06/15 Shmee AMPS 128, +2 211 , PMPS 286, Opinions on vets email and todays dose.

Previous condo

Hi everyone,
Sorry I have been away for a few days, I have had an overwhelming week. I knew this post would take a while and having to read over my vets emails too, so I have not found time to post. Thank you all who leant their support on my last condo. I have went back and re-read everything a few times and I appreciate it immensely.

I am trying to wrap my head around how to handle the situation with my vet. I attached her email to me after our last conversation, and the article she mentions.

She has been great so far but as of our last conversation (see last condo) she thinks I am going to kill Shmee because he is Somagyi-ing (I plan on giving her that Room & Rand paper, thank you Sienne), and she is no longer on board with TR. She didn’t even want me to increase him to 6 when I talked to her (he is now about to be at 6.5…). She wanted to talk to an internist to see if Shmee really needed the 12 hour fast for the IAA test (I wasn’t going to do it regardless, per Dr. Janine I would do like 6-8 hours), and the endocrinologist came back saying the IAA test is not needed and basically worthless. She said the IGF-1 test would be good to get, but said the IAA is unnecessary. I read over the sticky “acro and other high dose conditions: what we know”, and I am still not really understanding what the IAA test will tell me and how it can help. The links under the IAA section do not work except the petwiki page. Can someone please explain what the IAA test will tell me, and what use the information is? The article she gave me is from 2012. To my understanding, it is basically saying research has found that there are no good studies to prove what can get a cat into remission. I find it ironic that the research the endocrinologist provided shows nothing more than … there is no good research? I found it a little confusing. I have given her the medical journal in the past and the study to support TR, maybe I will have to just give those to her again when I tell her I will still continue to follow it. I also plan on telling her that Somagyi would mean that I am not catching him going low, when I know that I would catch it. So even if it does exist (it doesn't) I would catch the low number.

She also wants me to get pancreatic tests done (TLI and PLI). Thoughts? I am already about to spend $300 on the full panel bloodwork, IAA and IF tests, so wondering if this is also worth it?
(Background - if you look at his past bloodwork, his liver levels were very high. After a few weeks of Denamarin they came back down. Was about to go back for the new bloodwork to see his new levels, and this is when this whole thing started with her because I said I wanted the IGF and IAA tests done at the same time per Wendy’s suggestion.)

Lastly, Sienne said I need to follow TR more rigorously, but I still do not fully understand what I have done wrong. I have the TR sticky printed out in my binder and have read it multiple times so I thought I understood it. The only times he went over three days were when we saw greens, and I was told to wait 2-3 days after the greens to see if they come back from their bounce. The only thing I can think of is that you said if the nadirs are not mostly greens, then you want to increase. So if there is only one nadir on the dose that is green, then maybe I should be increasing and not waiting for the bounce to stop? I just want to be sure I have this down-pat.

Any advice or thoughts about her email/article would be appreciated, and I am going to tag a few people since it is late in the day and I want to be sure I get some of your advice.

@Sienne and Gabby (GA) @Wendy&Neko @Stacy & Asia @Olive & Paula @Tracey&Jones @Janine & Floyd @Carol in Chicago

My vets office is open late on Mondays, so in theory I can fast him for 6-8 hours before a late appointment and get some of these tests done then. I’m mostly worried about when I talk to her next, I want to be prepared with all the information I can be. Thank you all.

 

I don't think you should "fight" with your vet. It doesn't sound like she will be convinced. You have tried, and that is to your credit. There is no win here except getting Shmee the best care you can.

If it were me, I would find a vet that would work with me to help me give my cat the best care.

Before any fast, it should be agreed up front what tests you want done. I would ask others to please comment on panreatic tests - sorry I don' know about these.

 

As for your vet...she has been good up to now right? It sounds like she is right out of her comfort zone. I don't think you will gain any ground debating with her further as it sounds like she has dug her heals in.

Is there a reason you can't deal with the IM directly?

For the pancreatic tests ...is there an issue there outside of the diabetes? Does he have pancreatic flares? I believe she is looking for another reason for the high dose.

That all said...

 

First, I’m sorry sorry for the loss of your uncle.

As for pancreatitis, from what I have seen she doesn’t seem to have any symptoms. I’ve had years of experience with chronic pancreatitis with Max. Symptoms range from inappetence (most comm ), meatloafing, just not acting right, pain when palpated, vomiting, nausea and diarrhea. Different cats experience different symptoms and the same cat can have different symptoms with different flares. From my experience and so many others on a yahoo pancreatitis board the severity of a flare does not always match the number on the Spec fPL test . Since they test hormone diabetes and kidney disease can result in a positive test.

