Visit w/internal med vet on 10-23-23

Howiesmom

Howiesmom

Active Member
Hello!
I’m posting here vs the main health forum like I did with my last update on Howie in Sept. https://www.felinediabetes.com/FDMB...-ask-vet-besides-kidneys.281581/#post-3113039

Since my last posts, Howie dropped another .4lbs as he was weighed on 10-6 before his Solensia injection. So he’s down to 11.1lbs (was 13.3 at the beginning of summer). We also did a blood draw to check his B12 that was previously suggested. His Folate came back at 9.6 (reference point starts at 9.7) and Cobalamin came back at greater than 1000 (so within range). I have my first visit with a visiting internal med vet on Monday as my vet cannot come up with why he is losing weight short of maybe cancer. His heart murmur has progressed to what my vet thinks is stage 3-4 so the internal med vet will do an ultrasound. Due to all of Howie’s chronic conditions with acro, DM, arthritis, and pancreatitis, I just want him to be comfortable and have a quality of life for all the time I have left with him. He’s 15 and just looks and acts like an old man cat who sleeps or just sits there. No activity and not much interaction besides meal times. He does eat but takes about an hour to get it all gone. I’ve never met with this internal med vet before so have no idea what to expect or what to ask. I appreciate any advice as the visit will not be cheap. All his labs are updated in my spreadsheet.

Strangely, his BGs have gotten pretty low for his nadir. Last Sat he was in the 50s (lowest he’s gone in more than a year), and tonight he was down to 63. So I skipped insulin when he was in the 50s (my poor critter sitter was the one caring for him!) and I’ve done BCSs for 3 cycles in a row yesterday and today. Not sure if this is all connected?

@Wendy&Neko
@Suzanne & Darcy
@Larry and Kitties
 
Hi there. Honestly, I feel so much emotion connected with reading your message about Howie. His labs are not really bad. And I look at his spreadsheet and see so much good there with his BG. I start looking at his spreadsheet in January. I look all the way to today. I think, “Tracy is such a warrior for Howie; a warrior against acromegaly.” “And I wonder why we have to win the BG war and still seem to lose on so many other fronts.” I am sad for Howie, but I admire everything you have done and are still doing for him.

I hope the IM vet will have some ideas about what is going on. I would definitely supplement the folate, even though it’s just on the lowest end of the reference range. I’ve seen some cats like that, with similar deficiencies, who had a lot of GI problems with borderline low folate. They were definitely helped with folate supplementation. Most recently, this happened to a friend’s cat who is not even old.

I definitely think the heart condition can contribute to his overall decline. It is worth having an ultrasound done. Ginger had a lot of weight loss with her heart condition prior to being treated. But she didn’t have to deal with acromegaly on top of everything else. I will be thinking of you both. If I have any other thoughts about your visit between now and Monday, I will write here. Hugs to you, Tracy.
 
I'm hoping you have a really good IM vet appointment and can some answers and suggestions on how to help Howie. Neko's IM vet was really good at balancing all her various conditions and prioritizing what she needed most. I think I'd ask the vet why he thinks Howie is losing weight, and also to get the bottom of what is causing the heart murmur. And if he has any ideas why it's taking so long for Howie to eat. That may be a dental vet question, but there might another cause too.

Is Howie on any regular pain medications now? Most acros end up on something (buprenorphine or gabapentin) longer term. Bupe was a game changer for Neko. She had been quiet, not moving around or interacting much, to a cat that started playing again and looking for laps.

I agree on the ultrasound. Heart issues can impact their appetite/cause some nausea. Going off her foods was Neko's way of telling me about her heart. An ultrasound of the GI might provide some information about why he's losing weight, especially if you think he's getting enough calories in now. And remember, some cancers are quite treatable, especially small cell lymphoma. Quite a few kitties with it go into remission. It's a fairly common condition, unfortunately.

