Bandit on Steroids and Immunosuppressants--Lantus Starting Dose?

Hi Everyone! I'm back. A month or so ago I posted about Bandit, who hasn't been doing so hot. He had a severe case of pancreatitis, and his blood sugar was pretty high for a while. But then it dropped back down, and it's been going up and down ever since, going from low 200s to mid-100s and then back up again, so I decided to wait until it stabilized somewhere to start him on insulin. That was until a couple weeks ago. His anemia had not improved, so we had to do a bone marrow biopsy. When he came home he was on buprenorphine for a few days, and his numbers actually dropped into the normal range (85-120) for the first time since this whole thing started in mid-March. Once he went off the Bupe, his numbers inexplicably shot back up into the 300s. I thought maybe he was still in pain, so we tried putting him back on a low dose of Bupe, but it didn't help, and we discontinued the Bupe on Sunday because he didn't seem painful and it wasn't helping. Now he's been in the 300s for almost a week, and he's showing symptoms of his diabetes (drinking and peeing a ton). I think it's time to start him on insulin.

However, I have a whole lot of things complicating treatment this time. Bandit was diagonosed on 4/25 with immune-mediated myelodysplasia, which means his immune system is destroying its own red blood cells. So he is on a steroid (prednisolone), and an immunosuppresant (cyclosporine). They also found toxoplasmosis antibodies in a recent test, so he is on an antibiotic (clindamycin) twice a day, too, because they are afraid that the immunosuppresant will cause the infection to become active. I've been giving him a packet of Fortiflora in the morning because he's had loose stools since he went off the Bupe, a bit of canned pumpkin in his food, and a potassium supplement in his dinner. There's a lot going on, but with him being obviously symptomatic for the diabetes I do not want to wait any longer to start insulin because he's been spilling glucose into his urine for over a week now.

So where do I begin with this whole mess going on? I was going to start at 1 unit, but I've never dealt with a diabetic cat on steriods before so I don't know if that should be taken into account. Has anyone here seen a diabetic cat on steriods acheive good BG control while still on the steriod? The vet said its very possible he may have to be on the steroid long term. :-(

 

Sorry to hear that you and Bandit are back here. We've had a few kitties on prednilisone here. Melissa/Tarragon is one, for his asthma, and she's noted that extra pred causes his numbers to go up, but he's generally in good numbers. I've also seen some kitties only go up in the cycle they have prednilisone. Maybe start the Lantus and adjust for the numbers, once you see what his response is to the pred.

 

We've had some kitties on steroids at the same time....you always have to treat the most severe disease first, so if he needs the prednilisone, he needs it and you just adjust the insulin as needed.

How much does Bandit weigh now?

I'd probably start him at the normal starting dose and see what happens....if you have to go up, you can do that, but it's always safer to start low and work your way up

 

Shadow is on the same meds.... and just recently re-started insulin.
prednisolone and cyclosporin.
did they give you the modified cyclosporin?

I started at 1 unit.
I switched to pearls for the probiotic ( mine won't eat fortiflora anymore) and slippery elm bark.

 

Hey Julia!

Sorry that Bandit's back and that your both dealing with a host of issues. Looking at Bandit's SS, other than his first week or so, his highest dose was 1.ou. Since his numbers are bobbling around, I'd think about starting him on 0.5u and we can always fast track the dose up if necessary.

 

Are you dosing the steroid daily, or on alternate days? If alternate days, you may observe the glucose fluctuates between days on vs off the steroid.

 

Hi Julia, I'm sorry to hear that Bandit has health issues and hope that you can get them under control. Sending vines! Welcome back!!

Ella & Rusty

 

Thanks, everyone! I wish I had been able to get back online here before his dinner last night. He was 370 last night at dinner time, so I did start him at 1u at 7pm because I've been overly worried about his high BG (we haven't had a number below 300 in over a week) with everything else going on. Then this morning his AMPS was 240! Given that the Lantus would not have kicked in that quickly, I decided to scale back down to .5u. So we are going to start at .5u and hold there for a while and see how he does. Better safe than sorry! My partner and I are at work for his lunch mid-cycle 3-4 days of the week, so I definitely don't want to start him too high when I'm only getting one mid-cycle check a day for half the week.

