? 6/25 amps 270; Oren next steps

So I've been laying a bit low of late, but still reading and checking on things here in LL land. Oren has made no progress following my vets course of treatment,(new insulin, slow increases, some supportive diet care for pancreatitis) and she finally has presented the following suggestions.

Now that he is once again at 6 units following 2 wk curves and .5 unit increases, she still thinks the pancreatitis may be keeping numbers elevated. Since all we had is y/n from the snap Fpl test, she is suggesting either ultrasound and/ or follow up CBC lab work to check amylase/lipase and white blood cell counts now that it's been ca. Six weeks since diagnosis. She also finally suggested IAA and acromegaly tests. my question is if we get more info. About pancreatitis, what would the treatment approach be? He has had no severe symptoms, still eats like a champ, no vomiting, good hydration. I'm wondering where the best use of my money is? If he's positive for IAA, increasing insulin is really the only thing to do, right? And if it's acro, same thing (outside of the direct treatments for the acro, which I may not be able to afford. So while good to know these results, is it perhaps wiser to pin down the severity of the pancreatitis, and how would that effect his FDM treatment?

She also suggested if any of these tests came back negative, considering switching insulin.

I'm away until tue and tho I wanted to raise him to 6.5, was a little uncomfortable with doing so without being there to monitor. My pet sitter can do pre-shot tests only. So he'll go up as soon as I get home. Best he's gotten at 6 is a few scattered high hundreds.

I'd appreciate suggestions/opinions on next steps. I suspect an ultrasound is not cheap, I know basically how much to expect for the bloodwork/tests. I'm assuming all that would be -300-400$, not including the ultrasound.

Hope all beans and kitties are well.

 

Hi Megan - good to see you and Oren back. I've wondered how you were doing. I presume you are still with vet IS THAT CLEAR? It's clear (to me) that she hasn't dealt with cats that need higher doses of insulin. Pancreatitis can cause higher numbers, but not to 6 units.

On here, I've seen differing thoughts on how to deal with pancreatitis. I presume you've read Marje's Primer on Pancreatitis? Some vets don't bother with tests (the Spec FPL would be a better one if you do go for that, amylase/lipase not so much), and treat by symptoms. Is Oren showing any of the symptoms listed in the primer? If he's eating and not dehydrated, maybe all he needs is some pain meds, if he really has pancreatitis.

My opinion is that money spent on IAA/acro (IGF-1) tests are the way to go for now. Eliminating (or not) those possibilities will make the steps going forward clearer. My vet also showed reluctance to do these tests and thought I was wasting my money. The latest research has shown that one quarter of diabetic cats have acromegaly. For both IAA and acromegaly, you keep increasing until you get better numbers, then you increase or decrease as needed to follow the blood sugars. The internal medicine vets at Colorado State University that I talked to, as well as folks at the Royal Veterinary College in England (the leading area of acromegaly research in the world) have said that the best thing you can do for these higher dose cats is to manage the blood sugar and try to get them to spend as much time as possible under renal threshold. That's really no different than treating a regular diabetic, but the doses can be higher. Following Tight Regulation, as you were previously, can be a good way to go. You need to be more aggressive to get ahead of resistance. Holding a dose longer means getting behind the resistance and glucose toxicity getting the upper hand.

There are a few of us here who have or have had acrocats (Julie/Punkin, Marilyn/Polly, Andrea/Tennessee, Suki/Crystal, Peg/Toby - probably acro, Suzanne/Cobb, me and Neko). Punkin, Polly and Neko had SRT, the others did not. If Oren has IAA, then you also keep increasing, but the condition is supposed to be self limiting (go away) after some period of time around a year. Having just IAA, without acromegaly, is less common than having it with acromegaly. Treating acrocats can be frustrating. But if Oren has acromegaly, it doesn't change what he is now. With other people here with experience with this condition, there is great support.

As for insulin, is Oren reacting at all to the Lantus? Some kitties react to the acid nature of Lantus at higher doses (or even lower), but it's more noticeable the higher you go. Often higher dose kitties will switch to Levemir. We have had some cats (like Suzanne's Cobb) where the switch to Levemir seemed to help break his IAA.

I hope you have a good trip - relax and enjoy yourself.

 

Hi @Wendy&Neko , yes, too exhausted with life lately to run down other vets yet. Still w doc IsThatClear for now, tho i have a few other leads to check into. I would have to say Oren presents as the mild form of pancreatitis. Has maintained his appetite just fine, no serious lethargy, no meatloaf ing etc. he was on bupe for 5 days initially, and I didn't notice any change in demeanor or BG at that time. Maybe it wasn't long enough? He has not yet seemed bothered by the insulin, just the occasional flinch but mostly seems to ignore it.

If we get a blood draw for snap fpl I guess it would make sense to include the acro and IAA test at that time , it's just been such an expensive month for me (lots of other bills on top of his vet visits) that I want to proceed with the most efficient use of money. And I'm getting the message that increasing insulin is the result, no matter the condition. That means more $ on insulin too, which means I seriously have to consider going the marks marine Canadian route or I won't be able to afford it!

