Tubby the acro cat -- have questions

So I started the Acro dance with Tubby a little over a year ago, after adopting him from an elderly owner who couldn't properly care for him. Our original post is here: http://www.felinediabetes.com/FDMB/threads/any-acro-folks-around.140825/

Since then, his ear and skin infections have cleared and he's relatively healthy and happy. He still battles constipation (it has sent him to the ER and has also required surgery to remove blockages) and is a high-dose kitty at 12u Prozinc + 3.5u R BID. He has the classic clinical signs of acro and his IGF-1 is 218.

A year ago, we did a full workup at the university to determine whether he was a candidate for SRT. Bloodwork looked good, X-rays and ultrasound showed enlarged organs, his heart showed mild thickening of the interventricular septum, but there were no show stoppers. My vet conferred with CSU and they recommended a CT scan before making the trip there -- they said the pituitary tumors must be visualized in order to target them with SRT, but in a very small percentage of cats (2% or so) they're not visible, and so it would be a wasted trip if that was the case.

Even though CSU said they'd have to redo the CT scan there, it's a long trip so we went forward with the CT locally just to be sure. And of course Tubby was in the 2 percent.

With no tumors visible, I was told to wait a year and reevaluate. MRI was never mentioned.

So here we are a year later. We just re-did all of the same tests and everything is pretty much status quo, although the pituitary gland is a bit larger.

The university vet has been trying to reach someone at CSU to consult with but hasn't had any luck yet. I also put in a request for a consultation.

I have a lot of questions and was hoping some of you might have some insight.

1) Have any other acro cats had tumors that couldn't be seen on CT scans? What did you do?

2) Did any of your cats also need dental work? How was that prioritized vs the SRT? (Tubby has a few cracked and erupting teeth and is scheduled for a dental in late October, but the vet said some forms of radiation can impact healing so we need to ask q's).

3) Have any of your acro cats shown thickening of the intestines on abdominal ultrasound or have an actual diagnosis of IBD or intestinal lymphoma? Did you go forward with SRT? Do further diagnositcs? (Tubby shows thickening of the 3rd layer of the intestines, though shows none of the typical signs of IBD or lymphoma--unless constipation counts, that is).

4) When switching from Prozinc + R to Lev, is there a general guideline for where to start on dosage? I hadn't been able to shoot an exact 12-hr schedule the past year so stuck with Prozinc. I just picked up the Lev prescription, though, so am thinking about moving in that direction.

Thanks everyone!

 

Hello again - Neko and I have been to CSU twice, the first time 4 years ago. 3 years later her insulin needs were rising quickly and I expected her tumor was coming back so we went again. Both times her tumor was visible on the CT scan. But they did a quote for an MRI, in case it wasn't visible on the CT. When I discussed it with them, they said they did have some cats who's tumors did not show on CT and had to go to MRI. That also had one cat that showed on neither but they still proceeded with the treatment. If you PM me, I can give you the contact information of the radiatiion oncologist I dealt with. Dr. Yoshikawa was great to deal with.

Neko has had several dentals. In addition to tooth work, she also had a bony growth on the jaw that had to be removed. She had one dental before SRT and 3 afterwards. We did the ones afterwards as needed but it was quite a while after the first radiation treatment. Due to her heart condition now, she has had no dental since the second SRT and will not have any more.

Neko also has thickening of the bowel and has been diagnosed with IBD/lymphoma. Again because of the heart we are not getting a biopsy for a definitive diagnosis but we are going by what is seen on the ultrasounds. This was first diagnosed this May, last SRT was last November. And yes, constipation counts as a sign of IBD. Neko did the odd foamy vomit plus try poos and that was her only signs. She also has CKD and is on buprenorphine so lots of reasons to be constipated.

Do you have a spreadsheet for Tabby? Typically we start around the same dose of Lev as Prozinc, though some cats can show a strong initial reaction, so recommend doing the switch when you can monitor closely.

 

You may want to check out this thread
http://www.felinediabetes.com/FDMB/threads/leo-leoberry-the-high-doser.163717/
@JeffJ is keeping a great diary of his SRT journey.

 

Hi JL - please note I'll be busy over the next 3 days. The trip to CSU starts Saturday and is 2 days driving. I will answer any questions you have. In summary, Jeff and Leo's CSU trip is Sept 17-Sept 24 - starting in 2 days (Austin, TX -> Ft.Collins). Consultant assigned to Leo from CSU is Beatrix Janei - Radiology Resident.

Now, answers for Leo.

1) tumors on CT scans?
I'm taking a chance and just going there. I hope Leo is not in the 2%. I am sorry that Tubby was.

2) Dental work?
Leo is fine on dental.

3) Intestinal signs?
Leo may have some, we didn't image those. His external symptoms are:
- lower jaw growth = prognathia
- clubbed feet and heavily thickened claws
- slightly larger abdomen than normal
- neuropathy from diabetes
- His acro is confirmed, IGH-1 is 305.

