Insulin resistance after Pancreatitis

[Vicky & Gandalf (GA) & Murrlin]

Gandalf has been over his recent pancreatitis bout for about 3 weeks now, but I'm still struggling with getting him back to more blue numbers (100s) like he was having prior to the flare.

Our acupuncture vet suggested the pancreatitis caused his pancreas to produce some insulin to combat the resistance caused by the p-titis. I think that's how she explained it. Does that even make sense? So now I may be dealing with a sputtering pancreas???? Could that explain why he had great numbers yesterday and today he's +300 again? It almost seems like he's gone to a 24 hr cycle. He had the 70 at +10 on 1.1U on 222 PS. So he dropped good on 1.1U.

I increased this AM to 1.15U, as I have found it works if I increase in very small amounts. That's how I arrived at 1.3U which seemed to work good for most of the summer.

It just seems like we're still dealing with resistance, although I consider swinging numbers like going from 300s to 100s every other cycle as a sign of a bit too much insulin, which is why I've dropped his dose to 1.1U.

I'm about 10 days behind with SS update. If it's not updated when you look give it another half hour.

As reminder, I have to alter his dose on a weekly basis to account for the changes in our shot schedule. That's why you see a lot of 1.1U on his SS when our regular dose was 1.25U or 1.3U. And I use an external measuring device called a micrometer to measure precise doses which is why I am comfortable labeling my doses 1.3U or 1.1U, etc. Scale is 1U:1mm

 

[Melissa&Paul-Kyle]

Thanks for the update, Vicky.

Do you think the sputtering lasts only as long as the flare? I'd be interested to see what others have to write on this.

You know we had a full moon with the autumnal equinox this year- do you suppose there was any effect from that? ( I know some here feel the moon effects BG's )

 

[Vicky & Gandalf (GA) & Murrlin]

Thanks for the update, Vicky.

Do you think the sputtering lasts only as long as the flare? I'd be interested to see what others have to write on this.

You know we had a full moon with the autumnal equinox this year- do you suppose there was any effect from that? ( I know some here feel the moon effects BG's )

That it made for a stronger effect? Possibly. I can't see any reason for his BGs to have been that high and steady in the middle of the week, when it had been a few days since a schedule change.

 

[Sheila & Beau GA & Jeddie GA]

Hmmmm... that doesn't make sense to me: the pancreas produces more insulin to counteract insulin resistance from the pancreatitis.... That makes the pancreas into a "thinking" organ that can "plan" to offset the symptoms causes by its own disfunction. If that were the case there wouldn't be any symptoms.

I'd have to read up on the normal functions of the pancreas, but doesn't it produce and STORE insulin to be released as needed? Perhaps inflammation damages the cells by necrosis and that spills insulin? I would think that inflammation would impair insulin production.

But doesn't he eat a lot less when he has a flare? I know Beau does. That would mean less food = less blood sugar = the insulin dose needs to be decreased. I know that Beau's BGs are lower when he has a flare. I alsway took it to be from eating half as much (or less). And I think I have read other posts that comment on the same thing happening with their cats.

 

[Vicky & Gandalf (GA) & Murrlin]

Yes, Sheila, I saw Gandalf's BGs go down during his first flare, but not this one. And this one was also different in that his lipase was very high and his amylase, which is what we saw high during his first attack when p-titis was confirmed via fPLI testing. But they said the lipase is a better indicator of pancreatic function than amylase.

The acu vet mentioned inflammation, so you may be on to something, "Perhaps inflammation damages the cells by necrosis and that spills insulin? I would think that inflammation would impair insulin production."

He did it again today - BG lowered and he was 140 at PMPS. +8 was 164, so at least he surfed in that range.

 

[Vicky & Gandalf (GA) & Murrlin]

I like the Marvistavet site for pancreatitis info: http://www.marvistavet.com/html/pancrea ... line_.html

Scary stuff. But it makes me consider that Gandalf's flares could be caused by the possible IBD. I am adding the metronidazole to our p-titis regime next flare but will ask our vet if she thinks he can receive it on a regular basis or as pulse therapy, like the Clindamycin. More than likely he's going to flare again.

