06/11 Shmee, Vets words; "Shmee can crash and die" if I keep increasing him... see latest comments

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Amanda & Shmee

Amanda & Shmee

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Previous condo

Good morning everyone,
NYC was hectic and overwhelming but great overall! DH did a great job taking care of Shmee while I was away. There were no issues and he got down to 66 on Thursday 06/07. Last time he got a green he came back from his bounce on the 5th cycle, which would have been Saturday night, 06/09. I wish he would have gotten a test in the middle of the night but he did not. I am thinking this may be why his AMPS Sunday 06/10 was 343... possibly bouncing again from going low? I decided to keep him on 5.5U today... since 1) since he might have went low 06/09 PM (I know if we don't see it it didn't happen, but since it was DH and not me I feel like I might have caught it) 2) he saw green 06/07 so today will be his fourth day since then and 3) partly in denial.... I really do not want to raise him to 6. I am so scared for him that there might be something else that is wrong, because I remember you all saying you start to get concerned at 6U. Thoughts on his dose? I assume I should go up to 6 tomorrow if I don't see greens today? Side note - we have been slowly moving his dose up to 7pm because we have a concert tomorrow.. leaving at 7 pm after his shot and not sure when we will be back, probably around midnight... so take that into consideration with the possible increase tomorrow.

Today we go to get his full bloodwork panel done (to include SDMA). This is the 3.5 week mark off the Denamarin (trial to see if he really needs it). I also took your advice and am getting the full bloodwork done this time so we can have access to more information. I am very nervous my vet is going to want the ultrasound... she freaked out about his dose before the dental and now its even higher... the ultrasound place is an hour away and Shmee cries the entire 5 minutes in the car to the vets office... and I give him Gabapetin now since he gets so scared there. I cannot imagine having to take him to the ultrasound place. I am just so nervous overall :(

Any thoughts or advice would be appreciated, thank you.

On a lighter note, here is Shmee and Steve while I was away. This is his favorite chair. Every time Steve gets up Shmee steals it, haha :)

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Good for DH in taking care of Shmee while you were gone. Hope you had a good time. Shmee looks like he did. :)
Amanda & Shmee said:
because I remember you all saying you start to get concerned at 6U
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Cats need however much insulin they need. We have had and do have cats here on much higher doses, and for those cats, it's the right dose at the time. We don't get concerned at 6.0 units, but at that point, if caregivers have not already done so, we suggest they get their cats tested for acromegaly (IGF-1 test) and insulin auto antibodies (IAA). It is our experience that at six units, a kitty has a "high dose" condition. Cushings is also a high dose condition, but less commonly seen. 6.0 units is not really a magic number. We have seen high dose condition cats on less than six units of insulin, but we have also seen cats at just under six units turn it around and go down in dose.

You have been on this dose long enough. Yes, it's time to increase. You could wait until after the concert to raise his dose though. Better he be safe with you gone. I know that means six units. :bighug: Since you are getting blood work done anyway, why not add on the two tests for blood to be sent to Michigan State University. Suggest to your vet that you want to wait on a decision on the ultrasound until after those tests are back. It may be scary thinking Shmee might have something else going on, but knowing one way or another helps you know what you are dealing with, or rules it out.
 
Thank you @Wendy&Neko I will call to see how much those tests are today. So just to be sure - I ask for the acromegaly (IGF-1 test) insulin auto antibodies (IAA) to be sent to Michigan State University? That is the only place that does those tests? I appreciate it!
 
My total would be $289 for all three tests (full blood panel $137, IGF-1 & IAA $152)…. My credit cards are piling up but I do want to do what is best for him. Is it really worth me spending $300 to do this? I am guessing yes... I love data as much as you all do.
 
MSU is the only place in North America that does the IGF-1 and IAA tests. I thought it was worth it, I paid a lot more in Canada. With a diagnosis, I had an explanation and could plan for treatment. Getting the tests now, means one less additional charge for a blood draw later.
 
