Advice on insulin switch and pancreatitis management

Discussion in 'Feline Health - (Welcome & Main Forum)' started by Andra&Ozzy, Jun 1, 2016.

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  1. Andra&Ozzy

    Andra&Ozzy Member

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    Hello!

    I have been posting here on and off about specific things, but thought it was time to write a post on the overall situation and hopefully get some advice from all the knowledgeable people on here. Thank you to those who have helped me so far - this will explain the bigger picture more. The situation is this: Ozzy is 14 (15 in august), diabetic since 2010 (Caninsulin - only licensed one for pets until recently and vet was reluctant to try him on Lantus because of his erratic eating), IBD since longer than that. A month ago he developed pancreatitis. He's been on Buprenorphine (adjusted as and when), Cerenia (24 mg, a quarter or half, as needed), Pepcid (1/day), Mirtazapine (as needed, first a quarter, then went down to an 8th because of bad 'trippy' episode), occasional fluids (will ask question about this below) and at the moment a whooping 10/11 units of Caninsulin. We have been referred to an internal medicine specialist, but we are now waiting for an upper respiratory infection to clear before taking him there, which means that he is running very high blood sugars in the meantime (they were initially increased, vets think, both by the pancreatitis and the local steroid - Budesonide - that we tried for his inflammation). Getting him to eat has been very difficult, but this has picked up a bit in the last few days. He is now on Hills dry M/D. I am aware that he shouldn't be on this, but it is the only thing he will eat, other than the jelly from one single type of wet food (no nutritional value). I want to switch to a better wet food (please let me know what you'd advise, especially if they are available to buy in the UK). I am, for instance, looking at EZ complete online, to add to the cooked (which so far he won't touch), but I cannot see how I'll get this in the UK without paying astronomical charges. Vet is very reluctant to even think of switching to raw at this point, and i'm also very nervous about that, given his low immune system and concurrent illnesses/ infections. Ideally - IF he'd eat it, and this is a big if, given how picky he is - I'd want him either on home cooked + EZ or a decent wet food (I know a lot of people use Fancy feast classic, but these aren't available in the UK. The equivalent is Gourmet Gold, but they don't have the 'classics' and the rest gave him diarrhoea).

    We are on the brink of transitioning to a new insulin, but all depends on how quickly he can clear this infection (we are trying a third antibiotic at the moment, the other two have not worked). My questions are these:

    1) Any advice about the pancreatitis management other than what I have mentioned?

    2) How much and how often do you give subcutaneous fluids? I understand there are risks associated with giving too much (heart?). I have been pushing the vet's for fluids (even though he's not technically dehydrated), to help the pancreatitis, the constipation (he had a manual evacuation last month) and to decrease the chance of toxicity building up a a result of the high numbers.

    3) What insulin would you advise a switch to? The only ones licensed for animal use in the UK are now Caninsulin and ProZinc (only recently re-licensed). He could get Lantus or another one, but the vet would have to 'prove' that the others have not worked. I know that what works is very much animal-specific, but I'd really appreciate your thoughts.

    4) When I take him to the specialist, what would you ask about/ for? I imagine they'll want to repeat all the tests and possibly do more. He has had an x-ray, a scan, a spec fPLI, fTLI and CBC.

    Any other thoughts and suggestions much appreciated, on anything that I've mentioned or not mentioned. Thank you in advance!

    @scoobydoox @Critter Mom
     
  2. LindyKindy

    LindyKindy Member

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    I'm so sorry to see that Ozzy (and you!) are having such a hard time. My Gryff is going through a bit of this also. If I get some answers from my vets, I'll pass on what information I have. Gryff is doing well with the diabetes right now (but that can always change) He has had bloody stool for a few weeks now. The vet said IBD and pancreatitis. The next testing would be to a specialist to rule out cancer. She said to give high protein and low fat diet. Like Ozzy, he only wants to eat the dry Hills. He won't eat anything else :( I'm at a loss how to help him.
     
