if for sure, or maybe not. There have been cases where it hasn't been seen. With an IGF-1 number like Monkey's, we assume it's there and treat it like it is. Only if you are getting surgery or radiation therapy do you really need the CT scan. For some research on this see Case 2 in this paper:
(2020) Updates in Feline Diabetes Mellitus and Hypersomatrotropism
What are the therapies / courses of treatment
Cyber Knife
SRT
IMRT
Targeted dose therapy (single session radiation)
Carbergoline- can it cure acromegaly?
At a high level, treatments are radiation therapy (Cyber Knife, SRT, IMRT), surgical removal of the pituitary (hypophysectomy), and medical treatments. Sometimes SRT is given as a single dose treatment. CyberKnife is a more targeted/more expensive version of SRT. More details on treatments on post 7
here, along with a link so some places that did treatment in the US. Prices in that post are likely out of date now. Adding to that list is two places in the US that I know of that do the surgery, AMC in New York and a place in LA. Cabergoline does not cure acromegaly, surgery is the only option that really does that. But cats can go OTJ with radiation therapy and cabergoline, and there is some evidence the outrageously pricey pasireotide does that too. Even if they don't go OTJ, symptoms are greatly reduced and doses typically reduced too. And more importantly, better QOL.
Are we in the early stage of her diagnosis?
I've read somewhere that being diabetic is a later stage symptom of acromegaly. Not sure how much is really known about that - there have been a couple cats with acromegaly that were not diabetic. Neko had an acro symptom 6 months before diabetes, I later discovered. Honestly, it takes being diabetic before most acros are diagnosed.
What is her survival rate at 188/80%
No idea. The IAA has no impact on her survival, it just makes dosing more challenging. The IGF-1 number bears no relation to tumour size. This latter from the IM vets at CSU.
Is surgery an option for her age?
Or would radiation be a better way to manage?
What are side effects of radiation?
Surgery is absolutely an option, provided she has no heart issues. Here is
Sophie's story if you are interested in reading it, along with posts from a couple other people who had the surgery done, Titan at RVC in England and Schmee also at AMC. Apparently the quote was around $15K. Yikes. At the time, there was a donation helping people with costs and I don't know anyone who has had it done since the donation money ran out. You absolutely want the surgery done by a surgeon with experience doing it. Heard some bad out comes from a couple people who went to some place new. Another post you may find of interest:
Post pituitary surgery discussion of medication and other issues Radiation also requires anaethesia, but less technically challenging. Side effects of radiation are few if SRT/Cyperknife, more with IMRT. SRT can be some initial swelling in the brain - not common and just needs a couple days of pred. Longer term some small number go hypothyroid - easily treatable with meds. Some small number have the tumour come back, Neko one of the few I've heard of, but one of the kitties that went to AMC also had to go back on the juice after a while.
Basically, the decision to treat or not and if to treat which one often comes down to money.
All treatments but cabergoline are quite expensive. At the time we had SRT done, it was half it's current cost. On the up side, at that time, radiation therapy was the only treatment available and the rest have happened since then. CareCredit has been used by more than one to fund SRT.
I’ve heard Levemir is less “bouncy” than lantus - with flatter curves- onset at 4 hours and nadirs later in the cycle which might be better for my schedule. Can we switch? Do I need to reduce the starting dose?
In many cats, Levemir seems to have a bit better duration, hence flatter cycles. They still bounce as I can attest. The big things, should Monkey become a higher dose cat, is that the acid base of Lantus can sting at a point. Should that happen, that's another reason to switch. Plus an insulin switch can sometimes trick the antibodies. And yes, you lower the Levemir dose to 70% of the Lantus dose to start, as some cats show a marked reaction to the switch. Even more so if IAA in the picture.
With regard to her kidneys-
Fancy feast is high in phosphorus- and tiki cats is not too far below ff-her levels were borderline 11/14/20- what food should I be giving her?
Avoiding high phosphorus foods is a good idea. Acromegaly by itself is hard on kidneys. Weruva have a lot of low phos foods, and there are others - I did raw and homemade with premix that was low phosphorus. There are numerous options. Check out
this list.
Do you know if UF Vet school here in GainesvilleFl has Desire or ability to treat acro/ IAA?
IAA is only treated by Father Time. It's irrelevant otherwise. The vet school in Gainesville would be a good place to start. Your vet may know who to contact. Also see if their website talk about radiation therapy. It might be under cancer treatments as it was at CSU, though the tumour is benign, the treatments are also used for cancer patients.
What is the appropriate blood glucose range for acro cats?
Are you familiar with insulin dosing strategies for her needs as she progresses?
I will give you my opinion, don't know what your vet says about BG range in general. A lot of vets don't even want to see anything below 150 in non acros. With acro, you really want to try to keep her below renal threshold as much as possible. See note above about acro being hard on kidneys. Many people here with acros do very well with cats following TR. You just don't need to be as aggressive to seek reductions.
I'm alive again and working on the answers now - might take a while. 
