Percy seems insulin resistant and vomits frequently on empty stomach

Discussion in 'Lantus / Basaglar (glargine) and Levemir (detemir)' started by PercyJones, Jun 9, 2019.

  1. PercyJones

    PercyJones New Member

    Joined:
    Jun 8, 2019
    Hello FDMB, I previously posted this in the main forum and it was suggested I post here as Percy has been on Lantus for about a year now. Here is the link to the original post.

    http://www.felinediabetes.com/FDMB/...-vomits-on-empty-stomach.215422/#post-2387095

    I am a new member to the forum but I have been visiting the site from time to time since Percy was diagnosed with diabetes.

    Percy is a senior cat (13 years) and was diagnosed almost two years ago. After his initial diagnosis he went into remission for a few months after switching him to fancy feast pate. Ever since his diagnosis, he is constantly wanting to eat. I honestly don't know at what point he would stop eating. As a result, he has actually gained almost two pounds. He soon developed another problem where he would vomit on an empty stomach (only bile). So I broke his feeding times up into more frequent, smaller portions throughout the day. I had to buy those automatic feeders to make this possible. Feeding times and portions have evolved as I tried to find a good balance between total amount and enough feedings to keep him from vomiting.

    Currently, he is eating 4 cans of Fancy Feast pate per day. This is broken up over nine separate feedings per day. And in reality, he actually eats more than this because after inhaling his food, he finishes what the other cat left. Despite this, he still vomits at least once a week. I can tell that his throat is irritated due to the way his purring sounds. Also, occasionally there is a very small amount of blood in the bile that he vomits.

    Remission didn't last long and he had to go back on insulin about two months later. After going back on insulin, his sugar levels remained high 200s/low 300s for an extended amount of time and I slowly increased his dosage at my vets direction. Increased doses did not seem to help so he was switched to lantus. Initially, after switching to lantus, his sugar remained high for a few weeks, but began to come down again and reached normal levels of low 100s at a dosage of 4 units. This lasted for 6-7 months up until around Christmas time last year.

    During the holidays, I had to board him at the vet for the Thanksgiving weekend and he was so stressed while there he basically stopped eating. After he returned home he didn't eat at all for a few days, but eventually his ridiculous appetite returned. However, his blood sugar again rose to mid 300s and has stayed at those levels for the last 5+ months. Gradually increasing the dose of lantus didn't help. He is currently at 6.5 units.

    My vet is not too concerned about the sugar levels because he wasn't losing weight and she said she doesn't worry about diabetic cats that aren't losing weight. She said the vomiting problem is likely because of his pancreas and she gave me some medication for nausea and told me to give him a small dose of acid reducer (tried both omeprazole and Pepcid AC). Nothing seemed to help his vomiting problems and both acid reducers gave him diarrhea.

    I suspect that his sugar is higher has a lot to do with how much and how often he is eating. Basically, trying to balance his feeding amount/frequency with his blood sugar levels has been a nightmare. I haven't been able to find a balance and I am stuck because if I feed him less, I know he'll vomit much more frequently which will lead to the throat irritation becoming far worse.

    Any insight/advice would be appreciated.
     
  2. Ti-Mousse

    Ti-Mousse Well-Known Member

    Joined:
    Dec 2, 2018
    Welcome to you and Percy on the Lantus forum! Unfortunately, I can't help you with that health issue but my answer will bump your thread at the top of the list!
    Hope you get an answer soon and keep posting if you don't; sometimes on Sunday there's less people on site! :)
     
  3. Amanda and a Loudogg

    Amanda and a Loudogg Well-Known Member

    Joined:
    Jun 16, 2017
    Hello! I'm so glad you found your way to the L&L Board. We're so happy you're here! I quickly reviewed your previous post, and I agree with trying the Slippery Elm Bark for the vomiting. I've given it to my buddy Lou and his civvie sister Bella. We originally used the capsules (found HERE), and we're currently using loose powder (found HERE). It's definitely worth a try. I've just mixed it into their food with water (which I add water with each meal) and they have at it. Although I do know some kitties are not fond of the taste.