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  3. scoobydoox

    scoobydoox Member

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    @jayla-n-Drevon @Chris & China @Elizabeth and Bertie please tag anyone else that has exp with this and can help find the items she would need in the UK

    I would get all of his current medical records you already paid for forwarded to the specialist so you dont have to repeat anything including the x rays. There is no reason to have some tests repeated and pay double. I would push for the lantus or get a referal from the other uk members that have there cats on lantus and ring there vets. As for giving fluids when hes not dehydrated I would wait for more info from other members on that one. I am also wondering if some of he medications he is on are increasing his numbers? I know that food is probably a cause to higher numbers as well. What about home cooked food?http://www.catinfo.org/?link=makingcatfood
     
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  4. Andra&Ozzy

    Andra&Ozzy Member

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    Thank you and sorry to hear about your boy! I'll pass on any info to you too. Hopefully we'll get some advice from people here, too. Bloody stools must be really scary, we've been lucky enough to avoid that. The low fat thing has been debunked, as I understand it. Vets are now not so concerned about high fat (other than for weight management). This is what the internist told my vet on the phone. But they are very cautious about high carb... Which we haven't been able to avoid so far, due to our boys' difficulty with eating.
     
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  5. Andra&Ozzy

    Andra&Ozzy Member

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    Thank you very much! Vet didn't mention high numbers being caused by any of the meds when I asked. Hmm... I suspect it's mostly to do with his pancreas not working as well since the flare-up.

    I tried home cooked food, but admittedly not systematically, since he has been eating poorly since the pancreatitis attack and been even pickier than usual, so I've focused on having him fed rather than transitioning him at this point. I'll try again once he's stable...

    I will do as you suggest with having tests sent over. But I'm pessimistic about them allowing that- I've already been told that it's been a while, (3 weeks) and they want updates, plus they want to do their own tests, plus they have better equipment (this is true, they're probably the best in the UK).

    Thanks for tagging others! :)
     
  6. Critter Mom

    Critter Mom Well-Known Member

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    Jun 16, 2014
    Feed little and often if you can. If you can get Ozzy onto wet food add a teaspoon or two of water to each meal.

    Try Sheba Fine Flakes in Jelly Poultry Selection - 1.6% kilocalories from carbs - just meat, necessary vitamins and minerals and (IIRC) cassia gum for a little fibre. It's fairly bland and it's the only food that I've managed to keep Saoirse eating fairly reliably. (Took over 9 months of food trials to get there.)

    Try canned pumpkin for the constipation. (Libby's - available from Amazon UK.) Introduce it slowly. If that's not great ask here about Miralax (you can also get this on Amazon).

    For appetite, ask your vet about cyproheptadine (brand name is Periactin - an antihistamine). It's much gentler than mirtazapine and has a much shorter half-life therefore it's much easier to provide appetite support as needed (and it doesn't carry the risk of serotonin syndrome). Saoirse is a 10lb (4.5kg) cat and she was prescribed 1mg (1/4 of 4mg tablet) as needed, maximum 3 times a day. (NB: antihistamines can elevate blood pressure so get the vet to check Ozzy's BP). It's best to start on a low dose because too big a dose may cause lethargy and slight depression. One eighth of a tablet 3 times a day kept Saoirse eating throughout her worst pancreatitis flare.

    I have found that anti-nausea treatment is the cornerstone of successful pancreatitis management. Saoirse gets generic ondansetron twice a day (ETA: 2mg dose). Zofran, the branded version, is about TEN TIMES the price of a generic. The best ondansetron for cats is Bristol Laboratories generic - other generics can cause worsened constipation - try Pharmplex online for a source). Sometimes because of her early CKD I also give famotidine but the ondansetron has a much more beneficial effect without mucking around with normal digestion or the heart in the way that chronic administration of famotidine might. In Saoirse's case, while both Cerenia and ondansetron help with her nausea ondansetron, once it has kicked in and is then maintained seems to be significantly superior in reducing nausea.

    A full course of weekly vitamin B12 injections helps enormously with pancreatitis. Simple things like raising food bowls or warming food a little can encourage appetite.

    I'm really unwell at the moment and I'm sorry I can't write more. If you search my posting history for pancreatitis and nausea you may find additional ideas of things to try.

