Reducing a Dose

[Cynthia & Merlin (GA)]

Hi. This is my first post. I’m attaching Merlin’s spreadsheet here and hoping it is viewable. The reason for this long post is because I am freaking out that his bg number went up by 100 in 3 hours today. If someone (anyone) with experience in dropping a dose can take a look at this and offer their informed opinion, I’d be much appreciated.

I will note that Merlin’s reaction to his insulin dose is abnormal, to say the least. Within 10 minutes, sometimes less, he looks drugged. He lays down on his side with his eyes open and stares into space. He’s not low and I can get his attention (head up) if I go to him, but I could step over him and he won’t move (and he was always a scamperer before). I’ve taken a video of his condition and sent it to his Internist. She’s watched it several times and wants a full video from injection to reaction and a wider view so she can see his whole body. This started with his very first dose of ProZinc back in May to his last
shot this morning. He sleeps off his shot, sometimes for hours. I’ve asked high and low and did research to no avail.

Here is the note I wrote to my little guy’s Internist this morning:

Merlin’s blood glucose numbers are still really high. Nothing is changing and I’ve been giving him 3.5U Lantus for 9.5 cycles. His disposition is perpetually in a state of exhaustion. I took a good look at his spreadsheet for guidance and came up with a theory/some sort of explanation as to why his numbers are not changing.

His last hopeful run (if you can call it that), was on 6.24.18. He hit his first yellow and actually a blue in the same day. He was on 3U ProZinc. That evening we had him in ER and even without a shot that night and a continuation of the 3U Prozinc the next morning, he had another yellow. Unfortunately I was not testing as much between shots as I am now so I don’t have too much more data points to speak of.

Strength wise, 1.5U Lantus is close to 3U ProZinc (A U100 is 2.5x the strength of a U40 insulin).

At that same time, I was feeding him beef (and fish) and he was getting intermittent bouts of stomach distress which could have been a cause of his numbers being in the red at shot times. Since I changed his food to rabbit, it’s been 17 days since he’s had an ‘episode’. It took one day to clear out the beef and he’s been fine ever since. His poop is foul (sometimes more, sometimes less), but as we discussed last week it is possibly malabsorption.

Am I giving him too much insulin? I wanted to get your agreement on dropping him back to 1.5U Lantus to see if I missed his ‘perfect dose’. When I looked at him this morning, I knew I could not give him 3.5U Lantus. Even before his shot, he was lying on the bathroom floor, on his side, with his eyes open - staring into space. This is absolutely killing me.

I dropped him back to 1.5U Lantus this morning and am going to monitor closely. I’ll give him a few cycles to ‘dump the excess insulin’ and see how he reacts. If he is not reacting well (numbers too high), I can walk him back up using the Tight Regulation since he’s been at the increased Lantus numbers before.

Am I making any sense? I’m not at all educated in this, but I know my cat and my gut is telling me I need to step back. I have been peppering the support groups as well.

If Merlin continues to be at these high numbers, I’d like to get him tested for acromegaly and IAA sooner rather than later. These higher doses of Lantus do not seem common. This will give me more peace of mind going forward knowing what I may be up against. If he does have IAA, my research is showing it’s like a tug of war. If I slack on upping the dose, I’ll be at a really high unit in no time.

We can discuss his (hopefully) progress on our phone consultation Wednesday at 1:00 p.m.


https://docs.google.com/spreadsheets/d/13SHgmorU6TCfWWff20i9NtMCHhexw-tJeGFkhdJb6Yg

 

[Sienne and Gabby (GA)]

Welcome to the group!

When did you switch from Prozinc to Lantus. I may have missed it in your description. Also, it looks like you're using a phosphorus binder -- Epakitin. Is this a recent addition to Merlin's diet? Has he been tested (Snap or Spec fPLI) for pancreatitis?

Given your description of some of the food issues, have you ruled out IBD? Novel proteins will help with the problem and I'd suggest looking for low carb food that doesn't have gums or carrageenan. ZiwiPeak is pricey but may be a good option.

Any sort of inflammatory process may be causing numbers to be elevated.

I don't have a good explanation for Merlin's reaction to insulin. It is unusual, to say the least. One observation is that with Lantus, we increase the dose more frequently than what you have been doing. If you're planning on following TR, you likely noticed that after the first 5 - 7 days, the dose is evaluated every 3 days and increased if the numbers are not in a desirable range. If a cat is sitting in a higher range and the dose is held overly long, the cat's body treats the higher numbers as the new "normal." (This is referred to as glucose toxicity.)

As for the dose, 3.5u is not all that unusual. The best dose for a cat is the dose that works. We usually don't suggest testing for high dose conditions (both acromegaly and insulin resistance/insulin autoantibodies) until a cat reaches 6.0u but getting the tests run sooner is fine.

 

[Cynthia & Merlin (GA)]

Welcome to the group!

When did you switch from Prozinc to Lantus. I may have missed it in your description. Also, it looks like you're using a phosphorus binder -- Epakitin. Is this a recent addition to Merlin's diet? Has he been tested (Snap or Spec fPLI) for pancreatitis?

Given your description of some of the food issues, have you ruled out IBD? Novel proteins will help with the problem and I'd suggest looking for low carb food that doesn't have gums or carrageenan. ZiwiPeak is pricey but may be a good option.

Any sort of inflammatory process may be causing numbers to be elevated.

I don't have a good explanation for Merlin's reaction to insulin. It is unusual, to say the least. One observation is that with Lantus, we increase the dose more frequently than what you have been doing. If you're planning on following TR, you likely noticed that after the first 5 - 7 days, the dose is evaluated every 3 days and increased if the numbers are not in a desirable range. If a cat is sitting in a higher range and the dose is held overly long, the cat's body treats the higher numbers as the new "normal." (This is referred to as glucose toxicity.)

As for the dose, 3.5u is not all that unusual. The best dose for a cat is the dose that works. We usually don't suggest testing for high dose conditions (both acromegaly and insulin resistance/insulin autoantibodies) until a cat reaches 6.0u but getting the tests run sooner is fine.

 

[Cynthia & Merlin (GA)]

Hi and thanks for responding. Switch was 7/4. He is not taking a phosphorus binder; stopped that quite a while ago. His tummy issues seemed to be resolved when I switched to Instinct Limited Ingredient Rabbit as noted on chart over 17 days ago. No binders (just peas which I remove). My question centers around me reducing the dose and me freaking out over a 100 jump in 3 hours on the first day I reduced his dose.

 

[Cynthia & Merlin (GA)]

Hi and thanks for responding. Switch was 7/4. He is not taking a phosphorus binder; stopped that quite a while ago. His tummy issues seemed to be resolved when I switched to Instinct Limited Ingredient Rabbit as noted on chart over 17 days ago. No binders (just peas which I remove). My question centers around me reducing the dose and me freaking out over a 100 jump in 3 hours on the first day I reduced his dose.

Also, he was tested for fPLI and negative.

 

[Sienne and Gabby (GA)]

If I may offer a suggestion -- can you attach Merlin's spreadsheet to your signature. The instructions are in this post.

I wouldn't be freaked out. (Well, I wouldn't freak unless it was a big drop into numbers below 50.) It often helps to look at numbers in a larger context. There was a change in the numbers but overall, it looks like a pretty typical cycle for Merlin.

 

[Sandy and Black Kitty]

Hi there and welcome
How old is Merlin and how did you discover he was diabetic?

 

[Marje and Gracie]

Welcome and I’m so very sorry for what your sweet boy is going through. I can only imagine how heartbreaking it is for you.

I agree his reaction after his shot is extremely unusual and in the +8 years I’ve been on this board, I can’t remember seeing that reaction post injection in another cat. If you are willing, you can post the video here. The easiest way is to upload it to YouTube, get the link, then come back here and respond on this thread as you have been but click on the film icon in the tool bar above the text box (it’s the third to the right of the smiley face) and paste the YouTube link into the box, click “embed”, and we will see it.

Insofar as his BG jumping 100 in three hours, if you consider that each meter can have a 20% variance, you’ll see that he’s really just flat all day. Those of us who have been around a long time have seen much larger increases and decreases in the BG in shorter timeframes than that.

I’m assuming you feed him at shot time? I’m just wondering if this is all food related and not insulin related but it seems insulin related to you because it happens after the shot. But if you are feeding at the same time as the shot, and he’s lethargic all day, it makes me wonder if there’s another tie besides the insulin.

