? 9 Jan | Girlie AMPS 239; +5=130; +11=196; PMPS 230 Injectable methylcobalamin vs. tablets?

Condo: http://www.felinediabetes.com/FDMB/threads/8-jan-girlie-amps-196-4-97.189278/#post-2105681

Tonight will be Cycle 7 of a drop. I'm at work all day, so I don't know if she's going green, unfortunately. Given 130@ +5 this morning, perhaps not...

Yesterday her numbers popped up, but we were at the vet's for almost 2 hours as I went over all my questions about dosing, insulin, etc., and I think that really made her a bit anxious: she was not happy being there the days I was in hospital, that's for sure.

I'm not sure whether I should give her a couple more cycles on a drop, or whether I should be thinking of increasing her dose back up to 0.1. Always my dilemma..especially now that I'm back at work full-time and need to sleep at night. I need superpowers!

 

Thank you, @Alicia & Maggie and @Stacy & Asia for your comments re Rosy the pet nanny. I'll have to write when I have more time about what the vet said about Girlie's current numbers and dose and her view on it all and what she'd do. I think the page would burn, though, with scathing responses!

Anyone feel like getting mad?

 

Oh do tell, you can't leave us in suspense like that!

 

PMPS 230: how disappointing! Girlie, please come down tonight...you don't want a dose increase, do you?

 

She had a 68 just 4 cycles ago, do not much room for an increase.

The vet visit may be skewing things. With George he usually recovered from the vet within a few hours, but it may be different for Girlie.


I might wait to see if she hits green the next couple of cycles before taking her up. Let the numbers be your guide.

 

Okay, here you go!

Why did Girlie go so low and why were her shot times changed twice in four days? Answer: I don't know; I wasn't there; I'd have to check the records and I don't have them here. Basically she said it was pointless trying to figure out what happened while Girlie was there; also, there weren't specific instructions about when to feed, what to feed, what to do if she didn't eat, etc., so that was part of the problem as well.

Re: giving a dose of a drop: She'd never heard of that. She didn't believe you could accurately measure a drop. I asked her to get a syringe and some saline and demo'd it for her: she was skeptical that it was an accurate dose. I then asked her to demo how they would have drawn a 0.25 dose for Girlie. I think this is where the hypos came: they couldn't draw the right dose and gave her too much. I don't blame them for that as I don't think a lot of vets know much about drawing micro-doses. She was pretty iffy about Girlie's low doses. Anyway, when she mentioned accuracy, I mentioned the Roomp and Rand Management of Diabetic Cats and the insulin ruler and the fact that syringe lines weren't accurate, of course. I don't think she's read the Roomp and Rand (even though I did email it to her and told her that's what I was following with Girlie).

I asked what she would do/advise me re: Girlie's dose right now. She thinks:

• The greens are too low; she'd rather see Girlie in blues and yellows
  
• She's skeptical of the "drop" dose, so she'd probably recommend putting Girlie back up to 0.1 ONCE A DAY with higher carb food and Mirtazapine to get her to eat more food. Girlie would have higher numbers, of course, at one end of the spectrum, but that's what she would advise. (I'm putting my hands over my ears as I can hear some yells at that vet advice! )
• She'd probably put Girlie back on Lantus (Levemir is a bit unknown here in Australia)

Re: the boarding and how to prevent what happened over Christmas from happening again if I brought her back in there:

• They'd have to put Girlie in ICU so she could have a vet nurse attend her rather than regular boarding where it would only be animal attendants
  
• I'd have to come in to demonstrate how to draw a shot for her and test her BG on her ears
• I'd need to provide the 1/2 unit syringes, Alpha Trak 2 test strips and lancets
  
• I'd have to bring her own food in and set clear protocols for if X then Y (e.g. with not eating enough; when/if to skip a dose; what food to give for what numbers; etc.)

She said that Girlie would probably feel better staying at home, but she'd need to be looked after by a vet nurse given her age and all of her issues. She said she'd be happy to put up an ad from me if I wanted to send her one in case any of the vet nurses/techs there would be interested.

She saw Girlie at the very beginning when Girlie was so terribly ill, so when I finally took Girlie out of her carrier, she was very surprised at how well Girlie looked. She said that clearly, Girlie's diabetes was very well-managed; she was in great condition, good coat, no longer so dehydrated, etc. So at least that was a positive.

We did a test for methylcobalamin (to the tune of $200); generic bloodwork ($200); and phenobarbitone levels ($200): quite a very bill, I have to say!