    Useful links:

    https://www.idexx.com/files/small-a...pec-fpl-treatment-for-feline-pancreatitis.pdf

    Nausea symptoms & treatments


    Mogs

    ETA: Ask vet to check your cat's blood pressure; antihistamines can increase it.

    .
     
    Last edited: Jun 2, 2016
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  7. Critter Mom

    Critter Mom Well-Known Member

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    With close BG monitoring and fairly conservative dosing it is possible to successfully treat a pancreatitis kitty using this insulin. It might not be feasible to follow a particular protocol but, provided the Lantus is dosed fairly conservatively it can actually offer a better solution to the need to feed at odd times because its longer, gentler action can better accommodate small, regular meal feeding or grazing. It takes a bit of learning your cat and fully understanding how to manage the Lantus depot during periods where eating is less but with a bit of time, data, and familiarity it is doable. Actually at times where the cat's having a longer period of not wanting to eat (e.g. half a day) if one does need to skip a dose then the insulin stored in the depot can plug the gap in terms of supplying insulin to the body until the next dose is due.


    Mogs
    .
     
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  8. LindyKindy

    LindyKindy Member

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    Thanks, it's nice when we all can share information. The vet did say to give probiotics and food that is easier to digest. Is Ozzy constipated? I had only read that pancreatitis symptom was diarrhea, but Gryff has the opposite problem.
     
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  9. Wulfwin

    Wulfwin Member

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    Nov 4, 2010
    I don't have much to offer as my two cats are both relatively recently diagnosed with chronic pancreatitis (one in Dec, one a couple weeks ago) - one seems to fine with just a feeding schedule change and treating flares, the other we're currently trying 4mg of Cerenia every other day which seems to be working well for her so far, but I'm tagging @Carol & Murphy as well since she had a lot of invaluable advice information for me with my more recently diagnosed cat.
     
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  10. jayla-n-Drevon

    jayla-n-Drevon Well-Known Member

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    Oct 11, 2015
    HI--
    SQ fluids are helpful for a pancreatitis flare... it is also true that with heart issues it is a cautious balance. I do not see that you have a heart issue unless I missed it?
    I also see that you are using cerenia which is helpful but most of us who have kittys with nausea find that ordanastron works somewhat better and they can be used together. Cerenia is very helpful if vomiting is a problem...
    Personally I have had great success with fluid therapy .... It helps everything along and makes them feel better almost immediately.
    @tiffmaxee has lots of experience and wisdom...:bighug:
     
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  11. BJM

    BJM Well-Known Member

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  12. tiffmaxee

    tiffmaxee Well-Known Member

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    I just came on line. Mogs has really said it all. I use cyproheptadine instead of mirtazapine. Lately Max has been sneezing and I've been giving him Zyrtec which is acting as an appetite stimulant. If your cat has had any issues with mirt I would try something else. I also like zofran for nausea. Some cats need both cerenia and zofran if the nausea is bad enough as they work in different ways. Also often a large enough dose is not prescribed to be effective of both zofran and cerenia. Absorption is not as good as once thought they have found. Sometimes injections work better but they do sting many.
     
