R we getting into high dose territory?

[NyCatMom]

Hello

I’m not sure if this post belongs in this section or not but wanted the advice of people who had a high dose cat.

What tests did you request from your vet when you felt you were getting into high dose territory? The vets are saying she is insulin resistant due to underlying conditions. I am wondering what I should be asking them and what the folks on this forum wish they had requested earlier. We have an appointment in early May and I want to be prepared to ask the right questions.

Here’s the readers digest version of my cat, Honey, medical history.

Spring 2020 - I noticed vague symptoms. Ravenous appetite with diarrhea. Blood work looked good. Mildly elevated glucose. Novel protein diet lessened diarrhea

Sept 2020 - five day ER hospital stay for acute pancreatitis. Feeding tube. Started Lantus at home. The usual Suitcase of pancreatitis meds and feline ID. She did really well and the primary vet stopped the ID and insulin once her numbers stabilized. She hasn’t been the same since

Fall 2020 back on Lantus but control was harder to achieve. Blood glucose never really stable Fancy feast pate food. Referred to Cornell in Dec

Winter 2021- after endoscopy she was diagnosed with small cell lymphoma and chronic pancreatitis. Kidney infection mid March. Moved to Tiki cat low carb food from fancy feast. Progressive increases in Lantus not yielding results.

Current meds : Chlorambucil 2mg every 3 days , prednisolone 7.5 daily, Lantus 5 units twice daily. Cerenia as needed.

Last spec Fpl was 15, so pancreatitis still flaring up.

Thank you all for your time and consideration

 

[Wendy&Neko]

Hello over on this side.

What tests did you request from your vet when you felt you were getting into high dose territory?

Test for acromegaly (IGF-1 test) and IAA (insulin auto antibodies). Both tests are done at Michigan State University, provided you are in North America. When people get to 6 units we suggest they get those tests, but there is no reason to wait if you think there is something causing insulin resistance. We've had cats on less than 6 units test positive for both these conditions.

Current meds : Chlorambucil 2mg every 3 days , prednisolone 7.5 daily, Lantus 5 units twice daily. Cerenia as needed.

That's an odd protocol for chlorambucil (on my third SCL kitty). The method called "pulsed" dosing or dosing a larger dose every two weeks is much easier on cats. Are you talking to an internal medicine vet. If not, you should be.

Progressive increases in Lantus not yielding results.

Are you following any particular dosing method or just what the vet tells you to do? Lantus dosing is based on how low it takes the cat, not the preshots. There isn't enough mid cycle data on the spreadsheet to tell me if she is underdosed, or overdosed.

 

[NyCatMom]

Hello over on this side.

Test for acromegaly (IGF-1 test) and IAA (insulin auto antibodies). Both tests are done at Michigan State University, provided you are in North America. When people get to 6 units we suggest they get those tests, but there is no reason to wait if you think there is something causing insulin resistance. We've had cats on less than 6 units test positive for both these conditions.

That's an odd protocol for chlorambucil (on my third SCL kitty). The method called "pulsed" dosing or dosing a larger dose every two weeks is much easier on cats. Are you talking to an internal medicine vet. If not, you should be.

Are you following any particular dosing method or just what the vet tells you to do? Lantus dosing is based on how low it takes the cat, not the preshots. There isn't enough mid cycle data on the spreadsheet to tell me if she is underdosed, or overdosed.

Hello Wendy & Neko,

Yes, we are seeing an internal medicine specialist at Cornell who is the person recommending the Lantus dose increases. His last discharge summary stated he believes the lymphoma, chronic pancreatitis and prednisolone are contributing to insulin resistance. When I press the matter he asks me to stick with changing only one thing at a time so we can see how that change [diet, meds,etc] are impacting her body. I can see the logic in that but I am enormously frustrated on the diabetes management front. On the lymphoma side, she’s actually responding well. After a year of near constant diarrhea, she’s had perfect poop after two weeks on the chemo protocol.

We had a scare at her last visit when she had difficulty breathing and they rushed her into an oxygen cage. Rads show asthma and mild heart changes. cardiomyopathy ruled out by echocardiogram. The X-ray report states she has an enlarged liver too but her he was satisfied with all her blood work. Sometimes I wonder if I’m hoping for a miracle in getting her to a stable place. I’m seeing her primary care vet in two weeks. The internists office is about 45 mins away and I think the trip and drop off appointments are just too stressful for her.

