OK, should I pull the trigger and go OTJ with Sophie

sbluhrs

sbluhrs

Member Since 2012
Sophie was a big gulper until she had her surgery at AMC for Acromegaly on Sept 24th. Slowly coming down after going from 20 units to 1 or less of Levemir. Looking at her spreadsheet, I'm thinking that she might finally be ready to go OTJ.

She had an infection after her surgery, on antibiotics until last week. Also on antifungal, probiotics and psyillium fiber to firm up her poo. Off of these since last Wednesday.

.25 of a unit of Levemir is too much for her. Looks like the miniscule .1 of a unit is just about at that point, too.

So, I'd like to see what you think - Go for it or wait another week or two?
 
No, she's not ready yet.

We want them to be in normal numbers for at least a week (50-120 with the majority of the numbers under 100) before we start talking about doing an OTJ trial.

She's still getting Pre-shots in the high 100's and 200's.

I'm not sure why you reduced from .25 to .1 though......she's a long term diabetic and we usually wait for them to drop below 50 three times or below 40 once before reducing
 
Chris & China said:
I'm not sure why you reduced from .25 to .1 though......she's a long term diabetic and we usually wait for them to drop below 50 three times or below 40 once before reducing
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The joys of an open peered forum. I beg to differ Chris’s last point. Sophie is an acrocat that just had hypophysectomy. The rules on long term diabetics don’t apply in this csse. Sophie may or may not have a healing pancreas, but safety first.

I would continue on the 0.1 unit dose for a bit yet. How are you feeding her? A small snack around +8 or +9 might help bring down the preshots. I think we can assume her pancreas is mostly working.
 
Wendy, that is kinda how I was thinking. ECID, and an acro after surgery is even more different than the usual diabetic feline. Titan from the UK and Shmee both had their surgeries within a few weeks of Sophie's and were off insulin very soon after. But the time between their diagnosis as diabetic and then acro, while Sophie went for months between the two diagnoses. Also, their insulin dosage right before surgery was much less than Sophie's.

I really think that her pancreas is healing well, it just will take a little time to get back to 100%. Just so hard to be patient at times.
 
Oh, and just FYI, Sophie gets 6 meals per day - Shot time, +4, +8, repeat.... Even at night - have one of those timed feeders. That is why her spreadsheet regularly shows tests that often, except for the one meal at 3AM. She knows when she gets fed, and that she has to deal with the testing before hand, so it is no big deal. We call it Paying the Toll.... LOL
 
Joanne, that is a good question. Sophie took Metronidazole suspension 50 mg/ml, 1.5 ml, twice a day, and I spiked her food with saccharomyces boulardii and psyllium fiber. The latter two items came in capsules and I would add one capsule of each, with a little water as the psyllium was awfully dry.

So, I was killing the bad stuff in her system and putting in good stuff to help her.

Her poo wasn't perfect, but it improved quite a bit, and, once she was finally off the antibiotic, it is now normal. The only odd thing to notice is that the stool was larger than normal, looking like a cigar, not the usual thinner cat poo shape. Now all normal. Yes, I did a Happy Dance when I saw that, LOL!
 
Hey, everyone. Please look at Sophie's spreadsheet again. She's mostly just either on needle juice or no shot. Have decreased her meals to 4 regular meals a day, 7am, 12 noon, 7 pm and 11pm. Snack at 3pm and 3am. I'm thinking of just going to one shot a day of needle juice. But, it looks like she is close to being off the juice, finally, almost 2 months post surgery. The amount of desmopressin she also needs is much reduced and usually just needle juice once or twice a day. She actually looks tubby now, so that is the reason for decreasing the number of meals - has gone from under 12 lbs to almost 13 and she looks kind of fat even. Far cry from the waif I adopted in February of 2017. And she is spoiled rotten, LOL!
 
With that 31, I would definitely try an OTJ trial! If you haven't seen the instructions yet, here they are:

Start the trial on the next green pre shot.

If he/she is green at your normal test times, no need to test further until the next "PS" time; just feed small meals and go about your day. If he/she is blue at your normal "PS", feed a small meal and test again after about 3 or 4 hours. If his/her number is lower 3-4 hours after a meal, then the pancreas is working!

Post every day so we can monitor your progress and see if any tweaks are needed. He/she may have a sporadic blue number. Don't panic but post before you decide whether to shoot so we can have a discussion.

After 14 days of no insulin, we have a party!!

Sometimes the trial doesn't work the first time and we have to give a little more support in the form of resuming insulin. It's not the end of the world if that happens; we just give him/her the support needed. Our goal is a strong remission and it's better to take our time to get that than to rush into remission just to have it fail later on.