I appreciate you linking the SS and keeping such good notes. The fPLI was part of his GI Panel? How about his TLI, cobalamin, and folic acid results? If he didn’t have a GI Panel, has your vet mentioned it to you? I’m particularly wondering if your little boy could have exocrine pancreatitis insufficiency which is a nasty buggar but totally treatable once diagnosed.

I can’t find where I thought I read it but has anyone done an ultrasound on him? Do you have those results if they have?

I’m not sure where you got the SS, but it’s not our normal SS which is not a problem right now. The only reason I mention that is because ours has a tab for “Labs” that you can enter any lab work which can be helpful. Ours also auto updates to the board so as soon as you enter a BG, we can see it. We can work with what you have right now, but it would be great to have our SS linked into your signature block and I can help you with that if need be. For the moment, it would be very helpful to see his labs.

We will do our best to help you sort this out. Was his behavior markedly different today after reducing the dose (if it’s the insulin, I wouldn’t expect reaction to change yet because of the Lantus depot but thought I’d ask). I will say that an unregulated cat at these high numbers will act lethargic but not almost comatose and that sounds a bit like what you are describing.

 

[Cynthia & Merlin (GA)]

If I may offer a suggestion -- can you attach Merlin's spreadsheet to your signature. The instructions are in this post.

I wouldn't be freaked out. (Well, I wouldn't freak unless it was a big drop into numbers below 50.) It often helps to look at numbers in a larger context. There was a change in the numbers but overall, it looks like a pretty typical cycle for Merlin.

Hi and thanks for the instructions. I’ve posted Merlin’s SS and if you can view it, let me know I did it correctly.

I’ve reduced his dose from 3.5U Lantus to 1.5U Lantus yesterday morning after AMPS. Merlin is an anomoly and the reaction to insulin is frightening as described in my original post. I’m looking for guidance from this point forward to get his numbers down. The higher the insulin, the worse his disposition is. So far, the decrease has had little effect on his numbers, but a nice effect on his disposition and reaction to the shot. I’m beyond anxious.

 

[Cynthia & Merlin (GA)]

Welcome and I’m so very sorry for what your sweet boy is going through. I can only imagine how heartbreaking it is for you.

I agree his reaction after his shot is extremely unusual and in the +8 years I’ve been on this board, I can’t remember seeing that reaction post injection in another cat. If you are willing, you can post the video here. The easiest way is to upload it to YouTube, get the link, then come back here and respond on this thread as you have been but click on the film icon in the tool bar above the text box (it’s the third to the right of the smiley face) and paste the YouTube link into the box, click “embed”, and we will see it.

Insofar as his BG jumping 100 in three hours, if you consider that each meter can have a 20% variance, you’ll see that he’s really just flat all day. Those of us who have been around a long time have seen much larger increases and decreases in the BG in shorter timeframes than that.

I’m assuming you feed him at shot time? I’m just wondering if this is all food related and not insulin related but it seems insulin related to you because it happens after the shot. But if you are feeding at the same time as the shot, and he’s lethargic all day, it makes me wonder if there’s another tie besides the insulin.

I appreciate you linking the SS and keeping such good notes. The fPLI was part of his GI Panel? How about his TLI, cobalamin, and folic acid results? If he didn’t have a GI Panel, has your vet mentioned it to you? I’m particularly wondering if your little boy could have exocrine pancreatitis insufficiency which is a nasty buggar but totally treatable once diagnosed.

I can’t find where I thought I read it but has anyone done an ultrasound on him? Do you have those results if they have?

I’m not sure where you got the SS, but it’s not our normal SS which is not a problem right now. The only reason I mention that is because ours has a tab for “Labs” that you can enter any lab work which can be helpful. Ours also auto updates to the board so as soon as you enter a BG, we can see it. We can work with what you have right now, but it would be great to have our SS linked into your signature block and I can help you with that if need be. For the moment, it would be very helpful to see his labs.

We will do our best to help you sort this out. Was his behavior markedly different today after reducing the dose (if it’s the insulin, I wouldn’t expect reaction to change yet because of the Lantus depot but thought I’d ask). I will say that an unregulated cat at these high numbers will act lethargic but not almost comatose and that sounds a bit like what you are describing.

Thank you for responding. I do have a tab for labs but I deleted it when I originally set up his SS. I’ll try to get on that. He had a GI panel and an ultrasound so I can clue you in on all of that once I get set up properly. We are seeing an Internist so there is a specialist involved. He does not have exocrine pancreatitis insufficiency. I changed his food to Instinct Limited Ingredient Rabbit almost 3 weeks ago and it
has made his stomach issues no longer (fingers crossed ). My biggest fear right now is his reaction to dosing. I free feed so hunger is not an issue and I give him fluids (100 ml) at first every evening and now every other evening. It’s all on his spreadsheet. I do not know how to proceed with dosing after lowering g the dose yesterday and ramping back up knowing how he reacts. It’s so scary.

 

[Marje and Gracie]

Thank you for responding. I do have a tab for labs but I deleted it when I originally set up his SS. I’ll try to get on that. He had a GI panel and an ultrasound so I can clue you in on all of that once I get set up properly. We are seeing an Internist so there is a specialist involved. He does not have exocrine pancreatitis insufficiency. I changed his food to Instinct Limited Ingredient Rabbit almost 3 weeks ago and it
has made his stomach issues no longer (fingers crossed ). My biggest fear right now is his reaction to dosing. I free feed so hunger is not an issue and I give him fluids (100 ml) at first every evening and now every other evening. It’s all on his spreadsheet. I do not know how to proceed with dosing after lowering g the dose yesterday and ramping back up knowing how he reacts. It’s so scary.

I did see and read that you switched him to LID rabbit but the SS still remarks on vomiting, soft and or smelly and larger volume poo since the switch altho looks like his poo was normal yesterday.

But...could you pls respond as to when you feed him in relation to the shot? Also could you pls provide the info @Sandy and Black Kitty asked for in terms of how he was dx? I see he’s 14 and he was initially dx last Dec, went into remission, and came out in May. Did he need insulin last Dec and, if so, what did you use and what dose or we’re you able to get him back to normal BGs just with removing food?

From a dosing standpoint, we do not raise the Lantus dose by 1u at a time for a kitty below 6u. You risk zooming past the correct dose. I haven’t used PZ but I rarely see them raise doses by 1u at a time in the PZ forum. There’s a bit more latitude with PZ but, in general, we are all aware that it’s too easy to miss the correct dose by increasing by 1u on a lower dose cat.

You said reducing the dose has had a nice effect on his disposition and reaction to the shot. What does that mean exactly or...how are you seeing that manifested?

 

[Cynthia & Merlin (GA)]

Also, just a thought, I have electronic copies of all his labs, including ultrasounds, if you want to take a look before I have time to get them into a spreadsheet. I can also e-mail the video. Just pressed for time really. I’d spend 24/7 on this if I could.

 

[Cynthia & Merlin (GA)]

I did see and read that you switched him to LID rabbit but the SS still remarks on vomiting, soft and or smelly and larger volume poo since the switch altho looks like his poo was normal yesterday.

But...could you pls respond as to when you feed him in relation to the shot? Also could you pls provide the info @Sandy and Black Kitty asked for in terms of how he was dx? I see he’s 14 and he was initially dx last Dec, went into remission, and came out in May. Did he need insulin last Dec and, if so, what did you use and what dose or we’re you able to get him back to normal BGs just with removing food?

From a dosing standpoint, we do not raise the Lantus dose by 1u at a time for a kitty below 6u. You risk zooming past the correct dose. I haven’t used PZ but I rarely see them raise doses by 1u at a time in the PZ forum. There’s a bit more latitude with PZ but, in general, we are all aware that it’s too easy to miss the correct dose by increasing by 1u on a lower dose cat.

You said reducing the dose has had a nice effect on his disposition and reaction to the shot. What does that mean exactly or...how are you seeing that manifested?

So back in December, he was dx with diabetes. I immediately started research and removed all dry food that evening. Within a few days, we had an appointment with his vet and I declined insulin b/c I had seen an immediate change in how thirsty he was and how frequently he was peeing. Within a month, his number decreased to 82 (vet’s Alpha Trak).

 

[Cynthia & Merlin (GA)]

So back in December, he was dx with diabetes. I immediately started research and removed all dry food that evening. Within a few days, we had an appointment with his vet and I declined insulin b/c I had seen an immediate change in how thirsty he was and how frequently he was peeing. Within a month, his number decreased to 82 (vet’s Alpha Trak).