As for Howie's insulin dose, at some point the BCS is going to become his full dose. :)
 
Suzanne & Darcy said:
Hi there. Honestly, I feel so much emotion connected with reading your message about Howie. His labs are not really bad. And I look at his spreadsheet and see so much good there with his BG. I start looking at his spreadsheet in January. I look all the way to today. I think, “Tracy is such a warrior for Howie; a warrior against acromegaly.” “And I wonder why we have to win the BG war and still seem to lose on so many other fronts.” I am sad for Howie, but I admire everything you have done and are still doing for him.

I hope the IM vet will have some ideas about what is going on. I would definitely supplement the folate, even though it’s just on the lowest end of the reference range. I’ve seen some cats like that, with similar deficiencies, who had a lot of GI problems with borderline low folate. They were definitely helped with folate supplementation. Most recently, this happened to a friend’s cat who is not even old.

I definitely think the heart condition can contribute to his overall decline. It is worth having an ultrasound done. Ginger had a lot of weight loss with her heart condition prior to being treated. But she didn’t have to deal with acromegaly on top of everything else. I will be thinking of you both. If I have any other thoughts about your visit between now and Monday, I will write here. Hugs to you, Tracy.
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Thank you so much, Suzanne! You are so incredibly kind and sweet with your words. I Know Howie knows I’m doing my best for him, but I want him to just have the most comfortable life he can. My dad just lost his kittie of 14 years this week and she was skin and bones by the end. Do you have a recommendations for the folate supplement? OTC or something else? My vet just didn’t think 9.6 was anything that should be thought about but I can certainly bring it up with the IM vet too. I just wouldn’t know how much to give so he doesn’t go too high! Fingers crossed for a good visit on Mon!
 
Wendy&Neko said:
I'm hoping you have a really good IM vet appointment and can some answers and suggestions on how to help Howie. Neko's IM vet was really good at balancing all her various conditions and prioritizing what she needed most. I think I'd ask the vet why he thinks Howie is losing weight, and also to get the bottom of what is causing the heart murmur. And if he has any ideas why it's taking so long for Howie to eat. That may be a dental vet question, but there might another cause too.

Is Howie on any regular pain medications now? Most acros end up on something (buprenorphine or gabapentin) longer term. Bupe was a game changer for Neko. She had been quiet, not moving around or interacting much, to a cat that started playing again and looking for laps.

I agree on the ultrasound. Heart issues can impact their appetite/cause some nausea. Going off her foods was Neko's way of telling me about her heart. An ultrasound of the GI might provide some information about why he's losing weight, especially if you think he's getting enough calories in now. And remember, some cancers are quite treatable, especially small cell lymphoma. Quite a few kitties with it go into remission. It's a fairly common condition, unfortunately.

As for Howie's insulin dose, at some point the BCS is going to become his full dose. :)
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We still think Howie has extra gum tissue or tissue in his throat area as he struggles to swallow (so takes him a long time to eat). He doesn’t have any chompers, so we can rule out any dental issues! Howie is on transdermal bupe twice a day. I honestly don’t know how much of a difference it makes for him but don’t want to take him off to see. I didn’t see any drastic change when he went on it (mostly for arthritis and pancreatitis).
I’ve talked to my vet about SCL. He has seen his fair share of cases of it and doesn’t think Howie has presenting symptoms (vomiting, diarrhea, etc). Are there other things that would lead someone to think more seriously about it being a case? I’m assuming the ultrasound we’re doing for his heart will not also include GI tract. I could have sworn my vet said that he would have to do something more invasive to determine if it was SCL (?) I appreciate all your insights, Wendy!

It is crazy to think I did a BCS of only 6 units tonight! His standard dose for several weeks has been 11 units. Should I bump his dose down to maybe 9 or 10 units permanently? I have whole unit U100 syringes so can’t do half units with any accuracy with them. His highest dosage was 53 units BID in March 2021! He started cabergoline in Feb 2021 and it has taken until July 2023 to finally see the drop in dosage which I’m guessing is attributed to it!
 
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Howiesmom said:
Howie is on transdermal bupe twice a day.
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Maybe that form of bupe isn't working for him? Have you tried oral/sublingual? Or gabapentin? Some cats do better on one vs. the other.