This may sound crazy but if you are happy with this vet in how she treats other issues, you could have a ss just for her eyes. I must say I could never go to a vet that didn’t see me as a partner in the care of my cats. I’m spoiled that way. It got to a point that my vet managed all Max’s other issues and I handled FD. He even showed his vet students my ss for Max.

I hope you get this figured out so that you don’t need to spend so much time on how to deal with the vet and can concentrate on Shmee.

 

OK, where to start. First, these are for you.

I agree with Elise, not sure why the vet wants to test for pancreatitis in absence of signs of it. Sure pancreatitis can cause some insulin resistance and the need for higher dose, but not above 6 units. Save your money and decline those tests.

Instead, spend the money on the IAA test. Why? A couple reasons. Some cats have IAA and not acromegaly. It's not as common, but it does happen. If you test and get negative IGF-1, then you are left wondering why the need for more insulin. Sandy had exactly that experience with her Black Kitty. Which means a second blood draw, a second mailer, a second set of shipping charges when you could have just done a simple add on to the IGF-1 test.

It is true that being positive for IAA does not show clinical signs. However, and this is the big one, it does have implications for dosing. IAA is supposed to be self limiting over time, about a year. It was nine months for Neko. When the IAA goes away, dose requirements can drop quickly Black Kitty even went OTJ after testing at extreme high levels of insulin autobodies. The most relevant part is that dose requirements can drop quickly. If IAA is in the picture, you need to be really conservative on dosing decision when the dose trend is downwards and there is the possibility the IAA is breaking.

Correspondingly, there is also an implication for increasing doses. You really need to keep on top of increases when IAA is in the picture. If you linger on doses, the antibodoes get ahead of you. There is a look to an IAA kitty. They get to a dose, see a little blue or green, then the antibodoes take over and the dose does what I called "going stale". Neko first saw green at about 3.5 units, but didn't earn her first reduction until 8.75 units. Some doses in between I was too conservative, and she barely saw high blues.

By the way, there have been very few studies on antibodies in cats or dogs, so true, there is no scientic stand on it. The two papers I've seen were on very small numbers of IAA cats, and somewhat contradictory. However, there is a good sized practical body of knowledge here. We wouldn's just suggest getting the tests for our interest, but rather because it does make a practical difference for you.

If you like your vet for other things, all I can suggest is asking her to humour you. That's what I had to do. It's your money and you are the client. The clinic owner (another vet) poo pooed my "exotic tests". When both IGF-1 and IAA came back positive, I earned a lot of respect. Soon after, my vet identified another acro at the clinic. Clinic owner later admitted I knew a lot more than him about acromegaly.

 

Thank you so much everyone. I am going to try and stay with my vet, and I love Elise's idea of having a SS for her own eyes. This is a definite possibility. If she continues to butt heads with me and won't give up her Somolgyi (I can never remember the spelling) talk then I will be on the hunt for another vet.
@Tracey&Jones what do you mean, deal with the IM directly?
@Wendy&Neko I appreciate the explanation of the IAA test. It definitely makes sense.

As for dosing --
Shmee saw greens last night, so I was a little confused on whether I should increase him today. I thought I do not increase since he just saw greens last night, but since he hasn't seen mostly green nadirs this dose does that mean I should have increased him this morning according to @Sienne and Gabby (GA) ? I played it safe and kept the 6.5, but I am very curious what Sienne and others think I should have done today.

PS I just changed the date of my post since I made it late last night.

 

IM...internal medicinist.

Jones has his own IM and our regular vet.

 

Amanda, have/am going through the same regarding the IAA. My vet has been great over the years. With my first kitty he learned about Lantus and willing agreed to the exotic tests as they are called.

This time I've had to fight for each one and others. I was also told the IAA was worthless because it can't be treated so why do it. He did the IGF so since they go to same lab why not do both, he doesn't think Olive has either. Well IGF came back positive but he still says it's normal, so if I want the IAA he is willing. That's means as Wendy stated another vet visit, blood draw, shipping, paying for test. If you do one do both. The visit Olive had to do labs was traumatic this time for her. Right now I won't put her through this soon. Without vets knowledge I changed insulins and how I dosed her.

As to why I wanted theses tests done. Olive's dose was getting higher and the insulin was like giving water to her. Wanted to know why. Wanted to prevent DKA. She was miserable and looked awful. I think of this analogy, I could be wrong but it's understandable to me, it like a person who is dependent on pain killers, they get use to dose and need more. She needed more insulin to start breaking through the shell of the antibodies so the insulin could take over and do it's job.