Since the vets in the NYC area are not allowing clients in with their pets yet, I write up summaries, including the spreadsheet from this forum, and send it in with her along with a list of questions. I’m going to ask if my local vet can run the tests you mentioned.

 

[NyCatMom]

Honestly, some days I’m so frustrated, I just want to cry.

 

[Wendy&Neko]

Good to hear the cardiomyopathy was ruled out by echo! It's a common symptom of acros, Neko had it too. Enlarged organs are a symptom in general.

Did the IM vet (or any vet) talk about putting her on budesonide instead of prednisolone? Neko's heart couldn't take pred, and the groups.io small cell lymphoma group I'm on suggest budesonide for diabetics. So Neko was on budesonide. It did help her inflammations and did not impact her blood sugars.

Your local vet can totally get the tests run at MSU, no need to ask the IM vet for that. Most of us here gave up on asking our vets for help on dosing and just use the dosing methods we have here. You would have to start getting some tests in the PM cycle - one before bed is a good one. Many cats go lower at night. Neko had acromegaly, IAA, heart conditions (HCM, heart failure), kidney disease, and small cell lymphoma, with side helpings of pancreatitis, and I had her blood sugar quite well regulated. So it's doable.

I notice you don't have any pain relief such as buprenorphine on the meds shopping list. Pancreatitis can be very painful - pain can cause blood sugar numbers to go up. You might also want to see if you can get a prescription for ondansetron. It's usually a better med for combating chemo nausea, and targets different nausea receptors than does Cerenia, so good to have in hand. You can give both it and Cerenia if needed, which at times Neko did.

 

[NyCatMom]

Good to hear the cardiomyopathy was ruled out by echo! It's a common symptom of acros, Neko had it too. Enlarged organs are a symptom in general.

Did the IM vet (or any vet) talk about putting her on budesonide instead of prednisolone? Neko's heart couldn't take pred, and the groups.io small cell lymphoma group I'm on suggest budesonide for diabetics. So Neko was on budesonide. It did help her inflammations and did not impact her blood sugars.

Your local vet can totally get the tests run at MSU, no need to ask the IM vet for that. Most of us here gave up on asking our vets for help on dosing and just use the dosing methods we have here. You would have to start getting some tests in the PM cycle - one before bed is a good one. Many cats go lower at night. Neko had acromegaly, IAA, heart conditions (HCM, heart failure), kidney disease, and small cell lymphoma, with side helpings of pancreatitis, and I had her blood sugar quite well regulated. So it's doable.

I notice you don't have any pain relief such as buprenorphine on the meds shopping list. Pancreatitis can be very painful - pain can cause blood sugar numbers to go up. You might also want to see if you can get a prescription for ondansetron. It's usually a better med for combating chemo nausea, and targets different nausea receptors than does Cerenia, so good to have in hand. You can give both it and Cerenia if needed, which at times Neko did.

Thank you for the quick and uplifting response. Though there is plenty to celebrate on the lymphoma side, I get quite down when I see her gulping down water, having pees that are so big she gets cement paws and constantly crying for food. Of course, working from home for the last year means I see what goes on when I normally wouldn’t be here but she is more needy and clingy since she got sick. My other cats are jealous.

I have Cerenia, buprenex and Zofran at home but only give it to her when she is obviously feeling sick. On those days she runs over to her food but walks away without eating or lies with her head on her water bowl all day. Perhaps I should start treating her daily to see if that helps with her pancreatitis. When she was released from the Er vet in September 2020, she had a feeding tube and I had to give her watered down feline ID. She did great on ID even though it is high carb but maybe it was all the meds that made her feel better. The internist preferred Tiki cat, so we switched but I have days when I’m tempted to head back to the ID.

We tried the budesonide on her before we even had the endoscopy biopsy results in January but saw no reduction in any of her GI symptoms. Honestly, I can’t imagine how uncomfortable it must have been to have had the runs for a year! As soon as she started the prednisolone her stool became noticeably firmer and adding the chlorambucil made it perfect. The internist is keen to drop the prednisolone to the lowest possible dose as soon as possible. He wouldn’t prescribe it until we had the echo done.

