01/13 Fortune AMPS 285 +8 471 PMPS 527 (!) skipped dose vet visit

Yesterday

I’m so upset on so many levels.

We did not give Fortune his insulin dosage or feed him this morning at the direction of the vet office, for his ultrasound today. When I dropped him off (cuz COVID), I reiterated to the vet tech that took him he is diabetic and had not had his insulin. Could they please administer the insulin and feed him when possible? “No problem.”

I spoke to the vet at 3:50pm about the U/S, and he asked how much insulin Fortune got this morning(!) when he was prescribing a new regimen based on the results of his scan. I let him know that I did not give him insulin, which is what the office told me yesterday when I called to ask. “OK,” he told me. ARRRGH.

I got Fortune home around 5pm because of bad traffic, and sure enough his sugar is SKY HIGH! Bunny had a stressful day, and on top of it all he isn’t feeling well because of his high BG. I should have administered his dose today. So mad at myself for trusting the vet office.

Regarding his results…looks like he is out of remission. His intestinal lining is thick again and “angry,” and his pancreas is slightly enlarged, but thankfully no lymph nodes.

The vet wants to aggressively tackle the inflammation to get it under control. He prescribed a 50% increase in the pred, and wants to go to 2 IU. We discussed that the pred is contributing to the diabetes, and that we will have to increase the insulin to manage it.

The good news is his liver looks better than last time, and the pancreas involvement is mild, so the vet doesn't suspect triaditis or pancreatitis.

I brought up budesonide as an alternative to pred. He is familiar, and even though is it local vs systemic and does not impact BG, he shared that it is just not “as efficacious,” and clinically he doesn’t see the same results. He is confident we can manage the diabetes better with an increase in pred because of the home BG testing.

With the lack of a shot this morning, I’m not sure how best to approach the next dose, and if we should straight away jump to 2. In the TR guidelines it does say that you can increase .5IU at a time. However, would we do the shot at the same time this evening, or can I move the time up since we skipped?

His numbers are so high today, and I feel so helpless right now! He looks even skinnier after the vet, if that's possible, and the new vet techs seem so incompetent.

 

How frustrating! You have only had 5 cycles on 1.5. It’s suggested you increase after 6 if needed. I would shoot 1.5 tonight. If you prefer to increase tonight, you could take him up to 2.0. Since you skipped you can shoot at any time that you want to be your insulin time, as early as you like keeping in mind your next shot will be 12 hours from whenever you shoot. .

 

Thank you @tiffmaxee ! Yes, it is excruciatingly frustrating. I'm writing a strongly worded email to the vet, since I am still so very upset about it. I trust him and his office to take care of Fortune when he is in their care.

Oh, and that's awesome we can adjust the time! We have been moving up slowly in :15 minute increments at every shot, since the shooting time in the PM was so late (until we understood we needed to be strict about the 12 hours) but it was going to take us awhile to get to 8pm. That means I'll be able to get a +2 AND +4 reading tonight! Woohoo!

I will consider waiting another cycle to go to the 2IU. It makes sense to do that, and I know that is in the TR guidelines, I am just not clear why it's 6 cycles.

TBH I'm so nervous about increasing the prednisolone when he is still so unregulated. Poor boy's numbers are so high for so long.

 

The skipped shot actually requires you start the 6 cycle count over again. Given the use of prednisolone see what others think about increasing in the morning. I understand why you want to do it. I’ve ne Er increased sooner though. How much prednisolone is he getting and what is the new dose? With scl prednisolone is probably best considering the ultrasound showed thickening.
@Wendy&Neko Im tagging Wendy because she has lots of experience with scl and IBD unfortunately.

 

Does that mean six cycles on the old dose? Yikes! That makes me so nervous. Is there a downside to dosing up, or holding off? Would that cause "bouncing?"

He was on 5 mg. Going up 50% to 7.5 mg (1.5 tabs). I'm so sad because his July ultrasound showed he was in remission, but his diabetes has been out of control since May!

 

I don’t think I would wait for 6 cycles. I think based upon your numbers I would increase in the morning. See what Wendy thinks.

 

How frustrating on the miscommunication with the vet! The one bright side being able to easily reset your shot time. Is this vet an internal medicine vet? The recommendation of the SCL group to get an internist is a good one. I found it helpful to have one on board when managing multiple diseases. As my vet said when she "fired" me to the IM vet, it was beyond her pay grade. Always good to have a vet that knows their limitations.

Since you have seen yellows on the 1.5 unit dose, your next increase would only be 0.25 units.

 

He is a generalist, but I know he consulted with an oncologist and internist before recommending repeating the ultrasound. We saw an internist to get the SCL diagnosis back in 01/18, but it has been managed by our generalist vet since. Since joining the SCL group (thank you so much for the suggestion!), I re-reviewed the pathology report and it was inconclusive So we are not 100% sure if it is IBD or SCL. I'm waiting to post an update there until I have the full u/s report in hand, since my memory is not the best and they tend to ask very detailed questions - which is great, I just want to be prepared!

I do want to get a second opinion at this point. It feels weird to look for an internist without telling him, but I also am not sure if I feel comfortable asking for a referral. UGH. For some reason having it be a second opinion vs switching feels more manageable.

Thank you for the guidance on the dose! So tonight we would keep the 1.5 IU, and dose up tomorrow morning to 1.75 IU for at least six cycles? We haven't gotten the syringes that indicate .25 yet (they are coming!) so will be eyeballing it...

 

You usually will require a referral to an internist. If current treatment is not working or he is out of remission, I think it's fair to ask for a referral. You can still call it a second opinion. I didn't completely ditch my vet after starting to see the internist.

 

I just emailed him asking for that, along with sharing my thoughts on skipping the insulin dose.

Just checked his PMPS - 527!!!

He looks so peaky too. I really hope he finishes all of his food. This is before we increase the pred tonight as well. Worried about it going up from here.

@Wendy&Neko @tiffmaxee Just so I'm clear, we are going to do 1.5IU tonight and then 1.75IU in the am, or could we do 1.75 tonight? Is there are risk that we are going to see more bouncing?

Thank you!

 

Ok so we gave him a 1.5IU dose - compromise with DH was to shoot at 8:30/20:30

 

Don't forget to fill in his PMPS tonight and the dose on the SS

 

Since he’s so high I think I would increase tonight.

 

Already gave him his dose DH is giving him another .25 IU separately.

 

No. Don’t give more. You don’t want to do that ever. Start in the morning.

 

When you shoot twice you can get two different nadirs. You never shoot a second time if you give a fur shot either in case any got in.

 

Crap I just looked at her SS and see her husband must have given him the second dose of 0.25 u. She probably didn't see this in time Elise
I hope he will be ok tonight
@tiffmaxee

 

I answered the second I saw it but she didn’t see my response.
How long after was the .25 given?

 

Crap. DH already shot the extra .25 IU. about 15 min after the first one. Oops.

We'll keep checking his BG tonight at +2 and +4. Is there anything we should be looking for?

 

Since it was so close together I think all will be fine. I’ve never encountered this before. He might reach nadir twice. Since the two were so close together maybe it won’t make any difference. For the future you now know.

 

Looks like all is good.

 

Looking for your new thread. I see a nice start after the skipped dose yesterday. A +2 is a good idea.

 

I'm looking also Elise