4/18 | Jude: AMPS 132; +4.5 94; +8 87; PMPS 104; +3 74; +5 74

[Marielle]

yesterday's condo

Dang--he's not holding onto that preshot green like he did last night! I hope, at least, we'll see some greens this cycle.

And I hope everyone else sees some greens today, too!

Have a lovely Good Friday!

 

[MinnerPip]

I'm off Friday to Sunday. I think I'm going to take him to the vet tomorrow for a cystocentesis. Whether I do or not will depend on his p.m. and a.m. preshot numbers. It's kind of weird to me that he's going up and down, and I would think that if he has a UTI that his numbers would be going up. I just hate to take him for the test because it's not fun for him. So I'll see. What are your thoughts?

Hey … here’s some other info on water consumption. This is page from Vet Clinics of North America: Small Animal Practice book on Feline Diabetes.

 

[Tim & Pookey]

Hey … here’s some other info on water consumption. This is page from Vet Clinics of North America: Small Animal Practice book on Feline Diabetes.

View attachment 73602

This is interesting, I don’t know much about UTIs or CKD but it looks like they’re claiming increased water intake for both, at least in the case of this one cat. Good to know as an indicator.

 

[Marielle]

Hey … here’s some other info on water consumption. This is page from Vet Clinics of North America: Small Animal Practice book on Feline Diabetes.

View attachment 73602

This is interesting. Jude's thirst has never increased when he had a UTI. But, since I've had him, I've given him water in his food, so I'm basically forcing water into him. The only time his thirst increased was when he was first diagnosed with FD. He laid next to the water bowl and drank nearly constantly. And I was also giving him water in his food at that same time. Is it possible to give them too much water? I need to do that calculation on the 20mL/kg/d on Jude and compare to that.

Is that book something you'd recommend?

 

[MinnerPip]

This is interesting. Jude's thirst has never increased when he had a UTI. But, since I've had him, I've given him water in his food, so I'm basically forcing water into him. The only time his thirst increased was when he was first diagnosed with FD. He laid next to the water bowl and drank nearly constantly. And I was also giving him water in his food at that same time. Is it possible to give them too much water? I need to do that calculation on the 20mL/kg/d on Jude and compare to that.

Is that book something you'd recommend?

Yes. I love this book. It was expensive and that’s why I have not ever posted about it. I found indications that there may be ways to get downloaded copies of it for free or very low cost but I could never find an actual path that worked so I bit the bullet and bought the hardcopy book. I personally like having all this info in one place. Here are pics of table of contents in case that helps. Note also this was published 2013.

 

[Karolina & Nestle]

Hoping he slides down for you and shows you some green

 

[Maddie & Kai]

Yes. I love this book. It was expensive and that’s why I have not ever posted about it. I found indications that there may be ways to get downloaded copies of it for free or very low cost but I could never find an actual path that worked so I bit the bullet and bought the hardcopy book. I personally like having all this info in one place. Here are pics of table of contents in case that helps. Note also this was published 2013.

View attachment 73603

View attachment 73604

View attachment 73605

Have you found that most of the information aligns with what we practice here on the forum?

 

[Marielle]

@MinnerPip, I've been looking around, and I notice that a new 2023 issue of this journal focused on Diabetes Millitus in Cats and Dogs was released. Here is the link: https://www.vetsmall.theclinics.com/issue/S0195-5616(23)X0003-5. It looks like the subscription is $411, and that gives access to the printed as well as the online versions (for one year). I'm going to check with my vet to see if they have a subscription, and maybe he will let me read his copy (probably not, but it can't hurt to ask). I notice in the preface to the volume, which is free, Dr. Gilor writes this:

"If we could have three wishes for the management of diabetes in dogs and cats, they would probably be these:
1.That diabetes mellitus be viewed not as two specific diseases, type 1 and type 2, but as a syndrome of glucose dysregulation of myriad causes and mechanisms.
2. That the frustrations suffered by veterinarians and their clients over the treatment of diabetes in animals be quelled by understanding of the pathophysiologic basis of modern insulin therapy, and by setting clear and reasonable expectations for treatment outcomes.
3. That traditional blood glucose curves, misleading as they are when performed by intermittent sampling of blood glucose throughout the day, would cease to exist." (here is the link to the Preface: https://www.vetsmall.theclinics.com/article/S0195-5616(23)00039-6/fulltext)

That last point is certainly intriguing to me, and I would like to hear their explanation about wishing glucose curves to "cease to exist."