I am adding a note just for Sophie - I might trial regardless of getting a green preshot. She's diving too low on just barely any insulin even when starting in blue. And for any lurkers, this is a special case of a kitty who has had hyperphysectomy that should be curing her acromegaly and resulting diabetes.


Good luck with the trial!!!


Once he/she is through the trial successfully, you enter a new phase. Your cat is still diabetic but has now become diet-controlled. Continue feeding low carb food in the manner successful for your kitty. If you decide to change his/her feeding schedule, let your meter be your guide to the best times to feed. Avoid medications with sugar in them and steroid medications unless they are medically essential. Continue testing blood glucose weekly for the first month and then monthly forever. It's a good idea to weigh him/her monthly. Weight should remain stable. If he/she seems "off" or sick, or is showing signs of diabetes (excessive drinking, eating, urinating, weight loss), test his/her blood glucose right away. Keep the teeth and gums clean and healthy; dental issues can bring a cat out of remission. If you see rising blood glucose numbers, it's time for a visit to the vet!
 
Wendy&Neko said:
Start the trial on the next green pre shot.
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Congrats! I hope Sophie's OTJ trial is a success!

Wendy&Neko said:
How are you feeding her? A small snack around +8 or +9 might help bring down the preshots.
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Is this advice specific to acro cats or something to do with one of Sophie's other conditions?
I was under the impression that it was best to give all food prior to +7 unless kitty was hungry.
 
If kitty is on a very low dose of insulin, ie. close to remission, and their pancreas is sputtering, the small snack can help kick start the pancreas to work and bring down the numbers. Acros are a someone different case. Neko had a working pancreas so I bent the rules on late feeding to avoid my toes being chewed off. :p Plus her nadir was later anyway.

Rosie & Bailey said:
was under the impression that it was best to give all food prior to +7 unless kitty was hungry.
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The general idea is to feed the majority of food before nadir, which for many is around the middle of the cycle. After nadir, the insulin is waning and any carbs will slow it down, shorten duration, and likely cause higher preshots. My late cycle feedings tended to be very low or no carb small snacks.
 
I would certainly try stopping insulin. Congratulations to you for reaching this milestone! I am not sure I agree that Sophie is still a diabetic. We tell anyone who will listen, that Titan is not a diabetic any more . He produces enough insulin to handle the food he gets, and in his opinion he could handle a whole lot more!
Good luck!
 
We're going through some issues with the amount of steroid that Sophie has to get. She has been getting really tubby - has gained 3/4 of a lb since the last week in October and is ravenous. Took her to the vet yesterday for a blood draw for all the usual post-surgical blood tests, including cortisol. Waiting now for the results from my vet in Maine and what Dr. McCue in NYC has to say. John, has your vet had to tweak Titan's steroid dosage, etc. at all? I'll have to ask Amanda re: Shmee, too, about this to see what they might have done re: changing his dosage. Sophie is only on 1/4 pill twice a day of prednisolone 5mg and 1/4 of Levothyroxine .3mg twice a day, too.

I'm almost thinking that she needs a lower dosage of the steroid or maybe her adrenals are making enough for her now. Just waiting for what the vets have to say.
 
And, with a lower dosage of the pred, she probably would be OTJ for sure. And probably off of Desmopressin, too - only getting needle juice of that, sometimes only once a day, depending on her thirst and peeing amounts. And steroids can increase thirst, too. Still waiting.
 
Titans steroid (hydrocortisone) was doubled very shortly after surgery when he was going hypos BG. Later put back to 1 pill per day day. About a week or so ago our local vet suggested halving steroid dose again, but Camilla the IM doctor at RVC was against it so so far the dose is maintained.
 
Gee, that is a lot more than Sophie gets. How is his appetite and weight? The steroid they have Titan on is different than Sophie's.
 
Titans appetite is fine he eats everything he is offered . I think his weight is still going up slowly but he doesn't look overweight yet. Guess he weighs 5.6 kg.I need to study the steroids and the doses. The reason our vet was thinking about reducing steroids was because of some marginal kidney function results.
 