    I also agree with Wendy's assessment of testing for Acromegaly; however, I would also suggest including the test for insulin autoantibodies (IAA) as well. They can draw them both at the same time and they're sent to the same place. It would save you both time and money to do them at the same time. IAA is also a high-dose condition, where the body creates antibodies against the insulin. The insulin loses effectiveness as the antibodies work, so you have to keep raising the dose at controlled intervals to combat the the antibodies. My buddy Lou is an IAA-only kitty.

    I think your idea of feeding smaller meals multiple times a day is a great one. My civvie Bella will vomit up bile at certain times, usually if it's been a while since she's had a meal. With our current feeding schedule, they don't go more than 3 hours at a time without eating.

    Are you testing at home? I am concerned about the lack of at testing on the spreadsheet. We advise testing prior to giving insulin, both in the morning and evening to ensure it is safe to give insulin. Then we advise testing at intermittent times throughout the day/night to see how low the dose is bringing your kitty. Depot insulins like Lantus are dosed based on how LOW the dose brings the kitty, not how high they are at preshot. Testing more frequently as you are able would give you a better idea of how the insulin dose is working for your Percy. Please review the stickies at the top of the forum regarding dosing, our protocols (Tight Regulation - TR and Start Low Go Slow - SLGS), and other information, and let us know what other questions you have!!

    We look forward to getting to know you (What's your name?) and Percy better during this journey!
     
  4. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    Welcome to the group!

    It's perfectly normal for an unregulated diabetic cat to have a voracious appetite. Insulin is what allows the glucose resulting from food being metabolized to get into the cells. A diabetic's insulin is insufficient to do the job. When you are seeing high numbers, it means more insulin is needed to help the glucose get into the cells. Until a cat's numbers are better, your cat is literally starving because nutrition is not efficiently getting where it's supposed to go.

    I have a couple of thoughts, as well. First, please test each and every time prior to giving Percy a shot. While Lantus dosing is primarily based on the nadir, not all cats have their nadirs at +6. If you look at Gabby's spreadsheet (SS) in my signature, you'll see her nadir was early -- around around +2 or +3, except for those times when it wasn't. Nadirs can and do move around. Testing at pre-shot times insures it's safe for you to give insulin. Four shots -- one at each pre-shot time and one during the cycle are probably the minimum you need to be testing.

    With only one test per day, you have no idea if Percy's numbers are lower and his body is reacting by bouncing up into higher ranges. If you look at people's spreadsheets, you'll see that bouncing is a pretty common occurrence until a cat gets better regulated.

    Have you always been increasing Percy's dose by 0.5u? When a kitty is on 5u or less, we generally suggest increasing by 0.25u so you don't fly by what might be a good dose. Unfortunately, not enough insulin can look much the same as too much insulin. (I know, it doesn't make intuitive sense.)

    As Wendy and Amanda noted, once a cat is needing more than 5 - 6u of insulin, we suggest that you get your kitty tested for high dose conditions -- both acromegaly and insulin resistance. The labs need to be run at Michigan State. There is information on this in the post that I linked. These conditions are far more common than most vets have been taught. Roughly 25% of diabetic cats have a positive diagnosis. If your vet gives you a hard time, the best response is, "Humor me."

    This is a link to information on vomiting due to gastric acidity. I think you're on the right track with what you're doing. You might think about a treat ball for Percy to play with overnight.
     
  5. PercyJones

    PercyJones New Member

    Joined:
    Jun 8, 2019
    Thank you for that information on the Elm bark. I will check it out. I'll also make an appointment to get him to the vet for the tests you and others recommend. Thank you again for your help.

    I understand the appetite being a result of the diabetes. The strange thing is that he has been this way ever since I switched him to wet food after his diagnosis. That includes those periods of months at a time in which he has been regulated. He has had periods where his sugar has consistently been between 80 and 200 and even during those months he still ate as much as I would give him and was pestering me for more two hours later.