 

Need some methylcobalamin advice again: we don't have the blood test results back yet, but I asked what the vet would recommend if Girlie's levels are down and she needs the supplement. I mentioned the Zobaline tablets that I can get sent from the U.S. She said this is what she'd recommend instead, especially as Girlie's gut doesn't really work as well as it should. Also, just something else she mentioned: the Phenobarbitone could be influencing how Girlie's metabolising certain medications as she's not reacting as most cats do to Cerenia, for example, which the vet would expect to work within 12 hours max (takes longer for Girlie). She also wondered whether that could explain Girlie's early onset and dives on Lantus and Levemir. (They don't seem to buy into the theory of bouncing from low numbers at the vet's).

So: Methylcobalamin: They'd follow the Texas A&M protocol (I don't know what that is) which means giving her an injectable supplement once a week for 6 weeks: dose would be .25 ml = 250 mcg 1x/week and then a repeat of the blood test to see what her levels were. She thinks the shot would be better as it would be parenteral (away from the gut - not sure I spelled that right) and that would ensure that she got the right amount.

@Marje and Gracie and @Wendy&Neko , do you have any thoughts on this? Has anyone else used injectable methylcobalamin rather than the tablets?

I've been reading Tanya's page on this, but I have to admit, it's a little confusing for me.

 

I’m about to, hopefully, waiting to hear back from my vet. Have you read this bit on Tanya’s sounds like they recommend what your vet was referencing is what I intend to follow also (see Vitamin B12 Formulations: Oral or Injectable):

http://www.felinecrf.org/vitamin_b.htm

 

Yes, but I'm finding it a bit confusing! Am I wrong in understanding that injectable cynocobalamin is not as desirable as methylcobalamin? So the methyl is better than the cyno?

Are you going to do B complex as well, Stacy?

 

I don’t know what to say re: your vet visit. I can only assume because it was an emergency situation on your part that landed her there that they just hadn’t a clue how to deal with her, understandable to some degree, but they still should have notes and be somewhat accountable to provide them to you, I would keep on that and get a copy for your records.

They do not know how to test for BGs with an alpha track? That is so bizarre! I’m glad she at least acknowledged that you must be doing something right that her overall health seemed much improved. I hope she’s impressed enough with that to at least read the TR protocol! Although I don’t understand how she could concede that point and then recommend you change back to Lantus and dose once a day (has she seen your SS, and the difference on Lev vs Lantus)? Aye! Anyway, I hope you are able to have someone come to your home to sit for Girlie, it sounds like a much better option all around.

 

She saw the SS, but not all the way back to Lantus days. She doesn't like all the green numbers, though, and is skeptical of micro-dosing: I'd assume because she's not familiar with the insulin ruler, calipers, and how to do it. Also, you can't get 1/2 unit syringes in Australia - no idea why.
They know how to test with the AlphaTrak, they just decided to draw blood from her neck or forelegs instead when she was there rather than use their own alpha trak meter and strips: bizarre. You'd think they'd have a meter on hand at a veterinary specialist hospital, wouldn't you?

 

I just started the b complex this week, this would be day 3. The powder in the capsules is disgusting and bitter, but I mixed it up with some tiki cat mousse and Asia has been eating it up!

From what I understand, the methyl has been shown to be easier on the kidneys in humans, and we assume is the case for cats as well.

Methyl is better to stave anemia and cyno is better for other non CKD things, you can wait for Marje to expound on that one, she told me that bit and it’s too late at night for brain function at the moment.

 

From her neck?! Ugh! I would think that yes, they would have their own AT and use it, are they the only vet specialist hospital around? So very odd. You need to show her your been there, done that with Lantus SS! My vet was alarmed with the greens too, and I totally get it, but what they usually advise for FD looks nothing like the TR protocol and keeps their numbers nice and high, just not too high. So for that, I completely get where they are coming from, it’s not at all a dosing strategy I could see them recommending.

 

I'm with you there. Also, most people wouldn't be able to or want to test as frequently as many people do here. Now that I'm back at work full-time, I'm aware of just how limited my ability is to feed and monitor her closely, and that's going to affect everything I do dosing-wise with her from now on. Not everyone is willing - or able! - to put their lives on hold for their cat! I so envy the people here who clearly can be at home 24/7 with their cats. I'd love to do that, but I've got to pay the rent and the bills, so I don't have a choice right now, unfortunately. How I wish I could retire early!

 

Just been looking at Girlie's SS: how weird that her AM and PM PS have been almost identical on the human meter. I wonder why? Here's hoping she chooses a lower AMPS number tomorrow morning! Let's go back to blue, please, Girlie!

 

I have been giving Gizmo regular B12 (Methylcobalamin) mixed in his food for about a year. 1/2 cap (250mcg) AM & PM. He is also getting B-complex but it was started about 6 months ago and again just mixed into his food. I have not done the injectable B-12.

Re: this:
http://www.felinecrf.org/vitamin_b.htm#methyl_or_cyano
I wonder if it is just the oral or if it applies to the injectable too? IDK. Would be interested in what @Marje and Gracie says.

