New acro diagnosis

Jacques and Pumpkin

Jacques and Pumpkin

Active Member
Just got my results from MSU. Pumpkin’s IGF-1 is 541 nmol/L (reference range 12-92). IAA is also a little elevated at 31% (reference range <= 20%).

I guess I now have to pick between insulin only, cabergoline, surgery, and radiation.

Does anyone have experience with PetCure Oncology, especially the location in San Jose?
 
:bighug::bighug::bighug::bighug::bighug:
Now you have some answers as to why Pumpkin has been stubborn about getting regulated, and importantly, you know that there are treatments available. One of the things someone told me at this point in our journey - Pumpkin doesn't know she has acromegaly, she's the same cat she was before you knew about it.

I don't recall anyone here going to Petcure in San Jose, or actually, any of their locations recently, though I do remember them coming up in conversation before. If you are thinking of going there, you might first want to see if you can ask them how many cats they have treated with SRT for acromegaly.

A couple years ago, one of our members put together a list of options with pros and cons of treatment options, though it's now a bit out of date: https://felinediabetes.com/FDMB/threads/acromegaly-treatment-options.246606/ That member was in Ireland.

In the US, I only know of two places doing surgery, Washington State University, and AMC in New York. We have members here who have gone to both. I can point you to people and/or posts on those experiences if you want to explore further. SRT is a lot more available now than in my time with Neko, we do have members here who have done it relatively recently, including one just OTJ, and I can point you to a paper with a lot more details on it. Cabergoline use has also grown a lot because it is way cheaper, and you don't have to travel for it and there have been some good outcomes, including a few OTJ kitties. There has also been a large scale published study on it's use in South America. Again, I can get you links to that paper. Trade offs involve pricing, risk of treatment, and whether you have to travel. I had to drive 3 days each way to Fort Collins, Colorado. DH and I turned it into a travelling holiday with Neko.

If you are thinking of treating, I suggest you think of it sooner rather than later, so there is less damage done by the growth hormone.

Even if you don't treat, there are some different things you can try with dosing to help you Pumpkin closer to regulation faster.

At this point in my journey, I had a million questions. Please, ask away.
 
I’ve been pretty resigned to this diagnosis for at least a month now so I’ve already been doing a lot of reading. Other than Pumpkin being female it fit so well. Hard to regulate, didn’t go hypo even when I forgot to put her food where she could reach it for an entire day, weight dropped then stabilized, snoring, and feeling like something looked different about her paws and face but not enough to be sure. I get the impression vets over-emphasize the physical changes, but it makes a lot of sense to me that we’d only see those well after the insulin-resistant DM, because the IGF-1 can displace insulin right away but it’ll take a while for tissues to grow.

Anyway, questions:

1. Where have people been going for SRT, especially on the west coast? I’m in San Francisco. I’m not excited about the idea of trying to get a diabetic cat across the country. An hour drive to San Jose a few times over the course of week sounds much more doable.

2. What’s a good number of SRT acromegaly treatments to establish a good track record?

3. Please do share the paper on SRT.

4. I think I’ve seen you say in previous posts that Washington State has a poorer track record on hypophysectomy than AMC. Is that true/still the case?

5. Definitely let me know your thoughts on dosing.

6. If I decide to go with surgery/radiation, I assume there isn’t a huge amount of point to starting cabergoline before that, since it can take some time to act and has to be tapered before the treatment? Obviously depends a bit on wait times which I’m guessing could be long. Have there been any studies/forum experiences with cabergoline after SRT to help while the SRT kicks in?
 
I just wanted to welcome you to the acro family! I had a ton of questions (and still do sometimes) and this forum is full of angels who will help and support you! Big hugs!
 
Neko's only symptom on diagnosis was ravenous hunger, and getting to 6 units. Later on I found out her teary eye was probably due to soft tissue growth in the tear duct. I read a paper that said only 35% of acros present clinical symptoms on diagnosis. She never did snore, though towards the end her breathe got a little "airy". Also note, these kitties have probably had acromegaly well before the DM. Neko's teary eye showed up 6 months before.

