4/09 Bowdoin - New and need help!

Hi, our intro is below but I really need help with my acro cat Bowdoin. We're going on four months and he is still unregulated. Help! I don't know what's going on with his numbers but they don't seem to be moving much. We are currently at 9.5u Lantus 2x day using an AlphaTrak meter (which I'd like to change when we use up our strips).

I try to get pre-shot numbers and know we need to test more, we are working on it. At the beginning it took two people to do it. Now I can manage by myself but I have MS so some days it's all I can do to get everyone fed. Sometimes I'm not sure if I can do this.

Please help!

From our intro:
Hi, Bowdoin my 10yo male Maine Coon Cat (we also live in Maine) was diagnosed with diabetes at the beginning of December 2018. It was a surprise to all of us because I brought him in for increased appetite/weight gain and noisy breathing at rest/snoring. His labs showed a blood glucose of 286 at the vets which she thought could be attributed to stress. So we brought him in for a urinalysis and he tested over 1,000. She started him on 1u Basaglar/glargine. We are currently at 9.5u of Lantus/glargine 2x day, I switched over to take advantage of the discount card. Unfortunately he is still unregulated, really hungry, drinking and peeing a lot, not himself. It's been almost 4 months and I just want him to feel better.

I initially went into research mode and got totally overwhelmed so didn't post here. I thought I'd never be able to home test. I still have a lot to learn but feel a little more comfortable. I know I could have done some things better but I'm hoping with help from all the knowledgeable people here, that I can get on track.

I did stumble upon acromegaly and thought it sounded like what he presented with. We started sporadically home testing with a pet meter/AlphaTrak2 (which I would like to transition to a human meter) but I needed someone to help me hold him at the beginning so we tested when we could and we still had a lot failures and tears. I'm happy to say that I can now do it on my own with only a few failures here and there. After 3-4 pokes with no blood, I give us both a break. I try to get at least pre-shots and occasional curves with a mid-day when I can but need help with timing, interpreting and dosing. Our vet had us going 2 weeks before increasing dose .5 at a time and then 1 week and most recently the internal medicine specialist told us to go up 1u every 3 days. Which is what I think I read was ideal for timing, not sure about dosing since he is acro.

Diet wise, he had a renal cyst and one kidney removed when he was 2 so he was on Purina NF renal diet, mostly canned with a little dry. Until his appetite increased and then he got more dry. After diagnosis we went to strictly canned but both my vets weren't sure how to balance the renal diet with the diabetic (and pancreatitis) so I had an in depth consult with the Clinical Nutrition Service at Tufts University. The Board certified Veterinary Nutritionist came up with some options for a low phosphorous, medium protein, medium carb diet for his particular needs. It's currently canned Royal Canin Aging 12+.

So point me in the right direction for my next steps and any other information you may need and hopefully I can turn things around and learn even more to help my best bud.

Thank you!

 

Hello and welcome over here Susan and sweet Bowdoin. Dealing with acromegaly on your own is a lot of work, I hope we can help. If you haven’t already, I would start by reading the yellow starred sticky notes on the top of this forum.

First the dose. I am reluctant to have you increase every three days with the amount of testing you can do. We determine how to change the dose based on nadirs, or low points, and those happen somewhere mid cycle. Night times are often when cats go low as well, which is why we recommend before bed tests. And there is a phenomenon that we call bouncing, which is a cat’s temporary response to lower numbers than they are used to, and results in higher numbers, for up to six cycles. Not enough testing or testing at the wrong times can make it look like the dose is too low. So we use a cautious approach to increases. Increases can be done every three days, if you can get two tests (preshot plus one other), for each cycle. If those number of tests are not possible , then we would slow the rate of increases a little.

