4/24 CRYSTAL AMPS 277 +5 212 +10 194 PMPS 218, +3 306 - Gave "R" | Feline Diabetes Message Board - FDMB

4/24 CRYSTAL AMPS 277 +5 212 +10 194 PMPS 218, +3 306 - Gave "R"

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suki & crystal (GA)

suki & crystal (GA)

Member since 2014
yesterday

Happy Friday to all,

@Wendy&Neko @julie & punkin (ga) @Suzanne & Cobb(GA)

There were some interesting observations thrown up from my condo yesterday about Crystal's reaction to the R and possible IAA, thank you Wendy, Julie and Suzanne for your thoughts. Wendy said:

Look at Cobb's SS at the end of August last year. Suzanne went from R with every preshot in mid 200's and above, to no R because he was getting lower preshots and started turning all green, then to lowering the Levemir. She only used R after that for exceptions like fur shots. Neko's IAA started breaking mid August 2012, right after SRT. I wasn't giving R and it was a lower dose, but it was similar in that there were a lot of closely spaced reductions. With the amount of testing you do, you should be fine. The biggest thing to consider is to always err on the side of caution.

I'm still a bit confused as to how to interpret Cobb's SS and how both Suzanne and Wendy made the judgement call regarding reducing the Lev - until I can grasp it I think I will just have to continue asking for guidance. Wendy, when you say always err on the side of caution in what context should I be careful, administering R too much, or too little, or needing to adjust the Lev? Sorry for so many questions.

I've heard back from Ruth at the RVC today:

My name is Ruth and I am another of Stijn Niessen’s PhD students. Proliferation of the soft tissues around the muzzle and nose is certainly quite a common feature among acromegalic cats, especially in those with long-standing disease. In fact, one of our studies found that snoring, secondary to upper respiratory tract tissue proliferation, was one of the most common clinical signs among acromegalic cats and humans with acromegaly are often affected by sleep apnea.

Many acromegalic cats tolerate any breathing issues this causes. However, severely-affected cats can experience more severe breathing difficulties at times of stress such as hospitalisation and during hot weather. Humans with sleep apnea do experience an improvement after surgical treatment of acromegaly (hypophysectomy) but we unfortunately have no information as to whether breathing difficulties improve in cats after surgery. Definitive treatment of Crystal’s acromegaly by hypophysectomy may stop the progression of her upper respiratory tract changes. However, if you have decided against surgery (I appreciate you live very far from centres that offer this), the best management of Crystal’s breathing difficulties is probably to limit her exposure to stressful situations. Acromegalic cats can also develop heart muscular disease which can lead to heart failure and breathing difficulties due to fluid build-up on the lungs. However, your description of Crystal sounds as if her problems are attributable to changes in her upper respiratory tract.
Best wishes,


Ruth

I've replied along the lines of asking what tests, if any, I should ask my vet to do, maybe it will be enough to have a simple exam.

I gave Crystal 2u R this morning on an AMPS of 277. Currently her +10 is 194 :cool: so that's good. She doesn't appear so snuffly (this is becoming my favorite word) today and is more active than she was yesterday, when she slept for most of the day. I think I just have to take one day at a time and try to handle whatever she throws at me as best I can as she doesn't appear to be consistent in anything lately, she's certainly likes doing things her own way. :cat:

Vines to all kitties in need and their beans

Suki
 
Suki, coming down the dosing ladder (in my opinion) is a guessing game.

I think the biggest thing you have to keep in mind when coming down is the depot. Crystal has a LARGE depot. If you look at 9/11/14 to 9/13/14, you can see where I was trying to inch down and the depot got ahead of us, hence the skipped shot on the evening of 9/13. The weeks of 9/28 to 10/10 we held the dose at 17uL for almost 2 solid weeks, and then Cobb threw me a 49 one morning out of nowhere. I felt like at that point it was a clear sign he needed less insulin, come down a bit. I think we had had the discussion that, instead of going up at 25% increases, come down with a smaller decrease - 10%ish. I came down in whole units until I got to 10u.

You have to ignore the week of 12/28. I was out of town that week and that was the week Matt grabbed the wrong vial and was giving 7uR at PS times. That is why the numbers got incredibly strange. You can see when I got home on 12/31 and resumed giving the shots with just 7uL, the numbers fell right back where they needed to be.

I, personally, gave very little R when we switched to Levemir. Here's why...I was back working full-time so I wasn't around to test and really figure out the new Lev curve. We started Lev the evening of 8/7/14. You can see on 8/10/14 Cobb got his first streak of green. Green preshot. It was shocking. I only gave 11 doses of R after we switched to Lev -- until that last week in December.

Remember that your R and Lev work together. So when you err on the side of caution, remember Lev has that longer duration than the R does.

I would say -- since Crystal has such a large depot -- be prepared to give half doses on cycles where she has gone too low for your liking. And you'll just have to play around with how much to reduce a dose of Lev. Again, there are no rules for big gulpers and coming down the ladder. You have to come down, from my experience, at a larger decrease than "the protocol" says. I remember I shaved .25u off one dose and it was basically like I'd given the same dose because of that huge depot. I would think you might want to start with a decrease of 2u at a time until you get further down closer to 25 or 30. If you find the depot gets ahead of you, decrease at a bigger percentage.

That's just my 2-cents.
 
Sweet blue again! :cool: Good call on the R amount Suki.