Answers where I can.
1) Not sure where people go now on the west coast of the US, but we did have one person go to a place in Orange County. Post about Rocket's decision here. WSU used to do SRT, I've heard they don't anymore. SRT is expensive to put in a clinic, I was told the cost in concrete to line the room alone (and that was 10 years ago) was $1million, then you add the machine. :eek: A lot of places do the radiation therapy on successive days. Neko's started Monday for the CT scan, then Tuesday through Thursday was radiation and then we were done. So it's not driving several days but staying in a hotel room for that time.

2) You want them to have experience with feline treatments on the pituitary. Cushings also counts. I saw one of the head vets at Petcure trained at NCSU, that's a very good place to learn radiation oncology on acros, one of the top researchers (originally at CSU) was there. So I'd add any experience people have in vet school as solid experience. Once you have the vet's name, you can also snoop their research.

3) Article on SRT: https://onlinelibrary.wiley.com/doi/full/10.1111/jvim.15212 Neko is the double SRT kitty in the article. Author Lynn Griffin was her radiation oncologist. Some other posts you may find of interest:
Punkin's SRT journey
Leo's Acromegaly thread and SRT treatment starting post 67

I didn't put all of Neko's trips in one post, should have, but here is the journal:
Last travel day on the way there
8/7 First day SRT
8/8 Second day SRT
8/9 - Neko AMPS 142 PMPS 402 +3 333 - Done SRT!
Quite a few peeps who had SRT posted on those threads. The thing to remember, at that time, there was no other treatment possible. Plus it was cheaper than now. But IMHO, totally worth it for Neko. Glad I went.

4) I haven't seen a lot of stories from kitties who have gotten hypophysectomy in the US, period. All 4 cased I've heard about going to WSU had complications during surgery, 3 had to have follow on SRT because not all the tumour was taken. 1 didn't make it. Having said that, they are supposed to be great people to deal with and very responsive. The success of surgery is directly proportional to experience. We once had a member go to a neuro vet who said he'd be willing to try the surgery. Umm, no thanks! The guy at AMC was trained by folks at RVC (Royal Vet Clinic), gold standard in success with surgery. We've heard of two cats go there. One a complete success, the second the kitty had some personality changes and the tumour came back, though kitty passed from something else.

5) Dose increases can by by 10-15% of total dose, until you see blues, in which case you can slow it down. Another additional option is the use of R or Regular insulin. It's a fast acting insulin that can be used to help pull the numbers down a bit for the L insulin to have a better number to work with. You'd need a person experienced with R help you out. There's a lot to learn about using R, mostly about when not to use it. There's nothing written about it, because it ends up being custom per kitty. Also, think about Levemir and whether it's something you want to do. If you do, we'd do one thing at a time.

6) I've only seen one person decide to try cabergoline before getting SRT done, and he wasn't on it long. Probably not worth doing. I would not give cabergoline once SRT or surgery is done. Way too risky. Dose decreases can be rather drastic. We've seen 2 kitties go from around 8-9 units to nothing in 7-10 days on cabergoline, but also some not move for a couple months. It's too hard to predict what will happen. Even on SRT I had some weeks of roller coaster action, followed by lots of nothing. Again, too unpredictable. Hypophysectomy is even more drastic, as it can be curative.
 
I followed up with Pumpkin's vet about the acromegaly diagnosis today. Pumpkin is her first diagnosed acrocat. She has done all the same research I have and basically confirmed all the options I had found.

The one things she added was a suggestion to get the rest of Pumpkin's issues worked up (she has a recurring cough, and also had GI issues even before her diabetes diagnosis) so that we can see where she's at before making a decision on potentially expensive and challenging treatments. She recommended an internist she's had good experience with in the past. So, we'll see what that looks like.
 