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  13. Carol & Murphy

    Carol & Murphy Well-Known Member

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    Hi - so sorry to hear about Ozzy. Mogs has great advice (Mogs- sorry you aren't feeling well) Murphy has been on Prozinc which is not a bad choice for insulins, as you can increase or decrease the dose based on what the cat is eating. However, Murphy will be switching to Levemir in a few weeks
    Murphy gets cerenia 4 mgm once a day for 5 days, then one day off, then 5 days on, one day off, etc. If he has a flare, I increase the dose to 8 mg temporarily. Of all the drugs, I think this drug is the most essential. It has decreased his vomiting 95%. I don't think cerenia has anti-nausea properties - it is an anti-emetic-it and also has anti-inflammatory properties so it has a double action. From what I have read, decreasing vomiting is essential as some cats have an atypical anatomy which basically allows bacteria to back up into the pancreas if they vomit (if I understand this properly). If Murphy won't eat at meal time, I immediately pop 1/4 cypro and 1/4 ondansetron into his mouth (I always use both together) This almost always results in him eating at least something within the hour. Cypro can be increased to 1/2 tablet twice a day, and ondansetron can be given every 8 hours. I have found that if I give Murphy cypro several days in a row, the effect seems to wane, so I increase the dose, or better yet not give it for a day or two. If I think Murphy is having a pancreatitis attack, I do give him the bupe and also SQ fluids. I think the amount of fluids vary with the cats hydration status and their weight. Murphy does have mild mitral regurgitation - I can safely give him 100 ml I agree with BJ that fluids really do make them feel better- and quickly too. I highly recommend looking at the website www.ibdkitties.net for great tips on pancreatitis.
    Regarding Hills dry MD- I give that to Murphy when he is going hypo and I need to raise his sugar - that food really raises his blood sugar. Murphy has a long standing history of intolerance to wet food - I really believe he is sensitive to the fat content - it is said to not affect pancreatitis in cats, but it can set off IBD. In buying canned food, at all costs, I avoid anything with caraggeen or any of the gums (including cassia gum) as they can set off IBD especially caraggeen. Good luck - please let us know how Ozzy is doing
     
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  14. Carol & Murphy

    Carol & Murphy Well-Known Member

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    thank you very much
     
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  15. tiffmaxee

    tiffmaxee Well-Known Member

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  16. Carol & Murphy

    Carol & Murphy Well-Known Member

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    Elise - what dose of zolfran do you use? Do you find it to be constipating?
     
  17. tiffmaxee

    tiffmaxee Well-Known Member

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    Max gets 3-4 mg twice a day. According to a vet that responds on the yahoo lists it can be dosed .5-1 mg per pound every 8 hours.. If a lower dose doesn't work I would try a higher one. When I started using it Max was 14 pounds and I was just giving him 1 mg twice a day. That was the dose Tiffany got and she was just 9 pounds.
     
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  18. Critter Mom

    Critter Mom Well-Known Member

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    I've not used branded Zofran but ondansetron most definitely can constipate and, in Saoirse's case, I've found that that makes pancreatitis much worse. We discovered this big time last year when I could not get hold of the Bristol Labs generic ondansetron; the alternative generic that was dispensed constipated Saoirse badly and consequently both of us had a miserable week and a half till I managed to get the right drug to suit her.

    For info, I've found that bupe may also cause constipation. Mercifully, Saoirse does pretty OK with pumpkin added to her meals.


    Mogs
    .
     
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  19. tiffmaxee

    tiffmaxee Well-Known Member

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    Mine is ondansetron too. Max would get constipated a little so I would give miralax once a day which was sufficient. Now he's getting twice s day since his kidneys aren't doing so well.
     
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  20. Andra&Ozzy

    Andra&Ozzy Member

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    Mogs, thank you so much for your really helpful advice! Sorry I'm a bit late with the reply, had a mad day of more vet trips and vet conversations. He had another pancreatitis attack last night and have been trying to calm his pain. He also had a weird 'trippy' episode last night, on just 0.3 of the Buprenorphine. He looked like he was hallucinating, looking for an invisible fly. He didn't look like he was enjoying that at all, and it lasted for hours. :( I've spoken to the vet and they said that opioids often cause this. He's had much higher doses and the reaction was just being dopey, not "high". This is so difficult... I want to reduce his pain, but am afraid of upping his dose from the 0.25 I've kept him on since last night. I know there are other pain killers, but I've been told they come with more side effects. Any ideas on this?

    I'll take your advice and that of the other really helpful people on here. I'm very sorry to hear you're not well. I hope you feel better soon. <3
     
  21. Andra&Ozzy

    Andra&Ozzy Member

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    Thank you! I'm a little confused about Lantus. Everything I've heard on this forum and Facebook from people about Lantus is along the lines of it being gentle. My vet said that in her experience, Lantus causes quite a drop and keeps the glucose numbers low. So, it's good for cats without complications, but for Ozzy, who is up and down, prone to not rating enough or throwing up when I'm not home, it would be dangerous, because should a hypo happen, he'll stay in it for longer. Any thoughts?
     