As for SCL, not all cats show GI symptoms like vomiting or diarrhea. I belong to an SCL group (3rd kitty in a row with it), and there have been some cats in that group whose only symptom is weight loss. And yes, to properly diagnose SCL vs IBD, you need a biopsy, which can be done via endoscopy if certain parts of the bowel are thickened, otherwise needs surgical biopsy. Neko couldn't do either of those because they require anaesthesia which her heart condition did not permit. If there are inflamed lymph nodes you can get a needle guided biopsy as part of an ultrasound and send that off for PARR testing. That might possibly be done just via sedation. All good for discussion with the IM vet.

Heart ultrasounds are typically called echocardiograms.

Howiesmom said:
Should I bump his dose down to maybe 9 or 10 units permanently?
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I'd do it for now, who knows if it's permanently. At some point you may need to invest in half unit marked syringes again.
 
Wendy&Neko said:
Maybe that form of bupe isn't working for him? Have you tried oral/sublingual? Or gabapentin? Some cats do better on one vs. the other.

As for SCL, not all cats show GI symptoms like vomiting or diarrhea. I belong to an SCL group (3rd kitty in a row with it), and there have been some cats in that group whose only symptom is weight loss. And yes, to properly diagnose SCL vs IBD, you need a biopsy, which can be done via endoscopy if certain parts of the bowel are thickened, otherwise needs surgical biopsy. Neko couldn't do either of those because they require anaesthesia which her heart condition did not permit. If there are inflamed lymph nodes you can get a needle guided biopsy as part of an ultrasound and send that off for PARR testing. That might possibly be done just via sedation. All good for discussion with the IM vet.

Heart ultrasounds are typically called echocardiograms.


I'd do it for now, who knows if it's permanently. At some point you may need to invest in half unit marked syringes again.
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Thank you so much! I’m so glad I asked you for advice before my appt. Do you know if gabapebtin comes in transdermal? Howie is horrible about taking his Ondansetron pill so adding in another oral med sounds like all out war. And my other kittie has gabepentin in pill form to relax her before appts and completely knows it is mixed in her food and refuses to eat.
 
I have heard of some people giving gapapentin compounded into a liquid. A lot of medications don't work as well as a transdermal.
 
Update on Howie’s visit…
I’m not sure about this IM vet. She did the EKG and found a small amount of fluid in his lungs. They also did sone X-rays to get some other views. She is not sure if it’s the start of bronchial carcinoma and said a CT scan was the only way to tell. Unfortunately that is not in my financial future and he is 15 already. She did not feel he needed any heart meds but I need to monitor his respirations to see if he needs another set of X-rays in 2-3 months. My vet was present during the consultation.

She must not have reviewed much of his medical history to understand that I’m most worried about this weight loss that has no explanation. We talked about his low folate (9.6) and if we should supplement anyway. She said there’s not enough info to know if that is really too low to need supplements so just dismissed it. (Can I do this anyway without a vet’s guidance? If so, how much and can I just use OTC?) and we talked about SCL even if he doesn’t have the normal presenting symptoms of vomiting and diarrhea. Strangely, there was no discussion of doing an ultrasound of his GI tract or an endoscopy but he is going on Budesonide anyway to see if it helps. I have ZERO idea if that is smart or not with any actual diagnosis. We are also going to add in compounded liquid gabepentin to help with pain. My vet thinks I should still keep him on Bupe too. Any thoughts?? I don’t need a stoner cat who sleeps more than he already does!

I have no idea what to think and feel like we’re just grasping at straws and loading him up on more meds. I’m glad it’s not heart related! I did say that I just want him comfortable for the time I still have with him, so maybe I’m the one who led them to recommend this new treatment method? Is this dumb? I’ve already ordered the budesonide and Gabepentin. I guess the only good thing is that I brought up reducing his Cabergoline dose since it’s based on body weight and my vet recalculated it and said I should drop him from .6 to .5ml.