Neko was also my vet's first acro, until she knew what to look for and found another in her practice. Neko was also the acupuncture vet's first acro, until she knew what to look for and realized one of her own rescues had likely had it. Good to hear your vet is willing to learn. Pumpkin will not be her last acro.

I do like the vet's idea of getting the rest of the issues evaluated. We've seen a few acros with asthma, though it hasn't interfered with anything else, if that's what the cough is. GI issues are fairly common. What sort of GI issues are you seeing? I found the internist was good for balancing multiple issues and prioritizing what needed to be worked on.

As for potentially challenging and expensive treatments, cabergoline is neither of those.

Let us know when you are getting the Lev, and we'll talk about dosing.
 
Wendy&Neko said:
Neko was also my vet's first acro, until she knew what to look for and found another in her practice. Neko was also the acupuncture vet's first acro, until she knew what to look for and realized one of her own rescues had likely had it. Good to hear your vet is willing to learn. Pumpkin will not be her last acro.

I do like the vet's idea of getting the rest of the issues evaluated. We've seen a few acros with asthma, though it hasn't interfered with anything else, if that's what the cough is. GI issues are fairly common. What sort of GI issues are you seeing? I found the internist was good for balancing multiple issues and prioritizing what needed to be worked on.

As for potentially challenging and expensive treatments, cabergoline is neither of those.

Let us know when you are getting the Lev, and we'll talk about dosing.
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When I asked if Pumpkin was her first acrocat she said the first one to be diagnosed, but implied she had others that looked suspicious didn’t go through with the testing. I think she’s excited to get the opportunity to learn more about treating these kinds of cases. (Not in a bad way, she’s also very caring and I’d much rather a curious vet than a jaded vet.)

GI issues are the non-specific food allergy, sporadic vomiting of bile (not just in the morning, less frequent lately, but it’s still happening maybe once a month), and lately Pumpkin’s bowel movements have gotten less regular. I’m not sure that they add up to anything serious, but it’s worth checking out. I’m also going to try adding a bit more fiber in the meantime.

To be honest I’m feeling really worn out from caring for Pumpkin so the potential to get into remission is a strong consideration for me, but cost and logistics are also a challenge.

If it turns out she isn’t a good candidate for radiation/surgery or I can’t make it work, then cabergoline is probably my best remaining option. But for now I’m working on the assumption I’ll find a way to make one of the other ones work.

The main thing I know is that the status quo isn’t tenable. I’m feeling worn out and despite all my efforts Pumpkin just looks miserable all the time. She comes by for the occasional snuggle and occasionally acts more like herself, but mostly lies sadly next to her food and water. So, we keep cranking the insulin dose, try Levemir, and see if I can find a good IM vet to help me work through the next phase.
 
This phase is very tough on the caregiver. :bighug: I hope you have some outlet for some Jacques time, for me it was exercise (rowing and hiking). You need to take care of you too.

I like vets who want to learn too. First time Neko and I saw the acupuncture vet, I had told the front desk she had acromegaly. Vet had done a lot of reading before we first met her. She's now my regular vet. :)

For the GI issues, I'd suspect they'll want to run a GI panel (probably Texas A&M GI panel or equivalent) and possibly do an ultrasound to start.

As for treatment, it's mostly the heart that prevents SRT, though I even know of someone who lives not too far from me who also did SRT with her kitty (and the 3 day drive to CSU) with a heart condition. But it wasn't a condition that precluded anaesthesia. It just meant he stayed overnight at CSU for extra monitoring instead of going to the hotel at night in between sessions. Most places doing SRT will say you need an echocardiogram first. Some heart issues don't show up symptomatically until quite advanced. Also, the kidneys need to be able to tolerate anaesthesia, so current blood work also a prerequisite. Travel and costs are also big factors in deciding to do SRT or not.
 
