Cara and Wynken (GA)
Active Member
Hi all, I'm going to try to remember all of the things that I can recall the doctor saying after he saw Wynken on Monday. First of all, I just want to comment that Dr. Gilor is a lovely person who I really enjoyed talking to. He seems to have spent many years doing nothing but researching and thinking about feline diabetes. He enjoys talking about it, and although very technical, he's extremely humble about it. I really liked him!
So, after checking in (busy place!) I gave a history of why I was there to the vet student. I told her my highest priority was getting Wynk better regulated (out of the 300+ numbers) as well as understanding his variable response to insulin, including what seems like NO nadir, recently, just high and flat. I told her that because it was a long journey I didn't want to have to bring him back multiple times but would prefer to check for anything the doctor might want to check today. I mentioned acromegaly, and IAA.
So they took him in the back, to do their examination. After a while she came back out to get me in the waiting room, and brought me into a consultation room to meet the doctor. We talked for probably half an hour about Wynken and about insulin(s). I'm not sure how any of you will react to some of the things that I'm going to type out… And I will only say that it's my recollection of what the doctor said. Some of what he said surprised me.
He did say that to him the most important thing was to understand why Wynk's response to insulin seems to have changed. He was focused less on the insulin and more on understanding what might be an underlying condition in Wynken, to cause what we've been seeing. Right away when we started talking he asked if I wanted to do the blood test for acromegaly, and I said yes. He mentioned that it's starting to be understood that acromegaly is much more common in diabetics than previously believed, and he has learned to not rule it out based on how a cat looks, or even on their insulin dosage. It surprised me that he was not immediately dismissive of acromegaly! He asked if we would want to come back after getting those results (takes a week) for an ultrasound and chest x-rays to rule out other underlying conditions, or would we prefer to do those today? I said let's go ahead and do all the possible testing today. So the vet student left to arrange those tests with radiology, and that's why I spent the next four hours waiting for all that to get done. The good news is they didn't see anything too remarkable with the chest x-rays (other than MAYBE a very slightly enlarged heart, which she said they were actually arguing about whether it was enlarged or not… ) or the ultrasound (other than slight mottling of the pancreas, which they said can be normal with aging). So there was nothing with the diagnostic imaging to indicate an underlying condition. ((whew!)) I probably won't hear about the acromegaly test results until next Monday. Oh, and they also did a urinary sample for culture and sensitivity just to make sure that he no longer had a UTI.
I should mention that we did have a discussion about the different insulin types, and early in the conversation he offered me the option of simply going home with a new insulin and not doing any diagnostic work and seeing how Wynk did. I think he approved of that I at least wanted to check for the acromegaly first and not just switch insulin. He would have left the imaging for a later appointment, but I didn't want to. He also spoke about insulin antibodies and quite frankly got over my head kind of quickly. He said it is possible to have developed antibodies against any kind of insulin, regardless of which one it is, rendering it less effective. I had been prepared to hear him say that prozinc was not "the best" and move me towards Lantus or Levemir. However, he said that prozinc IS effective and stays effective in many cats. He mentioned that some manufacturing techniques can cause variability, and that the variability is increased by many factors related to injection technique (Rolling the vial, drawing up the dose) as well as the fact that Prozinc insulin is a suspension. He asked if I had tried different vials of prozinc, and I had. I showed him on the SS how for both vials sometimes the dose did something, and sometimes (more often) he just stayed high and flat on either vial. A definite takeaway for this group is that he certainly did seem to think that some Prozinc vials could be less effective than others. He didn't seem to think it was uncommon at all. But I could tell he was not "down" on Prozinc.
The only insulin he seemed "down" on was Vetsulin (no surprise there). Since Prozinc seems to of lost its effectiveness in MY cat, he recommended either Lantus or Levemir. Only he called them by the generic names "Glargine" and "Detemir". I don't remember all the things he told me about each one, and I'm sorry. He is a research scientist, and while I am a chemist… Some of what he said was unfamiliar to me.
But as we were discussing them, because my goals include getting his overall BG down, and because I'm willing to test as much as I am, it became apparent that Detemir (Levemir) was probably the better choice for Wynk. Levemir is a solution, not a suspension, which makes it much more homogeneous. So that's another advantage. He mentioned that it came in a pen, and that dosing adjustments were limited to exactly one unit increments. More on that later. Because I was leaving on this trip and because we don't have the results of the acromegaly back yet, we decided to wait until next week to make the actual switch.
So here are a couple of other things he said to me, some of which surprised me: he was too not concerned with Wynk's blood glucose being consistently in the 300 and 400 range. I asked him to repeat this point several times, because I told him it was my primary goal to get consistently below 200. I mentioned "renal threshold" and while he wasn't completely dismissive (he almost was!) he said that it was OK for him to be at those levels as long as the clinical signs were good. As a doctor, his focus was 100% on the fact that there had been a change in the way Wynk responded to the insulin and in understanding why. The high BG did not seem to be that big a deal to him. I asked him if he would be worried at these levels if it was *his* cat and he said no. Before anybody goes on a tirade about this, please appreciate that I'm just passing along what I heard.