I already give him pro-biotics, so I don't know what else to do for IBD, which is not severe as he doesn't have constipation or diarrhea. She told me that it was mild when I asked if I could continue it after 10 days when he still wasn't over the diarrhea last time by the whole course.

I also need to figure out how I can regularly give him the milk thistle as I think his liver needs better support. It always looks funky on ultrasound.

 

[Sheila & Beau GA & Jeddie GA]

Yeah, it's probably a good bet that he will flare again. What is his pattern? Every 4-6 months?

You are already doing all the things that you can for IBD, I think (raw food, no grains, fluids). I seem to remember reading something about some simple supplement like Vit D that was supposed to help IBD, but I can't remember what it was. I'll try to find it. And yeah, milk thistle. Can't you add that to his food?

 

[pamela and tigger]

And yeah, milk thistle. Can't you add that to his food?

It is pretty bitter tasting but aren't you already giving him Denamarin Vicky? I can't remember.

Vicky and Gandalf

Our acupuncture vet suggested the pancreatitis caused his pancreas to produce some insulin to combat the resistance caused by the p-titis. I think that's how she explained it. Does that even make sense? So now I may be dealing with a sputtering pancreas???? Could that explain why he had great numbers yesterday and today he's +300 again? It almost seems like he's gone to a 24 hr cycle. He had the 70 at +10 on 1.1U on 222 PS. So he dropped good on 1.1U.

I really feel that there are so many variables going on on any given day with our diabetic cats that nothing can be attributed to any one thing. I am pretty sure even our long term diabetics have 'some' working beta cells left that have stored insulin, but how much who knows, and their response to food can vary from day to day. They may or may not have much of a first phase insulin response which means they have to rely on a second phase insulin response and injected insulin in order to process their food. I can't believe we can ever mimic this whole process perfectly with the addition of exogenous insulin into the whole mix.

Among other things, what Sheila said about eating less during a flare makes sense too. And even without a flare going on is he eating the exact same amount and variety of food everyday? Probably not. So to me it is just so hard to predict what may happen on a day to day basis. We just do the best we can to try and keep them in decent ranges.

Thank you for the update Vicky. It is always nice to hear how the G-Man is doing with all his health issues and otherwise. I hope the flares are fewer and farther in-between from now on.

 

[Terri and Lucy]

Are you giving him fluids regularly, during and after a flare up?

 

[Vicky & Gandalf (GA) & Murrlin]

Are you giving him fluids regularly, during and after a flare up?

Yes, he gets fluids fairly regularly, especially when his BG is above 300. He has kidney insufficiency, with his levels of Creatinine just above high normal, but he's been steady there for 2 years now, so I feel the fluids are an important factor in staving off CRF.

And Pamela, I agree that there is so much going on with chronic disease and sometimes we just can't know how the equation works out with additional problems.

I asked our vet today about using the metronidazole on a pulse therapy basis and she thought it was worth trying. The only thing that's making me hesitant is that I forgot the pill is half a tablet BID - it's a BIG pill even halved and bitter so I have to get it down him quickly each time. He's not a problem piller, but she wants me to do a 14 day load period of it BID then going to once every other day or whatever we decide. Ugh, twice a day sucks.

The reason I asked is that I read on the MarvistaVet site that there's a possibility that IBD can make them more susceptible to pancreatitis as the bowel inflammation can affect the pancreatic ducts. So I'd like to lessen his pancreatitis flares and that seems like a possibility if we control the IBD better. He doesn't have symptoms, except this last flare with the bad diarrhea, but the radiologist has indicated his intestines have some thickening consistent wit IBD.

Off to bed. I'm still wondering about his dose, as he was 87 tonight, on 1.15U. I dropped to 1.1U and we shall see.

 

[Sheila & Beau GA & Jeddie GA]

The connection of IBD and pancreatitis is pretty convincing to me. I mean it makes real sense. The anatomy of how the pancreatic duct (and bile duct) connect to the intestine is not a great design. Too easy for gut bacteria to go "upstream" into the duct and travel into the pancreas or liver.

That's what Triaditis is and inflammation of gut, pancreas and liver. If his liver is questionable, I wonder if he has had chronic triaditis and it just wasn't possible to distinguish where one set of symptoms left off and another started - I mean is nausea caused by pancreatitis, IBD or cholangtiohepatitis?