I’m feeling very uncertain….
@Wendy&Neko
@Suzanne & Darcy
 
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Wow. That sounds like a lot of trying this and trying that. I would do it to see what helps. At this point you really are just trying to see what will make him feel better. I hope some of the med changes will help and I hope he will take them/eat them.
Howiesmom said:
She is not sure if it’s the start of bronchial carcinoma
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Why? Did she say she saw thickening of his bronchial passages? or what? And the fluid on his lungs? What is the cause of this? Did she say "scant" fluid? Did they do a report with heart measurements? I'm assuming she found all the chambers of the heart are within normal limits as to their size? Do they measure blood flow, etc? I guess she's not a cardiologist, so perhaps this isn't not what she does and it was done to rule out obvious heart issues. So if they have ruled out obvious heart problems, then that is good.
 
Here is what the Texas A&M GI Laboratory says about supplementing folate:

"Decreased Serum Folate
To our knowledge the benefit of supplementing folic acid to dogs and cats with gastrointestinal disease and serum folate concentrations below the lower limit of the reference interval has not been clearly demonstrated. However, because experimentally-induced folate deficiency can lead to clinical consequences and folic acid is cheap and safe we consider supplementation in animals with a decreased serum concentrations. The difficulty in administering pills to the patient and the severity of their hypofolatemia also influence our decision whether to treat individual patients or not.

Folic acid supplements sold for use in humans are readily available. We recommend a dose of 200 mcg for cats and smaller dogs (<20 kg BW) and 400 mcg for larger dogs (20 kg BW) PO once daily for 4 weeks. It is very important to also address the proximal small intestinal disease that is suspected as the underlying cause of the decreased serum folate concentration. If the animal’s clinical signs have resolved, we do not usually recheck serum folate concentrations. If the clinical signs are persistent, rechecking serum folate concentration 1 week after supplementation is stopped may be helpful."
 
Does he get a probiotic? I highly recommend Visbiome Vet, which has done wonders for my IBD cat. I mix it in with his food -- although sometimes I have to give half a capsule at a time. What we don't want is anything that makes Howie eat less (or more slowly since he already takes an hour.) Maybe mixed with a little bit of a Forti Flora packet it would work (only because the Forti Flora is so irresistible to so many cats.)
 
Did they say why they didn't do an ultrasound done, heart (echocardiogram) or other? An EKG plus xrays isn't really enough information on the heart. An echo should really be done by a cardiology specialist. Like Suzanne, would like to know more about fluid on the lungs.

I hope the budesonide helps. You should know within a week if it will. The only possible down side is that a smaller number of diabetic cats see some impacts on blood sugar with budesonide. It didn't impact Neko's numbers at all. She went on budesonide because her heart couldn't handle pred, but that was after an echo to see what was happening.
 
Suzanne & Darcy said:
Wow. That sounds like a lot of trying this and trying that. I would do it to see what helps. At this point you really are just trying to see what will make him feel better. I hope some of the med changes will help and I hope he will take them/eat them.

Why? Did she say she saw thickening of his bronchial passages? or what? And the fluid on his lungs? What is the cause of this? Did she say "scant" fluid? Did they do a report with heart measurements? I'm assuming she found all the chambers of the heart are within normal limits as to their size? Do they measure blood flow, etc? I guess she's not a cardiologist, so perhaps this isn't not what she does and it was done to rule out obvious heart issues. So if they have ruled out obvious heart problems, then that is good.
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There was very little fluid and not enough to draw but enough that showed up on the scans and that was slightly worried. She had no clue of the source and thought the only way to verify was a CT scan to make sure it’s not a mass that is growing. I got no report but I’m hoping/guessing she is preparing something for his chart. She was talking in very technical terms so I was having a hard time tracking everything she was saying. The gist of what I got was his heart seemed to be in decent condition even with the murmur. No mention of blood flow measurements.
 
Suzanne & Darcy said:
Here is what the Texas A&M GI Laboratory says about supplementing folate:

"Decreased Serum Folate
To our knowledge the benefit of supplementing folic acid to dogs and cats with gastrointestinal disease and serum folate concentrations below the lower limit of the reference interval has not been clearly demonstrated. However, because experimentally-induced folate deficiency can lead to clinical consequences and folic acid is cheap and safe we consider supplementation in animals with a decreased serum concentrations. The difficulty in administering pills to the patient and the severity of their hypofolatemia also influence our decision whether to treat individual patients or not.