Shmee is still ravenous, I’m reluctantly getting bloodwork done Wednesday to rule out B12 deficiency or EPI. Dr. McCue is adamant the Pred is not making him hungry, and we did a test of only .25 once a day to be sure, and he was still extremely hungry so I agree I don’t think it’s the Pred. The reason is he says that Pred only makes people and cats hungry when they are getting EXTRA. Shmee is no where near extra - he’s so far below amount of normal amount of cortisol that it doesn’t even show up on his bloodwork (Dr. MCue says that is ok? I guess the reason for the bloodwork is to be sure the pituitary gland is not re-growing, so it is ok for it to be very low - even though this still is scary to me). So I don’t know if switching to a different steroid would make a difference although it’s very interesting that the RVC uses a different one. Shmee is getting .25mg 2x a day. You said Sophie gets a very small amount of the pills - Shmee gets the liquid. How many mg’s does Sophie get?
 
I just tried to look at her labs but I don’t see them on her SS - our of curiosity what has her cortisol level been like?
 
I have to put Sophie's labs up on her SS. But I got the results over the phone from her vet here in Maine - cortisol still low, same range as Shmee. Interesting that he is also ravenous. She is getting 1/4 of a 5mg pill of prednisolone twice a day, and 1/4 of her levothyroxine pill 3mg twice a day. Has Shmee gained any weight? It just freaked me out that Sophie has gained so much since the beginning of the month.

Blood tests showed slightly elevated white blood count of 21,000, normal usually goes up to 20,000 at highest. I wonder if this is why her bg just won't stay down in normal levels, just a dite above, giving her only nj, often no shot. Also on a tiny, tiny bit of desmo - also nj, but when I don't give her this tiny amount, she starts to drink a lot and pee a lot. So weird.
 
Titan gets 2.5 mg hydrocortisone tablet once a day. The article says pred is 4 times as powerful in its anti inflammatory action; do you think that applies to every effect it has?
It's a known effect that it raises BG levels.
Good to hear from Amanda and Shmee.
Can either plse explain nj or needle juice to me?
TITAN is still drinkng and peeing....we trialed desmopressin tablets instead of eye dtops for a day...didn't make any difference.
 
So she gets 1.25mg twice a day, wow that’s a lot more than Shmee at .25 twice a day. I wonder how they determine this amount..... maybe since you are doing the pill that’s the lowest possible since it would be hard to do lower than 1/4. But if she still is showing very low cortisol levels it shouldn’t be the Pred causing the hunger according to Dr. McCue but maybe he will say to lower it to see if that works.

Shmee has not gained weight. He lost some at first. He’s not consistently losing weight now, it stays about the same.

I’m also curious what you mean by NJ.

Shmee is up to 4 .5mg Desmopressin pills a day :( this is going to end up costing me WAY more than insulin. And I have just a different cat.... I’m still at the point where this wasn’t worth it to me. Hopefully one day we will be in a better place.

@John Irene and TITAN you said Titan is still peeing and drinking - that is regardless of how much desmopressin you give him? How much is he getting now? Dr. McCue has me order this, I haven’t tried it yet but it’s supposed to measure their specific gravity / water content. Becuase I was having to measure his water intake every day.... but this should supposedly elimate that so I don’t have to measure his water intake every day for the rest of his life..... he said I should just be able to get a urine sample weekly and do this thing. That way once I tell Dr. McCue what the reading is, we can determine how much desmopressin he needs. Since he’s one of the oh-so-lucky ones that needs like he’s going to need it the rest of his life...

Ade Advanced Optics Tri-Scale... https://www.amazon.com/dp/B00C7ZBLMC?tag=felinediabetesfdmb-20
 
OK, one thing at a time.

Got Sophie's labs back, well, at least orally from the vet in Maine over the phone. Her WBC is up enough that she probably needs antibiotics again. (put her labs into her spreadsheet finally, but don't have the hard copy of the most recent ones so that will be in a few days). Just waiting to see what antibiotic Dr. McCue wants her on now. That may be why she is still on levemir as infections can elevate BG.

@Amanda & Shmee - is Shmee on Prednisone or Prednisolone? Sophie is on the latter and the 5mg pill is the smallest dosage, before being cut. The Prednisone comes in 1mg tablets and I'm wondering if that is what Shmee is on.

I'm definitely going to get that specific gravity device. Sophie is so close to not needing the desmo, or not needing much of it at all. Still, it looks like I will be needing to order a new vial of the stuff. It won't go to waste if she finally goes off of it as I have a friend who has a cat with diabetes insipidus who I could give it to. But I'd love to have this gadget to be able to see where she is at without the expense of the vet visit.

@John Irene and TITAN, NJ - Needle Juice - is when you push the needle into the vial and you release it. The miniscule amount of drug that is sucked into the syringe by just the action of the syringe's slight rebound if you have made sure it is pushed in to its full extent when you draw. It's just the tiny amount of insulin or whatever you use that is contained in the needle/section of the syringe before you start measuring units. Some people call it Just a Drop, my vet calls it Hub.