  22. Andra&Ozzy

    Andra&Ozzy Member

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    Yes, Ozzy is still a bit constipated. He had a really bad episode when pancreatitis started, and he had to be manually evacuated. My experience with him has been more on the constipation side than diahhroea. *touches wood* (although both are terrible) I'm afraid of overloading him at the moment with even probiotics (although I think we'll try them, longer term), be age he's got such serious, acute things going on (the pain and the infection). Once that abates a little, I'll supplement things. I've got methylcobalamine on standby too, for his neuropathy. I've been holding back for the same reason...
     
  23. Wulfwin

    Wulfwin Member

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    Typically Lantus is one of the gentler insulins, with a flatter curve throughout the cycle. Other insulins tend to be 'harsher' in that they take affect faster and cause a steeper drop over a shorter time period (Vetsulin or Caninsulin, if I remember correctly). I think what your vet might be concerned about is that Lantus is a 'depot' insulin - it actually creates a depot of stored insulin that is slowly absorbed and can affect the blood glucose for several cycles after the shot (see this sticky in the Lantus forum for more information about the depot). ProZinc, by comparison, is considered an 'in and out' insulin and doesn't form a depot. I've had one cat on Lantus and one on ProZinc, but the one with Lantus has been in remission for over 5 years now so I'll let more experienced users give advice on the pros and cons. I'm not sure how much difference one insulin versus the other would make though if a cat goes into hypo with no one home to intervene.
     
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  24. Andra&Ozzy

    Andra&Ozzy Member

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    May 18, 2016
    Thank you, that makes sense. I haven't got round to reading the sheets on the different insulins yet, that's the next thing I'll tackle. If Lantus forms a depot, I can see why she'd be worried. I was pushing for that over ProZinc because of all the great things I've heard from everyone about cats being in remission with it. Not that in hoping for remission now, but I thought it's the one that'll give us best control. Now I'm not sure... I'll keep reading and hopefully others will pitch in with their experience. I'm particularly interested in how cats with other complications have done on it, but having said that, all our kitties are such individuals and react to various things differently.
     
  25. Andra&Ozzy

    Andra&Ozzy Member

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    Thank you very much for this, Carol! This was really useful advice. I'm pasting everything onto a separate file to look over again and organise info. Ozzy is ok, but last night had another attack of the pancreatitis and he's been in a lot more pain since. Had a bad reaction to Bupe last night (at least I think it was to that) and so tonight I've only given him 0.25, instead of 0.3 last night, which gave him the weird reaction. I think it's probably quite intense, the pain, since he still seems uncomfortable and "not himself", but I don't know what to do now, in terms of the dosage. Why are you switching to Levemir from ProZinc? Did it not work for Murphy?
     
  26. Andra&Ozzy

    Andra&Ozzy Member

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    T
    hank you very much!
    My vet seems to think Ondansetron is a"harsher" pain killer and so wants to hold off on giving it to him, since he's having so many meds besides that. Is it a more "hardcore" drug than the rest? They said it was used in more critical cases, but this seems critical enough to me...
     
  27. Andra&Ozzy

    Andra&Ozzy Member

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    Thank you! Is Zofran Ondansetron? I tried getting the injections, since Ozxy does much better with needles than pills, but vet was worried it might cause him to fear the insulin, since this one stings. Oh, the joys of complicated medical issues...
     
  28. Andra&Ozzy

    Andra&Ozzy Member

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    May 18, 2016
    Thank you! ❤️ No, he doesn't have heart issues, other than a bit of thickening of the walls that the vet detected a number of years ago on a scan. But she said it doesn't count as a heart problem, just age related...
     
  29. Andra&Ozzy

    Andra&Ozzy Member

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    Thank you! ❤️
     
  30. tiffmaxee

    tiffmaxee Well-Known Member

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    I've not I he tend ondansetron but did cerenia and that stings too. I use tge pills for both, out in a gel cap and chase with baby food. And yes ondansetron is the generic for zofran.
     