Wendy&Neko said:
MSU is the only place in North America that does the IGF-1 and IAA tests. I thought it was worth it, I paid a lot more in Canada. With a diagnosis, I had an explanation and could plan for treatment. Getting the tests now, means one less additional charge for a blood draw later.
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Makes sense. I have so much going on in my life right now so I am just so overwhelmed. I am trying my best to keep it together and do what is best for Shmee.
 
My vet also said she is not comfortable doing the IAA test until she talks to someone at MSU since she does not know what the procedure for getting the blood is, like do they have to fast? @Wendy&Neko there aren't any documents online she can reference about the test is there? I looked at the Acro sticky and I see MSUs blood test estimate, but it only gives shipping info. She said she is going to try and call them today. I think I am going to have to reschedule the blood test if she doesn't talk to MSU and get back to me by 2pm because he needs to Gabapetin by then.
 
Latest update - they talked to MSU and since cats need a 12 hour fast for the IAA test this isn't as simple as we thought, so I cancelled my vet appointment today and am going to reschedule later once the tech talks to the vet. @Wendy&Neko any advice on how to go about this? Am I going to have to skip two shots and really not feed him all day? I had no idea he needed to fast for so long, it seems like a much more complicated situation now...
 
I didn't do a 12 hour fast for Neko, more like maybe six hours. I had an end of day blood draw. Most people don't fast their cats for the test. I still think the result was valid for Neko.
 
Wendy&Neko said:
I didn't do a 12 hour fast for Neko, more like maybe six hours. I had an end of day blood draw. Most people don't fast their cats for the test. I still think the result was valid for Neko.
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I am wondering what I should tell my vet then.... Hm. She does not feel comfortable doing the test unless we follow their instructions. I posted in the IAA group too to see how others handled this situation. Maybe if I can make her see that multiple people did not fast for 12 hours she will go along with it. Did your vet not care that you didn't fast for the full 12 hours or did you just say you did?
 
My vet didn't even tell me I had to fast for it. I too got a full blood panel done at the time, which usually requires some fasting, but they usually bend the rules a bit for diabetics. So 'as long as practical' was what I did.
 
Wow on the price. Just for info and you can check the MSU web sight. MSU only charges $18 for the IAA. The IGF I think is around $58. The instructions and forms are there also. You can print them out and give to vet. I will send you the link.

Olive was not fasted, neither was Smokey when I had him tested.
 
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Not to be overly cynical, schedule the test for an hour before shot time. Tell your vet your cat hasn't eaten since breakfast. What your vet doesn't know, won't be a problem. (In other words, you don't need to be 100% truthful.)

I'd also like to encourage you to rigorously follow TR if that's still the approach your following (I'm going by what's in your signature line). Evaluating Shmee's dose every 3 days could make a difference in getting those numbers to come down.
 
I did not fast Floyd 12 hours. If I did, I think he'd pack his hobo bag and hop a train somewhere! (or be meowing at me every 3 nanoseconds until he got fed).

Seriously, though, while a 12 hour fast may be ideal, the goal is to avoid lipemia (fat in the blood), which could invalidate the results. Lipemia is visible when the sample is spun down, so they can see this before sending the sample in (ie, if the sample is visibly lipemic, another sample after a longer fast can be taken). I timed blood draw about 6 or 8 hours after his last meal when I did Floyd.

[SOAPBOX] In defense of the vet's pricing (because I have to), I wanted to add that the insulted pre-paid overnight mailers (the sample is frozen and sent on ice) cost the vet ~$20. The vet has to mark-up the $96 test ($58+18+20) to $152 to (barely) cover the cost of supplies, tech time for blood collection and sample handling, packaging, filling out forms, arranging sample pick up, doctor time to research testing procedure, interpretation of results and discussion of results with client...... not to mention actually make a profit to pay themselves and stay in business. [/SOAPBOX]
 
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Thank you everyone! I ended up cancelling the vet appointment today so we can figure out how to proceed. Since it is the general consensus that 12 hours is not really needed then I will stick with 6-8. And I appreciate the explanation of the science behind it @Janine & Floyd ! I totally understand why the cost is high too, I am just going through a lot and didn't want to pile more on my credit cards if it wasn't truly worth it. But since the majority think it is worth it I will do it.