Oh, and @Amanda & Shmee, Sophie is also a grump, though she doesn't sound as grumpy as Shmee. She doesn't seem like she really wants to be by anyone, though she will sleep in my office room while I am working most weekday mornings, on our granite island or a counter in the kitchen, or on the bed in the guest room. She actually doesn't complain when our other cat sleeps on the bed (about 3 feet away) anymore, but she routinely will swat at him at meal time to tell him to not come near her plate (he never has). We need to feed our other cat, Enzo, a big sweet long haired black boy who looks to be part Maine Coon), in the sun room off the kitchen so that he can eat in peace as she would steal all his food from him and he would let her.

She doesn't purr for us much at all. I really think she is still going through a lot of changes in her body. My vet here in Maine thinks that her weight gain might just be from her hormone levels being all crazy right now due to the pituitary surgery, and that we won't be able to see where she will settle body wise/weight wise/ and mood/personality wise for months yet. It's hard to realize that it's only been 2 months since her surgery.

And one other thing, @John Irene and TITAN, sounds like Sophie is as lazy as Titan is. I am starting her on an exercise program where I carry her downstairs and then she has to run up the stairs - starting at 4 times a day and working up to 8 or more. When the weather is better we will be walking her outside, but, with the early snow here in Maine, the stair workout will have to be it. She really isn't into playing with wand toys, etc., so the stairs will have to do.
 
Just got a call from my vet here in Maine. She heard from Dr McCue and he said to keep Sophie at her present levels for desmo and steroids. The weight gain and the slight increase in WBC are probably all related to her hormones being wacky right now. It's really a wait and see period.

@Amanda & Shmee, I asked her about the amount of Shmee's dosage of prednisone vs. Sophie's prednisolone, and she indicated that they are basically equivalent in that the amount that Shmee is getting is basically the same dosage as Sophie's.
 
@Amanda & Shmee there is a tab on Titans spreadsheet comparing Desmopressin doses, but the important thing is that the amount absorbed in the gut is much less than the amount absorbed in the eye (per Camilla at RVC ) so the doses cannot be accurately compared . We have never adjusted the Desmopressin dose, it's always one drop in alternating eyes, 3 times a day. And it doesn't seem to be working but we are not too bothered at present.
 
@Amanda & Shmee, ordered the refractometer, will get here on Wednesday. Dr. McCue wants to know how we like using it. This would be a good tool for all those whose cats are put on desmo to have, as long as we find that it is easy to use and relatively accurate. My Maine vet is also really interested in how this works out for us.

We don't shoot insulin blind (well, I know neither you nor @John Irene and TITAN need to, LOL), but also no reason to dose the desmo blind.

BTW, I finally input all of Sophie's labs, including the most recent ones. And added columns on her SS for her desmo dosage. I'll add a column for her urine specific gravity and weight, too, as those are all things Dr. McCue would appreciate being tracked.
 
This has been a fascinating discussion on post surgery meds. A favour to ask of you, could you start a post on the high dose forum and point it here. A lot of info here is good for anyone with an acrocat considering surgery, regardless of which insulin they are on.
 
Done, @Wendy&Neko. I hope some of the others who have had the surgery for their cats would weigh in. Do many just disappear afterwards? Sophie is just 2 months post op and it would be great to know how others are 6 months, a year or more down the road.
 
No shot since Thursday AM, and hasn't had a PM shot for a week. She's been showing the pattern of a lower shot about 4-5 hours after meals and even when I test +8. Not holding my breath, but actively observing. I also started her with her exercise program a week ago and she has lost a little weight and doesn't look as tubby. She also doesn't seem to be ravenous and is starting to eat at a more normal pace.

Got my refractometer, but haven't gotten her to donate pee so that I can test. She's peeing fine, actually seems like she is getting ready to get off the Desmo. She just gets needle juice for that. Definitely peeing a more normal amount. So just waiting and actively observing with that, too. Dr. McCue said that their brains will have cells that will adapt to provide the right hormone to regulate their kidneys, so I guess that, like anything, ECID, and I will just wait for her to tell me what to do.
 
I am glad to see that Sophie has been able to go OTJ. I hope Sophie continues to do well with her post-surgery recovery.
 
Not totally off the juice yet, but getting there. I really think that she will be totally OTJ soon, though. It's never a straight, linear process - she has definitely taught me that. I really think that adding some designated exercise times - the required run up the basement stairs after a quick chase in the basement just prior to meals - is definitely helping.
 
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