Folic acid supplements sold for use in humans are readily available. We recommend a dose of 200 mcg for cats and smaller dogs (<20 kg BW) and 400 mcg for larger dogs (20 kg BW) PO once daily for 4 weeks. It is very important to also address the proximal small intestinal disease that is suspected as the underlying cause of the decreased serum folate concentration. If the animal’s clinical signs have resolved, we do not usually recheck serum folate concentrations. If the clinical signs are persistent, rechecking serum folate concentration 1 week after supplementation is stopped may be helpful."
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So if I’m reading this correctly, I should give him 200 mcg once daily for 4 weeks. What does PO mean? After 4 weeks do I stop? Assuming this is a tablet, can I crush it to mix in gpfood or do I have to give it whole?
 
H
Suzanne & Darcy said:
Does he get a probiotic? I highly recommend Visbiome Vet, which has done wonders for my IBD cat. I mix it in with his food -- although sometimes I have to give half a capsule at a time. What we don't want is anything that makes Howie eat less (or more slowly since he already takes an hour.) Maybe mixed with a little bit of a Forti Flora packet it would work (only because the Forti Flora is so irresistible to so many cats.)
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He is not on any probiotic. Do you give 1 capsule per day or per meal? Does it taste bad so you give a half capsule at a time? Is it mixed in food? He’s going to get so much stuff mixed in his food with Cabergoline, gabepentin, budesonide, folic acid, fish oil, etc! I hope he’ll eat it all!
 
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Wendy&Neko said:
Did they say why they didn't do an ultrasound done, heart (echocardiogram) or other? An EKG plus xrays isn't really enough information on the heart. An echo should really be done by a cardiology specialist. Like Suzanne, would like to know more about fluid on the lungs.

I hope the budesonide helps. You should know within a week if it will. The only possible down side is that a smaller number of diabetic cats see some impacts on blood sugar with budesonide. It didn't impact Neko's numbers at all. She went on budesonide because her heart couldn't handle pred, but that was after an echo to see what was happening.
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I guess I don’t know how to answer your questions as I don’t know what scans are supposed to show what and what I should have been asking for. I thought they said he had an EKG but my bill says an Echo was done. Here is a brief bio on her (Dr. Miller). https://lacrossevet.com/referring-vets/ She brought all of her own equipment. This is all too technical for a novice to know what I was walking in on. I’m frustrated and spent $1k US on an appt that apparently seems worthless based on so many questions I can’t answer.
 
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I'm glad the echo was done, and not an EKG. Travelling specialists are quite common, they typically bring their own equipment. I was worried it was just an EKG and you can't say the heart is OK with just that and xrays. So that is good news.

I also give Visbiome, though not the pet version as that's not available in Canada. I just give the unflavoured packet - 1/20th of a packet per meal. The recommended dose for cats is 5-10 billion CFU per kg of cat per day. Typically that works out to about 25-50 billion for an average cat. Howie may be bigger. Visbiome Vet has 112.5 billion CFU per capsule. So maybe 1/2 a capsule per day. I've never had a problem with mixing it in with food.
 
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I give a whole capsule of the Visbiome Vet per day mixed in a small amount of Fancy Feast Savory Salmon Feast (he doesn’t have kidney disease) or (a better choice) Weruva BFF OMG packet food called Chicken and Salmon Shine Bright which is a super moist brothy food that is low phosphorus and low carb. As a matter of fact, those packet foods by Weruva might really be something that Howie could eat easily because he could kind of just lap them up. They’re so moist that you never need to add water. They’re designed to be very hydrating.
 
I’m happy you did get the echocardiogram done. An EKG checks the electrical activity of the heart and cane be used to diagnose certain heart conditions, but you needed the cardiac ultrasound, which is what you paid for.
 