As soon as I read all of your comments above, my vet called me back. Whew I need a glass of wine after that phone call.....
I am not a good fibber at all, it is really hard for me... so I was honest about everything. She said that the lab was very adamant about the 12 hour fast, so we would have to skip a shot or feed him early and do a half dose. I told her I would really like to do an 8 hour fast and not 12. She said she has zero experience with this test (the IAA) so she wants to follow what they said, but she is open to talking to an internist (or internalist? Not sure) to see if they think 8 hours would be acceptable. She sees his spreadsheets so she would know if I lie and say I did not give him the full dose of insulin when I actually did...
Then the call got even more interesting.... and led me to tears after hanging up.
She asked how high his dose was right now and what his numbers were. When I said he was on 5.5 and explained he was getting low and then bouncing for a few days she went off on her Somolgyi effect rant again. The tone in her voice was very scared and concerned. I have heard on this message board before that this Somolgyi concept is drilled into vets in medical school so I understand.... but I told her there was lots of data on this message board to support that he is ok. She kept saying this is a very high dose and I should absolutely not do the increase and she is afraid I can kill him. I can hardly even type those words.... that she thinks I can kill him. I reminded her that she was ok with the TR protocol, but she has now changed her mind. She said she really wants him to stay on each dose for at least a week. I am not going to follow her instructions because I know this forum has gotten over 400 cats into remission and I think she has maybe gotten a handful ("very few" were her words) of cats into remission. But now... I do not know what to do. I have to wait for her to talk to the internist about the IAA test and call me back in a few days.

From the notes I wrote down while she was on the phone she said: he might go too low, become insulin resistant, and will "crash and die". She also suggested doing two pancreas tests from Texas A&M vet school (TLI & PLI).

On top of this and some other things my dad called me earlier to tell me my uncle passed away. I have had such a horrible day.
 
Amanda & Shmee said:
Thank you everyone! I ended up cancelling the vet appointment today so we can figure out how to proceed. Since it is the general consensus that 12 hours is not really needed then I will stick with 6-8. And I appreciate the explanation of the science behind it @Janine & Floyd ! I totally understand why the cost is high too, I am just going through a lot and didn't want to pile more on my credit cards if it wasn't truly worth it. But since the majority think it is worth it I will do it.

As soon as I read all of your comments above, my vet called me back. Whew I need a glass of wine after that phone call.....
I am not a good fibber at all, it is really hard for me... so I was honest about everything. She said that the lab was very adamant about the 12 hour fast, so we would have to skip a shot or feed him early and do a half dose. I told her I would really like to do an 8 hour fast and not 12. She said she has zero experience with this test (the IAA) so she wants to follow what they said, but she is open to talking to an internist (or internalist? Not sure) to see if they think 8 hours would be acceptable. She sees his spreadsheets so she would know if I lie and say I did not give him the full dose of insulin when I actually did...
Then the call got even more interesting.... and led me to tears after hanging up.
She asked how high his dose was right now and what his numbers were. When I said he was on 5.5 and explained he was getting low and then bouncing for a few days she went off on her Somolgyi effect rant again. The tone in her voice was very scared and concerned. I have heard on this message board before that this Somolgyi concept is drilled into vets in medical school so I understand.... but I told her there was lots of data on this message board to support that he is ok. She kept saying this is a very high dose and I should absolutely not do the increase and she is afraid I can kill him. I can hardly even type those words.... that she thinks I can kill him. I reminded her that she was ok with the TR protocol, but she has now changed her mind. She said she really wants him to stay on each dose for at least a week. I am not going to follow her instructions because I know this forum has gotten over 400 cats into remission and I think she has maybe gotten a handful ("very few" were her words) of cats into remission. But now... I do not know what to do. I have to wait for her to talk to the internist about the IAA test and call me back in a few days.