As far as feeding and dosing, it’s test/feed/shoot within 15 minutes.

 

[Cynthia & Merlin (GA)]

As far as feeding and dosing, it’s test/feed/shoot within 15 minutes.

We noticed he was lethargic in the latter part of winter 2018. He was also vomiting and had diarrhea. It’s a longer story, but after a trip to the ER, sugar had been spilling into his urine somthere was the 2nd dx.

 

[Cynthia & Merlin (GA)]

We noticed he was lethargic in the latter part of winter 2018. He was also vomiting and had diarrhea. It’s a longer story, but after a trip to the ER, sugar had been spilling into his urine somthere was the 2nd dx.

Originally our vet put him on ProZinc. If you read through the remarks on his spreadsheet you will see that he has had intermittent bouts of diarrhea. At some point we decided he needed to see and Internist. It was at the first appointment with the internist that she put him on Lantus. It was she that decided after a period of time to increase his dose from one unit to two units. At that time I did not know the guidelines for increasing doses.That is how we got from one unit to two units and when she wanted to increase to three units I was uncomfortable and told her that I would only go up by half units. Now that we are at 3.5 units I looked back on his spreadsheet and the 1.5 units was missed.

 

[Marje and Gracie]

We noticed he was lethargic in the latter part of winter 2018. He was also vomiting and had diarrhea. It’s a longer story, but after a trip to the ER, sugar had been spilling into his urine somthere was the 2nd dx.

So they never diagnosed him via a couple lab tests (blood) or a fructosamine?

 

[Cynthia & Merlin (GA)]

Originally our vet put him on ProZinc. If you read through the remarks on his spreadsheet you will see that he has had intermittent bouts of diarrhea. At some point we decided he needed to see and Internist. It was at the first appointment with the internist that she put him on Lantus. It was she that decided after a period of time to increase his dose from one unit to two units. At that time I did not know the guidelines for increasing doses.That is how we got from one unit to two units and when she wanted to increase to three units I was uncomfortable and told her that I would only go up by half units. Now that we are at 3.5 units I looked back on his spreadsheet and the 1.5 units was missed.

Since around that time in looking back on the equivalency of ProZinc versus Lantus, Merlin had at least a few good numbers on three units of ProZinc which is close to the strength of 1.5 units Lantus. I hope I am making sense.

 

[Cynthia & Merlin (GA)]

So they never diagnosed him via a couple lab tests (blood) or a fructosamine?

Blood and fructosame was done to dx him both times.

 

[Cynthia & Merlin (GA)]

I did see and read that you switched him to LID rabbit but the SS still remarks on vomiting, soft and or smelly and larger volume poo since the switch altho looks like his poo was normal yesterday.

But...could you pls respond as to when you feed him in relation to the shot? Also could you pls provide the info @Sandy and Black Kitty asked for in terms of how he was dx? I see he’s 14 and he was initially dx last Dec, went into remission, and came out in May. Did he need insulin last Dec and, if so, what did you use and what dose or we’re you able to get him back to normal BGs just with removing food?

From a dosing standpoint, we do not raise the Lantus dose by 1u at a time for a kitty below 6u. You risk zooming past the correct dose. I haven’t used PZ but I rarely see them raise doses by 1u at a time in the PZ forum. There’s a bit more latitude with PZ but, in general, we are all aware that it’s too easy to miss the correct dose by increasing by 1u on a lower dose cat.

You said reducing the dose has had a nice effect on his disposition and reaction to the shot. What does that mean exactly or...how are you seeing that manifested?

Sorry, I do not remark on poop unless it was not normal. His diarrhea/soft poop stopped a day after the food switch. He’s been pooping normally since. I noted that yesterday’s poop was the first time it wasn’t foul smelling or slightly foul smelling. Internist likened it to ‘smelling like sewage’ and probably from malabsorption. Yesterday’s poop was the way it should smell.

 

[Marje and Gracie]

Originally our vet put him on ProZinc. If you read through the remarks on his spreadsheet you will see that he has had intermittent bouts of diarrhea. At some point we decided he needed to see and Internist. It was at the first appointment with the internist that she put him on Lantus. It was she that decided after a period of time to increase his dose from one unit to two units. At that time I did not know the guidelines for increasing doses.That is how we got from one unit to two units and when she wanted to increase to three units I was uncomfortable and told her that I would only go up by half units. Now that we are at 3.5 units I looked back on his spreadsheet and the 1.5 units was missed.

There were a lot of doses missed but we don’t usually do “rebound checks” as you have done unless the data really looks like a dose was skipped and the cat is very obviously overdosed. At this point, I’d leave the dose at 1.5u bid and increase as per the Tight Regulation Protocol, if it’s possible for you to do it. You are currently getting a lot of good testing data...plenty to do TR.

Blood and fructosame was done to dx him both times.

Usually when we switch from PZ to Lantus, the starting dose should be close to the dose where you were seeing some progress on the PZ. So, for instance, if a cat was on 4u of PZ and just starting to see some blue, we would start the lantus at about 3.75u.

With so much testing data from PZ and early lantus not available, I’m trying to determine if his PZ dose was too high or too low. However, you started him completely over when you switched to lantus but the increases were just too much.

Have you tested him this morning since AMPS?

 

[Cynthia & Merlin (GA)]

There were a lot of doses missed but we don’t usually do “rebound checks” as you have done unless the data really looks like a dose was skipped and the cat is very obviously overdosed. At this point, I’d leave the dose at 1.5u bid and increase as per the Tight Regulation Protocol, if it’s possible for you to do it. You are currently getting a lot of good testing data...plenty to do TR.


Usually when we switch from PZ to Lantus, the starting dose should be close to the dose where you were seeing some progress on the PZ. So, for instance, if a cat was on 4u of PZ and just starting to see some blue, we would start the lantus at about 3.75u.

With so much testing data from PZ and early lantus not available, I’m trying to determine if his PZ dose was too high or too low. However, you started him completely over when you switched to lantus but the increases were just too much.

Have you tested him this morning since AMPS?

Yes. His +3 was 379. I plan on doing every 3 hrs.

It’s not easy when am Internist tells you to start and a particular dose and then increase it when you don’t know what you are doing. Also, Merlin has such an unusual, and frightening reaction to dosing that increasing his dose gives me unbelievable anxiety. I do not know what to do.

 

[Cynthia & Merlin (GA)]

And can I say thank you for peppering me with questions and trying to understand where I am. I now understand the protocol of TR, but how could I ever have known that in the very beginning. My vet went up by 1 unit every two
weeks on ProZinc until 3 units and then the Internist started us at 1 unit and went up by 1 increments as well. Why aren’t they telling me what you’re telling me!

 

[Cynthia & Merlin (GA)]

I did see and read that you switched him to LID rabbit but the SS still remarks on vomiting, soft and or smelly and larger volume poo since the switch altho looks like his poo was normal yesterday.

But...could you pls respond as to when you feed him in relation to the shot? Also could you pls provide the info @Sandy and Black Kitty asked for in terms of how he was dx? I see he’s 14 and he was initially dx last Dec, went into remission, and came out in May. Did he need insulin last Dec and, if so, what did you use and what dose or we’re you able to get him back to normal BGs just with removing food?

From a dosing standpoint, we do not raise the Lantus dose by 1u at a time for a kitty below 6u. You risk zooming past the correct dose. I haven’t used PZ but I rarely see them raise doses by 1u at a time in the PZ forum. There’s a bit more latitude with PZ but, in general, we are all aware that it’s too easy to miss the correct dose by increasing by 1u on a lower dose cat.

You said reducing the dose has had a nice effect on his disposition and reaction to the shot. What does that mean exactly or...how are you seeing that manifested?

Regarding his disposition since the decrease in dosage - more alert, not sleeping it off for hours, lying with his head upright way more, coming down the steps to wait at the gate for food (he lives upstairs, other cat downstairs- long story), eyes clearer. He still has some of the effects (looking stoned), but not for as long.

 

[Marje and Gracie]

And can I say thank you for peppering me with questions and trying to understand where I am. I now understand the protocol of TR, but how could I ever have known that in the very beginning. My vet went up by 1 unit every two
weeks on ProZinc until 3 units and then the Internist started us at 1 unit and went up by 1 increments as well. Why aren’t they telling me what you’re telling me!

