insulin resistance & next steps

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KlingersPeople

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Hi, we have been reading the site for several months since Klinger was diagnosed & are posting for the 1st time. Help, please!
Klinger is on Lantus (glargine) 2x/day; not overweight (less than 14 lbs and he's a big maine coon cat); eating a high-protein, low carb canned food; according to the vet and everything on this site we are doing everything 'right.' But just when we thought his dose (4 units 2x/day) was sufficient to stabilize his BG to 200 or under for a week, then it jumped again off the charts. So with the vet's ok we have been gradually increasing his doses. This past week he has been getting 7 units of Lantus 2x/day at meals yet his BG levels remain consistently in the 500s or off the charts (600+). The glucose meter is accurate; we test before each meal and do a glucose curve each weekend. His only symptoms are consistent with high BG - ravenously hungry, very thirsty, peeing a lot, but otherwise in good health for a 13 yr old cat. We expect to be upping his dose again soon.
The vet says he sounds insulin resistant and the question is Why. We have him on antibiotics while they grow a urine culture. They say if antibiotics have no effect the next step would be an ultrasound. But they could not say what this ultra$$ound would show other than an enlarged pancreas. We see the FDMB forum mentions other conditions like IAA, Cushings, etc require high insulin doses.

Here is the thing: we are reluctant to spend a lot more $$ on a series of tests for an answer when ultimately the treatment will be the same, i.e., manage his BG with as much insulin as it takes to to get to safe BG levels. Are we thinking clearly? We'd appreciate a reality check.
 
Maybe pop over to the acromegaly forum and see what they think. It would help though if could provide a few weeks data in one of our spreadsheets - we would want to check he isnt bouncing - esp since it sounds you only get midcycle tests in once a week

Wendy
 
Hi, there's some useful info here from one of the 'stickies' in the Acromegaly forum:

"How do we spot a potential acromegalic cat? Questions we ask.

*Cats are normally flagged up as potentially not being 'normal diabetics' when they are getting higher than normal doses of insulin and/or it's proven difficult to get control over their BGs.

*Just like a 'normal' diabetic cat we think/ask the same questions of a cat’s mom/dad before we think of acromegaly – basics such as appropriate diet, right insulin and doses, and hometesting need to be sorted out first. For example:

1) How long has your cat been on insulin?
2) At what insulin dose did you start?
3) How was the insulin increased and by how much, and over how long a period of time?
4) How did you determine that an increase was needed?
5) Are you home testing now, and if so, have you kept a record?
6) What food are you feeding?

*Once the more common causes of having a cat on high insulin doses have been dealt with, for example dry food, too fast dose rises, infection, etc., - then we start thinking that something else might be going on.

*Acromegalic cats typically have certain patterns or issues going on with them that act as 'red flags' to point us towards thinking 'acromegaly'. It's a collection of these issues that just aren't 'right'. We then start asking more hi-dose specific quesitons such as:

7) Have you noticed changes in the way your cat breathes? Any changes in their eye sight?
8) Have you noticed any behavioral changes in your cat? For example, appearing to be in pain, avoiding bright light.
9) Have you noticed any physical changes in your cat's appearance?
10) Has your cat had a tendency to gain weight despite no increases in amount of food you are feeding?"

Eliz
 
The tests for Acromegaly and IAA are very well established, and in North America - the only lab is in Michigan. (makes it expensive for Canadians)
if you do these two tests (same lab, save on shipping by getting both tests done at the same time), you get a definite yes or no answer.

The testing for Cushings is very squishy -- lots of tests and you get a maybe / maybe not unless the skin is tearing and very fragile.

The treatment of IAA is banging away with insulin.

The best treatment for Acromegaly is SRT - stereotactic radiation - best place is Colorado State Univ but other locations have been trained by CSU and been getting the equipment.
In some cases - the cat has gone off insulin after the treatment and symptoms of acro have decreased (appetite normal, return to a normal weight, etc). Sometimes the dose is decreased.
 
Some questions:

- When you raised a dose, how much was it raised at 1 time? Do you, by chance, have a list of dates and doses? or dates and dose increases?
- How long between each dose change?
- Are you checking mid-cycle tests to see how low he goes and when it starts to come back up?