This next part might be unpopular, but we talked a lot about dosing. I showed him the 0.3 mL U 100 syringes, that I use with the U40 Prozinc... I had brought two different kinds (8mm needle and 12.7 mm needle - he seemed impressed that I had tried the longer needle, even though in my case it hadn't helped). We talked about the half unit markings, and how each mark represented 0.2 units of U40. One thing he seem to feel VERY strongly about was that the syringes give the impression of accuracy but are not really accurate. He certainly did not seem to think it was worth talking about a difference of (or shooting) 1.8 units versus two units. He cited a study where insulin had been measured then precisely checked ( we did not discuss how but presumably with an incredibly accurate balance) and the repeatability of the measurements was abysmal.
Oh KAY..... Having spent over 20 years of my life drawing things up in syringes in both the human pharmacy setting AND in industry laboratories using chemicals, I could see what he was saying. I came away from this discussion of dosing realizing that while we (all of US) are using the best tools we have at our disposal, the tools are not manufactured to a very tight tolerance, and are not as precise as we would desire. So we probably have an illusion of accuracy. I don't know how this particular point will strike many of you, but I am a self-confessed control freak… And so actually this point was somewhat liberating for me.
Back to the Levemir… When he mentioned it came in the pen I told him I had no experience with that. However, I did mention that I had read about people using syringes to pull doses out of a pen, for better "precision" with the dose. He shook his head back-and-forth for quite a while as he described again how this gives the illusion of better accuracy without delivering the accuracy that is actually needed. Even though the levimir pen delivers either 1u, or 2u, or 3u... And nothing in between, he said the pen is designed to deliver an accurate dose, and that is how he recommends using it. He mentioned he would start Wynk off at one unit (and that it might not be enough) but that he would get exactly one unit for a week or two, and then do a curve. And then we would adjust up if needed to an accurate 2u. I recognize that some people reading what I'm writing might take issue with this because they may be pulling insulin out of a pen with a syringe. To be honest, I'm not sure how I feel about this, either. I have never used an insulin pen. I am just trying to convey what I heard the doctor say.
OK, this has gotten very lengthy, and I was only able to write it because I woke up pretty early in my hotel room but now I have to get ready for my conference. Please feel free to discuss all of this and I am very interested in everyone's thoughts!!!! But I probably won't be able to check back until much later today.
So, after checking in (busy place!) I gave a history of why I was there to the vet student. I told her my highest priority was getting Wynk better regulated (out of the 300+ numbers) as well as understanding his variable response to insulin, including what seems like NO nadir, recently, just high and flat. I told her that because it was a long journey I didn't want to have to bring him back multiple times but would prefer to check for anything the doctor might want to check today. I mentioned acromegaly, and IAA.
So they took him in the back, to do their examination. After a while she came back out to get me in the waiting room, and brought me into a consultation room to meet the doctor. We talked for probably half an hour about Wynken and about insulin(s). I'm not sure how any of you will react to some of the things that I'm going to type out… And I will only say that it's my recollection of what the doctor said. Some of what he said surprised me.
He did say that to him the most important thing was to understand why Wynk's response to insulin seems to have changed. He was focused less on the insulin and more on understanding what might be an underlying condition in Wynken, to cause what we've been seeing. Right away when we started talking he asked if I wanted to do the blood test for acromegaly, and I said yes. He mentioned that it's starting to be understood that acromegaly is much more common in diabetics than previously believed, and he has learned to not rule it out based on how a cat looks, or even on their insulin dosage. It surprised me that he was not immediately dismissive of acromegaly! He asked if we would want to come back after getting those results (takes a week) for an ultrasound and chest x-rays to rule out other underlying conditions, or would we prefer to do those today? I said let's go ahead and do all the possible testing today. So the vet student left to arrange those tests with radiology, and that's why I spent the next four hours waiting for all that to get done. The good news is they didn't see anything too remarkable with the chest x-rays (other than MAYBE a very slightly enlarged heart, which she said they were actually arguing about whether it was enlarged or not… ) or the ultrasound (other than slight mottling of the pancreas, which they said can be normal with aging). So there was nothing with the diagnostic imaging to indicate an underlying condition. ((whew!)) I probably won't hear about the acromegaly test results until next Monday. Oh, and they also did a urinary sample for culture and sensitivity just to make sure that he no longer had a UTI.