It's also been an emotionally draining month on the personal front, so I am a bit guilty of not being as aggressive with his treatment as perhaps I should. Trying to balance everything best I can. Thanks for the info. Hope you and Neko are having a good summer! Back at you!

 

If you want to retest the fpl, see if the vet will do the Spec fpl instead. Might cost more though. But I'm not sure what an additional fpl test will tell you. Some cats have chronic pancreatitis. I always ask myself, what would I do differently with the information.

Neko is on bupe for her arthritis pain - I noticed a change in BG within a couple of days of starting it.

Managing a diabetic cat is all about balance. You have to look after you too.

 

I agree on not getting the SNAP test. It isn't as accurate and doesn't give a number. It just isn't worth doing in my opinion. My Max has had chronic pancreatitis for going on six years and likely caused him to become diabetic. If you get the Spec fPL it is best to try and fast Oren for at least six hours. In an ideal world they like at least double that but I've never fasted Max more than 8 hours and that was before FD. The reason for this is it can skew the results by about 10-15% which can make a difference if the results are in the gray zone. I'm also with Wendy on thinking even if your cat has pancreatitis it doesn't explain the need for large doses of insulin. Treatment for pancreatitis is making sure they eat enough by giving small amounts of food at a time, cerenia or ondansetron or both for nausea, fluids if they help, and pain meds so getting a positive test won't change much in that regard. Some cats have concurrent IBD and do well with a grain free diet or novel protein. Many don't do well with fish, beef, and some chicken. It's a trial and error thing. Also you don't want to feed a high fat diet but fat doesn't play the role in this for cats that it does for humans and dogs. Amylase/lipase doesn't rule it in or out with cats like it does for dogs.

I hope you get Oren figured out soon and feeling better.

 

Hi, I think that's why she wanted an ultrasound, to rule out/confirm IBD...but again it sounds like the Pancreatitis isn't the major issue here. By the way, I believe the turkey/giblets fancy feast he's now eating exclusively is grain free, but not a novel protein. I do give him plain cooked chicke, mixed in. He loves it, but I wonder if I should discontinue it for a while to see if that makes any difference? Since the diagnosis Was by SnapFPl yes, I don't have values, just yes/no. I meant to say getting blood for the specFpl this time, my tangling g of the terms, sorry.

It's sounding like I should go with IAA/acro tests then, and keep an eye on pancreatitis symptoms, since now he reallyisn't showing terrible symptoms. I somehow think even if he comes back positive on those, she'll not be a fan of TR, just doesn't agree with the timing of increases

 

Hi Megan,
I'm glad that Dr. IS THAT CLEAR has come around to idea of testing for IAA and Acro. I think that at the very least the test will help you rule out the conditions.
When it was clear that Tennie was a high dose cat, I had to decide to go with an ultrasound or the IAA/Acro tests. Because he had a bout of Pancreatitis, the vet thought that it may have been what was causing the high dose.

Vets still seem to think that Acro is a rare condition. But as Wendy has said, up to something like 25% of diabetic cats are testing positive for Acro.

I went with the IAA and Acro tests and don't regret it a bit. With that said though, it is not an easy decision to make, especially when funds are limited.

 

Max doesn't seem to have IBD. the ff turkey is one of the ones I give him and you are right. All the classics (pates) are grain free. He also gets the chicken which has fish in it, and the chicken and liver. I don't know why he gets pancreatitis. Originally it was from my other cat being sick. The ultrasound is not a bad idea but won't be definitive most likely. It will let you know if there might be IBD/lymphoma. It's impossible to tell which it is from an US but it could show all is normal there. Any vomiting or diarrhea? If you have the US I highly suggest it be done by a board certified radiologist. Max had his first by a vet and he mentioned everything but pancreatitis and exploratory surgery. I got a second opinion from my internist who made me have another US by his radiologist and all was normal except for pancreatitis. So the second did cost more but the first was a waste of money. It's only as good as the person doing it and their skill.

 

I would choose the acromegaly test (IGF-1) and the iaa tests done in a heartbeat over anything else. Everything points to you having a high dose kitty, and if you have some certainty on it, then hopefully Dr. IsThisClear can let go of trying to control Oren's dose increases. If those tests come back negative, then that's important information too - something else is going on to cause his need for a high dose.

There were at least 2 kitties that were iaa only - Sandy's BK and Donaleen's Ozy - were both negative for acro but positive for iaa. If that's the case, it would be really important to know.

In my mind, information is power. You still don't know what you're dealing with and your vet is hindering you from adjusting the dose by evaluating his blood sugar. It's certainly possible that Oren has some chronic pancreatitis. Punkin had one acute P-titis episode and then chronic after that. I just don't think pancreatitis could possibly explain his dose. At least I haven't ever seen a cat over 6u that didn't have one of the high dose conditions.

When you've used up the insulin you have, I'd encourage you to switch to Levemir. Some cats continue as they were on Lev, but some have dramatic improvements, including Cobb and Ozy.

Here's a post on acromegaly that includes how to get the testing done, if you want to do that.

It's great to see you, Megan. I hope things get easier for you!