From the notes I wrote down while she was on the phone she said: he might go too low, become insulin resistant, and will "crash and die". She also suggested doing two pancreas tests from Texas A&M vet school (TLI & PLI).

On top of this and some other things my dad called me earlier to tell me my uncle passed away. I have had such a horrible day.
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Oh Amanda, I am so very sorry to hear all of this. Your vet is being ridiculous and cruel and that's the nicest thing I can say about her right now. You're the one paying for the test, so if you don't have Shmee follow the "proper preparations", I feel like that's on you and not her. I can understand her being in the dark about things, but then she should consult with an expert before she contacts you, not call you and make you feel awful. It's not like you're twiddling your thumbs, upping the dose, and hoping for the best. You're a very active participant in Shmee's sugar dance. I can't say much else about her suggestions.. I'm fuming too much on your behalf. But I just wanted to stop by and lend you my support. I am so sorry about your uncle. :bighug::bighug::bighug::bighug:
 
I'm so sorry to hear about all you have had to deal with today. I can only offer sympathy on the passing of your uncle, but I hope I can offer some thoughts for moving forward with your vet. The first question you have to ask yourself is can you partner with her to care for Shmee? Do you have respect for her professional expertise and value her advice enough? If not, you should consider finding another vet. I suggest you consider thinking about this only because her comments (while hurtful to you) seem to be about Shmee. In her experience, it doesn't sound like she has had the opportunity to work with a higher dose cat and as a result this is well beyond her comfort zone. She is so far outside of her comfort zone that she is resorting to following "rules" as in the fasting protocol. Rather than the logic that Dr. Janine described, she is going by the "letter of the law". This tells me she lacks the confidence and experience to vary from the published guidelines or help you understand the options.

When she says crash, I'm sure she means going hypo, which is something we all worry about, but I know you worry more because of the high dose. There have been other posts here where owners were told by their vets that doses over X units would be fatal.

Partnership is a two way street. If you can partner with her, she will need to partner with you. This may mean learning more about new things including high dose conditions and also dedicated owners who will do things like frequent home testing. If you are willing and able to partner with her, you will need to assess if she is willing and able to partner with you.

My vet is not a world class expert in FD, but he is a world class teacher and has decades of experience. These are two things that are priceless to me because my Rosie has other more common health conditions. I can mostly handle the FD (and he knows that), but I need help with her other chronic conditions. My file at the vet office is clearly labeled as a "high maintenance" client, but I don't care. I also have his personal cell phone number for use in an emergency because it is in the end all about the care and well being of my family.

If you determine either one of you can't partner with the other, please reach out to other members in your area for a vet recommendation. I have to believe there are others who have recommendations that will help you.

:bighug: :cat: :bighug:
 
:bighug::bighug::bighug::bighug::bighug::bighug: My condolences on your uncle.

Sorry your vet is being such a drama queen. Given the amount you test, I challenge your vet to find the holes in the spreadsheet when you could be missing lows. I remember another caregiver here who's cat's dose was less than 2 units and her vet was sure she was overdosing her kitty. She wasn't of course. Safe increase amounts, increasing/decreasing as per the protocol means you are doing the right thing. How many spreadsheets has your vet seen?

At one point, I had considered firing my vet, but like Carol, I realized there were many other things she was good at. One was listening to me, the other was doing her homework and being willing to learn. The diabetes care was left to me, she managed the other conditions. There were also times when I had to ask her to humour me - such as running the high dose tests. I was the client, paying for work to be done. It continues to amaze me how many times people still have problems getting those tests done.
 
I too was in your shoes. My vet was bound and determined to make sure not to go over 6 units. If you look at Phoebes ss last year you will see she went up to 24units. I still had to work with my vet and she came to just ask if Phoebe was doing ok diabetes wise. She could not argue with the data. I could not afford the tests so we just treated her as she is a high dose kitty. We switched to levemir and now we have worked it down to 1 unit. At the time we switched we also had started R insulin so not sure if that did it or the switch from lantus to levemir did it. But just wanted you to know I too was scared to go against my vet, I knew she had My girls best interest at heart, but I was bound and determined to be an active sugar mom. As are you. Big hugs. Head bumps and scritches to Schmee. Adorable head rest.
 