Also, and this is only tangentially related: I'm intrigued in this volume for a number of reasons, of course, but one of which is that this volume is edited by Dr. Chen Gilor, who teaches and practices at the University of Florida in Gainesville, and is a renowned feline diabetes expert. We are located about four hours from Gainesville, and have taken our previous cats there for treatment in the past (one cat had an unusual heart problem and received two (human) pacemakers there (when the battery ran down, we had to replace the first one), which kept him alive until he was about 20). My brother has tried to encourage me to take Jude to see Dr. Gilor, but I've been resistant to do so because I don't think Jude's diabetes is all that unusual, and I can't imagine that Dr. Gilor is going to tell us anything more than what my local vet or this group is telling me (perhaps I'm wrong about that).

 

[Maddie & Kai]

@MinnerPip
3. That traditional blood glucose curves, misleading as they are when performed by intermittent sampling of blood glucose throughout the day, would cease to exist." (here is the link to the Preface: https://www.vetsmall.theclinics.com/article/S0195-5616(23)00039-6/fulltext)

That last point is certainly intriguing to me, and I would like to hear their explanation about wishing glucose curves to "cease to exist."

Please let us know what you learn. That is very interesting, indeed.

 

[Helen + Noogi]

Agree - this is very intriguing!

 

[MinnerPip]

I saw that too Mary!!! I did not understand what it meant and also found the $411 price to get online subscription. At first I thought maybe it was referring to doing the curves periodically, every few weeks or so in vet office, which I thought was a rather common protocol in years gone by, before at home testing became the recommendation. But not sure.

Minner has her annual exam next Saturday. I will ask my vet about this resource too!

well … i just checked amazon and the kindle version of 2023 issue was 60 bucks so I bought it. Let me see if I can see why they say that.

 

[Marielle]

well … i just checked amazon and the kindle version of 2023 issue was 60 bucks so I bought it. Let me see if I can see why they say that.

Awesome! I might get that as well. Tell me if you think it's worth it.

ETA: I went ahead and purchased it too. Looks interesting!

 

[Marielle]

It looks like that at least one of their arguments for not encouraging glucose curves is that they see it as an inaccurate determiner for hypoglycemia--they prefer CGMs. Here's the page that summarizes this:

 

[Marielle]

They also talk about the dangers of hypoglycemia in the same article. Here is the introductory bit for this article, and I'll post the continuation of the introduction below

 

[Marielle]

 

[MinnerPip]

Currently reading the chapter/paper on glucose counter-regulation, co-authored by the doc near you Mary. It claims that subclinical insulin induced hypoglycemia (IIH) occurs quite frequently in cats, much more so than the relatively low percentage of clinical IIH. It also cites a BG value below 60 as hypoglycemia based on recently published Agreement Language in Veterinary Endocrinology. I am guessing this is possibly a factor in promoting his/the statement about desire for blood glucose curves to cease to exist. The authors state that BG curves underestimate the frequency of IIH b/c of their intermittent nature. Various stats provided plus comparing to CGM and the incidence of IIH detected with the curve methods ve CGM.

References to vocalization and pacing as a few in the list of clinical signs of IIH are making me think my trying to keep Minner out of the 50s and even above 70 may be supported. These are signs of glucose deprivation in the brain that activates the autonomic nervous system … yet not all cats will put forth these clinical signs when experiencing IIH.

The paper goes into much technical detail about the counter regulatory pathways to IIH in healthy cats and dogs, and how these pathways are impaired in diabetics. It claims that even 2 subclinical incidents further deteriorate any counter regulatory pathways not already jeopardized. The authors completely debunk the Somogyi effect (or rebound hyperglycemia).