On addition to acromegaly, insulin autoantibodies and Cushings, another very rare possibility is a glucagonoma - a tumor which produces glucagon, thus increasing the glucose. Or some other endocrine disruption increasing glucagon secretion.
 
Hi,

Thanks for the responses.

I don't have time to post all our readings right now but will do so soon.

Klinger does not have any symptoms of Acromegaly. We are increasing insulin dosage appx. every 5 days. Now at 8 units of Lantis BID. He is eating a high protein diet, Merrick Cowboy Cookout and a few similar, as we read that Purina DM has too many carbs. He has lost about 1 1/2 lbs. over past two months since he was diagnosed. We'd tried pure ground turkey & chicken [including bones] on advice of a vet but that caused an intestinal blockage and an expensive trip to a small animal ER. His skin is not fragile though he is losing so much body fat that I worry there isn't much subcutaneous fat left to hold the Lantis reserve. Anyone know the best places on the body to do injections? I've read that people vary their injection sites. Should cats?

Local vet today washed her hands of us. Said we are doing everything she knows to do. To learn more we will have to go to diabetes specialist vet 1 1/2 hrs. drive away. Klinger throws up every 15 minutes during a car ride so that will not be fun for him. What would this vet tell us that we don't already know? Based on our research, all the possible aggravating conditions will either be alleviated by more insulin or Klinger is terminally ill. He has had 2 weeks of antibiotics to cure any hidden infection. Indicated because newly created WBC's were evident in blood test made when he was in the ER. He is exhibiting weakness in his hind legs, I presume this is due to neuropathy.

Any more advice?

Thanks,

Rick
 
Dont worry - here is a link to how to set up a spreadsheet... http://www.felinediabetes.com/FDMB/viewtopic.php?f=6&t=18207 and we can look for bounces.

Ok a few thoughts just to confirm can you answer these questions

1. When did you move him to a low carb diet? There is no way he is getting access to any dry at home or elsewhere? (while he is outside if he goes outside, dog kibble, treats etc) Maybe double check your foods on here to ensure they are under 10% calories from carbs.. lower the better http://www.catinfo.org/docs/FoodChartPublic9-22-12.pdf

2. There is no dental issues? Has he ever had his teeth cleaned?

3. You are keeping the lantus in the fridge (not the door)? You dont shake or roll it correct?

4. He isnt on steroids?

Some cats are just high dose cats - and some have the conditions listed by other people above. In those cases you just keep increasing the insulin and you eventually find a breakthrough dose and the numbers start to come down. One report I read says they dont suspect insulin resistance unless the cat is over 6 units or 1.5 per kg which is 9 units in your case. although on this forum we start to wonder over about 6 units. Here is the paper. http://www.2ndchance.info/diabetescat-insulinresistance.pdf

Anyway lets look at his numbers.

Wendy
 
Thanks for the article, Wendy & Tiggy. Will check it out.
1. moved him to a low carb canned diet at his initial diagnosis. He doesn't go outside much any more & we're a mile away from other neighbors anyway; no food lies around.
2. there should be no remaining dental issues... he had his last teeth removed last november. The vet checked his mouth again last week and saw no sign of infection or abscesses.
3. yes, lantus in the fridge, not the door & we never shake or drop it. We're using the pen with a smaller compartment than a vial so it doesn't go beyond the recommended 28 day shelf life.
4. not on steroids
Numbers later when we're home... Thanks everyone. This is helping.
 
Wendy, [& Tiggy if you are reading this - Klinger can't read Internet posts 'cause he isn't tall enough to reach the screen.]

Answers:

Klinger has been on pure meat or less than 10% carbs for two months. He only goes out to sit on the porch. Too much snow for him now. Even during the summer he rarely catches anything. No other houses nearby for him to poach food.

No tooth issues. He had Gingivitus three years ago and most were removed. The rest were taken last November. Three vets have confirmed there is not any infection in his mouth.

Lantus is in the fridge, not the door. It is clear and unshaken.