Writing that makes me think about how different cats "experience" CP. Some are nauseated, some are not, etc. Beau never throws up or has diarrhea, but he is clearly in pain and stops eating. Maybe those different symptoms indicate the extent of inflammation. Like nausea mean the liver is involved or something.

Here's a pretty good article on feline pancreatitis that mentions triaditis:
http://www.manhattancats.com/Articles/pancreatitis_test.html

 

[pamela and tigger]

I asked our vet today about using the metronidazole on a pulse therapy basis and she thought it was worth trying. The only thing that's making me hesitant is that I forgot the pill is half a tablet BID - it's a BIG pill even halved and bitter so I have to get it down him quickly each time. He's not a problem piller, but she wants me to do a 14 day load period of it BID then going to once every other day or whatever we decide. Ugh, twice a day sucks.

Flagyl is very bitter tasting. My vet had it compounded into something I could add to his food. Made it much easier since we gave it for thirty days total.

The reason I asked is that I read on the MarvistaVet site that there's a possibility that IBD can make them more susceptible to pancreatitis as the bowel inflammation can affect the pancreatic ducts. So I'd like to lessen his pancreatitis flares and that seems like a possibility if we control the IBD better. He doesn't have symptoms, except this last flare with the bad diarrhea, but the radiologist has indicated his intestines have some thickening consistent wit IBD.

Well, like Sheila says all this stuff does possibly point to a triaditis dx. What were his liver values on his latest bloodwork?

Here is my 'journey' with Tigger's triaditis dx a few years ago. It might help in trying to figure some of this stuff out that is going on with Gandalf. I am not trying to bore you with my experience but maybe something will click here.

BTW, the turning point after giving him the Flagyl was the Actigall. I had done a lot of research and found that among other things this was being used as an anti-inflammatory. Thankfully, my vet was willing to try it. Tigger was on it for more than two years but it helped a lot soon after starting it.

"Actigall (Actigall is a natural bile which is found in small quantities in the body and works as an anti-inflammatory. It cuts down the amount of cholesterol that forms in your cat's liver and reduces the amount of cholesterol that is absorbed from the intestines. It also prevents other bile salts from harming the liver and improves the flow of bile around the affected organ."

Also, interestingly so, Tigger went completely off insulin during this time. I don't know if any of this has anything to do with Gandalf's current bg levels, but again, maybe something will click with you. They are all individual as you know.

Spring of '07 - Tigger

Tigger's numbers were getting erratic again so was contemplating switching to Levemir. Then in April he had what appeared to be a pancreatic attack, vet treated with Amoxi and he seemed much better. After that his numbers started getting lower and lower and I was reducing his dose accordingly.

In June '07 I took him in for bloodwork again because I was concerned that he was needing so little insulin and sometimes going for days not needing any at all. Not a time to rejoice necessarily since he has been diabetic almost four years and I was concerned something else might be going on.

He was diagnosed with Cholangiohepatitis which is an inflammation of the biliary structures and the surrounding liver tissue (ALT 2302 (28-100) & AST 830 (5-55). He was diagnosed with an Ultrasound and x-ray. Vet started him on Clavamox with liver supplement of Denamarin. He was on this ab for eight weeks. After week four more bloodwork was done. His ALT and AST were still elevated but slightly improved but now CK was elevated as well. He continues to have very 'normal' blood sugar values and goes days and days without any insulin, or very little.

Additional bloodwork taken at the end of the eight weeks. Liver values (ALT and AST) were still elevated. ALK Phosphatase and everything else still pretty normal, but now the CK was very high (3118 RR 64-440). Started him on Flagyl.

9/05/07 - Bloodwork taken after three weeks showed CK back down to normal and he was feeling much better. Also needing insulin again, albeit very little. Not throwing up as much everyday after eating grass. Something he was doing for a long time before this - obsessively so while getting progressively worse over time. His ALT And AST were unfortunately still high though. Vet said to finish out the Flagyl for a total of 30 days and then recheck his values in another month. He is hoping the liver will show some improvement on its own over time.