 

[Marielle]

Currently reading the chapter/paper on glucose counter-regulation, co-authored by the doc near you Mary. It claims that subclinical insulin induced hypoglycemia (IIH) occurs quite frequently in cats, much more so than the relatively low percentage of clinical IIH. It also cites a BG value below 60 as hypoglycemia based on recently published Agreement Language in Veterinary Endocrinology. I am guessing this is possibly a factor in promoting his/the statement about desire for blood glucose curves to cease to exist. The authors state that BG curves underestimate the frequency of IIH b/c of their intermittent nature. Various stats provided plus comparing to CGM and the incidence of IIH detected with the curve methods ve CGM.

Yes, I posted on that above!!

 

[MinnerPip]

Yes, I posted on that above!!

You are faster than me!!! Omg, we honed in on the same stuff!!! I was reading it and taking notes.

 

[Marielle]

It also cites a BG value below 60 as hypoglycemia based on recently published Agreement Language in Veterinary Endocrinology. I am guessing this is possibly a factor in promoting his/the statement about desire for blood glucose curves to cease to exist. The authors state that BG curves underestimate the frequency of IIH b/c of their intermittent nature. Various stats provided plus comparing to CGM and the incidence of IIH detected with the curve methods ve CGM.

This number--below 60--is super worrisome to me, since we (in this group) are looking for nadirs in the 50 to 80 range, especially given the article's argument that hypoglycemia and hyperglycemia episodes cause damage to the counterregulatory responses and can lead to future hypo episodes.

 

[MinnerPip]

So after reading that and having Minner at PMPS tonight of 55, I need to recalibrate and not just TRY to keep her out of the 50s, I should aim higher. I’ve always said I don’t want her even in the 60s. I need to slowly get her nadir up, and get away from feeding frenzies.

yes, just read your last remark, we’re on same wavelength again. I would rather her be a little higher, get to feed her less and stay totally out of 50s and 60s.

i wonder if the gainesville doc would do remote consult. I’d love to talk to him, albeit probably a fortune

 

[Marielle]

So after reading that and having Minner at PMPS tonight of 55, I need to recalibrate and not just TRY to keep her out of the 50s, I should aim higher. I’ve always said I don’t want her even in the 60s. I need to slowly get her nadir up, and get away from feeding frenzies.

yes, just read your last remark, we’re on same wavelength again. I would rather her be a little higher, get to feed her less and stay totally out of 50s and 60s.

i wonder if the gainesville doc would do remote consult. I’d love to talk to him, albeit probably a fortune

I would like to talk to others about this difference in the hypoglycemic threshold. I think vets approach FD differently than perhaps our group does because their (vets) typical patient isn't our animal--because their typical patient's cgs aren't caring for their animals as we are on this group. Their typical patient comes to see them maybe once a month (maybe) and they don't home test. Of course CGMs are more accurate in catching hypos than someone who is not home testing daily. Many of us here who aren't using CGMs may not test hourly, but we test quite frequently. So I see us as a bit different. We're pretty vigilant about hypos. That said, I need to look more at the research to see if they actually claim that below 60 is damaging (or is that just a number they pick that is inflated because most patients don't test at home, and they don't want their non-testing patients to come close to a hypo?). I don't know if any of that makes sense, but the bottom line is I want to ask around about this and read/research more. I realize that these are peer-reviewed findings; I'd just like to read others who are supporting these findings. I'd love to hear what some of the senior members on this group think as well.

I think you would be a perfect candidate to ask for a remote visit with Dr. Gilor. Minner has a complicated case, and he could probably offer some important advice. When we've gone to their clinic in the past, it wasn't that much more expensive as I recall (it's been a number of years). Of course the procedures we had were expensive because they were cutting edge (at the time), but I don't think a consult will be too out of reach. I could be wrong about that, though I hope not. I think it would be great to talk to him about Minner. Please let me know if you do it.

 

[Marielle]

It also cites a BG value below 60 as hypoglycemia based on recently published Agreement Language in Veterinary Endocrinology.

Here it is! You posted this earlier. I need to look at this further.