(I've started a new spreadsheet for him--just linked it in my signature. His old spreadsheet is still there in the second tab. I need to fill him some numbers from his meter for the last couple weeks, too.)

Not exactly sure what Bandit's weight is at now--normal for him is around 12 lbs. He was down to a little over 10 lbs a few weeks after the pancreatitis attack, but he was back up to a little over 11 lbs when he was last in for the bone marrow biopsy. His appetite seems to have returned (probably a combination of the steriod and the high BG), and he still looks a bit thin but not overly thin. He goes back to Cornell on the 11th for more tests, so I'll get an accurate weight for him again then.

We are doing the steriod once daily--right after breakfast. It's a liquid suspension, 1ml. I didn't realize there were different types of cyclosporine--I'd have to look at the box when I get home to see exactly what it is. I got it at the hospital pharmacy so I'm assuming it's modified for pets. I know they're solid yellow capsules and he gets them once a day before dinner.

By the way, thank you all for telling me about Mark's Marine Pharmacy. I ordered a 5 pack of pens yesterday for $158! I seriously don't know what I would have done if I had to pay full price. The bone marrow biopsy set me back another $1000 in hospital bills, and with Bandit going in for $150-$250 worth of bloodwork every two weeks on top of that, I am so financially drained right now. :-(

 

Bailey is also in the throws of pancreatitis - she has been on predisolone for almost two years. Bailey didn't respond well initially to cyclosporine and she seems sensitive to changes in diet, so my vet is opting for what he describes as the conservative approach. The idea is to get her off the pred. and onto the cyclosporine. We've switched to the metabolic food and she has adjusted, and I'm also giving her Cerenia which she also seems fine on. So, next is the cyclosporine, I'm picking that up today. The hope is that the Cerenia will help her tolerate the cyclosporine this time around, but as my vet put it, whether she will tolerate it is one of the big difficult questions we are facing. Her face rubbing and overgrooming has roared back since switching from the hypoallergenic food, all but confirming that her pancreatitis is caused at least in part by food allergies. I'm not sure what form the cyclosporine will be - the compounding pharmacy advised that they got a fax but sent back questions about dosing and hadn't heard back, so I'm hoping a suspension I can put in her food, but we will see. My vet wants her taking it for seven days to see how she does on it before attempting to reduce the pred. Other than the food, we aren't even dealing with the diabetes yet - we need to get the pancreatitis under control or everything else becomes very difficult. So I feel for you as it sounds like Bandit is facing even more issues. My girl is so uncomfortable right now (itchy) but not, I think, in a lot of pain - at least since she is playing with her toys etc. and seems interested in what I'm doing, I hope pain doesn't become an issue. because if I have to go back to giving her buprenorphine too, I think I'm going to lose it. Getting new food and two new drugs is enough without introducing a third. That would be four drugs (until she is off the pred) and we haven't even considered insulin yet.

It's complicated. Sorry you are going through this sort of thing too.

 

you've already gotten lots of good advice, julia, so i really just wanted to send you a little moral support. I'm so sorry Bandit's having a hard time and I hope his med will help him feel better.

 

Just to warn you, the cyclosporine suspension is really expensive! We went with capsules because they were $30 vs over $200 for the liquid. But it turned out ok because the prednisolone increased his appetite, and now he'll gobble up the pills in the duck & pea pill pockets with no problem. That wasn't the case a few weeks ago when he was still inappetent from the pancreatitis. I actually went back and got the antibiotic a second time in pills because the pills are easier now.

Good luck with her...things should get easier once the inflammation goes down, and that can take time. I fed Bandit whatever he would eat in the meantime. I'm only just starting to switch his food back from Sheba/Fancy Feast.

 

the cyclosporine is expensive. I just paid $104.63 for 60 ( 2 months) 25mg capsules but it was much more at my local pharmacy. That's the modified version.

I recommend Diamondbackdrugs.com ... your vet just faxes a prescription to them .