    The reason I only test him once a day is because Percy is a difficult cat. I have to do everything while he's eating. He makes it impossible to check his sugar unless he is distracted by food and while it's possible to give the shots to him while he's just laying about, he makes it difficult and jerks away often. Doing it while he eats makes it easy. I will try to do blood sugar tests before his injections but it will be a race to get that done and his injections before he finishes his food.

    In regards to the testing done at Michigan State, can I assume my vet would be aware of this? Despite his high dosage needs, the vet hasn't mentioned these other conditions as possibilities.

    Thank you for your advice and for the links.
     
    Last edited: Jun 9, 2019
  6. Wendy&Neko

    Wendy&Neko Well-Known Member

    Joined:
    Feb 28, 2012
    You mention that Percy jerks away from the shot. Lantus has an acid base, and some kitties will react to that, more often at higher doses. One possible solution to think about is switching to Levemir instead of Lantus. The insulin action is similar, but onset and nadir are a couple hours later with Levemir.

    My Neko had the acromegaly appetite, but quickly learned that getting a test meant getting a treat or two. The treat distracted her and rewarded her.

    Not all vets know about the MSU tests for high dose conditions. My vet thought that you didn’t need to test for acromegaly until they got over 10 units, so I had to ask her to humour me. Neko tested positive for both acromegaly and IAA and never got as high as 10 units.
     
  7. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    As Wendy noted, creating the association between tests and treats may help. I'd see if something like chicken hearts or gizzards would work. They are chewy. I use freeze dried mussels. They are very stinky, though -- which is why I think my cat likes them. Even 1/2 of a mussel may keep your cat's head in his bowl while you test.
     
  8. PercyJones

    PercyJones New Member

    Joined:
    Jun 8, 2019
    I called my vet his afternoon to find out if she knew about the tests for acromegaly and IAA. She called me back and told me she checked with her lab and was told that they can do the test for IAA, but that it is not often done as it doesn't change the treatment. She told me it would cost $125. I guess she didn't ask specifically about testing for acromegaly so I asked her to find out for me. I did mention Michigan State, but she seemed unaware (I live in Florida). So she's going to call me back tomorrow after she finds out more. I guess I'll see what she has to say, but I'm not especially confident I'll get a positive response.

    I was going back over everyone's response and saw mention of possibly having gone past his correct dose and giving him too much insulin as a result. What might I do to insure this isn't the case. Would reducing his dose significantly and then slowly increasing it again by .25 units be advisable?

    Edit: The vet just called back and the lab can do the acromegaly test, but it will cost $290. She told me that even if we can confirm that he has either insulin resistant disorder, it won't change treatment. Which basically would consist of slowly increasing dosage as I have been doing or possibly trying another insulin such as vetsulin.

    Thoughts?
     
    Last edited: Jun 12, 2019 at 11:44 PM
  9. Amanda and a Loudogg

    Amanda and a Loudogg Well-Known Member

    Joined:
    Jun 16, 2017
    I find myself annoyed with your vet. Knowledge is power, and it's ridiculous about what they're charging for these tests. Here's the link to the MSU Testing Catalog HERE. The test for acromegaly (insulin like growth factor-1) costs $58 and the test for IAA costs $18. My vet quoted me at $130 + shipping (the tests, shipping, the blood draw, and the vet's mark-up/profit), and it ended up being $155 total. I did send information from the MSU website on costs, so I don't know if that helped sway their pricing. They're generally not ridiculous with their lab test pricing overall. She is right about not necessarily needing to have an IAA diagnosis, since there isn't any treatment other than dosing based on the blood glucose numbers. However, I personally would need to know what is causing the numbers to be higher, why the insulin seems like it's not working, and why sometimes he has lower numbers for seemingly no reason. The knowledge does help, or at least it helped me immensely. It might be worth it to bring up MSU's pricing and ask for a price breakdown for their charges. There's quite a huge discrepancy with what they're charging, and it would be interesting to see where those extra hundreds are going.