This is very common that vets raise doses by too much at a time. Do not blame yourself at all and there is no blame or criticism by us towards you because we see this kind of dosing by vets on most of the cats that come to the board.

I saw three board certified internists with Gracie and not one of them had a clue about diabetes and all said I should just not test. This board is where I found the answers and education I needed.

Each member here has to become comfortable at their own speed with the way we do things here as opposed to vets but there is a happy medium that the majority of us reach with our vets. My vet is incredible and she always admitted I knew way more about FD than she did so she never tried to insert herself into our dosing. We work as a team with no egos so even with my healthy cats, if I bring her new info, she’s always happy to read and discuss.

Regarding his disposition since the decrease in dosage - more alert, not sleeping it off for hours, lying with his head upright way more, coming down the steps to wait at the gate for food (he lives upstairs, other cat downstairs- long story), eyes clearer. He still has some of the effects (looking stoned), but not for as long.

I’m glad he’s better. We just need to see how his BG responds to the dose and take him up in smaller increments if he needs an increase. Again, I appreciate all your detailed remarks on the SS.

I’m happy to look at labs when you have time to post them. We had a member whose kitty was fairly well regulated but then went completely off the rails and his BG shot up. Looking at his labs, his creatine kinase had also shot up and, long story short, he had cardiomyopathy. His dose climbed, she had the acro/IAA testing done, and he had also developed IAA which is a high dose condition that we can break through. I find that a lot of vets can be very dismissive over changes in labs......not one vet she had seen said a word about his creatine kinase shooting up.

I’m going to be gone several hours but I, and others, will check back in. Remember, though, that if you see much better numbers today, it’s possible it’s the 3.5u depot. It’s going to take up to six cycles (could be led) for that to drain where we can see what the 1.5u dose is really doing.

 

[Cynthia & Merlin (GA)]

This is very common that vets raise doses by too much at a time. Do not blame yourself at all and there is no blame or criticism by us towards you because we see this kind of dosing by vets on most of the cats that come to the board.

I saw three board certified internists with Gracie and not one of them had a clue about diabetes and all said I should just not test. This board is where I found the answers and education I needed.

Each member here has to become comfortable at their own speed with the way we do things here as opposed to vets but there is a happy medium that the majority of us reach with our vets. My vet is incredible and she always admitted I knew way more about FD than she did so she never tried to insert herself into our dosing. We work as a team with no egos so even with my healthy cats, if I bring her new info, she’s always happy to read and discuss.


I’m glad he’s better. We just need to see how his BG responds to the dose and take him up in smaller increments if he needs an increase. Again, I appreciate all your detailed remarks on the SS.

I’m happy to look at labs when you have time to post them. We had a member whose kitty was fairly well regulated but then went completely off the rails and his BG shot up. Looking at his labs, his creatine kinase had also shot up and, long story short, he had cardiomyopathy. His dose climbed, she had the acro/IAA testing done, and he had also developed IAA which is a high dose condition that we can break through. I find that a lot of vets can be very dismissive over changes in labs......not one vet she had seen said a word about his creatine kinase shooting up.

I’m going to be gone several hours but I, and others, will check back in. Remember, though, that if you see much better numbers today, it’s possible it’s the 3.5u depot. It’s going to take up to six cycles (could be led) for that to drain where we can see what the 1.5u dose is really doing.

Thank you for that, and for the reassurance. I have a conference call with his Internist in about 1/2 hr. I’ve given her the written protocols on TR (the one from Queensland and Tilly’s) and am going to tell her this is the road ahead because what was prescribed before did not work. And yes, I do know that his deposit ‘shed’ needs to empty some. I will ask again that this group look and see what happened over the next few days and ask how to proceed as well.

Thank you so much!

 

[Cynthia & Merlin (GA)]

Hi. I’ve added a tab to my spreadsheet with all of Merlin’s labs. I ran out of time for the GI Panel so here goes:

Cobalamin Fasting >1000 ug/L

Folate Fasting 10.3 ug/L

Pancreatic Lipase Immunoreactivity Faating 1.7 ug/L

TLI Fasting 28.8 ug/L

Also, based on our conference call today with Merlin’s Internist, we are having him tested for agro/IAA (I am actually at their offices now. She is thinking his difficulty with dosing and his almost intermittent comatose behavior could be neurological. It was something I was pushing for anyway.

I would appreciate some guidance on his BG chart going forward. For now, he is holding flat, possibly still shedding his Lantus reserve.

Thank you so much!

 

[Marje and Gracie]

Thanks for posting his labs. Two things stand out to me....his phosphorus is pretty high especially for a cat that doesn’t have CKD. His hematocrit is a bit low. It should ideally be above 40% altho it’s trending up a bit.

We should see how he does on this dose for six cycles.

I’m surprised the vet would test for acro and IAA now. Even at 3.5u, he wouldn’t be considered high dose.

 

[Wendy&Neko]

One in four diabetic cats has acromegaly according to a large scale study. In that study, the average dose was 7 units, ranging from 1.0 units to 35 units. We have seen higher here. We also have a few cats with "high dose" conditions on lower doses, one at 0.5 units now (though she did go higher) and a couple in the 3-4 unit range. For the majority of her time with diabetes, Neko was on less than 3 units. I have also seen recommendations to get cats tested if they haven't been regulated after six months. I hope the tests are negative, but it'll be good to know one way or the other.

 

[Cynthia & Merlin (GA)]

Funny you should mention phosphorus. I asked the same question to both his vet and his Internist just last week:

*****

Phosphorus

If your cat's phosphorus level (in blood tests) is over 6 mg/dl (USA) or over 1.9 mmgl/L (international), it is too high and you need to get it under control.

Even for cats with lower phosphorus levels, if the cat's phosphorus multiplied by total calcium is higher than 70 in US values or 5 in international values, the cat is at risk of tissue calcification (see secondary hyperparathyroidism) and will usually need binders.

The kidneys of a CKD cat can no longer efficiently excrete excess phosphorus, so the vast majority of CKD cats will develop levels of phosphorus in their blood which are too high: this is known as hyperphosphataemia.

In contrast to the protein debate, there is no dispute about the importance of treating hyperphosphataemia because of the problems it causes. Indeed, an update on the Western Veterinary Conference 2017 reports that "phosphorus restriction may be the "single most powerful treatment," according to Dr. Chew.

Merlin - 7.6 Phosphorus
x 11.2 Calcium
85.12

I pulled a few pieces of the info above from the website listed below to get an overview of where Merlin stands:

https://www.felinecrf.org/phosphorus_binders.htm

There is so much more info on this website. Looking to you, for your understanding regarding Merlin having CKD, and for a recommendation on what binder is the best for him.

Note: Merlin’s creatinine was 2.6 back in April. BUN was in a good place, but his SDMA increased to 20 in a range of 0-14 which indicated kidney disease probably. His USG is 1.028 and was 1.046 on 12.11.17 so definitely a big change. He is in the early stages of the kidney disease.

What else, besides fluids and phosphorus binders, should I be doing for him?

*****

Vet deferred to Internist (actually wanted to charge me to consult) but finally said (after I kept asking to just please give me a recommendation for a phosphorus binder) that the level looked quite normal. Internist said at this time she wouldn’t recommend a binder and that the SDMA is not always a good indicator, including the fact of the fluids maybe having an impact.

Anyway, what would you do?

 

[Cynthia & Merlin (GA)]

Thanks for posting his labs. Two things stand out to me....his phosphorus is pretty high especially for a cat that doesn’t have CKD. His hematocrit is a bit low. It should ideally be above 40% altho it’s trending up a bit.

We should see how he does on this dose for six cycles.

I’m surprised the vet would test for acro and IAA now. Even at 3.5u, he wouldn’t be considered high dose.

ALSO - we are testing for acro/IAA because of a suspicion of something neurological with Merlin. This has to do with how he reacts to dosing. To us it makes sense. His Internist did an evaluation on him today and something is just not right. So one way or another we’ll know.

 

[Cynthia & Merlin (GA)]

ALSO - we are testing for acro/IAA because of a suspicion of something neurological with Merlin. This has to do with how he reacts to dosing. To us it makes sense. His Internist did an evaluation on him today and something is just not right. So one way or another we’ll know.

What is hemotocrit and why does that raise a small flag for you?

Thank you!