60 prednisolone tabs were $32.95
and 10 mL of bupenorphine oral is $32.95

 

Thanks. It is the liquid form and it is expensive, even though they sold me the smallest bottle (in case it doesn't work out). Her appetite was already decreasing before I gave her the first dose yesterday, but with a little work I managed to get her to eat all the food with the pred. and cyclosporine in it. It is funny, when I moved the bowl to the area where I used to give her treats, which are now off limits due to her new diet, she finished off what she hadn't eaten. I suppose she misses the ritual. Anyway, given that her appetite is down and she's always been a fussy cat when it comes to food (I am still astonished she is eating the wet food) liquid really is the best option for now. Maybe once things have stabilized, I can consider less expensive options. Provided that will work. Who knows. If the capsules' flavour is hidden by pill pockets, that could work, and she would get the crunchy treats she misses so much.

I am still a little freaked that she is diabetic, but right now, the only focus is the great enemy - pancreatitis. Hope Bandit's battle with this nasty condition is successful.

 

Thanks, but between the exchange rate and duty (I live in Canada) there probably won't be much savings for me. But it looks like a helpful site.

 

If she is not eating well, it may be best to not mix her meds in the foods and give them to her an hour or so after her meals (by squirting them in her mouth). You really want her eating as much as she will at this point, and the smell of the meds can turn her off the food. Plus, you want to make sure she is getting all her meds fully to help her get better. I looked up cat pilling and liquid medicine videos on youtube and they helped me alot getting all Bandit's meds in him! There is a trick to knowing where to put your fingers to open up their mouths. I would avoid giving the meds at meal time so she doesnt associate them with food...that is something Bandit's current doctor told me that I never even thought about before because he has always been so good with meds until the pancreatitis.

 

Oh, and trust me, the diabetes is easy compared to all this. Once you learn how to test and give injections, the stress is not nearly as bad as dealing with the pancreatitis. I hope her numbers go down on their own once the pancreatitis resolves, but if not, treating the diabetes is not hard once you learn.

 

So much to learn and of course, each kitty is different. Not eating all the recommended amount of food (one can, rather than the one and 3/8ths I was told to give her) just started the last couple of days and I imagine it was due to how she was feeling so I hope it passes as she improves. Not to get my hopes up too much, because it is only the second day on the cyclosporine but she seems to be doing better. She is eating more again, playing with her toys with more energy and really seemed to enjoy the sunbeam that was shining into my place today. She spent more time sleeping in my lap, looking comfortable rather than on a chair under the table in the meatloaf position. I gave her a much smaller portion of food with the meds in it today and gave it to her by the sofa where I used to give her treats and she ate it all, so that's promising. In the past, when I was out of treats I would give her a small handful of her regular crunchy food and she would eat that, so I think the ritual is important to her. I thought I would use that to my advantage and it worked well. Tomorrow I bump up the amount of cyclosporine to the next increment, so we will see if that makes more of a difference - right now the amount is so tiny I can't imagine she can taste it. Her other meds are done up at a compounding pharmacy and are chicken flavored, so I'm hoping they mask the cyclosporine. Otherwise, I will have to find another way, as you recommend. How old is Bandit and how long has he had diabetes? Does your vet intend to keep him on both the pred. and the cyclosporine? Mine is pretty keen that we get her off the pred. Of course, Bandit has a bit more going on with the immune disorder, but I'm just curious to know if the pred. is short term in his case.

 

Agreed. My vet seems to think chances are good that the diet and getting her off the pred. will be enough. The pred. really is the likely culprit in all this. Other than changing her food, the focus has been on the pancreatitis. Actually this bout, worrisome as it is, is not as bad as her first one two years ago. Back then her fPL was 50, this time around it is 37. Still elevated, but a better number. I am really hoping the cyclosporine is tolerated and helps this time. Even if I do have to treat her diabetes, it will be easier if her pancreatitis is under control. And I understand pred. can make it more complicated. Thanks for taking time to send the supportive words, even though you are going through your own issues. It is appreciated.

 

I agree about giving the meds separate from eating.
Mine knows every time and just won't eat if I try that method.

I've learned to be quick, open that mouth, get that pill down... and give her a treat or squirt of water or something so she has a chaser.
capsules are the worst. big enough to be spat out, I have to get them in fast and deep.
fortunately, this new cyclosporin is in a gel type cap and slides easily.