Rozanna and Boots

[Rozanna]

Boots was diagnosed several months ago with diabetes. Turns out he is insulin-resistant due to an acromegaly. The vet said there are 3 options: 1) treat with medication; 2) have radiation treatment; 3) surgical removal of pituitary gland. Boots is an 11 year old neutered male. All options seem scary to me, as well as expensive. Looking for advice. Based on your experience, which option is best for Boots. We are in South Carolina.

 

[Suzanne & Darcy]

NC State does the Stereotactic Radiation Therapy. One of our members had her cat treated there. It would definitely be worth looking into it to at least get information. My cat had better blood glucose numbers and a greatly reduced dose of insulin on Cabergoline, which is not that expensive. However, the acromegaly continued to damage his kidneys and we lost him. If there’s any way you can do the SRT treatment, I would try it. We could not even get into NC State because of COVID (even in 2021). I blame myself, however. I should have tried harder or done something else. Everything went downhill quickly for us and it was too late because he was not a candidate for anesthesia.

We have had cats undergo the SRT treatment here with good results. @Madm4444 is soon to have her cat, Buster, treated with SRT. She recently had a consultation and can probably answer some questions for you. Our @Wendy&Neko is very knowledgeable regarding Acromegaly and its treatment

 

[Wendy&Neko]

Did your vet suggest any locations for treatment? Any near you?

Surgical removal of the pituitary probably means a trip to New York City or New Jersey (I think the vet works both places) and possibly winning the lottery to pay for it. You do want to go somewhere that they have quite a bit of experience doing this procedure. It is delicate work. We've also seen members that had cats have bleed outs when the surgery was done by someone with less experience. Or the surgery not get all the pituitary which meant adding on SRT on top. If you fancy a trip to London in the UK, the Royal Vet Clinic has the gold standard surgeons with the highest success rate. We also do have members whose cat had very successful surgery and off insulin in very short order.

Several members have gone to NCU for SRT with successful results. I'd check to see how long their waiting list is, at one point it was hard to get in there. Another somewhat related option is Cyberknife. It has a beam that is more narrowly focussed and slightly better results but also costs more $$. If you have several options, definitely get price quotes. They vary quite a bit. Of course, adding in travel and hotel stays does add to your cost. SRT is available in a lot more locations than it was in Neko's days.

If cost is an issue or Boots isn't good with travel, cabergoline is definitely an option. We've had 5-6 cats go off of insulin on it, most go to a lower dose and improved quality of life. Note, I didn't think Neko was good with travel but drove 3 days to Colorado State University anyway. She got a lot better with travel and even went on short holidays with us afterwards.

Both SRT and surgery (hypophysectomy) have had cases where the tumour returns. A small percent, but Neko was one of them. I had to take her for SRT a second time.

 

[Rozanna]

Thank you for your reply! My vet said surgical removal of the pituitary gland could be done in London, or in Washington State. I saw that the mortality rate is up to 15%, which I don't think is very good odds! For the radiation, she said the closest place is Upstate Vet in Greenville, SC, which would be about 1:45 away. I found NC State on my own, which would be about 3:45 away. She didn't really recommend anywhere or any procedure, just gave me the facts (and prices!).

I am really wanting some guidance on this! Boots is very laid-back and tolerant of most anything - the vets all love him. He was my mother's cat (she passed away in 2017) which makes him even more special. I want to do what's best for him, but at the same time, 15,000-20,000 is pretty expensive and I am retired. There seem to be several different types of radiation, and I can't tell which is best. I also want to go somewhere with a good reputation and a high success rate.

Any suggestions/recommendations?

 

[Wendy&Neko]

If you do radiation therapy, you only want SRT (stereotactic radiation therapy) or CyberKnife. Both procedures involve multiple beams of radiation from different angles that only overlap in the area of the pituitary. This greatly reduces the side effects of regular radiation therapy that has a single higher intensity beam towards the pituitary, possibly damaging tissue on the way. Note, this is radiation on/near the brain, you really want to avoid damaging tissue there. SRT typically involves 2-4 days in a row of anaesthesia, first day for a CT scan, then 1-3 days of radiation, depending on the cat and the protocols used. The nice thing is you can travel there, stay for a few days (cat comes back to hotel in the afternoon), then you are done.

In addition to cost of radiation, don't forget to factor in blood work and probably an echocardiogram to check his heart, which they'll want to do before moving ahead with radiation. And travel costs.

Does Boots have any other medications conditions (kidneys etc.) or is he generally healthy? Radiation therapy involves multiple anaethesias, hence the request for blood work and an echo before hand.

A quote from the Upstate Vet website:

Radiation treatment doses are given in intervals, rather than a single large dose, to allow for repair and survival of the normal tissue surrounding the tumor. For example, a common protocol for tumor control is 16 to 20 treatments over approximately four weeks.

That is the linear accelerator, which you do not want. One of the vets, Dr. Lee, has an interest in SRT. I'd be tempted to contact Upstate Vet and ask them if they have SRT, and how many cats they've treated for acromegaly.

Medical treatment, called cabergoline, is now the most common treatment people here are doing. It's way cheaper and just means giving a daily med at home. Generally people have been fairly happy with the results. What size insulin dose is Boots on now? And which insulin?

 

[Rozanna]

Thank you, everyone, for your responses! Sorry I have been slow to acknowledge.

Boots was diagnosed in August of last year with diabetes. He was started on Toujeo because my vet felt that was a better choice for a "grazer" like Boots. We would go back monthly for a recheck. Every time his numbers were in the 400s - the vet kept raising the dosage but his numbers never went down. She changed him over to Glargine/Lantus to see if that would make a difference, but it didn't. She suspected he was insulin resistant, so she did a CT scan and found he had a 5mm pituitary tumor. That's when she informed me of the 3 choices- surgery, radiation, or medicine. That's where I was when I contacted you Mar. 3. Meanwhile, his insulin dosage was raised to 5.

Last Weds. he went in for testing and plotting his curve. This time his numbers reached a high in the 700s. Subsequently they raised his dosage to 7.

The vet and I had a phone conference this past Mon. She and I had both done more research, and she felt like the best plan would be to try the cabergoline first and she how that works. After 3-4 months we will re-evaluate and see where things stand. If we have to move on towards radiation, I am leaning towards NC State, which is about 4 hours away.

Boots is relatively healthy, but he was diagnosed with hyperthyroidism a few months before the diabetes diagnosis, and he takes medicine for that. Unfortunately, he has recently started spraying, which I am assuming is from stress, so I am thinking of trying some Feliway plug-ins.

Thank you all for your counsel and advice, and I will continue to look forward to your helpful suggestions.

 

[Wendy&Neko]

Are you home testing Boot's blood sugars? Many cats test higher in vet clinic due to stress, and you don't want to base his dose on stress induced higher numbers. If you do decide to treat the acromegaly, there can be really sudden drops in the amount of insulin Boots will need. I strongly recommend getting used to home testing before you start treatment.

Was an IGF-1 test ever done on Boots? That's the usual test for checking for acromegaly. And it's much easier on the cat (no anaesthesia) and your wallet. FYI - cabergoline works better on smaller tumours.