No steriod use. At 17 lbs., now 14, he is not a very athletic cat. However he is a world champion fur producer. Just took a towel out of the dryer that we use to cover my wife's living room chair. Really is Klinger's chair. Takes five minutes to pull the fur our of the dried towel to the point that I'm willing to re-use it to cover the chair.

He is still grooming himself though not so well on days is BGl is over 500. Purrs, even while receiving insulin shot.
 
Ok thats good to know. So lets see his numbers and we can go from there.

You might want to go to 5-8% carbs or lower.

Do you test for ketones?
 
Vets have tested for Ketones twice, most recently on March 1st. None.

It is difficult to get lower than 5% carbs. Cowboy Cookout isn't that much better in posted numbers than Friskies pate [5 vs. 10] which we where feeding for years before Klinger was diagnosed, at less than 1/3 the cost. We now carry Laura Pierson's chart to the store when shopping for cat food.
 
Ok sounds good. You should pick up some ketone testing strips to test at home though especially since he likes to sit at high numbers. Ketoacidosis is very serious and very expensive to fix.

Are you in the US ? you can get ketone strips for like $10 at walmart.
 
KlingersPeople said:
Hi,

Thanks for the responses.

I don't have time to post all our readings right now but will do so soon.

Klinger does not have any symptoms of Acromegaly. We are increasing insulin dosage appx. every 5 days. Now at 8 units of Lantis BID. He is eating a high protein diet, Merrick Cowboy Cookout and a few similar, as we read that Purina DM has too many carbs. He has lost about 1 1/2 lbs. over past two months since he was diagnosed. We'd tried pure ground turkey & chicken [including bones] on advice of a vet but that caused an intestinal blockage and an expensive trip to a small animal ER. His skin is not fragile though he is losing so much body fat that I worry there isn't much subcutaneous fat left to hold the Lantis reserve. Anyone know the best places on the body to do injections? I've read that people vary their injection sites. Should cats?

Local vet today washed her hands of us. Said we are doing everything she knows to do. To learn more we will have to go to diabetes specialist vet 1 1/2 hrs. drive away. Klinger throws up every 15 minutes during a car ride so that will not be fun for him. What would this vet tell us that we don't already know? Based on our research, all the possible aggravating conditions will either be alleviated by more insulin or Klinger is terminally ill. He has had 2 weeks of antibiotics to cure any hidden infection. Indicated because newly created WBC's were evident in blood test made when he was in the ER. He is exhibiting weakness in his hind legs, I presume this is due to neuropathy.

Any more advice?

Thanks,

Rick
Click to expand...

Hi Rick,
Well, if you are giving your cat 9units of Lantus twice a day and the cat's alive, i think you got yourself a likely acromegalic cat.

I smiled when I read the part about no signs of acromegaly.... high dose over 5u twice a day is one sign.... my girl, Shadoe, had no signs of acromegaly either, except the high dose of 9u BID.
I had to argue with the vet because she was female, she had fine features and was a petite girl, and as the vet said to me, 'she doesn't look acromegalic.'
Well, her dose kept rising and she developed the pot belly over time, BIG pot belly. I finally convinced the vet to test her at 14u BID. Of course the test came back positive.

When I took in my 2nd acro, they took one look at my Oliver and said, 'Yup, that's an acro!'

For your BG test numbers, you don't need to post all of them, but it would be very helpful if you could post at least the last few days' worth of numbers to give an idea of what sort of numbers you are getting at this dose.

There are low dose acros and high dose ones. A couple have hit a dose of 7u, then just went off insulin... it happens because acros are not diabetic, but rather they have diabetes because they are acromegalic, have a tumor which secretes excess growth hormone. There's a big difference.

Anyway, if you are feeding a low carb wet food diet, and your cat has no issues with eating as in all the teeth are bad, and you are up to 9units twice a day.... you got yourself an acro is my guess.

There are several places where you can get more info on feline acromegaly.
This site FDMB has another that is just for acromegaly... if you go to catacromegaly.com you will find a great deal of info that's been gathered. You can also find many other owners of acro cats on facebook in the Feline Acromegaly group - several of the members are also members on this board as well, because most of us thought our cats were diabetic, but as the doses kept rising, we learned otherwise.