Question- how did the vets treat the hypo events when Girlie was with them?

As to the vets comment - I got nothing. A lot of us here have just adopted the "nod and smile" response with our vets. I am very fortunate that mine recognizes that I am capable of managing FD and am diligent with testing and dosing and is behind me (and Gizmo) 100%.

 

Nice to find someone else in my shoes who works all day AND needs to sleep at night. I’ll be following your condos with interest.

 

FYI I was given injectable B12 from vet too but it was cyanocobalamin NOT methylcobalamin. It was pink in colour. I’d check what it is.

 

First, the vet should have been able to tell you why they did what they did and certainly there should be records! I'm surprised you didn't explode, but I'm proud that you didn't! But you made your point by showing her Girlie's condition when she is well-regulated under the protocol you described. I hope Rosy turns out to be the answer you're looking for.

 

Wow, just wow about the vet comments. This is when you just nod and smile while seething in silence.

I agree about holding the dose. Now that you are back to work, I wouldn't increase until you can monitor, probably this weekend.

 

The tests that are done by Texas A&M are for cyanocobalamin, not methylcobalamin and they are part of a GI panel. If her B12 levels are low, she needs cyanocobalamin injections, not methylcobalamin (which is usually given orally but there are some places where you can get injectable in the US...compounding pharmacies).

There’s pretty much nothing that your vet said that I’d agree with. Before you raise her dose, I’d see where she ends up tomorrow. If she’s not back down in green, it’s likely time to think about a dose increase back to 0.1u.

 

You are giving it correctly because Gizmo has CKD. So, as Stacy said, it depends on why one is giving B12. If it is for CKD or neuropathy, it’s methylcobalamin usually given orally. If it’s for the gut, appetite, it’s usually injectable cyanocobalamin.

 

@Marje and Gracie , with Girlie, it would be for neuropathy. So if the vet wants to give injectable cyanocobalamin, that's not going to do anything, is it? Injectable methylcobalamin would be better - or oral?

Also, I read Tanya's page - a lot of info there to figure out.

I'm just wondering about the dose my vet is suggesting she'd use vs what Tanya suggests. My vet is suggesting she'd give way more than Tanya's page says:

• Aussie vet 0.25 ml (250 mcg) injection once a week for six weeks
• Tanya has similar amount but not once a week for six weeks

Any thoughts?

 

Sorry if I misunderstood about the B12. I thought you were discussing gut issues because of the reference of the TAMU protocol which is for gut issues and cyanocobalamin injections.

Injectable methylcobalamin is extremely hard to find. In the US, there is one, maybe two compounding pharmacies for it. If you can give it to her orally, that is your best bet. If you are targeting neuropathy, you need the methylB12.

The dosing for neuropathy is higher than that given for CKD, which is what is on Tanya’s page. For cats in CKD, Helen recommends you give a lower dose (1 mg) for neuropathy but that might not help her as much or it might take longer.
Here is a quote from Tanya’s regarding neuropathy and B12 in CKD cats:

I think your vet is really confusing her B12s.

 

So much for being a specialist vet, eh?

Just so we're on the same page: the vet is testing the B12 level (blood test results not back yet), but the reason we're looking at this is because of neuropathy - especially weakness/wobblies in her hind legs (not gut issues). So I'm assuming that she needs methycobalamin (not cyano) and that injectable methyl would be okay if we can get it in Oz, but oral is also fine. Is that right?

From Tanya's page it does look like you can get injectable methylcobalamin here in Australia. I'm just wondering about the dosage, though, as 250 mcg (0.25 ml) of methylcobalamin injected 1x/week for six weeks sounds a little high compared to what's on Tanya's page. Do you think I should get a second opinion on this?

From Tanya's page:
"Vitamin B12 Injectable Dosages

Doses are lower than for oral administration because less is wasted when the injectable form is used.
A commonly used dose for injectable cyanocobalamin is 250-500mcg every week or every two weeks. Drugs recommends 0.25 to 0.5 ml of the 1000mcg/1ml concentration (so 250-500mcg), every 1-2 weeks as required
Although it is more bioavailable than cyanocobalamin, I understand from those who have used injectable methylcobalamin that the dosage is the same, i.e. 0.25ml of the 1000mcg/ml strength (which is 250mcg), but it is normally only given every 2-4 weeks, although some members of Tanya's Support Group give it more often. Be guided by your vet on the best protocol for your cat."

 

The B12 tests, if they are similar to what TAMU runs, are only indicative of cyanocobalamin levels and have nothing to do with neuropathy. If the levels are low, it’s because of malabsorption and she needs cyanocobalamin.

 

Okay, so now I'm confused! Can she get the cyanocobalamin if she's low in that on the blood test and also get the methylcobalamin to address the neuropathy? Isn't the methyl the one that we want for the neuropathy/wobbly legs?