  31. tiffmaxee

    tiffmaxee Well-Known Member

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    Ondansetron is not a pain killer. It is a nausea medication with few side effects. The only ones I have seen are constipation and maybe a little sleepiness but that could be due to age or the pancreatitis. If your vet said it is harsh and for pain I wonder if he has ever used it. If you read the articles on pancreatits by the vets you will see it listed. Some vets prefer drugs for pets as they can sell them. I first used ondansetron in 2010 and have recommended to many here with good results.
     
  32. Carol & Murphy

    Carol & Murphy Well-Known Member

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    Ondansetron is the generic name for Zolfran - it is almost a miracle anti-nausea drug developed for humans on chemotherapy - it is a very effective anti-nausea There is another one as well - I can't remember the name now -- I have never given the injections only the tablets
    If Murphy is having an actual bad attack of pancreatitis, I would give him 8 mg on cerenia daily, sq fluids, bupe, maybe 1/2 tab of ondansetron 2 or 3 x day and 1/4 tab of cypro and hand feed very small amounts of wet food every half to one hour if possible. Ondansetron is standard veterinary treatment for nausea. Are there any other vets in the area that you can take Ozzy to?
    I'm changing to Levemir not because Murphy doesn't respond to it, he does quite well, but it has been erratic - particularly when he has some inflammation from IBD or pancreatitis, his numbers go up and I have to give more insulin then his numbers go down and I have to give less. It's doable, but it's a lot of work and stress, I'm switching just to see if I can get smoother numbers with Levemir.
     
    Last edited: Jun 3, 2016
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  33. Andra&Ozzy

    Andra&Ozzy Member

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    Thank you, that makes sense about the switch. And thank you, also, for the advice on dosage. I'll use this. I think that this vet is good, so don't want to change quite yet. I'll insist again on the Ondansetron. I can probably have it posted from my old vet, if that doesn't work.

    I'm very nervous about the switch, because he's such a "special case" in everything we've tried so far. At the moment, his numbers are going higher and higher, in spite of the fact that we've increased his Caninsulin dose to reduce his numbers over the weekend. The switch to a ProZinc is on Monday. I don't think he's going low and then bouncing up, because I'm checking. But the nadir is higher than it was on lower doses.
     
  34. Carol & Murphy

    Carol & Murphy Well-Known Member

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    Andra - since you are switching to Prozinc on Monday, I suggest you start posting to the Prozinc forum this weekend - that way, @Sue and Oliver (GA) , @Rachel and @Robin&BB can begin to help you with a starting dose, and help with dose adjustments come Monday
     
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  35. tiffmaxee

    tiffmaxee Well-Known Member

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    Pancreatitis can definitely elevate the BG until it is under control. So can pain from anything. Good luck with the switch.
     
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  36. Andra&Ozzy

    Andra&Ozzy Member

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    May 18, 2016
    Thank you very much. Yes, I hadn't thought of the fact that pain itself/ stress will also elevate his numbers. Of course it does.
     
  37. Andra&Ozzy

    Andra&Ozzy Member

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    May 18, 2016
    Thank you, Carol! And thanks for tagging people. I will post this weekend and hopefully they'll be around.
     
  38. tiffmaxee

    tiffmaxee Well-Known Member

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    My Max first got pancreatitis from my other cat being sick. Even the stress of a visit will bring it on for him. So just keep that in mind as you raise the dose that if he starts to feel better you might need to lower it. So test a little more often then you would.
     
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  39. Andra&Ozzy

    Andra&Ozzy Member

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    May 18, 2016
    Thank you. I will. Testing him pretty often anyway, poor guy. He's bleeding more, too. It does stop, but goes on for longer than before. Is blood pressure also raised by high numbers? I'm pretty sure that when he's higher, his ears are warmer, and the blood flows a lot more freely.

    Poor Max! He must be a very empathetic, sweet boy. Ozzy is the same, very stressed by vet visits. This is why I'm doing the switch over to the new insulin myself, from home. They wanted him in for the day, for a curve, but I explained that the numbers would be useless anyway, since he's so stressed from being there that he's all over the place. Plus, the thought of him suffering again in there, when it can be avoided...
     
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  40. Carol & Murphy

    Carol & Murphy Well-Known Member

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    Poor babies!!
     
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