I should mention that we did have a discussion about the different insulin types, and early in the conversation he offered me the option of simply going home with a new insulin and not doing any diagnostic work and seeing how Wynk did. I think he approved of that I at least wanted to check for the acromegaly first and not just switch insulin. He would have left the imaging for a later appointment, but I didn't want to. He also spoke about insulin antibodies and quite frankly got over my head kind of quickly. He said it is possible to have developed antibodies against any kind of insulin, regardless of which one it is, rendering it less effective. I had been prepared to hear him say that prozinc was not "the best" and move me towards Lantus or Levemir. However, he said that prozinc IS effective and stays effective in many cats. He mentioned that some manufacturing techniques can cause variability, and that the variability is increased by many factors related to injection technique (Rolling the vial, drawing up the dose) as well as the fact that Prozinc insulin is a suspension. He asked if I had tried different vials of prozinc, and I had. I showed him on the SS how for both vials sometimes the dose did something, and sometimes (more often) he just stayed high and flat on either vial. A definite takeaway for this group is that he certainly did seem to think that some Prozinc vials could be less effective than others. He didn't seem to think it was uncommon at all. But I could tell he was not "down" on Prozinc.
The only insulin he seemed "down" on was Vetsulin (no surprise there). Since Prozinc seems to of lost its effectiveness in MY cat, he recommended either Lantus or Levemir. Only he called them by the generic names "Glargine" and "Detemir". I don't remember all the things he told me about each one, and I'm sorry. He is a research scientist, and while I am a chemist… Some of what he said was unfamiliar to me.
But as we were discussing them, because my goals include getting his overall BG down, and because I'm willing to test as much as I am, it became apparent that Detemir (Levemir) was probably the better choice for Wynk. Levemir is a solution, not a suspension, which makes it much more homogeneous. So that's another advantage. He mentioned that it came in a pen, and that dosing adjustments were limited to exactly one unit increments. More on that later. Because I was leaving on this trip and because we don't have the results of the acromegaly back yet, we decided to wait until next week to make the actual switch. So here are a couple of other things he said to me, some of which surprised me: he was too not concerned with Wynk's blood glucose being consistently in the 300 and 400 range. I asked him to repeat this point several times, because I told him it was my primary goal to get consistently below 200. I mentioned "renal threshold" and while he wasn't completely dismissive (he almost was!) he said that it was OK for him to be at those levels as long as the clinical signs were good. As a doctor, his focus was 100% on the fact that there had been a change in the way Wynk responded to the insulin and in understanding why. The high BG did not seem to be that big a deal to him. I asked him if he would be worried at these levels if it was *his* cat and he said no. Before anybody goes on a tirade about this, please appreciate that I'm just passing along what I heard.
This next part might be unpopular, but we talked a lot about dosing. I showed him the 0.3 mL U 100 syringes, that I use with the U40 Prozinc... I had brought two different kinds (8mm needle and 12.7 mm needle - he seemed impressed that I had tried the longer needle, even though in my case it hadn't helped). We talked about the half unit markings, and how each mark represented 0.2 units of U40. One thing he seem to feel VERY strongly about was that the syringes give the impression of accuracy but are not really accurate. He certainly did not seem to think it was worth talking about a difference of (or shooting) 1.8 units versus two units. He cited a study where insulin had been measured then precisely checked ( we did not discuss how but presumably with an incredibly accurate balance) and the repeatability of the measurements was abysmal.
Oh KAY..... Having spent over 20 years of my life drawing things up in syringes in both the human pharmacy setting AND in industry laboratories using chemicals, I could see what he was saying. I came away from this discussion of dosing realizing that while we (all of US) are using the best tools we have at our disposal, the tools are not manufactured to a very tight tolerance, and are not as precise as we would desire. So we probably have an illusion of accuracy. I don't know how this particular point will strike many of you, but I am a self-confessed control freak… And so actually this point was somewhat liberating for me. Back to the Levemir… When he mentioned it came in the pen I told him I had no experience with that. However, I did mention that I had read about people using syringes to pull doses out of a pen, for better "precision" with the dose. He shook his head back-and-forth for quite a while as he described again how this gives the illusion of better accuracy without delivering the accuracy that is actually needed. Even though the levimir pen delivers either 1u, or 2u, or 3u... And nothing in between, he said the pen is designed to deliver an accurate dose, and that is how he recommends using it. He mentioned he would start Wynk off at one unit (and that it might not be enough) but that he would get exactly one unit for a week or two, and then do a curve. And then we would adjust up if needed to an accurate 2u. I recognize that some people reading what I'm writing might take issue with this because they may be pulling insulin out of a pen with a syringe. To be honest, I'm not sure how I feel about this, either. I have never used an insulin pen. I am just trying to convey what I heard the doctor say.
OK, this has gotten very lengthy, and I was only able to write it because I woke up pretty early in my hotel room but now I have to get ready for my conference. Please feel free to discuss all of this and I am very interested in everyone's thoughts!!!! But I probably won't be able to check back until much later today.
You'll have to let me know if you get them, and how you feel they work for you. I'm going to try to do a little bit of reading ahead of time… Because I know that a new insulin is going to be completely different in his body. Despite what the doctor said I still want him below 200 as much as possible, and in the low 100s if I can get him there. I am very hopeful that the new insulin, once we receive it, will be the way to get us where we need to go.