 

[Cynthia & Merlin (GA)]

One in four diabetic cats has acromegaly according to a large scale study. In that study, the average dose was 7 units, ranging from 1.0 units to 35 units. We have seen higher here. We also have a few cats with "high dose" conditions on lower doses, one at 0.5 units now (though she did go higher) and a couple in the 3-4 unit range. For the majority of her time with diabetes, Neko was on less than 3 units. I have also seen recommendations to get cats tested if they haven't been regulated after six months. I hope the tests are negative, but it'll be good to know one way or the other.

We are testing for acro/IAA because of a suspicion of something neurological with Merlin. This has to do with how he reacts to dosing. To us it makes sense. His Internist did an evaluation on him today and something is just not right. So one way or another we’ll know.

Thank you!

 

[Gill & George]

First of all, hello and welcome, I'm sorry that you're having such a hard time with your boy. Like the others I am not aware of any kitty having the response you are describing to insulin.

Strength wise, 1.5U Lantus is close to 3U ProZinc (A U100 is 2.5x the strength of a U40 insulin).

I just wanted to clarify this,
A u100 insulin is more concentrated than a U40 insulin, but not necessarily stronger.
Let me try and explain.
If 1ml of PZ contains 40U of insulin 1ml of Lantus will contain 100U of Lantus.
So if you were using a syringe that was calibrated in ml, to give 40units in PZ you would measure out 1ml, and in Lantus you would have to measure out 1/100*40=0.4ml


Now if you are using insulin syringes calibrated for the appropriate insulin, that is, you are using U40 for PZ and U100 for Lantus,, when you draw the dose you are drawing the actual units of insulin, but the actual volume would be smaller for Lantus, the calibrated syringe already 'works' it out for you.

Does that make sense?

All that said, I'd stick with the 1.5 u Lantus for now, and increase following the TR protocol.

What else, besides fluids and phosphorus binders, should I be doing for him?

My kitty has early CKD, I have opted for a low Phosphorus food, his P is lower than Merlin's, also to avoid problems with nausea and acid tummy I feed snacks at regular intervals (every 3hours), and to aid his hydration I add water to all of his snacks and meals, he doesn't mind his food soupy. If he is feeling nauseous, raising his bowl when you feed can help encourage them to eat.

Recently George's labs came back with a low hematocrit of 28% and a note from the lab that he had non regenerative anemia, he was acutely ill at the time, he had really bad teeth, which were giving him the following symptoms.
Lethargy
Glazed watery eyes
Sneezing
Snuffling
Diarrhea
Vomiting
His BG went up and he came out of remission.
He started being picky about food and skipping snacks and not asking for his food, eventually going off it altogether, which being the foodie that he is was the symptom that most alarmed me.

These symptoms didn't all come on at once, but with the benefit of hindsight I know now that his teeth were to blame for them all, after ABs, extractions, he has done a complete U turn. I also have him on some B vitamins. Hopefully his anemia will be resolved when he gets his next blood test, ideally I would have liked to get a reason for his anemia, but that wasn't possible here, it's possible the infection in his mouth was responsible, who knows.

Has Merlin had his mouth looked at?

@Marje and Gracie will give you a better explanation of the importance of hematocrit.

 

[Cynthia & Merlin (GA)]

First of all, hello and welcome, I'm sorry that you're having such a hard time with your boy. Like the others I am not aware of any kitty having the response you are describing to insulin.





I just wanted to clarify this,
A u100 insulin is more concentrated than a U40 insulin, but not necessarily stronger.
Let me try and explain.
If 1ml of PZ contains 40U of insulin 1ml of Lantus will contain 100U of Lantus.
So if you were using a syringe that was calibrated in ml, to give 40units in PZ you would measure out 1ml, and in Lantus you would have to measure out 1/100*40=0.4ml


Now if you are using insulin syringes calibrated for the appropriate insulin, that is, you are using U40 for PZ and U100 for Lantus,, when you draw the dose you are drawing the actual units of insulin, but the actual volume would be smaller for Lantus, the calibrated syringe already 'works' it out for you.

Does that make sense?

All that said, I'd stick with the 1.5 u Lantus for now, and increase following the TR protocol.





My kitty has early CKD, I have opted for a low Phosphorus food, his P is lower than Merlin's, also to avoid problems with nausea and acid tummy I feed snacks at regular intervals (every 3hours), and to aid his hydration I add water to all of his snacks and meals, he doesn't mind his food soupy. If he is feeling nauseous, raising his bowl when you feed can help encourage them to eat.

Recently George's labs came back with a low hematocrit of 28% and a note from the lab that he had non regenerative anemia, he was acutely ill at the time, he had really bad teeth, which were giving him the following symptoms.
Lethargy
Glazed watery eyes
Sneezing
Snuffling
Diarrhea
Vomiting
His BG went up and he came out of remission.
He started being picky about food and skipping snacks and not asking for his food, eventually going off it altogether, which being the foodie that he is was the symptom that most alarmed me.

These symptoms didn't all come on at once, but with the benefit of hindsight I know now that his teeth were to blame for them all, after ABs, extractions, he has done a complete U turn. I also have him on some B vitamins. Hopefully his anemia will be resolved when he gets his next blood test, ideally I would have liked to get a reason for his anemia, but that wasn't possible here, it's possible the infection in his mouth was responsible, who knows.

Has Merlin had his mouth looked at?

@Marje and Gracie will give you a better explanation of the importance of hematocrit.

Thank you for responding! I will take a closer look at your explanation for ProZinc U40 vs. Lantus U100. My brain is not exactly working now due to lack of sleep and worry.

Merlin is free fed and always has food available. In addition, this offsets any chance of his tummy being empty and the result nausea that can follow. I also add lots of water to his food.

I addressed the phosphorus concern in a previous post and will probably just start adding back the Epakitin I was given by his holistic vet - who, by the way, raised the issue of possible anemia. If you have a better suggestion for a phosphorus binder, I’d love to know. I am going to press for more answers on both these fronts.

In addition, Merlin’s teeth are definitely on our radar. He has crummy teeth and has had them cleaned every year with some years having extractions. It is something I talked with his Internist about last night. His last cleaning was October 2017.

I should also post his ultrasounds. There is some concern with a thickening of his gut and is on the Internists radar as well (we all talked about it together yesterday). Is there a way in this board to post a document?

Much, much appreciated and good luck wth your little one. Fingers crossed the anemia is so much better.

 

[Marje and Gracie]

Vet deferred to Internist (actually wanted to charge me to consult) but finally said (after I kept asking to just please give me a recommendation for a phosphorus binder) that the level looked quite normal. Internist said at this time she wouldn’t recommend a binder and that the SDMA is not always a good indicator, including the fact of the fluids maybe having an impact.

In CKD cats, one of the major predictors of longevity and QOL is phosphorus control. It is much easier to keep P from going up than it is to get it down (see below) so I’m surprised that either vet would think the P level is normal and that you don’t need to take action right now esp considering his Ca level. Dehydration can cause the SDMA to be higher but if you are giving subq fluids, that would not cause an increased SDMA.

Often, it’s not enough to just feed a low P diet because the only diets that are truly low P are the renal prescription diets. I, personally, wouldn’t feed these nor do two great well known vets, Dr. Becker and Dr. Lisa Pierson (who is a feline vet nutritionist and a member of this forum who posts occasionally) recommend these diets. They are full of poor ingredients and they restrict protein which is not a good thing to do in the early stages of CKD. I understand you are up against the wall a bit on the diet as the LID Rabbit is helping him but it’s very high in P. Ideally, you want a food that is no more than 200 mgP/100 kcal or is no more than 1.00%P on a dry matter basis. Even at that, you will need to add binder. I prefer aluminum hydroxide powder as it is tasteless and can be mixed in with food. You don’t want to use Epakitin because it is a calcium based binder and his Ca is already too high.

In fact, if he were my cat, I’d probably ask my vet to rerun his labs (same panel as last time which looks like a senior panel) and if Ca is still high, do an ionized calcium test on him to see if he actually has hypercalcemia. Here is more info on hypercalcemia. Some of his symptoms could potentially be attributed to hypercalcemia although his serum calcium levels, at this time, are high (in the range of hypercalcemia) but not critically so. Still...every cat is different.