The food you are feeding is going to make it harder to regulate him. My girl also had kidney issues, though not at the start of her diabetes journey. I fed raw food and just tweaked which ones when she got her CKD diagnosis to be the low phosphorus ones. A low phosphorus, low carb diet can be found either with commercial canned or raw food, or with home made. Did the nutritionist say why Bowdoin needs just medium protein food? And what percentage protein is that? Low carb is much better than medium carb for diabetics, and cats in general.

For treatments, there is a range from surgical, radiation, and medical. The first two are quite pricy but we have had cats here undergo both. My Neko had sterostatic radiation therapy, back when it was both cheaper and the only option around. Current cheaper medical options include cabergoline, which a number of acrokitties here have tried. We have had three cats go into remission on it, and most others have reduced their dose needs, and more important,had some clinical improvements in their acro symptoms. Did any of your vets talk to you about treatment options?

Again, welcome and keep asking questions.

 

Thanks again Wendy. I've read the yellow stickies numerous times but with my MS brain, things don't seem to stick - memory issues. So I keep re-reading, print out and highlight and read again if I'm focusing on something specific. I'll go back and read about bouncing. Feel free to point me back towards them anytime!

I will definitely try to test more often. If I can only get three, when should I shoot for? I think I read nadir but I'm not sure I can tell what that is from his current curves. He seems to be lowest pre-shot. And about how long after the PM shot is "before bed". I shoot between 7-8pm and usually go to bed at 9pm but I suspect that might be too soon.

Here are some of the notes from the nutrition consult with the Clinical Nutrition Department at Tuft's University (board certified Veterinary Clinical Nutritionist) http://vetnutrition.tufts.edu/:
"Nutritional Goals
• Meet essential nutrient needs
• Obtain and then maintain a body condition score of 5/9 (ideal weight 16 lb?)
• Low phosphorus (ideally < 120 mg/100 kcal)
• Moderate protein (8 - 10 g/100 kcal)
• Moderate sodium (<100 mg/100 kcal)
• Low carbohydrate (< 5.7 g/100 kcal)
• Consider fish oil (omega-3 fatty acid) supplementation

Recommendations:
• Bowdoin has early kidney disease although his values – BUN, creatinine, phosphorus, SDMA and urine specific gravity – don’t always all point in the same direction or have the same magnitude of increase from normal. His kidney values have been relatively stable in the past 5 years since his kidney was removed. More recently, he has developed diabetes which has been harder to control and there is some suspicion that he could have acromegaly.
• Many cats with diabetes will respond favorably to high protein and low carbohydrate diets, although they do not have the same effect on all cats. Some cats will also respond to higher fiber diets, either with moderate or low carbohydrates. Consistency is important for diabetes regulation – ideally, you want to feed the same diet every day at the same times, and in the same amounts. There may be some flexibility for multiple meals throughout the day in cats on glargine, but it is still important to feed a consistent diet and monitor intake.
• Management of chronic kidney disease relies on some opposite principles – we want to keep phosphorus low (it is generally high in high protein/low carbohydrate diets) and protein moderate (in early disease). Renal diets are typically higher in carbohydrates to compensate for the lower protein, although there are some canned renal diets that are lower in carbohydrates because they make up for the lower protein with fat.
• We follow the International Renal Interest Society treatment guidelines (http://www.iris-kidney.com/) and monitor phosphorus very closely in cats with kidney disease as it is has been linked with progression of disease. Bowdoin’s phosphorus is currently 5.2 and we’d like to keep it less than 4.5 mg/dl for stage 1 and 2 disease. He is currently eating a low phosphorus diet but is not receiving a phosphorus binder.
• Pancreatitis in cats is relatively common, but we have very little data with regards to appropriate diet for cats with chronic pancreatitis. In dogs, we reduce dietary fat levels, but this is difficult in cats because they do not tolerate carbohydrates as well as dogs so there is a limit to how low we can drop the fat and compensate with carbs or protein. Moreover, Bowdoin’s other health concerns suggest that a moderate protein, low carbohydrate diet would be best at this point and that is incompatible with a low fat diet. Thus, at this time, we are not specifically addressing his pancreatitis as we want to focus on the two health issues that are likely more diet responsive.
• To address Bowdoin’s diabetes and kidney disease, we have to compromise somewhat as we will not be able to meet all of our goals with one diet. The two main options are to either feed the lowest phosphorus low carb diet we can find (potentially with a phosphate binder) or to feed the lowest carb renal diet, depending on which disease we want to prioritize. As Bowdoin’s renal values have been stable for a long time, I’d suggest prioritizing his diabetes first, but adjusting if his kidney values worsen (especially his phosphorus).
• Below are the commercial diets that seem to be the best compromises for Bowdoin at this time. The NF is provided for comparison. All of the below diets but the Royal Canin Aging Care will need to be purchased from Dr. Barksdale or with her approval.
• Of these diets, I think the Royal Canin Aging Care is the best compromise and would be my first choice."