I would just ask my vet about the fluid in the lungs. He/she should have an answer- even if it’s “I am not sure, but we just need to keep an eye on his respiratory rate.” Did they tell you how to count his breaths per minute? I always wait until my heart kitty is sleeping peacefully (not twitching or dreaming - and they definitely should not be purring when you do this) and I use the timer on my phone to count each rise and fall of her chest for thirty seconds- then I double it. Some people will count for 15 seconds and multiply by four.
 
Wendy&Neko said:
I'm glad the echo was done, and not an EKG. Travelling specialists are quite common, they typically bring their own equipment. I was worried it was just an EKG and you can't say the heart is OK with just that and xrays. So that is good news.

I also give Visbiome, though not the pet version as that's not available in Canada. I just give the unflavoured packet - 1/20th of a packet per meal. The recommended dose for cats is 5-10 billion kg of cat per day. Typically that works out to about 25-50 billion for an average cat. Howie may be bigger. Visbiome Vet has 112.5 billion CFU per capsule. So maybe 1/2 a capsule per day. I've never had a problem with mixing it in with food.
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Thanks Wendy! I’ll check into it for sure!

Do you have any thoughts on giving him both the liquid Gabapentin and the transdermal Bupe? My vet suggested not taking him off the Bupe. I just don’t want him totally sleepy and stoned. His thought was that they work in different pain receptors so to keep him on both instead of just switching to just Gabapentin. I’m still waiting for it to arrive from Wedgewood.
 
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Suzanne & Darcy said:
I give a whole capsule of the Visbiome Vet per day mixed in a small amount of Fancy Feast Savory Salmon Feast (he doesn’t have kidney disease) or (a better choice) Weruva BFF OMG packet food called Chicken and Salmon Shine Bright which is a super moist brothy food that is low phosphorus and low carb. As a matter of fact, those packet foods by Weruva might really be something that Howie could eat easily because he could kind of just lap them up. They’re so moist that you never need to add water. They’re designed to be very hydrating.
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In checking out Visbiome Vet, that is a steep price and we don’t even know if he’s got IBD or SLC for sure. I know a probiotic has many other positive attributes. Is there any other product you might know/recommend? This had been an incredibly expensive month between this vet bill this week, 2 new compounded meds, a food shipment, refill of Mirataz, a Solensia injection, and he needs a refill of Cabergoline soon. Thank goodness his insulin needs have greatly decreased but I’ll be needing to order a winter refill soon too from Marks. And that is just for Howie…not my other kittie too.

Howie only eats Weruva food! He eats Jeopurrdy pate for his main meals (1 pouch/day) and then has a BFF Play small pouch divided among his mini meals. She’s been on Weruva food for more than a year! A miracle happened today…I stopped his pumpkin and put him back on Miralax so mixed a little water in.I have to make sure I don’t get too much as he hates soup. Well…mister Howie ate both his breakfast and supper in 20-25 min! I don’t know if that was just a thing today but I’ll take it as a major win!
 
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Suzanne & Darcy said:
I would just ask my vet about the fluid in the lungs. He/she should have an answer- even if it’s “I am not sure, but we just need to keep an eye on his respiratory rate.” Did they tell you how to count his breaths per minute? I always wait until my heart kitty is sleeping peacefully (not twitching or dreaming - and they definitely should not be purring when you do this) and I use the timer on my phone to count each rise and fall of her chest for thirty seconds- then I double it. Some people will count for 15 seconds and multiply by four.
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They said 20-30 breaths per min is normal. If he gets up to 40 I should bring him in for another set of X-rays.
 
Howiesmom said:
They said 20-30 breaths per min is normal. If he gets up to 40 I should bring him in for another set of X-rays.
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Depends on the cat, which is why you should monitor him now. Neko was a low rider, low 20's was good. I had to take her to the vet when she got to 26, and they found fluids. Over 30 I'd be looking for any other signs something is off.

Howiesmom said:
Is there any other product you might know/recommend?
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Proviable is a good one. The problem is it's not as concentrated so you need more of it. A package of the Visbiome packets lasts me about 8 months. I've seen some people give RenewLife, though I can't remember which formulation.
 
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