Blue AMPS 402 10/12

Silly us!

 

Silly us indeed, Jeanne, relying on all that evidence. What were we thinking?!




Mogs
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Crazy internet trolls we are

NOT

 

I'm back. I really feel we were on the verge of him regulating. If you look at the last week he was in the blue one entire day and then he dipped into the green. I think I'll probably keep going on as normal. I might not want to test as much as I've been doing since he is stressed and needs rest.
Do you all think I could do this safely?

 

Glad you're home safe, Patty.

That's cool, Patty. You'll need to factor that into dosing decisions. Obviously there is always the chance that Blue might throw you a curve ball but using your spreadsheet data should help reduce the risk of that.

WRT insulin treatment going forward, I'd like to first hear what your vet says to you about dosing, target range, the reasons for his recommendations and any comments he has on the pancreatitis side of things. At the end of the day, he's the one with the degree, and he's the one who's done the diagnostics so it's important to see what his treatment advice is.

Tips:

- Ask for a copy of Blue's test results, etc., and also the BG readings/dosing info for his stay at the vet's (so you'll have an idea of where the depot's at and what has been working for Blue during his treatment).

- Ask for a supply of supportive meds to take home so that you can address any eating issues, etc., promptly while he's convalescing (pain relief, anti-nausea, appetite stimulant for the pancreatitis side of things).


Mogs
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I have two meds for Blue. Amoxicillin and Cerenia for nausea and vomiting.

Dr. Johnson said they found that 1 unit in the morning stays with Blue for 18 hours and they want that one big drop. If .5 is given it took him down but then back up and then the next .5 took him down to far. They're okay with him going way up because he is still acting normal. I'm still waiting on their BG testing.

I don't know

 

Awww (((((Patty))))) hold on for the "experts" I'm sure they will calm your worries.

 

Good about the Cerenia. Would like to have seen something for pain relief (bupe).

What's their definition of "down too far"?

Exactly how far up is he going? How high are they happy to see him running?

Just because a cat may act normally at higher BG levels it doesn't mean having the cat running at those levels is good for its overall health.

First impression is that the vet is trying to apply canine diabetes principles to feline diabetes, and using Lantus as an extra-long-lasting in-out insulin like Vetsulin, but that's only an opinion formed with incomplete information. Impossible to know what's going on in the vet's head without knowing the target range he wants to keep Blue running in. (@tiffmaxee, @Red & Rover (GA): Any thoughts?)

I really hope that you manage to get the actual blood glucose readings and dosing info from the vets, Patty, not just a broad-brush summary of what they tried while Blue was with them.

But now to the most important thing: is your Bluebird home yet???

(((Blue)))


Mogs
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BTW, can see the PDF OK.

Kwestion: What test(s) did they run to diagnose the pancreatitis? (No fPL tests in the lab results above.)


Mogs
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Possibly what they are not taking into account is the depot – if there is any depot left (nothing on the spreadsheet after 12 Oct).

I can see the pdf but am not great at reading labs. Patty, it would be a good idea to delete the pdf, cross your last name and contact information out, then upload it again.

 

Good point. Should have thought of that. (Too busy looking at the data. Sorry! )


Mogs
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I deleted but having a hard time taking off info and uploading. I'm working on my iPhone.

 

Maybe wait till you get home where it'll be easier?


Mogs
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No labs but here he is in his ”bed”. Glad to be home.

 

(Assuming the iPhone means you're away from base.)

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We’re home. Just busy with everything. Might have to wait until tomorrow.
Hope you're feeling okay Mogs.

 

Blue's home!!!!!

(((Patty and Blue)))


Mogs
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I thought its be easier in my iPhone. I'm not very savvy with my PC. I've always used Mac

 

There's no fire.


Mogs
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I'm a heathen - never used a Mac.


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I have only ever used Mac so when my daughter gave me the PC laptop I haven't really used it because it's so different. Now I'm trying to learn fast. I might try my iPad next. Maybe it'd be easier.

You need some rest my friend...

 

Where are the lab reports? Haven’t been on much and just came on only for Blue. I don’t agree with your vet on dosing.

 

I’m on an iPad most of the time.

 

The spreadsheet has a tab for labs. All you need to do is plug in the numbers.

 

I took them down because they have my information on them. I resized in scanner but now I can't seen to upload again.

 

Patty I fear if you listen to this vet all your progress will be gone. What if you black out your info and take a picture? Or use the tab on the spreadsheet.

 

I guess it'll be tomorrow. My eyes were dilated and I'm struggling.

 

No rush. Relax and enjoy being with Blue.

 

I know. I don't know enough yet to make an informed decision. Is there something wrong with dipping twice?

 

How is Blue??? (Great photo, BTW.)


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Dipping twice???

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I don’t understand dipping twice either. What do you mean?