Regarding the hematocrit, anything below 30% is considered anemia but treating it aggressively does not usually occur until it gets below 20%. The reason CKD cats are prone to anemia is because the kidneys produce the hormone erythropoietin which causes the bone marrow to make red blood cells. Kidneys need B vitamins to make erythropoietin. CKD cats pee a lot and excrete a lot of the B vitamins. Less B vitamins means less erythropoietin means less RBCs that the bone marrow can make. Therefore, you can usually slow down the process towards anemia and avoid using the heavy guns when it goes below 20% by giving methylcobalamin (B12) and multi B vitamins orally. Here is an excellent discussion on the B vitamins needed and dosing. I’ve had three cats with CKD and one with PKD (which is a different monster but presents as CKD) and with the three that just had CKD, I was able to keep their hematocrit up around 28%. None of those three passed from CKD and were stable with it for a very long time.

One thing you might consider discussing with the vets and starting him on is calcitriol (scroll down on the page till you see it). It used to be that calcitriol was used when a CKD cat was diagnosed with secondary parahyperthyroidism (which is not the same as hyperthyroidism). It was given daily at a fairly high dose and blood chemistries had to be monitored closely. Now, the trend is changing and, because this condition is quite common in CKD cats, calcitriol is often given at a small dose, twice a week, or even pulse dosed to prevent the condition and also to help the kitty feel better, in general. While calcitriol given daily at higher doses can potentially increase Ca levels, given twice a week at a low dose does not seem to have an effect on the Ca levels. If your vets are not up on this new trend, you might have a hard time convincing them. The link I gave you above has a good discussion and gives links to studies that might help you discuss this better with the vets.

I should also post his ultrasounds. There is some concern with a thickening of his gut and is on the Internists radar as well (we all talked about it together yesterday). Is there a way in this board to post a document?

You can take a photo and then upload it by clicking on “upload a file” at the end of your post, browse to the document, select it, and then once loaded on the board, select “full image” so we can see it.

If he stays at these numbers above 300 through the sixth cycle tonight, I recommend that you increase his dose to 2u with tomorrow morning’s shot.

 

[Cynthia & Merlin (GA)]

In CKD cats, one of the major predictors of longevity and QOL is phosphorus control. It is much easier to keep P from going up than it is to get it down (see below) so I’m surprised that either vet would think the P level is normal and that you don’t need to take action right now esp considering his Ca level. Dehydration can cause the SDMA to be higher but if you are giving subq fluids, that would not cause an increased SDMA.

Often, it’s not enough to just feed a low P diet because the only diets that are truly low P are the renal prescription diets. I, personally, wouldn’t feed these nor do two great well known vets, Dr. Becker and Dr. Lisa Pierson (who is a feline vet nutritionist and a member of this forum who posts occasionally) recommend these diets. They are full of poor ingredients and they restrict protein which is not a good thing to do in the early stages of CKD. I understand you are up against the wall a bit on the diet as the LID Rabbit is helping him but it’s very high in P. Ideally, you want a food that is no more than 200 mgP/100 kcal or is no more than 1.00%P on a dry matter basis. Even at that, you will need to add binder. I prefer aluminum hydroxide powder as it is tasteless and can be mixed in with food. You don’t want to use Epakitin because it is a calcium based binder and his Ca is already too high.

In fact, if he were my cat, I’d probably ask my vet to rerun his labs (same panel as last time which looks like a senior panel) and if Ca is still high, do an ionized calcium test on him to see if he actually has hypercalcemia. Here is more info on hypercalcemia. Some of his symptoms could potentially be attributed to hypercalcemia although his serum calcium levels, at this time, are high (in the range of hypercalcemia) but not critically so. Still...every cat is different.

Regarding the hematocrit, anything below 30% is considered anemia but treating it aggressively does not usually occur until it gets below 20%. The reason CKD cats are prone to anemia is because the kidneys produce the hormone erythropoietin which causes the bone marrow to make red blood cells. Kidneys need B vitamins to make erythropoietin. CKD cats pee a lot and excrete a lot of the B vitamins. Therefore, you can usually slow down the process towards anemia and avoid using the heavy guns when it goes below 20% by giving methylcobalamin (B12) and multi B vitamins orally. Here is an excellent discussion on the B vitamins needed and dosing. I’ve had three cats with CKD and one with PKD (which is a different monster but presents as CKD) and with the three that just had CKD, I was able to keep their hematocrit up around 28%. None of those three passed from CKD and were stable with it for a very long time.

One thing you might consider discussing with the vets and starting him on is calcitriol (scroll down on the page till you see it). It used to be that calcitriol was used when a CKD cat was diagnosed with secondary hyperparathyroidism (which is not the same as hyperthyroidism). It was given daily at a fairly high dose and blood chemistries had to be monitored closely. Now, the trend is changing and, because this condition is quite common in CKD cats, calcitriol is often given at a small dose, twice a week, or even pulse dosed to prevent the condition and also to help the kitty feel better, in general. While calcitriol given daily at higher doses can potentially increase Ca levels, given twice a week at a low dose does not seem to have an effect on the Ca levels. If your vets are not up on this new trend, you might have a hard time convincing them. The link I gave you above has a good discussion and gives links to studies that might help you discuss this better with the vets.


You can take a photo and then upload it by clicking on “upload a file” at the end of your post, browse to the document, select it, and then once loaded on the board, select “full image” so we can see it.

If he stays at these numbers above 300 through the sixth cycle tonight, I recommend that you increase his dose to 2u with tomorrow morning’s shot.

Such great, detailed information! Thank you so much. A lot to digest. I plan on putting together this I formation for my Internist since my vet is just passing everything over really.

Your information gives me a roadmap as to how this may be all connected and I cannot tell you how important it is for me to know and understand this. I am aware of some of the things you said (Dr. Pierson, no to prescription food) so I am a little clued in. You really lay a lot more out there for me to chew on, especially another possibility for his ‘episodes’ of eyes glazed and looking right they me - seizures. The results for the acro/IAA will be in in about a week and if that is not his diagnosis, I now have another path.

I’ll try to post his ultrasounds for you to look at and yes, an increase to 2u Lantus BID tomorrow is in order depending on his numbers tonight. I doubt anything will change with his numbers coming down, but ECID.

Really appreciate you checking in.

 

[Marje and Gracie]

Such great, detailed information! Thank you so much. A lot to digest. I plan on putting together this I formation for my Internist since my vet is just passing everything over really.

Your information gives me a roadmap as to how this may be all connected and I cannot tell you how important it is for me to know and understand this. I am aware of some of the things you said (Dr. Pierson, no to prescription food) so I am a little clued in. You really lay a lot more out there for me to chew on, especially another possibility for his ‘episodes’ of eyes glazed and looking right they me - seizures. The results for the acro/IAA will be in in about a week and if that is not his diagnosis, I now have another path.

I’ll try to post his ultrasounds for you to look at and yes, an increase to 2u Lantus BID tomorrow is in order depending on his numbers tonight. I doubt anything will change with his numbers coming down, but ECID.

Really appreciate you checking in.

You’re welcome. I am not a vet and so my goal is to just give you information to discuss with your vets. The benefit is I am giving you the information from the eyes and experience of a caregiver and one that tries to stay on top of developing research. Vets are so very busy and they often see more than one species at a time. I can’t imagine how very hard it must be to stay on top of all that, see patients, and have any kind of personal life. The good vets are the ones that will gladly take what you bring them and look into it. The not so good ones are the ones that tell you to stay off the internet, they know what they are doing, don’t question them. None of us are infallible or right 100% of the time. And no matter how much experience or knowledge one might have, we are dealing with living beings and their bodies react as they will. We need to listen. You’ve done a great job of observing and recording what you see and learn about Merlin.

Insofar as the acro/IAA and neuro component, I’m going to tag @Wendy&Neko. Wendy is our resident guru on high dose conditions and she stays on top of all the current research. There is the obvious that acro is caused by a pituitary gland tumor and the pituitary at the base of the brain. The tumor causes excess amounts of growth hormone to be excreted. I know some of these acro cats will show some eye issues. In fact, Wendy has remarked to me that she noticed a discharge from Neko’s eyes and didn’t think much about it until after she was diagnosed with acro. However, I don’t know if acro can cause some of the symptoms you are seeing and that’s why it’s important for someone like Wendy to pop into the discussion.