It's pretty important to know if your cat has acromegaly or not because of the health issues that acro cats may have, and you don't need to have the expensive treatment if you can't afford it, but if you consider it, it's best to have done sooner rather than later. Most people just handle the best they can with insulin, so no need to feel that without going for SRT, your cat will just go downhill.... that's just not true.

My Oliver got ill just over a yr ago after getting vaccines, and he went off insulin within 10days... he's still off insulin to this day and super healthy except for his megacolon.

Please don't be upset about your vet. If you like your vet for other cat related issues, then there's nothing to stop you from sharing what you learn with your vet. My vet at the time had no clue where to submit to test for acromegaly and IAA but I got the info here on FDMB from others, and shared with my vet. Another acro owner's vet was able to diagnose another acro cat just from the info she learned from the first acro owner. Not knowing does not make the vet bad; a vet refusing to learn from info given is not good. A specialist won't be the answer if your cat has acromegaly, so stick with your local vet and you can learn together.
 
Hello.
I just happened to have this bookmarked for someone else learning about insulin resistance... and /or acromegaly ....

Once we see a cat get to 6.0u, we suggest that you consider getting the tests run for a high dose condition. The tests for insulin resistance (insulin auto-antibodies; IAA) and acromegaly (insulin-like growth factor; IGF-1) are run through Michigan State University vet lab. Your vet can draw the blood and ship it to the lab. You'll need to follow the instructions for shipping so the sample gets to the lab directly (vs. spending time at the loading dock). Without the tests, there's no way to really know how aggressive you need to be regarding dose. There is also information in the high dose forum about these conditions.
Click to expand...

go to this post http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=90045 and find where Sienne replied....
You can click on " Michigan State University vet lab " and it will take you to the website for more information on getting this test run.
 
Here are the two links.... be sure you have the vet request the IGF-1 test as well as the IAA test because some cats have one, the other, or both. It is sort of important to know on both.

IAA Test
IGF-1 (Acro) Test
 
Klingers' stats are now posted. See footnote. No nadir in 3/9 BGL curve. Ping pong effect evident even when on steady Lantus dosage.

His coat is a mess. This fastidious cat no longer grooms himself. Continuing weight loss, about 15% over past two months. Extreme sensitivity to touch except where skin is thickest at his ruff so we have stopped brushing him. Loss of muscle mass in hind quarters to the point he can barely scramble up onto a low sofa. He is constantly hungry and thirsty.

Based on his insulin resistance and his observable symptoms we've decided that his insulin resistance is due to HAC, Cushing's disease, and not acromegaly. We did a lot of reading about this on Sunday and don't expect a good outcome. Even with risky surgery or prohibitively expensive radiation his life expectancy would be no more than a year.

It takes increasing amounts of insulin to keep his blood sugar at less than critical levels. We gave him a total of 27 units on Sunday and never achieved a BGL below 600. At levels below 400 he has some vitality but we know the internal organs are suffering and muscle loss and/or neuropathy is becoming more pronounced. We realize that at some point in time, possibly already in the past, we switch from seeking a cure to providing hospice care for as long as his quality of life seems acceptable to him. Not an easy decision.

Any advice would be welcome.

Rick
 
Rick:

It may be worth testing for high dose conditions but I'm saying this very tentatively. The first thing that jumps out at me from your spreadsheet is how doses have been increased. With Lantus, the maximum we increase a dose is 0.5u until a cat is at 10.0u. You've been increasing by double that amount when the dose was in the lower ranges. While you might assume that if you increased by a greater amount, the numbers would drop like a stone, that's not always the case. Sometimes, especially if you are only getting pre-shot tests, all you see are high numbers. Too much insulin as well as too little insulin can produce numbers that are in the higher ranges.

I'd encourage you to read over the links in this post regarding the Lantus dosing protocol. I'm also attaching the paper published in one of the leading vet journals regarding this protocol for both you and your vet.