Thank you for making me feel better.

 

[Wendy&Neko]

If she needs the pred, we just work the dose around it. We've also seen some cats on pred that are somewhat regulated. It is doable. I do know though, how hard it is managing multiple conditions. You are doing a great job. If you get the IGF-1/IAA tests done and negative (fingers crossed) that'll mean just one less thing to worry about.

 

[NyCatMom]

I will add, her primary care vet is a real gem. She hasn’t seen her in months yet calls me once a month to see how she is doing. Each time she reminds me to keep her comfort at the forefront of her treatment and not my desire to keep her with me. I’ll be interested in knowing what she thinks about her condition when she finally sees her again.

 

[NyCatMom]

If she needs the pred, we just work the dose around it. We've also seen some cats on pred that are somewhat regulated. It is doable. I do know though, how hard it is managing multiple conditions. You are doing a great job. If you get the IGF-1/IAA tests done and negative (fingers crossed) that'll mean just one less thing to worry about.

I'm not sure if its related to changing her prednisolone to once daily or my adding daily Cerenia to her meds but we had our first yellow reading (296) since February.

 

[Wendy&Neko]

Yeah for yellow! Any chance of getting a night cycle test in a couple hours? You are missing half your data, so it's hard to tell whether she's seeing nicer numbers at night. Those before bed tests will really help figure that out.

 

[NyCatMom]

Yeah for yellow! Any chance of getting a night cycle test in a couple hours? You are missing half your data, so it's hard to tell whether she's seeing nicer numbers at night. Those before bed tests will really help figure that out.

At the risk of sounding crazy, I think I see a pattern to her BG readings. I give her the prednisolone in the evenings a few hours after her meals with a spoonful of food. Her numbers shoot up and stay high until after her morning shot and her lowest number is consistently right before dinner. When her prednisolone was 5mg twice daily she never dropped at all. Then we reduced it to 7.5 daily but now with instructions to give once daily. I chose to give it to her at night as I am still working from home due to COVID so it’s easier to monitor her during the day.
Taking nighttime numbers are much harder for me. I have a 99 yr old parent who lives with me and by the time I take care of them in the evening, I am exhausted. I get up at 5am to take care of Honey but my evenings are filled caring for my parent. I can’t wait to finally take a vacation!!!!

 

[Wendy&Neko]

Her numbers shoot up and stay high until after her morning shot

How can you tell without tests at night? You still have no idea what she is really doing, without any night time tests. I'd strongly recommend before bed tests each night, even if it's just 2-3 hours after shot time. Sorry to keep harping on this, but Neko once went three months in a row going low at night and earning reductions, and bouncing during the day. If I hadn't gotten any night time data, I would have kept increasing, instead of giving the dose reductions she needed. My routine was wash face, brush teeth, poke cat, turn out the light at night. Takes but a moment.

 

[NyCatMom]

HI Wendy & Neko,

We made the decision to let her go this morning. She had lost 2 pounds in two weeks, stopped eating and had continuous diarrhea despite an arsenal of treatment. She was no longer enjoying life.

She also tested positive for Acromegly (#329).

My heart is broken and I will miss her terribly.

 

[Larry and Kitties]

Sending purrs and prayers at this difficult time.

 

[Wendy&Neko]

My deepest sympathy. Your post on Health sounded like she wasn't doing well and you made the right decision. Fly free little girl.

 

[Howiesmom]

I am so sorry for your loss. Losing fur family is so hard. Im sure journey over the bridge was a peaceful one. Big hugs to all of you.

 

[Suzanne & Darcy]

I’m so very sorry to read this. You did an awful lot to help Honey with multiple health problems. I can tell that you loved her a lot. I know how much it hurts and what a hole it leaves behind when we say goodbye to our furry family members. My sincere condolences.

 

[NyCatMom]

I’m so very sorry to read this. You did an awful lot to help Honey with multiple health problems. I can tell that you loved her a lot. I know how much it hurts and what a hole it leaves behind when we say goodbye to our furry family members. My sincere condolences.