4) Prozinc to Levemir
Leo just switched. Prozinc was way too expensive. Look at the "prices and notes" tab on Leo's spreadsheet. I reduced the dose too much when changing to Levemir. Leo was far more responsive to Prozinc. But at 18u per shot, I would be spending $130 every 11 days = $12/day just on insulin. That's ~$4,050/year. That's not viable. In summary, Prozinc was more effective than Levemir, but too expensive.

Leo has been almost impossible to regulate. I am careful and give him just enough food to maintain weight. Yet his BG on Levemir is 220-350 including nadirs. Without some change, this high BG is doing him in. His neuropathy has progressed considerably in just 2 months.

Please PM me if I don't see your questions. I will respond by Monday, when I'm at Ft Collins, mostly being bored and enjoying some actual cool weather.

I dont' know what the "+3.5u" means in your post, from sentence "12u Prozinc + 3.5u R BID". I dose Leo BID @18u each time.

 

Thanks for all of the GREAT information.

We heard back from CSU today and it was enlightening. Our vet had forwarded Tubby's test results, CT scans, and case history to CSU and, after discussing his case in detail, they are absolutely comfortable labeling him "acromegalic," even though the tumors are presumably microadenomas rather than macroadenomas (and therefore not visible).

They also believe he is a good candidate for SRT. We'll be getting more information next week, but it sounds like they're comfortable proceeding even without visualize the tumors. Thank you @Wendy&Neko for mentioning that possibility. It completely contradicts what we were advised a year ago but I was at least able to prepare questions knowing that the option exists. I hate that we might have lost a year unnecessarily, but it is what it is.

I'm curious about the suspicion that SRT might adversely impact the kidneys. Can anyone explain the theory or hypothesize as to why? Is it the actual radiation (given how targeted stereotactic is supposed to be, that doesn't seem intuitive)? Or the back-to-back anesthesias? Or impact on other pituitary functions ... thyroid perhaps? Tubby's Creatinine and BUN are normal but he's throwing significant protein in his urine, with no UTI, so of course kidney status is always on my mind.

Has anyone tracked kidney function closely both pre-and post-SRT to monitor changes?

What do most acrocats who have SRT ultimately die from?

According to my vet, CSU said that the outcomes are similar whether they target visible tumor cells with SRT or irradiate the entire pituitary. I'm having a hard time wrapping my head around that. I mean, if that's true, why target visible tumors at all? Why not just irradiate the entire pituitary on ALL acro cats and catch all of the microadenomas that might be lurking unseen as well?

The vet and I also talked about the net difference between hypophysectomy vs irradiating the entire pituitary gland (as would occur for Tubby if no tumors are visible on MRI). It's academic, I suppose, as there's no practical option for going the surgery route at this time.

As for switching from Prozinc to Lev ... any thoughts about timing? Does it make sense to dive into that before SRT or wait until after? I'm almost more comfortable with an in-and-out insulin at this point and continuing to use R boosters, but I am willing to switch now if needed. I'm just not sure how many variables I want to add to the equation.

@JeffJ - safe travels, and I'll be watching your story closely. As for Tubby's dosing, the "12u Prozinc + 3.5u R" reference means that Tubby gets 12 units of Prozinc PLUS 3.5 units of "R" insulin (a VERY fast-acting and short-duration insulin) twice a day. The R is used as a "bolus" insulin to help control Tubby's high numbers and offset his food spikes. It requires extreme caution as it can be quite harsh and downright dangerous if one doesn't understand its power.

Finally, has anyone seen their acro cat throw lower than typical numbers after being bathed or perhaps after traveling in a car or going to the vet? I've noticed a phenomenon with Tubby whereby his BG tanks every time he gets a bath or goes on a several-hour car trip, and he hangs there for up to 12 hours. Nothing else changed (same type and volume of food eaten, etc.) but I start seeing almost normal BGs and we end up in a no-shoot range. It's really quite peculiar, but it seems to be repeatable. I'm wondering whether stress can cause the reverse of what we see in normal diabetic cats (i.e., stress in this case lowers rather than raises BG?) ... I dunno, cortisol release or something triggers the tumors to secrete less or the insulin receptors to be more available?

No spreadsheet for Tubby yet. I might need help with that. I have ancient spreadsheets for my other two GAs but haven't logged on in years and need to track down my logon credentials. :-(

 

Thanks for the info. As far as tanking. Leo has only tanked twice. And today was the day. I think it was due to lack of food. He probably ate 1/3 of normal. I have reduced his dose to 2/3 normal, and fed him more than normal dinner. At this point I will change nothing, except as a response to the SRT after it occurs. But if you look at Leo's numbers, he has been almost impossible to regulate on levemir.