 

He's doing great. Marching on me now and giving me kisses.
The .5 dose they said only drops it so far then BG comes back up but not enough. Then I give another .5 and he goes to low. So he goes up down up down. They want only one dramatic lowering and don't care how high it goes after. They said for Blue the first dose in morning of 1 unit lasts for him 18 hours. They don't want a flat line of BG. I don't understand enough to ask them the correct questions.

 

and telling you all about it

 

Bluebird loves his mama!!! (((Blue)))


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I tried the labs again...no go.

 

Is what I relayed making any sense? Dr. Bruno called when I was checking in at eye doctor and when I picked up Blue I asked Dr Johnson the questions. Dr. Bruno was gone. It's so hard without sitting down eye to eye and going through everything. I'm already going in blind so struggling to ask the right questions.

 

Awwww (((((Patty)))))

 

The main aim of using a depot insulin is for numbers not to go up.

What do they consider to be 'up enough'? (I dread their answer.)

What do they regard as too low?

They're either referring to two nadirs a day (which is what we want diabetic kitties to have from their two doses of insulin per day), or to bouncing (not likely if they think 'he comes back up but not enough': we know only too well just how high Blue can bounce).

Do they think Blue is a diabetic dog?

Have they said *why* they want this?

This, to me, sounds like they want Blue's response to Lantus to fit what they think feline diabetes should look like. (Note: If your vet has been used to treating cats with in-out insulins like Vetsulin in the past they may not have got their head around how depot insulins work best, namely keeping BG levels low and flat.) ETA: Also, they are applying canine diabetes management principles to a cat.

Snap verdict? --->



(ETA: @tiffmaxee, @Red & Rover (GA): Thoughts?)


Mogs
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There's no panic on the labs. Tomorrow when you have some time is grand.



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I don't think the attachment is working.

They said he was over 600 and they were okay with that.

 

Or tonight's good too! .

Can see the reloaded labs fine.


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I don't understand their thinking.

 

You can see them? I can't open them.

 

Mogs
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Thank you. I never thought about that.

 

Yep. I get the option to open the PDF in a Firefox tab or in Adobe Acrobat Reader.


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LOL I know, right? When she was telling me I think my mouth fell open.

 

You're not alone in that, Patty.

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Well, I'm not shooting tonight. I might try the 1 unit since they already screwed up all we have done. They also want to see him in a week for another curve. I don't know what to do. It's a dilemma because that's my vet. I need them. I just don't think they know what they're doing.

 

Why?

It would be better for you to run the curve at home and email the data to them. If it's run at the vets it is likely to be stress-influenced (inferior data and an unnecessary expense).

They have put you between a rock and a hard place.

Sadly, neither do I, Patty. Neither do I... <sigh>

What's even more upsetting is that I think their treatment plan is more likely to reduce chances of achieving remission.

Questions:

1. Was this the clinic that set Blue on a starting dose of 2IU Lantus BID?

2. Roughly what did Blue weigh at time of diabetes diagnosis?

3. Did they recommend Lantus or did you request it?


Mogs
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I just saw labs. They ran a SNAP in house for pancreatitis. It seems to show possible virus but I don’t see any sign of infection requiring antibiotics.

The fructosamine shows he’s not controlled as far as diabetes but not sure how valid since he’s been high and not getting proper insulin dosing the last few days.

Do you remember what happened when you gave too high a dose when we first met? I’m concerned.

 

Yes this is the same vet. Dr. Johnson was who wanted to give 2 units twice a day. While speaking with Dr. Bruno he said he starts at 1 unit twice a day. There's a conflict right there. It's like a guessing game.
He weighed the same. 7 lb. And I thought he would gain as much as he eats.
No, I knew from nothing about any kind of diabetes so didn't request Lantus.

 

Seriously? Wow

 

No high white count. Maybe I am missing something.

 

I'm not good with reading labs but his BUN is a little elevated which scares me.

Another thing. I asked about remission and they weren't hopeful.

 

No way would I drop him for a curve. Induce more stress in a cat recovering from pancreatitis and likely to run high being back there? This is a tough situation. This may sound stupid but can you plead poverty?

 

BUN can be a bit high from a higher protein diet. Creatinine is normal.

 

https://vet.uga.edu/category/diabetes-clinic

This is University of Georgia. I wish I had thought to go there earlier. I'm already into so much $$$ and I know it's costly to go there.

 

I've done two curves already for $100+ each time and I ask myself why I'm doing it.

 

First up, starting dose (from FDMB TR/SLGS Dosing Methods sticky, based on published Roomp-Rand study):

How to determine an initial starting dose for glargine or detemir when following the Tight Regulation Protocol:

• the formula is 0.25 unit per kg of the cat's ideal weight [every 12 hours]
  
• if kitty is underweight, the formula frequently used is 0.25 unit per kg of kitty's actual weight
• if the cat was previously on another insulin, the starting dose should be determined by taking prior data into consideration

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Blue was underweight so that's what his starting dose should have been based on.