    With Percy being at such a high dose, I'm leery of going all the way down and starting over. If you can try to test more to see what Percy's doing during cycles you might be able to catch lower BGs that indicate the dose might be too high (way to go getting preshot tests in!). We'll see what other experts think about this aspect.
     
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  10. PercyJones

    PercyJones New Member

    Joined:
    Jun 8, 2019
    Percy's sugar has spiked to well over 400 the last couple of days each time I tested.

    The only change I've made is I've been giving him some freeze dried chicken treats to keep his stomach full. I stopped giving him those treats yesterday. Tomorrow, I will be home all day so I hope to get a few more tests in. Eight hours after his shot is a good time to test, correct? Sorry, I'm sure its been said in this thread or my original, it's just a lot of information you guys have given me. I really appreciate all the advice, it's just kind of overwhelming.

    These 400+ tests have me very discouraged. His sugar levels have seemed to continuously risen over the last 6 months or so. Going from normal to where they are today. It feels like I'll never be able to reverse the trend.
     
  11. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    Your vet is not entirely wrong but like Amanda noted, there's more knowledge needed than your vet knows or is aware of.

    First, you need more tests. You've not posted a curve. Do you know when Percy's onset and nadir fall? From what's on Percy's spreadsheet, there's really no way to know what's going on with his numbers. If a cat is diagnosed with a high dose condition, there's a point at which the dose should be increased by a larger amount or decreased by a larger amount given the nature of the condition. At this point, there's no way to know if you're dealing with acromegaly and/or IAA or glucose toxicity.

    If it were me, I'd share the cost for labs at Michigan State with your vet and ask your vet to humor you and get the labs drawn and sent. BTW, there are a handful of vet schools that are resources nationwide for getting labs run. Michigan State had been the only place we've known that runs test for acro and IAA. TAMU (Texas A & M) dose a huge volume of labs for GI disorders. Most local labs do not get the volume and don't run specialized labs on a frequent basis.
     
  12. Bron and Sheba

    Bron and Sheba Well-Known Member

    Joined:
    Feb 21, 2015
    Sheba had the same problem with vomiting on an empty tummy and I solved the problem by giving her something small each hour during the night such as some chicken broth and maybe a small piece of chicken in an auto feeder and twice a day at 3 pm and 3 am I'd give her slippery elm bark slurry which I think is really good for tummy issues. It needs to be kept 2 hours away from medications though as the SEB will coat the tummy and stop absorption.
     
  13. PercyJones

    PercyJones New Member

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    Jun 8, 2019
    What is my vet not entirely wrong about? Is there a difference in treatment if I know if he has one of these conditions? Or if I know which one he has? If the treatment is to slowly increase his dosage regardless, I honestly don't feel like its worth it. It's not the cost I'm worried about. I'd pay it if there was a chance it might change things, but it's more about his quality of life. He hates the car. He hates the vet. He throws up every single time he gets in the car. The only time he isn't looking to eat everything in sight is when he gets back from the vet.

    The last time I had a glucose curve done on him, his numbers were still good and it was a very flat curve. His numbers were in the low 200s the entire 12 hour period. But then I got him home and he wouldn't eat for two days because he was traumatized by the stay at the vet. I can get that documentation from the vet and post it here if you think it would help, but those are old numbers from about six months ago.

    Thank you for the advice. I did get some slippery elm bark and have been giving it to him for a few days now. He has only thrown up once in the last week which is an improvement. And I did try chicken broth but he is not interested in it. I was shocked. It's the one thing I've found he won't eat. I had been mixing the SEB with water and some freeze dried chicken which he liked a lot, but this latest increase in his sugar levels coincide with my giving him the freeze dried chicken in between meals as a snack, so I want to see if his sugar comes back down if I don't give it to him. I will try mixing the SEB with his regular food.
     