SRT for Leo will be in several days - Wed, Thur, and Fri. Theresa and I share your concern about timing and missed treatment. Our primary vet is uneducated on SRT and Acro. She only had 2 Acro cats prior, and they passed soon. We should have sought out another vet or a specialist 8 months ago. It is easy to sit back and armchair quarterback our situation, but life is also busy and has been with us.

 

Hi! Interesting question about stress lowering blood sugar. I think it is definitely possible, and probably one of those ECID (every cat is different) things. I'm not sure that it's related to acro or not, or just an individual response. Punkin never exhibited higher blood sugar in response to stress. One time we were at the vet when he was having low numbers - I took the meter and gravy with me and kept testing him while in the waiting room. There was a loud slobbery barking dog being weighed probably 6' away from us and it didn't increase his blood sugar.

The record of punkin's SRT is in my signature line, including lots of information about it, although we had it done 5 years ago (this week) so things may have changed some since then.

Punkin had 2 dentals done - the first was done by basically a country vet, followed by an infection, antibiotics, and a c. Diff. infection that was 40 days of antibiotics to kill. The next dental, done after his SRT, was done by veterinary dentist. Far more expensive but I felt he was fragile and wanted more than a country vet doing it. You can click here to find an accredited veterinary dentist - luckily, the one closest to me came into my town once a week or so.

Most of the high dose kitties are on the Lantus/Lev insulin support group. We've had doses there as high as 80u + R. You are welcome to post there where you'll find a lot more support and help.

Welcome back to FDMB - and kudos to you for adopting Tubby!

 

Sorry for the late reply, for some reason I didn't get the notification.

First, the kidneys. Proteinuria is a common symptom of acrocats. Neko's had proteinuria (and is taking benazapril) for a couple of years now. If your vet hasn't started Tabby on that, you might want to discuss it. Proteinuria is hard on the kidneys. There is no tie between proteinuria and her SRT treatments. As for damage to kidneys, any anesthesia that can damage kidneys. Neko went into her last SRT when she was at stage 2 of CKD, and they had me do bloodwork the week before and week after we returned last November. Fortunately we were lucky that there was minimal change at that time, though it turned out we only had 2 instead of 4 days of anesthesia due to her heart block that showed up after the first day of antesthesia. One other possible side effect on kidneys is from the thyroid. Some small percent of SRT kitties go hypothyroid (punkin was one of them), and with those kitties you need to give thyroid meds to protect the kidneys.

As for throwing lower numbers at the vet, yes, Neko has done that before! Not sure whether it's the impact of the vet or just what she would have done normally that day. But our 3 day road trip back from Fort Collins was rather exciting as Neko decided to start earning reductions within days of her SRT treatment. Either that or her IAA decided to pick that inconvenient time to break.

There isn't really good data on this. I'm not sure anyone is tracking this. I've seen some pass from heart conditions - and those had heart issues going into SRT so the SRT slowed down the progression of the heart disease. Other kitties have gotten whatever nasties older kitties can get. Neko's got kidney disease and small cell intestinal lymphoma battling it out, with a side helping of heart issues.

Glad to see you've got a spreadsheet going , and some greens. The timing is really up to you on switching to Levemir. It does take a little while wrapping your head around the change to a depot style insulin so you do want to do it when you can monitor and post here (or Lantus/Leveir board) regularly for help.

 

Hi JL

I was just looking thru old posts, and I see that Tubby has made the journey to the Rainbow Bridge in October 2017. It was about one year after his SRT treatment.

The candle that burns the brightest, also burns the quickest. I'm sorry to see that Tubby was with you for such a short time. I hope he enjoyed his time with you, and I hope he had a safe journey to the bridge.

....Jeff

 

Thank you, Jeff.

For awhile it seemed we were running a parallel path with you and Leo ... SRT at around the same time, high hopes, a few setbacks, lowering insulin doses, then GI issues, and so on. Leo found his way through it all but Tubby kept racking up more and more complications. He had a sharp decline in kidney function and didn't respond to treatment. Sigh. He hid a lot from us over the years, as cats often do.

Thanks for noticing and posting. Means a lot!

 

I am so sorry for your loss. Our acros are such tough kitties, but they have so much going against them.

 

So sorry for your loss. Rest In Peace Sweet Tubby

 

You and Tubby fought a valiant battle together.

 

Thank you all for the kind sentiments. Tubby had a rough final month and I still replay some of it in my mind. Acro really is a beast and even the experts missed and/or misinterpreted some things. He was such a trouper through it all. Wendy, I thought of you and Neko as I sat in the quiet, dimly lit room at the university during Tubby's final hours, he cuddled in a heated bed on my lap, me racking my brain for a medical "hail Mary to the end zone." Jeff, I thought of you and Leo too.

They teach us a lot, these acro kitties. And they take a piece of us with them ...

 

Over a year later, some moments are still on playback with me too. They definitely teach us a lot.