Now I'm wondering if we should change to a low phosphorous low carb food with potentially a phosphorous binder that she presented as one of the options.

As for acro treatments, I have discussed options with his IM vet and am continuing to do research on which direction we want to take. Right now I'm leaning towards cabogoline or maybe SRT if I can figure out the logistics of getting somewhere for treatment.

 

I drove for three days each way to get to Fort Collins for SRT. Needless to say, it was an adventure.

As for the yellow stickies, I still reread them occasionally. Content changes and there is a lot in there.

If you can only get three tests a day, two must be preshots. Mix the others up. Think of the spreadsheet as a jigsaw puzzle where you want to fill in gaps. A +2 test at night occasionally may be interesting, of if you get up before AMPS, a +10 or +11. It does look like Bowdoin does nadir later, not uncommon with acros, Neko did the same. Though her nadirs were really all over the place. That would make spot checks around +6-+9 useful. I would like to see six cycles with two test before increasing, so at three tests a day, that would be six days. But let’s see how the next couple days go. With later nadirs we may be able to increase faster. As you get to 10 units total dose, you can increase by 1 unit a time while all his numbers are still high. For any lurkers, this suggestion is for Bowdoin only. He has acromegaly and special circumstances even though not eating low carb food.

Have you been to to Tanya’s CRF site? https://www.felinecrf.org From what I have heard, high quality protein is important at early stages of CRF. Neko’s IM Vet was supportive of her raw diet. I guess I am a little hesitant when vets push diets only available through them.

 

Welcome to the group!

A couple of questions:
The notes you included above indicate that there is a "suspicion" that Bowdoin has acromegaly. Has the vet actually sent out blood to have your kitty tested for both acro and insulin resistance?
What IRIS stage is Bowdoin at?

What the nutritionist didn't mention is that is larger cats, tests like SDMA may show a higher range simply due to the size of the cat. (I have a Norwegian Forest Cat - a breed that is just a bit smaller than a Maine Coon) who is in early CKD. His SDMA values, and other kidney test results vary. Granted, Bowdoin has only one kidney so I don't know how that effects the test results. My vet encouraged high protein and low phosphorus. Gizmo is on a raw diet and his kidney numbers have been good.

I am very reticent to encourage you to keep a diabetic cat, especially a cat with kidney issues, on any dry food, if in fact, that's what you're feeding your kitty. The Royal Canin Aging dry is 44% carb (approx). The canned food is in the 4 - 6% (approx) carb range, which is fine. I would encourage you to add water to Bowdoin's food. The info on the Royal Canin site did not include phos levels for the canned foods.

 

Wow, three days?! That must have been quite the adventure.

We'll work on getting a minimum of 3 tests a day and more if I can stay up later (or wake up in in the middle of the night) I'll try to get an after bed.