I could be 150% off base, but there is just something telling me that his reaction isn’t due to the insulin......there is something else going on and it happens to be coincidental with his shot time. But, that is total speculation and I have no scientific basis for it. I could be every kind of wrong about it

 

[Cynthia & Merlin (GA)]

You’re welcome. I am not a vet and so my goal is to just give you information to discuss with your vets. The benefit is I am giving you the information from the eyes and experience of a caregiver and one that tries to stay on top of developing research. Vets are so very busy and they often see more than one species at a time. I can’t imagine how very hard it must be to stay on top of all that, see patients, and have any kind of personal life. The good vets are the ones that will gladly take what you bring them and look into it. The not so good ones are the ones that tell you to stay off the internet, they know what they are doing, don’t question them. None of us are infallible or right 100% of the time. And no matter how much experience or knowledge one might have, we are dealing with living beings and their bodies react as they will. We need to listen. You’ve done a great job of observing and recording what you see and learn about Merlin.

Insofar as the acro/IAA and neuro component, I’m going to tag @Wendy&Neko. Wendy is our resident guru on high dose conditions and she stays on top of all the current research. There is the obvious that acro is caused by a pituitary gland tumor and the pituitary at the base of the brain. The tumor causes excess amounts of growth hormone to be excreted. I know some of these acro cats will show some eye issues. In fact, Wendy has remarked to me that she noticed a discharge from Neko’s eyes and didn’t think much about it until after she was diagnosed with acro. However, I don’t know if acro can cause some of the symptoms you are seeing and that’s why it’s important for someone like Wendy to pop into the discussion.

I could be 150% off base, but there is just something telling me that his reaction isn’t due to the insulin......there is something else going on and it happens to be coincidental with his shot time. But, that is total speculation and I have no scientific basis for it. I could be every kind of wrong about it

I so appreciate you and the folks at this forum. It’s a well-rounded approach as opposed to FB groups that do well with one/two issues. In my case, Merlin’s condition is very complicated. The information provided here gives me the chance to evaluate what is posted as it relates to my little guy.

Thank you for tagging Wendy & Neko. As much as I want her help and guidance, I’m really hoping I don’t need it.

I’ve uploaded both of Merlin’s ultrasound reports along with an X-ray as well. Just more date points for all of this.

One of the things my Internist related to me when her report was done in July was that the thickening in his intestinal tract could possibly be food related. It was one of many possibilities. I am encouraged by the fact that since I changed his diet three weeks ago, he has had no issues in that regard (KNOCK WOOD). The first ultrasound he had was back in December with his regular vet. The thickening (sludge as she referred to it) was there as well and I had not nailed down a proper diet for him
She prescribed Ursodial then.

OK. Wish me luck tomorrow increasing his dose. I so want him to feel good again.

 

[Cynthia & Merlin (GA)]

View attachment 38211 View attachment 38212 View attachment 38213 View attachment 38211


I so appreciate you and the folks at this forum. It’s a well-rounded approach as opposed to FB groups that do well with one/two issues. In my case, Merlin’s condition is very complicated. The information provided here gives me the chance to evaluate what is posted as it relates to my little guy.

Thank you for tagging Wendy & Neko. As much as I want her help and guidance, I’m really hoping I don’t need it.

I’ve uploaded both of Merlin’s ultrasound reports along with an X-ray as well. Just more date points for all of this.

One of the things my Internist related to me when her report was done in July was that the thickening in his intestinal tract could possibly be food related. It was one of many possibilities. I am encouraged by the fact that since I changed his diet three weeks ago, he has had no issues in that regard (KNOCK WOOD). The first ultrasound he had was back in December with his regular vet. The thickening (sludge as she referred to it) was there as well and I had not nailed down a proper diet for him
She prescribed Ursodial then.

OK. Wish me luck tomorrow increasing his dose. I so want him to feel good again.

Oh, and can you suggest/recommend the phosphorus binder I would want to look at. There’s a few on the market. Thank you!

 

[Marje and Gracie]

View attachment 38211 View attachment 38212 View attachment 38213 View attachment 38211


I so appreciate you and the folks at this forum. It’s a well-rounded approach as opposed to FB groups that do well with one/two issues. In my case, Merlin’s condition is very complicated. The information provided here gives me the chance to evaluate what is posted as it relates to my little guy.

Thank you for tagging Wendy & Neko. As much as I want her help and guidance, I’m really hoping I don’t need it.

I’ve uploaded both of Merlin’s ultrasound reports along with an X-ray as well. Just more date points for all of this.

One of the things my Internist related to me when her report was done in July was that the thickening in his intestinal tract could possibly be food related. It was one of many possibilities. I am encouraged by the fact that since I changed his diet three weeks ago, he has had no issues in that regard (KNOCK WOOD). The first ultrasound he had was back in December with his regular vet. The thickening (sludge as she referred to it) was there as well and I had not nailed down a proper diet for him
She prescribed Ursodial then.

OK. Wish me luck tomorrow increasing his dose. I so want him to feel good again.

Ursodiol is for the gallbladder. She remarked on some distinction on it and ursodiol, which is a bile acid, can improve the flow of bile to the liver. Good that there was no annotation of an obstruction because you wouldn’t want to give ursodiol in that situation. She also remarks that the gallbladder sediment could be indicative of cholangiohepatitis which is a liver and gall bladder inflammation. Usually, with cholangiohepatitis, you’ll see elevation of some of the liver enzymes (ALT, ALP, GGT, maybe bilirubin). His values are normal. Is he still on ursodiol?

It always concerns me when a vet mentions that there is mild intestinal thickening which might be inflammatory bowel disease but doesn’t pursue it past that. This happened with my Gracie....for three years the IM specialist told me she had very, very mild intestinal thickening and when I grilled him on whether it could be IBD, he would say, “likely not since she doesn’t have any symptoms”. Well, it was and with IBD, it’s not a question of “if” it will become lymphoma but “when”. Not trying to give you something else to worry about but I would follow up on it once you get past this immediate issue. Often times, it is food issues that causes IBD. IBD can be treated but it typically isn’t cured.

Have you followed up on his heart?

I’ve always used aluminum hydroxide powder. While it can be constipating, none of my cats had that issue. There is concern it can cause aluminum toxicity but you’d have to give a lot of it over time. My Gussie got 1/4 tsp daily for three years and never had an issue. While I have not used it and there’s not a lot of info on its efficacy in cats, I do see more and more people trying Niacinamide (Scroll almost to the bottom of the page) as a binder. There is some concern it will increase Ca in cats so I’d be cautious. At the bottom of the page I linked, Helen gives pros and cons of each binder.

Good luck on the dose increase!!!

 

[Wendy&Neko]

I am glad you increased, I personally would not have gone back to 1.5 units as 3 units Prozinc was barely getting him to blue. Keep evaluatingnthe dose every sixmcycles and increasing by 0.5 units if all you are seeing is numbers over 300.

Neko's eye tearing was due to soft tissue growth blocking her eye ducts, not neurological at all. But rather a result of excessive IGF-1, which is in turn triggered by the growth hormone output. She also avoided bright light before I had her treated. The pituitary tumour, if it grows large enough, can press on the optic chiasm. However Neko's tumour was tiny, that wasn't the cause. She did get a glazed eye look in high numbers, and that resolved when her blood sugar improved. Neurological issues due to acromegaly tend to be later stage symptoms, due to a larger tumour, pressing on the brain. Circling or other gait issues are one such symptom.

Two out of many other acro symptoms are heart issues and arthritis. Neko had bad arthritis, including spinal stenosis, and thickened joints. Any plans to get an echocardiogram?

 

[Cynthia & Merlin (GA)]

Ursodiol is for the gallbladder. She remarked on some distinction on it and ursodiol, which is a bile acid, can improve the flow of bile to the liver. Good that there was no annotation of an obstruction because you wouldn’t want to give ursodiol in that situation. She also remarks that the gallbladder sediment could be indicative of cholangiohepatitis which is a liver and gall bladder inflammation. Usually, with cholangiohepatitis, you’ll see elevation of some of the liver enzymes (ALT, ALP, GGT, maybe bilirubin). His values are normal. Is he still on ursodiol?

It always concerns me when a vet mentions that there is mild intestinal thickening which might be inflammatory bowel disease but doesn’t pursue it past that. This happened with my Gracie....for three years the IM specialist told me she had very, very mild intestinal thickening and when I grilled him on whether it could be IBD, he would say, “likely not since she doesn’t have any symptoms”. Well, it was and with IBD, it’s not a question of “if” it will become lymphoma but “when”. Not trying to give you something else to worry about but I would follow up on it once you get past this immediate issue. Often times, it is food issues that causes IBD. IBD can be treated but it typically isn’t cured.

Have you followed up on his heart?

