I've been thinking for a while that i would like to share some of punkin's story, in the hopes that it might help some future cat diagnosed with acromegaly. it's been a very educational year for us - i've learned a lot and have only one regret about the choices i've made along the way. Punkin was diagnosed with acromegaly within a month of 3 other cats all using Lantus: Gus, Tommy & Guinness. Before the diagnosis was made, all of us were following the TR Protocol, trying to push our cat's BG into the 50-100ish range. With each diagnosis, others with acro cats would pass on what they understood about treating a cat with acro. Bev, Lauren, Linda & I all heard the same comments: "Blue numbers are an acro cat's greens." "Acro cats have a working pancreas. They can't go below 100. If you give them high carbs, their pancreas will kick in, pushing the BG even lower." "You can't pull up the BG of an acro cat with a small amount of carbs. If he goes below 100, open a can of high carb food and give him the whole thing." "don't give an acro cat pills." Like the others, I was devastated by the diagnosis and confused by all of the advice. I'd been following TR and pushing punkin down into lower BG's and he seemed to come up just fine with a little bit of high carbs. Was he suddenly different because of the diagnosis? Did he read his condo like everyone joked about and would he now respond differently to carbs? It didn't make sense to me, but I treasure the little guy, and above all else wanted to keep him alive. So when the diagnosis arrived, i immediately let his BG numbers drift upward. Holding them between 100-200 was pretty impossible, so i settled for letting him go as high as he went, but trying to get the nadir to about 100. As with everything with feline diabetes and cats, easier said than done. At first we were just going to increase the dose as he needed, but as i have written about in the post on Punkin's SRT, we changed our minds and took him to CSU to be treated in September 2011. Since that time i've done a lot of research on acromegaly and especially on Feline Diabetes & Glucose Toxicity and exactly what happens in the cat's body with diabetes. I've also studied many spreadsheets of cats with acromegaly to see what different tactics people have taken. Tommy's IGF at diagnosis on 5/14 was 313. He was 15yrs old. Lauren left the forum and has managed Tommy's care on her own. Lauren continued to follow the TR Protocol, and Tommy has seen green numbers under 100 pretty much every day since that time. The highest dose he got to was 12u, in a combination of Lantus and a small amount of R (1unit or less). he is currently getting 4.75 units per dose. Tommy's SS Gus was diagnosed on 6/1 with an IGF=220. Bev also continued to follow the TR Protocol, although like me, she backed away from the green numbers. The highest dose Gus had was 11.5u. He passed away in February at the age of 16 of unknown causes, not diabetes-related as far as is known. At his death he was on a dose of 7units. Gus' SS Punkin was diagnosed on 6/1 with an IGF=281. I did not follow the TR Protocol, but instead kept punkin above 100 all the time. Not quite 4 months later when Punkin had the SRT done, he was at a dose of 15.5u. I learned more about the risks of high numbers and more about the consequences of glucose toxicity in January 2012, and returned to following the TR Protocol at that time. Seven months after the SRT, punkin is on a dose of about 7units and he is daily in green numbers. Punkin's SS Somewhere in the past couple of years the idea came up on FDMB that cats with acromegaly can't go under 100 because their pancreas still works. This was based upon the idea that if the pancreas still worked, when you gave a cat high carbs, their pancreas would go into overdrive, pumping out insulin, which combined with the insulin you've injected would cause a cat's BG to drop even lower. This was the source of the advice we received when our cats were diagnosed. I have searched for spreadsheets showing evidence of this and have not found any. If this premise were true, cats with acromegaly would never see a food spike. you would feed them and their BG would drop. it wouldn't just occur when the cat had low numbers, it would occur all the time. scientific evidence is a test that is repeatable with the same outcome. I have been unable to find any evidence of an acro cat's BG dropping from being fed. To the contrary, I've seen many repeated examples of a cat exhibiting a food spike when eating. Punkin always does. There are cases where a cat is simply on a freight train with their BG going down, usually when they are clearing a bounce. Outside of that particular situation,I have not seen cats whose BG dropped upon eating, acro or not. As best as i have been able to ferret