Wendy&Neko said:
This phase is very tough on the caregiver. :bighug: I hope you have some outlet for some Jacques time, for me it was exercise (rowing and hiking). You need to take care of you too.
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Right now the toughest part is never ever getting to sleep in, not even on the weekend. I used to be able to sleep through Pumpkin's wakeup calls thanks to the automatic feeder, but now I have to get up every morning to test, feed, shoot. Once I'm up, I'm up. I'm a night owl, so it's just translating into less sleep. I can't move her shot later because there are some mornings I need to be out the door by 7:30 for work. And I would need to bribe her with a 6 am or so meal anyway if I want a hope of sleeping in.

Unfortunately the best time for my hobby (nature photography) is near sunrise and sunset. I can't be out at my favorite spots at sunset during the summer because it's too close to her shot time. It was much better in winter when the sun would set around 5 pm and then I could get home in time for the PM shot. My wife can take the evening shots some of the time, but we're coming up on a long stretch when she'll be traveling for work.

Maybe if we can get the acro more under control I can look at doing PZI and being a bit more flexible about shot times. That won't really help with my morning issue, but being able to be out until 9 pm more nights would be a huge relief.
 
How often do you need to be out the door for work by 7:30? Just wondering if it's possible to move your schedule around so you can shoot later some other days and work your way back for the day you need to leave earlier. Bribes can go in an autofeeder. I was lucky that it turns out I can fall back to sleep after getting up. Getting Neko onto Lev also helped, cause she was flatter and more predictable. And I had a bit more wiggle room on shot times. You are right though, getting her more regulated will help.
 
Wendy&Neko said:
How often do you need to be out the door for work by 7:30? Just wondering if it's possible to move your schedule around so you can shoot later some other days and work your way back for the day you need to leave earlier. Bribes can go in an autofeeder. I was lucky that it turns out I can fall back to sleep after getting up. Getting Neko onto Lev also helped, cause she was flatter and more predictable. And I had a bit more wiggle room on shot times. You are right though, getting her more regulated will help.
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Tuesday-Thursday but the exact days vary a lot and sometimes on short notice. Maybe I could move things back on the weekends so I can recover some weekend sleep.

The bribes would involve feeding Pumpkin in the pre-shot window when we normally fast her. I guess getting a fasting test every day is better than nothing?
 
As far as the preshot window, it's something we tell new members who don't have much data on kitty's numbers, and don't know how much of a food bump their cat gets. With a few +1 tests to learn that, and with her still in high numbers, it's not really a concern. If kitty gives you a green preshot (yes, it will happen one day), you want to know if it's safe to shoot. You can take into consideration the food bump and see if without that it'd still be safe to shoot. With preshots above 200, not an issue.
 
I think you mentioned somewhere else that with acro kitties we don't aim to regulate them quite as low as regular diabetics. Now that Pumpkin is threatening to break into the blues, that might become relevant. How should I adjust the reduction and increase thresholds? And, once she's into the blues, I'm guessing I should go back to more like 5-10% increases?
 
Our goal with acros is not to force reductions, but rather get to the point where they are mostly under renal threshold. Now ECID, but for Neko, that mean having her nadirs in the 70's. Unless your acrokitty has had treatment of some kind, there is no need to change the reduction threshold. Increases can still be by 10%.
 
1. Where have people been going for SRT, especially on the west coast? I’m in San Francisco. I’m not excited about the idea of trying to get a diabetic cat across the country. An hour drive to San Jose a few times over the course of week sounds much more doable.

2. What’s a good number of SRT acromegaly treatments to establish a good track record?
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Hello! I just saw your post today. I know you're in SF, but since you asked for recommendations on the west coast, I thought I'd mention the oncologist we went to here in Southern CA. His name is Dr. Bommarito, currently with the Veterinary Cancer Group of Los Angeles (he treated Rocket at the Tustin location, but has since moved). It looks like the company is part of "Thrive" now, so prices etc. might be different.