It may be that you need to radically drop your dose and essentially start over in order to determine if Klinger is a truly high dose cat.
 

Attachments

KlingersPeople said:
Klingers' stats are now posted. See footnote. No nadir in 3/9 BGL curve. Ping pong effect evident even when on steady Lantus dosage.

His coat is a mess. This fastidious cat no longer grooms himself. Continuing weight loss, about 15% over past two months. Extreme sensitivity to touch except where skin is thickest at his ruff so we have stopped brushing him. Loss of muscle mass in hind quarters to the point he can barely scramble up onto a low sofa. He is constantly hungry and thirsty.

Based on his insulin resistance and his observable symptoms we've decided that his insulin resistance is due to HAC, Cushing's disease, and not acromegaly. We did a lot of reading about this on Sunday and don't expect a good outcome. Even with risky surgery or prohibitively expensive radiation his life expectancy would be no more than a year.

It takes increasing amounts of insulin to keep his blood sugar at less than critical levels. We gave him a total of 27 units on Sunday and never achieved a BGL below 600. At levels below 400 he has some vitality but we know the internal organs are suffering and muscle loss and/or neuropathy is becoming more pronounced. We realize that at some point in time, possibly already in the past, we switch from seeking a cure to providing hospice care for as long as his quality of life seems acceptable to him. Not an easy decision.

Any advice would be welcome.

Rick
Click to expand...

Rick,
I think I would still test for acro and IAA because if positive, that dose of 27u is not really that high... one of my acro cats reached a dose of 37u twice a day, and my other reached a dose of 21u twice a day.... their numbers came down to lovely ones in the 100s, so it may just be that you are not giving enough insulin.
Depending on the activity of the tumor, some acro cats need a great deal more insulin, with some getting 50units twice a day and one cat reached 104units twice a day... he went for SRT treatment and he went off insulin in 6months.

I know the two tests are pretty firm positive in their results; the Cushings testing results are not as firm.... are you having issues with thin skin tearing? The Cushings cats that I've known were not high dose either.

The issues with grooming will improve as you get close to your good dose of insulin. With your numbers, you could consider holding a dose for 6 shots and then increase by 1unit until you reach the dose of 20units twice a day. At that point, some have found they get close to good results by increasing the dose by 2units for a few shots and dropping down 1unit if you get good numbers too quickly.

Several acro owners have been where you are now. It's not easy to watch our cats look poorly as we work towards the good dose but we do get there and you can tell when the weight loss slows then stops, and the urine becomes less, and you see the odd attempt at grooming. You can get there, but only if you continue with the dosing until you reach where needs to be.

ETA:
Quick question about your stats.... what are the 4u at +6 and the 5u at +5 in your curve the other day? Are you giving more Lantus at mid cycle or are you giving shots of R at that point?
Either one, it looks like you are giving too much insulin and causing the 600s, and as you will see with the Lantus protocol, you will be having too much overlap.

As was suggested, you could maybe try going down in dose to maybe 5units twice a day, and holding that dose for at least 3 days to let the excess insulin pass and be settled in the lower dose.
I would say for you to be checking for ketones daily with KETOSTIX because you don't to have more issues.... one ingredient for DKA is not enough insulin.

You did have some decent numbers at the 5u dose and you did hold for 6 cycles, but the increases by whole units and no testing /curves may have allowed for you to pass the good dose.
By going back to 5u, holding for 6 shots, then increasing to 5.5u dose and holding again for 6 shots, you will have a better chance to arrive at the dose your cat needs.
You may end up at the dose where you are right now, but at least you will know that you arrived at this high dose in a way that you did not pass where you need to be.
 
Hi, just thought we would follow up and thank everyone for your support and advice. After this, we will post on the acro-iaa-cushings forum. For the past few days Klinger has stabilized somewhat (his lowest BG reading was 193 and highest was 478 at 12 units of Lantus 2x/day) which may not be ideal but much better than when we originally posted. He is clearly feeling better. Now that we've grasped the idea he's likely an acro-cat it's a little easier to cope. Thanks again - all your perspectives are helpful as we sort thru this. Klinger says 'meow' (='tuna today?')
 
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