I have been to Tanya's site in the past when I had a kitty with CRF and I know there are differing opinions on protein levels. I'll have to take another look at it. I was disappointed that the diets that the Vet Nutritionist recommended were prescription except for the Royal Canin. Especially since their website says "We’ll be straight with you – we are not employees of any pet food companies and we don’t have any ownership interest in any companies that make pet food, treats, or supplements. Our goal isn’t to sell you anything – we just want to answer your questions about feeding your pet, and help you find a feeding program that works for both of you." Perhaps these diets are what they know best and have been through clinical trials. I figured I'd take the nutritional breakdown of the recommendations and source a commercial option.

 

Thank you for the welcome Sienne!

When we had the nutrition consult done at Tufts there was a suspicion of acro but since that time it's been diagnosed. He's been tested twice for acro (207 the first time and over 300 the second) but not for insulin resistance. That's next on our list. I don't know what IRIS stage Bowdoin is at but the vet said early. From Tanya's site I suspect he's just squeaking into stage 2 since his creatinine was 1.7 mg/dL. From the vet nutritionist..."Bowdoin has early kidney disease although his values – BUN, creatinine, phosphorus, SDMA and urine specific gravity – don’t always all point in the same direction or have the same magnitude of increase from normal. His kidney values have been relatively stable in the past 5 years since his kidney was removed." (I had to fill out an extensive questionnaire and they requested all his records from his vet and IM specialist.)

Bowdoin has been eating only canned food since his diabetes diagnosis in December. Before that he had been on Purina NF Kidney Function both canned and dry. More canned than dry but as his appetite increased, unfortunately I increased the dry. After his diabetes diagnosis neither of my vets were sure what to feed him with diabetes and kidney issues so we continued on the NF, just canned until the Tuft's Nutrition Consult. I have always added water to Bowdoin's food and continue to do so.

 

Thanks for the information. It's very helpful.

The only thing I'd suggest you take a look at are the ingredients in what you're feeding. Looking at the Royal Canin, it's not made with high quality protein (e.g., pork by-products, brewers rice flour, wheat gluten, powdered cellulose, etc.) There's no muscle meat in the ingredient list. Personally, I shy away from feeding my cat anything where the first ingredient for protein is a "by-product" and the food contains sawdust (aka powdered cellulose).

 

Yes, I figured I would take the nutritional breakdown of the recommendations and source a commercial option with higher quality ingredients. Another thing on my list!

 

Wendy, I've updated his SS. Should I post a separate thread and how do I format the title?

 

The subject line for posting follow our "standard" format:

date --- kitty's name --- AMPS#, +hour#, etc.​

If you have a question, you can use the icon to indicate it or type something in that will get people's attention.

 

Thank you Sienne!

 

Hi Wendy, I've been trying to get three tests a day. Looks like I should be increasing. What do you think?

 

I'm not seeing the values in the U or units column of the spreadsheet since 4-8, just the blood sugar values.

 

Oops, I keep forgetting to input it. I've updated it.

 

I am glad you increased, nice to see a bit more pink. Any chance of getting some second tests in either the AM or PM cycle? I am only seeing the two daily tests now.

I read your comment about chewing. Do you have access to a veterinary dental specialist? Acromegsly can cause both soft tissue growth and bony growths. My general vet was going to remove one of Neko’s teeth, but the specialist discovered soft tissue growth on the gums and shaved a tooth to make it easier to eat. A few years later, she also got a bony growth on the lower jaw, which I could easily feel. The dental vet removed it. He thought it was bone cancer, but we dodged that bullet.

 

Back to red PMPS tonight. I skipped a third test yesterday but I plan on getting a before bed test this evening. Should I try to get +9, +10 or +11's in the next few days?

Thanks for the heads up on the dental issues. There are no dental specialists in Maine, I'd have to go two states over to Massachusetts. He seemed OK today but I'll keep an eye on it.

 

If you can get a +9 or +10 the next few days, that would be good information to have.

I am spoiled having a dental specialist 10 minutes away. Sometimes there are regular vets who specialize in dentals only.