Dr. Bommarito had already worked with quite a few SRT kitties when we took Rocket there in 2019. Our regular vet at the time knew of him, and said he's one of the best in the country. It seems like most vets do 1-3 sessions of SRT (at least at that time, not sure about now), but Dr. B's regular protocol for cats was 30gy total, over 5 days (6gy per day).

Rocket is gone now... but SRT gave him almost three and a half more years with us, and he was a much healthier and happy kitty during those years. :) If I had the choice, I'd do it all over again. Here's a link to my "happy" update here from early 2022, for more info on him, if it helps:
https://felinediabetes.com/FDMB/threads/rocket-a-long-overdue-update.257477/

Best of luck to you; please keep us posted. And big hugs to Pumpkin! :)
 
Karen&Rocket said:
Hello! I just saw your post today. I know you're in SF, but since you asked for recommendations on the west coast, I thought I'd mention the oncologist we went to here in Southern CA. His name is Dr. Bommarito, currently with the Veterinary Cancer Group of Los Angeles (he treated Rocket at the Tustin location, but has since moved). It looks like the company is part of "Thrive" now, so prices etc. might be different.

Dr. Bommarito had already worked with quite a few SRT kitties when we took Rocket there in 2019. Our regular vet at the time knew of him, and said he's one of the best in the country. It seems like most vets do 1-3 sessions of SRT (at least at that time, not sure about now), but Dr. B's regular protocol for cats was 30gy total, over 5 days (6gy per day).

Rocket is gone now... but SRT gave him almost three and a half more years with us, and he was a much healthier and happy kitty during those years. :) If I had the choice, I'd do it all over again. Here's a link to my "happy" update here from early 2022, for more info on him, if it helps:
https://felinediabetes.com/FDMB/threads/rocket-a-long-overdue-update.257477/

Best of luck to you; please keep us posted. And big hugs to Pumpkin! :)
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Thanks! Los Angeles isn’t too bad, especially if I could fly down using JSX. A bit pricier but super fast check-in so we can minimize time Pumpkin is in transit. I’ll look into it.
 
Visited the internist. I guess it could have been worse, but I wasn't super thrilled.

First issue, is that the detailed history I wrote up didn't make it into her chart, so I got to dictate it all to the tech over the phone from the parking lot, doing my very best to make sure all the details made it in accurately. Then I got to repeat the whole thing to the internist.

Internist said that she aims for BG values between 200 and 300 because cats don't live long enough for the DM complications we see in humans to be a major factor, and Pumpkin was in that range on much lower doses. I pointed out that's on a human meter which we know reads low. She said I don't have any data to confirm that. I pointed out that Pumpkin's water intake only improved after we started getting below 200. She pushed a Freestyle Libre. I said there was no need since I'm getting enough testing and the Libre is human calibrated too. We changed the subject after that.

On the cough and IBD, her general advice was focus on the symptoms, which don't seem to affect Pumpkin's quality of life. But, if I'm considering SRT she thought I should go a bit further, up to endoscopy if needed, to make sure there isn't another issue that will shorten Pumpkin's life anyway. (I think... she kept highlighting the cost of SRT as a thing that would justify a more intensive workup).

They did an ultrasound and drew some blood. Ultrasound showed enlarged lymph nodes, issues in the lining of the intestines, and enlarged kidneys. She said the lymph nodes and intestines are consistent with IBD. Kidneys could be from the acromegaly or could be a sign of kidney disease.

On SRT, she suggested UC Davis instead of PetCure in San Jose. Said PetCure is currently remodeling so they aren't taking new patients, but even if they were, if it were her cat she would go to UC Davis.

Blood test results tomorrow and then I'll get a followup to discuss next steps.
 
UC Davis is a great place to go, they have some people very knowledgeable about feline diabetes there, including acromegaly. We've had members here go to them.