 

[MinnerPip]

I would like to talk to others about this difference in the hypoglycemic threshold. I think vets approach FD differently than perhaps our group does because their (vets) typical patient isn't our animal--because their typical patient's cgs aren't caring for their animals as we are on this group. Their typical patient comes to see them maybe once a month (maybe) and they don't home test. Of course CGMs are more accurate in catching hypos than someone who is not home testing daily. Many of us here who aren't using CGMs may not test hourly, but we test quite frequently. So I see us as a bit different. We're pretty vigilant about hypos. That said, I need to look more at the research to see if they actually claim that below 60 is damaging (or is that just a number they pick that is inflated because most patients don't test at home, and they don't want their non-testing patients to come close to a hypo?). I don't know if any of that makes sense, but the bottom line is I want to ask around about this and read/research more. I realize that these are peer-reviewed findings; I'd just like to read others who are supporting these findings. I'd love to hear what some of the senior members on this group think as well.

I think you would be a perfect candidate to ask for a remote visit with Dr. Gilor. Minner has a complicated case, and he could probably offer some important advice. When we've gone to their clinic in the past, it wasn't that much more expensive as I recall (it's been a number of years). Of course the procedures we had were expensive because they were cutting edge (at the time), but I don't think a consult will be too out of reach. I could be wrong about that, though I hope not. I think it would be great to talk to him about Minner. Please let me know if you do it.

I agree with all points. And have often wondered about the tough job of dvm needing to give guidance that caters to individual caregiver capability, willingness, affordability, flexibility etc etc. my doc once told me he wasn’t worried one bit about minner and hypo, b/c he knows me (w/o calling me anal and super high strung). I worry about it all the time.

I’ll contact gainesville next week and inquire.

 

[Marielle]

my doc once told me he wasn’t worried one bit about minner and hypo, b/c he knows me (w/o calling me anal and super high strung). I worry about it all the time.

That made me LOL. My doc, and especially his vet techs, are amazed (stunned?) by me. When I pull out the SS, my vet is all over it; the vet techs look at me as though I'm alien. I'm actually so fortunate my vet is so accepting of what I do, most of it influenced by the good folks over here. He has actually tried to learn more about FD because he is treating Jude, which I completely love and appreciate.

Let me know about UF.

 

[Laurie&Petey]

This number--below 60--is super worrisome to me, since we (in this group) are looking for nadirs in the 50 to 80 range, especially given the article's argument that hypoglycemia and hyperglycemia episodes cause damage to the counterregulatory responses and can lead to future hypo episodes.

Do you think this lower target is to account for the human meter? When I had to use the Relion a couple weeks ago, Petey was spontaneously in the greens. While comparing on the AT3 he was actually blue.

 

[MinnerPip]

Do you think this lower target is to account for the human meter? When I had to use the Relion a couple weeks ago, Petey was spontaneously in the greens. While comparing on the AT3 he was actually blue.

It’s a very good question. Here’s what I find even more perplexing. The main objective of the Agreeing Language in Veterinary Endocrinology (ALIVE) is to establish standards that allow comparison among studies. You can read about this effort, the technique used to arrive at consensus etc and the set of agreed definitions for DM. Here is the NIH link that will lead you to a download of the results. You’ll find reference to “species validated method to measure glucose”, but no actual comment on meter types.

https://pubmed.ncbi.nlm.nih.gov/36182064/

Then, going back to the article on counter regulation and IIH which cites the ALIVE standards, there is statement saying “when near euglycemia was a treatment goal (target BG of 60-160 mg/dL, measured by non-vet glucometer)”

So …. If the 60 in ALIVE is expert consensus on hypoglycemia cutoff, and if that is not based on human meter, then even within this current counter regulatory paper, we are co-mingling, and this is the very issue ALIVE is trying to eliminate.

anywho …..

 

[Marielle]

Do you think this lower target is to account for the human meter? When I had to use the Relion a couple weeks ago, Petey was spontaneously in the greens. While comparing on the AT3 he was actually blue.

Good question! I need to read further and more in depth.

 

[Helen + Noogi]

Thank you so much Mary and Laura for sharing this information. So interesting (what I can understand of it that is, which is by no means all - the language of academic papers does make my brain hurt a little).

I am very interested in hearing what else you learn, as well as what the more senior members here have to say on these findings on hypoglycemic threshold in particular, especially as Noogi loves lower dark greens.