Interesting update from RVC. For additional tests, you might want to talk to your vet about an echocardiogram - it's an ultrasound of the heart. Hypertrophic cardiomyopathy (enlarged heart, specifically the left ventricle wall) is a common enough condition with acrocats and can be managed with medication. I had a previous non acro cat with HCM, although I found out too late. There often aren't obvious signs of it. It can cause wheezy breathing and ultimately lead to a saddle thrombosis or stroke with a blood clot to the spot between their hind legs. It's very painful. Two days before his scheduled echo, my guy had a stroke and lost blood flow to his hind legs. We had him PTS. There can be some recovery with blood thinners and physical therapy, but it's painful and a large percentage of such cats have a repeat event. Early detection and prevention is the way to go.

As for interpreting when IAA might be breaking, we will be here to coach you through it. The first clues for Suzanne was that she was holding the same dose, when all of a sudden Cobb started getting a lot greener on a dose that was previously only occasionally getting green, and she was no longer needing R. A rule of thumb I used, and Suzanne too, was to reduce when the BG went below 70. Normal TR reduction point is 50, but we padded that a bit for safety. When I say always err on the side of caution, I mean if there is a question to reduce or not - then reduce. If you are ever uncertain what to do, chose the safest option. Look back on 3/7 and 3/8 when Crystal got green. You did a skip and reduced dose to drain the depot. With a large dose, we are just more cautious about the action of the large depot.
 
Recap on today's figures:
277 AMPS
275 +3
212 +5
211 +6
214 +8
194 +10
218 PMPS

Just phoned my vet, she is away until the 4th May on holiday so have an appointment that morning for a general exam of Crystal's health, focusing on possible respiratory problems. Her last visit was back in January. Also waiting to hear back from Ruth at RVC whether she has any suggestions/recommendations for the visit to the vet that might give me a clearer picture of how advanced the acro is (not sure I want to hear this but best be prepared I suppose).
 
sorry I posted before seeing both your replies, that's what comes of typing with one finger on a tablet. Thanks for explaining in detail Suzanne and Wendy, I need to read it a couple of times with the SS in front of me so that I understand.
I did actually wonder about that 7u of R Suzanne, I'm glad you explained what happened as I was very confused by the numbers.
So here's the million dollar question, what is considered too low? Am I anywhere near that yet? Or would we be talking about green numbers, I was very nervous the one time Crystal hit the greens but it's all relative, I was also very nervous with giving R and now I feel much happier about it.
Wendy, that makes good sense and I like the idea of having a figure in mind to watch out for (70) - I think I've just answered my own question right? So a way to go yet as there has only been that one occasion of hitting the greens. Sorry to hear about your previous kitty with HRC, how sad for you. I'm going to make a list of things to talk to the vet about, and obviously heart problems are a big thing for acros. She was okay at her last visit but I don't know whether she has had an echocardiogram, she's had some sort of test back in October but not sure exactly what, need to confirm. A lot to mull over and absorb. Thank you both for taking the time to clarify and, more importantly, confirm that you will be around to guide us through the rough waters. I'll keep you posted when I hear back from the RVC. Crystal's + 3 was 306, so perhaps another go at R in the morning, what do you think?
 
One additional thing about respiratory issues - an acro cat with enlargement of the soft tissue in their airway needs a smaller tube than a "regular" cat if they ever need to be intubated, for surgery, for example.

Some acro cats also feel like they can't breathe if they are on their back, so unless Crystal hangs out on her back regularly, be wary of the vet flipping her over onto her back. Most exams can be accomplished without putting a cat directly on their back.

Punkin's symptoms didn't progress that far, and post SRT the respiratory stridor disappeared. The soft tissue enlargement did as well. He slept on his back all the time and seemed fine with it. He did like to lick but he wasn't drippy like you and Suzanne are describing.

How are Crystal's pupils? Punkin's tumor was pretty big and it apparently lay across the optic chiasm, causing his pupils to be fixed (blown open) some of the time. His pupils didn't close to slits when their was a bright light around. That's something to observe and see if Crystal's having.
 
@julie & punkin (ga) thanks for that useful info Julie about not putting her on her back and also the narrow tubing, i'll tell my vet to put it on her records as well, just in case. Interesting about the pupils, Crystal's are always open and black, but they do go back to slits in the sunlight.
I've had another reply back from Ruth at RVC and will attach it later.

Crystal's AMPS was 306 so I gave her 2.5u of R this morning, I'm around all day to watch her. Btb for an hour or so, Bbl.
 
Here's Ruth's second reply:

Acromegalic cats can develop kidney disease secondary to their high circulating growth hormone concentration so it could be worth asking your vet to perform a blood sample and urine analysis to check this in Crystal. Intermittently checking kidney function can be a good idea in older cats, anyway. The drug that we trialled in acromegalic cats at the RVC was called long-acting pasireotide and can significantly improve some cats’ diabetic control, including inducing diabetic remission in some. However, it is often associated with changes in stool consistency. This is manageable in many cats but can be quite detrimental in a few. Long-acting pasireotide has recently been launched on the human market in the USA for treatment of human acromegaly (tradename Signifor LAR) but has not yet been launched in Europe.


Best wishes,


Ruth

A good suggestion from Ruth for our upcoming vet visit on the 4th May. Will start a new post for today's R trial but just wanted to keep all the relevant info on one post.
 
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