Got any more details on the ultrasound report? Endoscopy may not be good enough for diagnosis, depending where in the small intestines the "issues" in the linings are. Endoscopy doesn't reach the middle of the small intestines, just the beginning or the back end if done like a colonoscopy. Not sure I'm fond of this internist. :rolleyes: If the "another issue" is small cell lymphoma, which is the other thing likely, it is treatable and cats can go in remission. Got one at home now who's gone 5 years past her SCL diagnosis. And truth be told, same cat has IBD too and that's the more annoying to treat. Did the blood draw includes tests for B12 (cobalamin) or folate levels?

Potential kidney issues are yet another reason you want to try to keep her numbers below renal threshold, not in the 200-300 range internist suggested.
 
Got the reports this morning. I’m guessing I’ll get a call in a bit to discuss next steps.

abdominal ultrasound was performed and the urinary bladder large and normal, the kidneys lacked a normal corticomedullary junction and the cortices hyperechoic and the kidneys measured 4.29L and 4.41R, the spleen was normal with normal blood flow and 0.7cm in thickness, the liver was slightly hyperechoic but otherwise normal, the gall bladder contained anechoic bile, the stomach contained some food, the intestines were mildly fluid filled and lacked normal wall layering and measured 0.21-0.34cm in thickness, there was a reactive lymphadenopathy with the largest node measuring 0.53 x 1.51cm, the nodes were surrounded by hyperechoic omentum, there was no free fluid
​
And the report on the blood tests (will add to my spreadsheet when I have time)

Overall, Pumpkins laboratory tests look good. The BUN is slightly elevated but the SDMA and creatinine are both normal making a renal cause of the elevated BUN unlikely. The CK is high and this is likely from her being in a catabolic state from the poorly regulated diabetes and or the GI disease. The vitamin B12 level is high suggesting Pumpkin has dysbiosis from underlying GI disease. This is often seen when animals have underlying GI disease that results in changes in gastrointestinal motility. Since this could influence glucose regulation it would be a good idea to consider endoscopy with GI biopsies so that we can best tailor therapy to address this. Regardless, I would recommend placing her on a potent probiotic​

​
 
Hmm, still no details on where in the intestines the thickening is. The problem, as I said before, is that a endoscopy doesn't reach everywhere in the intestines and could miss some of the disease. Having said that, current SCL kitty (3rd one) was diagnosed with endoscopy because thickening was in the duodenom which can be reached by endoscopy. The ileum can be reached by the back end. However, the jejunum can not and thickening there required a surgical biopsy. As would thickening if in some of the layers of the intestine also require surgery. You don't want a misdiagnosis by not getting the right data.
 
The internist gave me a call. The thickening isn't localized to one particular area. She ways we can most likely can get the answers from endoscopy, but not 100% guaranteed and there's a small chance that doesn't give us anything conclusive and a surgical biopsy is needed.
 
A surgical biopsy isn't that bad an option. Kitties tend to recover fairly quickly from it. I belong to a SCL group, though it's not quite as busy as FDMB. Most people join that group not knowing if it's IBD or SCL. Sometimes people will try a novel protein approach first, and see if that helps. If so, there is at least a component of IBD.
Jacques and Pumpkin said:
and measured 0.21-0.34cm in thickness
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that means some parts were normal thickness.
 
It’s been a while since I posted. Some life changes took up all my time. I’ve been keeping Punpkin’s spreadsheet updated.

Those life changes also ruled out going ahead with surgery or radiation.

We started Punpkin on probiotics for the IBD finally. It actually made a significant difference. Her BMs got more regular and her BG control improved.

We started trying cabergoline two weeks ago. I backed off her insulin dose a bit in case it had an immediate effect. Once it became clear that wasn’t happening, I went back to a slightly conservative dose that’s keeping her in greens and blues.