9/13/07 - Last day of Flagyl - Tigger's insulin needs vary a lot now. He will go for a while needing a small dose consistently on a BID schedule ranging in the low 100's to double digits. Then he will bring himself down after a meal without insulin which he never was able to do before. So we will just ride this out and see where it takes us after (hopefully) his liver heals.

Tigger is still throwing up bile and eating grass more than he should be. Started him on Actigall and this improved in a matter of days. We will continue to monitor his liver values on a monthly or every other month basis.

12/07 - Tigger had complete feline geriatric profile done and CBC and urinalysis. His liver values are a little up from last bloodwork so I will be more diligent about giving him his Denamarin. He is still getting the Actigall daily. His T4 was in the low range of normal, but his FT4 was slightly high. We will recheck in a month or two.

1/17/08 - Had a urinalysis done and everything is normal...SP 1.058 which is good.

1/08 - Tigger is doing well - good appetite and playful and gaining weight. He is still on the Actigall And Denamarin and we will go back next month for more bloodwork. His diabetes is controlled but not as tightly controlled as I would like. With his liver not functioning at its best, I am reluctant to push him in too tight of a range. After his next bloodwork I will hopefully see an improvement in his liver values and hopefully we can switch to Levemir at that time.

3/08 - more bloodwork...feline geriatric profile and CBC. His HCT was slightly high as was his MCH...just slightly though. Auto Platelet really low...vet not too concerned at this time about these. Unfortunately his liver values are still elevated. His ALK Phos. continues to be in the normal range, but his ALT is 1042 (not much improvement) and his AST is 364, still not much improvement. His CK was in normal range though although his GGT was on the low side. Nothing else really stood out except for glucose and cholesterol being on the higher end and his potassium was a little high. T4 was 3.2.

Will hold off on starting the Levemir.

January '09 - His liver values did finally return to normal and we started Levemir.

 

[Vicky & Gandalf (GA) & Murrlin]

I'll have to compare Gandalf's blood values to Tigger's and get back to you all.

Thank you so much for the info on what you gave Tigger. I may ask about the Actigall. May I print out your itinerary of what you experienced with Tigger for my vet? I'm very interested in it because you mentioned it reduces cholesterol because his chol. is always high. I did not know chol. formed in the liver. So I'm very interested in it for him. The only thing I was really told about chol. is that it's not as harmful in cats as in people.

 

[pamela and tigger]

I'll have to compare Gandalf's blood values to Tigger's and get back to you all.

Thank you so much for the info on what you gave Tigger. I may ask about the Actigall. May I print out your itinerary of what you experienced with Tigger for my vet? I'm very interested in it because you mentioned it reduces cholesterol because his chol. is always high. I did not know chol. formed in the liver. So I'm very interested in it for him. The only thing I was really told about chol. is that it's not as harmful in cats as in people.

He may know the Actigall as Ursodial.

You can print it out if you like.

From what I have read though cholesterol levels are higher in diabetics than normal cats. Looking back on all his lab tests in '07 when we discovered his liver disease, his cholesterol was normal, but that was when his diabetes was in remission for a few months. It was high in the years prior.

Still not sure why he went off insulin though, but seemed like it had to be related to his badly functioning liver. And then his cholesterol went back up again when his diabetes returned later that summer.

It continued to be high into '08 and on into '09 even after being on the Actigall for over a year. Even when his liver values went back to normal at the end of '09 his cholesterol was still high. So it really doesn't look like the Actigall helped in that regard. My vet has never commented on Tigger's high cholesterol levels. He was just happy to see the liver values come down finally.

As far as what it means in cats here is what I found. I had heard the same as you about its meaning in cats not being as bad as in people so I haven't paid much attention to it. It has been a year next month since he had bloodwork done so I need to take him in. He has not had anymore Actigall since about then either. It was $100/month compounded through the vet and since his liver values were well back into a good range, I just discontinued it.

"Cholesterol: Cholesterol does not have the same connotation as it does in human medicine. Hardening and obstruction of the vessels of the heart is not a common problem in canine and feline medicine. Rather, cholesterol deviations are generally secondary signs of other diseases. Animals with inadequately functioning thyroid glands often have elevated cholesterol. Starving animals or those with poor levels of nourishment may have lower than expected cholesterol."

http://www.peteducation.com/article.cfm ... 44&aid=989