So with Wendy's, Karen's, Chris's and I think Kris was in on it, started what I call warp speed TR. Since I'm home most of the time, if not me DH is here (Olive is rarely left alone, not because of FD though) it's just our life. When Olive hit 3 units of the Lantus we went warp speed, hit 8 units still no improvement, switched tho lev at lower dose, waited for depot to build and went warp speed again hitting 8.5 units and finally started seeing some improvement. She needed what she needed, it's just the way it is. We are now down to 6.25 units and not in warp speed anymore.

When back to the vets for 3 month follow up and he shook his head and said it was to much to fast we can change to N insulin. I showed him the ss. He could not deny her progress in glucose or her other lab values. A lot of abnormal values have come down or in normal range. Now he says keep doing what we are doing. If I still want the IAA he is willing to do it. Now butting heads over the acro. I just saw another vet who says she has it and is looking into it. So I might just have to change vet at least for her. It's a shame, he was so good to us over the years, but she needs help and we're just not getting it from him. Sometimes vets become complacent and to comfortable in their practice.

Something to keep in the back of your mind, you might have to consider the same for Shmee welfare.

 

I just sent her an email basically saying I want all three tests originally requested (full blood panel including SDMA, IAA, and the IGF), and that I will still be following TR. So we will see how she responds. If she is not willing to humor me or do the tests I will start looking for another vet.

I never really thought of this option. Are you saying I should consider just switching my vet to the endocrinologist she talked to?

I am sorry to hear this Paula, it is crazy to me how many people I see on here saying their vets disagree with their decisions. It is sad but like you said they become complacent.

 

Maybe an idea. Jones' IM deals with the IBD, vet deals with all other stuff (dental, limping) and medication refills. The information from the IM is shared with his regular vet - I give all his notes to them to copy into their system. That way she is not left out but I do have a specialist taking care of the really tricky issue.

The one thing is the FD is really left to me!

 

My vet is the same. Completely disagrees with my treatment of Silver. Says I should be giving way more insulin than I am. Can't or won't understand bouncing. I have the advantage in that I don't need the vet. I can walk into a pharmacy without a prescription and pick up what I need. Silver only sees the vet in emergency situations.

 

I am still so curious about his dose and want to be sure I understand TR correctly! @Sienne and Gabby (GA), @Wendy&Neko, or anyone else really, I would love to get your opinion on whether or not I should have increased him today and if I should tomorrow. Should I still be waiting for the bounces to break? I still don't understand fully what I was doing incorrectly before.

 

Just my opinion, but I think you could increase tomorrow.

My reason for this is because although yes, you do have to be aware of bouncing, the 6U dose only got him into the 70's and he popped back up quickly ( you don't say on your SS when/what you feed so I'm assuming if he got any food, it was just his usual low carb)

If he'd gone a lot lower or it took a long time to get him up (or you fed something higher carb), I might say to wait, but in his case, each time he's gone low enough to cause a bounce, he hasn't gone THAT low and he popped back up within the next hour....That's why I think he could stand the increase....to try to get him to spend more time in greens and hopefully lower the overall numbers too

So even if there may be some bouncing going on, he's not getting into healing numbers long enough when he does drop

Anyway, that's my 2 cents.....others may disagree

 

My $0.02, keep in mind that is Canadian so worth less.

With TR, you can hold 10 cycles if they see green, but you could also increase. He is still spending the majority of his time above renal threshold, and I would like to see more blue/more green in there. I think Shmee is close, but not quite there in dose. More juice can bring down the entire range of numbers. BTW, with high dose cats, green may or may not be "healing". For example, acrocats often have a working pancreas, it's the benign pituitary tumour that is causing the insulin resistance. For a cat that has been in high numbers for a while, the greens can help combat glucose toxicity, another type of insulin resistance.

 

Have you heard back from her yet? I'm curious to know what she says!!

 

Forgot to comment on the endocrinologist. I think I would prefer an IM vet. They have a broader range of knowledge. Once Neko added other conditions to her acromegaly and CKD, my vet felt out of her comfort zone and referred us to an IM vet. IM vet's can be really good at balancing multiple conditions, not just endocrine diseases. My vet was still part of the picture and I got meds from her as that clinic is closer.

 

I appreciate this immensely Chris! Your explanation has helped me understand the process a little better and not feel as scared to increase him.

Thanks for the explanation Wendy! This also makes me feel less scared to increase him. More blues and greens would be lovely

I have been so nervous checking my email... but no she has not gotten back to me yet. I called and set up an appointment for the earliest "late" appointment they had, which was 5:40 Thursday. So we shall see... if she accepts my email and doesn't turn me away Thursday will be a very interesting visit that's for sure!

 

@Chris & China that explanation was helpful to me too! Thx