I’ve always used aluminum hydroxide powder. While it can be constipating, none of my cats had that issue. There is concern it can cause aluminum toxicity but you’d have to give a lot of it over time. My Gussie got 1/4 tsp daily for three years and never had an issue. While I have not used it and there’s not a lot of info on its efficacy in cats, I do see more and more people trying Niacinamide (Scroll almost to the bottom of the page) as a binder. There is some concern it will increase Ca in cats so I’d be cautious. At the bottom of the page I linked, Helen gives pros and cons of each binder.

Good luck on the dose increase!!!

Yes, my bad. Gall bladder. And no, he was on Ursodial for a limited time and that ended.

Our Internist is definitely concerned about the intestinal wall thickening. IBD is one of the reasons mentioned. After the results from the acro/IAA test, this is her main concern. Teeth are also in the radar, but the intestinal wall thickening is top on her list. So are you saying this could be the early stages of lymphoma? Not that we haven’t though about it and we know our Internist is concerned along these lines, but just because the wall is thickened is this a sure sign of early stages? Ugh.

We have two recommendations for a cardiologist and we just got them from our Internist a week ago. We will follow up. No endoscopy without seeing one anyway (if that’s where this takes us). This is so much!

Aluminum hydroxide is what you suggested in your previous post. My question is brand. Where did you purchase?

Thank you once again!

 

[Cynthia & Merlin (GA)]

I am glad you increased, I personally would not have gone back to 1.5 units as 3 units Prozinc was barely getting him to blue. Keep evaluatingnthe dose every sixmcycles and increasing by 0.5 units if all you are seeing is numbers over 300.

Neko's eye tearing was due to soft tissue growth blocking her eye ducts, not neurological at all. But rather a result of excessive IGF-1, which is in turn triggered by the growth hormone output. She also avoided bright light before I had her treated. The pituitary tumour, if it grows large enough, can press on the optic chiasm. However Neko's tumour was tiny, that wasn't the cause. She did get a glazed eye look in high numbers, and that resolved when her blood sugar improved. Neurological issues due to acromegaly tend to be later stage symptoms, due to a larger tumour, pressing on the brain. Circling or other gait issues are one such symptom.

Two out of many other acro symptoms are heart issues and arthritis. Neko had bad arthritis, including spinal stenosis, and thickened joints. Any plans to get an echocardiogram?

Hi! Thanks for chiming in. I really was at a loss for what do with dosing and I dropped back to 1.5u Lantus b/c it was the only time I saw any movement in his numbers and because each time I increased, I lost him more and more (he became more tired, so much less alert). Our Internist held his dose for longer than the TRP (which she does not recommend, but I am pursuing now). One of the FB support group members likened the dose being held longer to a ‘slack and pull’ which was getting us nowhere fast. I had to trust my gut and drop him; he is much more alert now even though his numbers are horrid. Going forward, even though I know will help his numbers, scares me so. He’s very complicated. My learning curve is steep.

Cardiologist is on the horizon. Just got two recommendations last week.

Much appreciated!

 

[Marje and Gracie]

Yes, my bad. Gall bladder. And no, he was on Ursodial for a limited time and that ended.

Our Internist is definitely concerned about the intestinal wall thickening. IBD is one of the reasons mentioned. After the results from the acro/IAA test, this is her main concern. Teeth are also in the radar, but the intestinal wall thickening is top on her list. So are you saying this could be the early stages of lymphoma? Not that we haven’t though about it and we know our Internist is concerned along these lines, but just because the wall is thickened is this a sure sign of early stages? Ugh.

We have two recommendations for a cardiologist and we just got them from our Internist a week ago. We will follow up. No endoscopy without seeing one anyway (if that’s where this takes us). This is so much!

Aluminum hydroxide is what you suggested in your previous post. My question is brand. Where did you purchase?

Thank you once again!

No, I don’t know that it’s the early stages of lymphoma. It could just be IBD at this point in time and it might stay that way for a long time. Sometimes it’s years before you see a progression. Let’s hope!!

I chose to do endoscopy to find out and wish I hadn’t. Based on my experience, Wendy treated as if lymphoma in her two cats and her current kitty and you can ask her about that. I do wish I had gone that way and tried budesonide and Leukeran but many members have gone the endoscopy route with no issues. There is an awesome Ras Feeding for IBD cats on FB. You don’t have to feed raw to post there. Great support and great knowledge.

Oh, sorry. I always bought my aluminum hydroxide from thrivingpets.com. There are other places to get it but I liked them for a lot of my CKD supplies.

 

[Wendy&Neko]

My kitty Neko could not hav either endoscopy or surgery for biopsy because her heart could not stand anesthesia. I had no choice but to treat as Lymphoma, though it could have also been severe IBD. She showed no IBD symptoms before diagnosis, I rather suspect it was SCL. She was on budesonide, as her heart could not stand prednisolone. Kitty number two was on pred and Leukeran as is kitty number three. Number three had an endoscopy, but it was for something else. Since she has some bowel thickening and protein allergies, I though it was IBD, but asked them to take a sample while doing the endoscopy. She recovered fine from the endoscopy. Unfortunately the results were emerging SCL.

 

[Cynthia & Merlin (GA)]

No, I don’t know that it’s the early stages of lymphoma. It could just be IBD at this point in time and it might stay that way for a long time. Sometimes it’s years before you see a progression. Let’s hope!!

I chose to do endoscopy to find out and wish I hadn’t. Based on my experience, Wendy treated as if lymphoma in her two cats and her current kitty and you can ask her about that. I do wish I had gone that way and tried budesonide and Leukeran but many members have gone the endoscopy route with no issues. There is an awesome Ras Feeding for IBD cats on FB. You don’t have to feed raw to post there. Great support and great knowledge.

Oh, sorry. I always bought my aluminum hydroxide from thrivingpets.com. There are other places to get it but I liked them for a lot of my CKD supplies.

Thank you for the info on the aluminum hydroxide. I am going to start adding it to his food. So much info my head is swimming. But the key is organization and I’m glad I have his numbers and remarks charted, along with adding in his labs, and posting the ultrasounds and radiograph. The info I am receiving here is priceless.

So why do you wish you had chosen a different path instead of the endoscopy? I may be having to make a decision myself soon.

And phew on the lymphoma. It could be, depending on what we find, but it’s not a definite. Right now I cannot take much more. First thing is getting his numbers down!

 

[Cynthia & Merlin (GA)]

Thank you for the info on the aluminum hydroxide. I am going to start adding it to his food. So much info my head is swimming. But the key is organization and I’m glad I have his numbers and remarks charted, along with adding in his labs, and posting the ultrasounds and radiograph. The info I am receiving here is priceless.

And phew on the lymphoma. It could be, depending on what we find, but it’s not a definite. Right now I cannot take much more. First thing is getting his numbers down!

 

[Cynthia & Merlin (GA)]

No, I don’t know that it’s the early stages of lymphoma. It could just be IBD at this point in time and it might stay that way for a long time. Sometimes it’s years before you see a progression. Let’s hope!!

I chose to do endoscopy to find out and wish I hadn’t. Based on my experience, Wendy treated as if lymphoma in her two cats and her current kitty and you can ask her about that. I do wish I had gone that way and tried budesonide and Leukeran but many members have gone the endoscopy route with no issues. There is an awesome Ras Feeding for IBD cats on FB. You don’t have to feed raw to post there. Great support and great knowledge.

Oh, sorry. I always bought my aluminum hydroxide from thrivingpets.com. There are other places to get it but I liked them for a lot of my CKD supplies.

Why do you wish you did not do endoscopy?

 

[Cynthia & Merlin (GA)]

My kitty Neko could not hav either endoscopy or surgery for biopsy because her heart could not stand anesthesia. I had no choice but to treat as Lymphoma, though it could have also been severe IBD. She showed no IBD symptoms before diagnosis, I rather suspect it was SCL. She was on budesonide, as her heart could not stand prednisolone. Kitty number two was on pred and Leukeran as is kitty number three. Number three had an endoscopy, but it was for something else. Since she has some bowel thickening and protein allergies, I though it was IBD, but asked them to take a sample while doing the endoscopy. She recovered fine from the endoscopy. Unfortunately the results were emerging SCL.

So sorry. It’s not fair, is it. These are tough to read and I know really tough to go through. I’m not quite sure what SCL is so I will look it up. I have so much fear my little guy is heading into even more troubled waters. He has intestinal thickening and protein allergies as well. I just have to keep moving forward.

If you don’t mind me asking, what was the charge for the endoscopy. We’ll most likely be facing this soon.