Thank you everyone. It was a hard conversation but like @Carol in Chicago was saying, I do want to partner with my vet and I value her opinions greatly, so I hope she doesn't dump me after she finds out I am not going to listen to her and will increase as needed. I totally agree she is just out of her comfort zone.

Wendy&Neko said:
Sorry your vet is being such a drama queen.
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haha, I like this description.

Sienne and Gabby (GA) said:
I'd also like to encourage you to rigorously follow TR if that's still the approach your following (I'm going by what's in your signature line). Evaluating Shmee's dose every 3 days could make a difference in getting those numbers to come down.
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I got wrapped up in the vet convo before and forgot to ask about this. I am following TR and I do evaluate his dose every three days. Can you tell me where exactly you think I made mistakes or more specific on what I should be doing differently? I would love to learn. Or are you just referring to this 5.5 dose? I thought I was increasing correctly. The reasons I didn't increase this time around at the 5.5 are listed above in my first post. And it looks like tonight he might go under 100 like I thought he might, so didn't I make the right decision since I am about to catch a green tonight and will need to hold this dose for a few more days? I am just trying to learn, I appreciate the advice!
 
Amanda, I was where you are since I got Olive in February. Bit of history first. When I had Smokey, he was on Vetsulin. I didn't know about any others except prozinc which at the time could not afford and he would not prescribe it because of cost. When Smokey reached 5 units vets said there was nothing else and he was at max dose and couldn't go higher. I found fdmb. Asked about Lantus, he said no, he wasn't familiar with it. I did it anyway. Once I had data he couldn't deny and he learned with me. We knocked heads on pancreatitis and heart disease. I won each time.

Olive here arrives, has a lot of symptoms Smokey had. She had hard distended abdomen and was very uncomfortable. Vet didn't want to do anything for a few months until she was on insulin for awhile. Long story short I had testing done on my own elsewhere. Lantus wasn't working for her but refused to change it unless it was to N. I did it anyway. She was reaching higher doses I asked for the acro, iaa, cushings tests. We butted heads, he did the tests except for iaa as he was told its a worthless test. I was royally pissed. Then he tells me she is not acro, but her score says she is. A few days go by, I start calling other vets, all I can think about literally day and night is how do I get help for her. Then he calls again and said yes she's acro and he will look into treatment. He's never had an acro kitty and admitted he knows nothing about it. I had already made appt to get another opinion and we go tomorrow. He doesn't comment about using lev. As far as dosing, he said keep doing what I'm doing. Try to keep her under 250. Sometimes you just have to smile and nod at them. As long as your home testing, you won't kill your cat. You are the voice for your cat. Speak up if you don't agree with your vet.
 
With TR, if you're not seeing mostly green nadirs, you want to increase the dose. Once nadirs are mostly green/in normal range, you hold the dose for 5 days/10 cycles. From the TR sticky:

INCREASING THE DOSE

    • Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
      • if your cat is new to numbers under 200, it is recommended to hold the dose for at least 8-10 cycles before increasing. (You are past this point.)
      • when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing

    • After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
    • After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.
There are some additional ways to fine tune a dose but Shmee is still bouncing around. At this point, I would not hold a dose overly long (i.e., not more than 5 days if nadirs are <100).

Your vet needs to get some continuing education credits in diabetes. The next time you talk to her, could you ask her to please produce the research on Somogyi in cats prescribed Lantus? She'll have a wonderful time. The concept of Somogyi was coined by Michael Somogyi in 1938. It was based on a small number of human subjects. Obviously, Lantus/Lev was not available. More rigorous research over the years has not been able to replicate the original human study. In other words, Somogyi doesn't exist. There is a fairly recent research paper by Roomp & Rand (the same people who developed the TR protocol) that looked at Somogyi in cats on Lantus/Lev and debunked the notion of Somogyi in their sample.
 
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