In hindsight, all the issues Honey experienced over the last two years tie into the Acromegaly diagnosis. She was potbellied, had raspy breathing and snoring, arthritis, cardiomyopathy, insulin resistance, enlarged internal organs. My primary care vet said she was only the second cat in their practice to test positive but that because it is deemed a rare condition in cats they don’t typically run the tests. My take away for folks on this forum is that we know our cats better than anyone and we need to advocate to get them the treatment we think they need. I wish I had pushed for the testing sooner but when I was raising the red flag last year that something wasn’t right with her, we were in the midst of the NY COVID surge and the vets were only seeing extreme emergencies. It was months before I was allowed to take her to be evaluated and she wound up in the ER ICU three times in eight months. On the one hand I feel like I tried my best for her, on the other I wonder if I should have tried to continue to nurse her through this last flare. I’m sure my doubts are just part of the grieving process but it’s been a rough week so forgive me to babbling on.

 

[Suzanne & Darcy]

In hindsight, all the issues Honey experienced over the last two years tie into the Acromegaly diagnosis. She was potbellied, had raspy breathing and snoring, arthritis, cardiomyopathy, insulin resistance, enlarged internal organs. My primary care vet said she was only the second cat in their practice to test positive but that because it is deemed a rare condition in cats they don’t typically run the tests. My take away for folks on this forum is that we know our cats better than anyone and we need to advocate to get them the treatment we think they need. I wish I had pushed for the testing sooner but when I was raising the red flag last year that something wasn’t right with her, we were in the midst of the NY COVID surge and the vets were only seeing extreme emergencies. It was months before I was allowed to take her to be evaluated and she wound up in the ER ICU three times in eight months. On the one hand I feel like I tried my best for her, on the other I wonder if I should have tried to continue to nurse her through this last flare. I’m sure my doubts are just part of the grieving process but it’s been a rough week so forgive me to babbling on.

Oh no. You are not babbling on at all. I have been through (and actually am now unfortunately going through) similar situations and when I have made the “final” decision, I go back and question everything I did and everything that I did not do. I think that is normal. I know that I have made mistakes, and sometimes I just didn’t have enough information to do better. Many times (like now) the vets don’t have the answers either. Many times you are walking a tightrope trying to manage different conditions. Sometimes the therapy for one condition has the potential to exacerbate the other(s). It’s very hard. I only know that in the end I made a decision based on love and a desire to end suffering. But I still questioned whether if I had just persevered a little longer or tried something else that I could have turned things around. I also know that if I had done so and it didn’t work out that I would have blamed myself for prolonging my kitty’s suffering for “selfish” reasons. It’s a no win situation. So try to remember the love and try not to be so hard on yourself.

 

[Liz & Minnie]

Oh, I am so sorry to read this too. You have been on a difficult journey and please try not to second guess your past decisions (easier said than done). We all do the best we can based on what we know at the time.

 

[NyCatMom]

Oh no. You are not babbling on at all. I have been through (and actually am now unfortunately going through) similar situations and when I have made the “final” decision, I go back and question everything I did and everything that I did not do. I think that is normal. I know that I have made mistakes, and sometimes I just didn’t have enough information to do better. Many times (like now) the vets don’t have the answers either. Many times you are walking a tightrope trying to manage different conditions. Sometimes the therapy for one condition has the potential to exacerbate the other(s). It’s very hard. I only know that in the end I made a decision based on love and a desire to end suffering. But I still questioned whether if I had just persevered a little longer or tried something else that I could have turned things around. I also know that if I had done so and it didn’t work out that I would have blamed myself for prolonging my kitty’s suffering for “selfish” reasons. It’s a no win situation. So try to remember the love and try not to be so hard on yourself.

Thank you so much for your post. I have been beating myself up all weekend wondering what I could have done differently and whether I should have taken her back to the emergency vet for another extended stay to stabilize her. She had been in the ICU back in September and another week in February and each time returned home to a long slow recuperation. I was hoping the vets would have more knowledge about balancing different conditions but I think most people on the board have more experience because we live it everyday.
I’m still working my way through the guilt of not trying to do more but I will forever be grateful for the support I received here.
Praying for the best for Mr Darcy (what a great name) and for you Suzanne for doing everything you can to care for him.