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  14. Chris & China (GA)

    Chris & China (GA) Well-Known Member

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    May 10, 2013
    IDEXX now offers both IAA and Acro testing.....I wonder if the price quoted of $290 also includes a full Senior panel and that's why there's such a difference in the cost between IDEXX and MSU?
     
  15. Chris & China (GA)

    Chris & China (GA) Well-Known Member

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    May 10, 2013
    If it's IAA, then the treatment is increasing the dose until you hit a "breakthrough" dose....IAA usually resolves itself in about a year, so of the two diseases, your vet is most "right" about this one.

    With Acromegaly, there are other treatments like surgery, SRT and a drug called cabergoline that has had some success....but the main benefit to knowing if there's acromegaly involved is that it can be hard on other parts of the cat's body like the heart.
     
  16. Bron and Sheba

    Bron and Sheba Well-Known Member

    Joined:
    Feb 21, 2015
    If you are doing testing there is no need at all to take your kitty to the vet for a curve.
    Alphatrak Meters are expensive to run. Have you thought about a human meter?!
    As a treat you could give him a small piece of cooked chicken breast. That has no carbs. Or have you tried giving chicken hearts raw? They are a real treat for cats. Don’t give more than 7 a day though.
    How many times a day are you feeding him? We recommend dividing the food up into maybe three meals in the am cycle and three meals in the pm cycle. eg feed at AMPS, +3 and + 6 and same for pm cycle. That way Percy might not feel so hungry. Also adding some water to the food fills them up a bit more.
    Was he a hungry cat before the FD? Unregulated FD cats are almost always hungry but so are some cats who aren’t FD cats. One of my current cats who is not an FD kitty is always on the lookout for food. Don’t lose heart. Cats that have fallen out of remission are almost always harder to get regulated...... except for the odd one that does as it’s told!
     
  17. PercyJones

    PercyJones New Member

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    Jun 8, 2019
    It's hard to say if he was a hungry cat before the diagnosis. We fed the cats dry food and just kept the bowl full, not really knowing any better. Whenever the bowl would get close to empty, Percy would start bugging us for food. It was a joke between my wife and I that he was upset because he could see the bottom of his bowl. I do wonder if part of the vomiting is in his head as he must constantly be thinking about food. His feeding schedule is below. He is fed Fancy Feast 3oz pate.

    6:00 AM - 1/2 can (shot)
    9:00 AM 1/4 can (autofeeder)
    11:30 AM 1/2 can (autofeeder)
    2:30 PM 1/4 can (autofeeder)
    4:15 PM 1/2 can
    6:00 PM 1/2 can (shot)
    8:30 PM 1/2 can
    11:00 PM 1/2 can
    3:00 AM 1/2 can (autofeeder)

    So that's four cans a day, but keep in mind that our other cat almost always leaves some of his food which Percy most certainly eats during those times when they are fed by the autofeeder. This schedule has evolved as I try to keep his stomach full so he doesn't vomit. As I noticed times where he was vomiting, I tried to break up those feeding times into smaller chunks.

    I've tried the treat approach prior to testing in the past, he simply does not let me stick him unless he is actively eating something. As I said in an earlier post, I tried the freeze dried chicken breast recommended by another poster and both cats loved it, but my giving him that has coincided with this latest increase in sugar levels so I've stopped for now to see how that affects his sugar.

    What are the benefits of a human meter? I got the alphatrak2 because that's what was suggested as the best option.

    I am going to try to get a curve today. We'll see how it goes.
     
  18. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Well-Known Member

    Joined:
    Dec 28, 2009
    The benefit of a human meter is that the strips are way less expensive.

    There are other freeze dried proteins. You can usually find them with the dog treats. If the only ingredient in the chicken treats is chicken, it shouldn't have a huge effect on numbers. Jill had said that Alex's numbers would bump up by about 30 points given that Alex was very sensitive to the effect of food.

     
  19. PercyJones

    PercyJones New Member

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    Jun 8, 2019
    I managed to get a curve done yesterday. Let me know what you guys think. Wondering if I should increase his dose again.

    Thanks again!
     

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