out, I believe this idea came from a situation where one cat had an experience that scared the owner, and the warning was repeated until it became a rule. The simple way to determine this for your own cat is to try it out. give your cat high carb food and see if it will counter the effect of the insulin and increase the BG. If the BG increases after eating, there is evidence for you that carbs bring up your cat's BGs. If your cat doesn't exhibit an increase in blood glucose from carbs, then perhaps you have a cat that is less carb-sensitive. It would benefit each of us to determine this for our own cats, including exactly what amount of carbs might be needed to pull their BG up if it goes low. On the other hand, it is entirely possible & likely that the larger the dose of insulin being injected into a cat, the more carbs it might take to raise their BG, and the longer it might take. Lantus and Levemir are both longer-acting insulins that form a depot in the body and slowly release. The larger the dose, the larger the depot, the longer it might take to work through low numbers. This would be a factor of dose size, however, not whether or not the cat is acromegalic. Personally, the size of the dose concerns me far more, in regards to treating low numbers, than the fact that a cat has acromegaly. the larger the dose, the more care i would take. In fact, the desire to avoid a large dose would be enough for me to be aggressive in keeping punkin's BG under 100 as much as possible, if i had it to do over again. after Punkin's SRT, we experienced sudden drops in the growth hormones put out by the acro tumor, causing an immediate drop in the amount of insulin needed. That process caused by that radiation mimics the natural process of the tumor pulsations, in effect, causing the same issue that might arise if a cat's tumor pulsations "shut down" some. At least what we experienced was not so sudden that it isn't manageable. There is also some evidence that by keeping a cat's BG consistently down, one may avoid Glucose Toxicity, in which the cat's body becomes accustomed to higher BG numbers and develops a resistance to the insulin. This causes a need for greater and greater volumes of insulin in order to pull the BG down. Sustained high blood sugar also contributes to the failure of the pancreatic beta cells and amyloidosis. It is worth reading and learning about these complications for cats. I have wondered what the reason might be that acro cats who are kept on Tight Reg with their numbers mostly under 100 seem to maintain lower doses. Do their pancreases supplement the insulin being injected? Do the lower BG's simply prevent glucose toxicity and the need for greater and greater doses? I don't know. But the evidence was there that if we had not had the SRT, by allowing punkin to be in higher numbers, we were on the path to much larger doses. The flip side of this is that while acromegalic cats would have had a working pancreas initially, any cat who remains in high numbers long enough will suffer irreversible damage to their pancreas. The research by Rand indicates "at a blood glucose concentration of 30mmol/540mg, insulin secretion is minimal by 3-7 days in previously normal cats" http://www.uq.edu.au/ccah/index.html?page=43391&pid=0 It is worth noting that many cats with acromegaly follow the Tight Regulation Protocol developed by Rand Roomp with good success. Here are some spreadsheets that give examples of that: Porscha Buckwheat Chika Boo (had SRT) Milo (had SRT) From the German Katzen Forum, which follows the Tilly Protocol, essentially identical to the TR Protocol: Kimba Josey I think it's helpful to remember that ECID isn't just a slogan - it's the truth when it comes to cats. Every Cat Is Different. That includes cats with acromegaly or other high dose conditions. If there was one thing I would've done differently in this journey with punkin, i regret that i spent 7 months being afraid of letting him go below 100. I wish i had continued with the TR Protocol the entire time and believe he would be better for that. I look at Tommy's spreadsheet and see a spreadsheet that is enviable among cats with acromegaly. I understand that people give advice based upon their understandings and I truly believe all advice given to me was well-intentioned. But my primary failure was in not remembering that the burden was upon me to know my own cat. Punkin could go below 100. Punkin's BGs could be raised with high carb food. Punkin can take pills without trouble. Blanket statements do not serve anyone well. Nothing applies to every cat. For what it's worth, I hope this serves those to come in the future who are faced with decisions on what to do after a diagnosis of acromegaly. Doing it over again, I would have stayed the course with the TR Protocol.