So far the cabergoline doesn’t appear to be helping. In fact, Pumpkin is continuing what seems to be a slow but steady decline. She’s continuing to eat and drink and come by for snuggles, but her energy is down further. Her tail is mostly held low these days, and she’s starting to spend a lot of time under the bed, which she only does when she gets stressed or scared.

Not sure how much longer I should keep trying the cabergoline. I know it can take a while to kick in, but I don’t like how sad she’s looking these days.
 
You are only giving cabergoline every other day. Most people give every day unless there are GI symptoms. The quickest we've seen cabergoline work is around 10 days and you are on day 8. It might even take longer with EOD. Some cats take a couple months of every day dosing for it to start taking effect. I wouldn't stop cabergoline yet. Keeping my fingers crossed here for you. :bighug:
 
It took m9nths for cabergoline to have any effect on my Snuffles. After 2 2/12 years on cbergpoline I am see seeing a reduction in insulin needs. His AM dose is mw under 5 units and PM under 4 units. I can maintain BGs <120
 
Well, maybe I just needed a tiny bit more patience. Pumpkin just earned her first reduction (I didn't actually see the <50 but she gets a meal an hour before I wake up for her first dose so I'm having to guess a bit on the morning measurement) and she appears to be more than holding onto it. We might be close enough to try a second reduction. And she appears to be cheering up. Not getting a full upright tail, but she's starting to perk it up.

I'm going to keep at the every other day dose for now and reevaluate it we stall out.
 
Pumpkin continues to appear to do well on the cabergoline. We’ve done 4 reductions now, taking her from 32 to 24 units.

There were some bobbles along the way, like the day I finished her morning routine and just could not recall whether I’d given her insulin or not. Turned out not based on her numbers that day. Followed up by my first fur shot in months a few days later.

I’m guessing having to eliminate that much blood glucose led to dehydration, which led to constipation, which took some sorting out (subcutaneous fluids, miralax for a couple days, more pumpkin puree).

Amazingly through all that stress she keeps needing lower doses. My wife is traveling right now so I’m being somewhat cautious and reducing if I see two measurements in the greens. We’ll target lower numbers before reducing once we can monitor her for more of the day again.
 
Awesome to see Pumpkin doing so well with the reductions. :):)

Jacques and Pumpkin said:
I didn't actually see the <50 but she gets a meal an hour before I wake up for her first dose so I'm having to guess a bit on the morning measurement
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If you are going to feed her that late in the cycle, best to test then feed, or wait to feed until PS time. You don't want to shoot a preshot number that has been influenced by food. When Neko's dose started dropping fast after SRT, I moved her TR reduction point to 70 until the reductions slowed down. It gives you just a little bit more room for safety.

When cabergoline starts to work, it can work quickly, so best be cautious. Also remember, after a reduction, the larger dose can still influence 6 cycles after the reduction. Sometimes that can mean doing a half or skipped dose to drain the depot. If you are pretty sure it's cabergoline working, it's OK to take back to back reductions, or take larger reductions than you normally would. Safety first.
 
Wendy&Neko said:
If you are going to feed her that late in the cycle, best to test then feed, or wait to feed until PS time. You don't want to shoot a preshot number that has been influenced by food.
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I know it's unideal, but it's a compromise to let me get a reasonable amount of sleep. Pumpkin would wake me up well before 7 am until I added the 6 am feeding, and I was really starting to suffer from the lack of sleep. She tends to nadir right around pre-shot time anyway, so even when she fasts before her PS test I'm still having to shoot low numbers.

She's put on a bunch of weight and started eating less, so I recently reduced the size of her 6 am meal. That should reduce the influence from the late meal. Between that and being trigger-happy on the reductions, hopefully I'm limiting the risk.

I'll keep the half/skipped dose options in mind if it turns out I'm getting ahead of myself back-to-back reductions. I've also been thinking about slightly larger reductions. We'll see how this set of back-to-back reductions goes. I think I may finally have gotten a little ahead of her dose.
 
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