* Weight at time of Dx = 7lb = 3.2kg

* Starting dose = 0.25 x 3.2 = 0.75IU q12h (rounded down to nearest quarter unit).

Is it Dr. J. that is insisting you give the dose of 1IU once a day and made all the other comments about Blue's response that you mention above?


Mogs
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It's both. They're tag-teaming me. She works for him so I get it.

 

Patty, you've probably got a better testing technique than they have. They're well aware that you are perfectly capable of doing the necessary tests. The readings you take at home provide a much more reliable picture of Blue's response to his insulin dose. Perhaps suggest that if they wish to re-examine Blue after a week you'll be happy to bring him in for a check-up but you want to do the curve at home for the reasons outlined here. If they then say the check-up isn't necessary, it's one less car trip for Blue.


Mogs
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Another thing, and this is crazy...they said if he gets lethargic give him syrup and even gave me a syringe of it. No test just guess

 

I'm going back and forth on this. I might go back to the .5 very 12 hours but as I mentioned earlier maybe not test so much because I believe he thinks I'm causing him stress. I need to look at his spreadsheet and make a plan.

 

That is crazy! Blue doesn’t mind testing. If he did he would hid3 from you. You mentioned before you need a new vet. I agree. I don’t mean to stress you more but give a sugar baby sugar if lethargic? You have seen what hc does to him.

 

Yes. When they told me that all I thought about was you telling me the sugar high wouldn't last long. The other day he was very low for a couple of hours and I was feeding high carb food along with honey. The way they want me to proceed is go in blind.

 

Phosphorus is normal too.


Mogs
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If what you're seeing from them is their typical approach to management of a feline diabetic, I very much doubt many of their FD patients ever achieve it.


Mogs
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Am I correct in understanding from this that the vet thinks you are causing Blue stress because you're checking his blood glucose levels?


Mogs
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He didn't say that in so many words but it was implied. I don't believe he wants me to test at all.

 

The only things (apart from the expected high BG and abnormal Snap fPL) that I could see off were the elevated BUN (possibly due to high protein diet) and the platelet results (which machines sometimes have problems counting due to clumping).


Mogs
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Sadly this is a line a lot of vets parrot. Without justification.


Mogs
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This is fundamentally wrong. And I'm assuming they were measuring this on a pet meter.

In my considered opinion, any vet with a basic understanding of feline diabetes would not be OK with a cat being this high. At minimum they should be looking to see Blue loosely regulated, i.e. below the renal threshold for the majority of the time while minimising risk of hypoglycaemic episodes. Per the Merck Veterinary Manual, the renal threshold falls in the range 250-290mg/dL (pet meter) - a far cry from their 600mg/dL!

When BG is above the renal threshold there is greater risk of damage to the kidneys and also increased risk of UTIs developing due to the sugar in the urine (nourishment for bacteria).


Mogs
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I was pretty shocked. I get frightened when he's that high, just like when he's too low

 

Again, utterly wrong. If there's any concern about whether a cat may be hypoglycaemic the best thing you can do is check its blood sugar level. It's not rocket science.

I do have a theory that some vets have very poor testing technique which would, of course, be stressful to the cat and they then automatically assume that the cat's human is equally challenged in the testing department. At the practice where Saoirse was first diagnosed I brought her in to them for a couple of curves (got no support for home testing) and they made mincemeat of her ears. I was in the hospital area when they were doing the last test. It took three people to get the test, and they were poking in the wrong part of the ear. When mishandled like that, of course a cat's going to be stressed out of its mind. At home, it wasn't long before Saoirse started sitting at her testing station, waiting for me to do her sugar check. Single-handed.


Mogs
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I'm quite gobsmacked myself, Patty.

I am soooooo upset for you!!!!!!!!

(((Patty)))




Mogs
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Yes, Blue does fine with me. They cut their nails to the quick to get blood at vet. Now that would be stressful.

 

This is a picture of Saoirse waiting for her sugar check:





She look stressed to you?


Mogs
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WHAT??? To check their blood glucose????

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That terrible. Poor baby! I feel bad testing a lot on Blue. His ears get red but not as bad as that sounds.

 

She was gorgeous Mogs. I love black cats.

Yes, cut their nails to the quick. Cruel

 

Separate spreadsheet for the vets with fewer tests on it.

New thread tomorrow, please. This one is very long.

 

Saoirse's ears were in complete tatters by the time they finished with her.


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Click on her profile link in my signature. The picture therein was taken in 2009 but that's exactly how she looked after a couple of months on Lantus. My beloved girl... ((((Saoirse))))


Mogs
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That's utterly barbaric.

Words fail...

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Oh yes, she's very pretty. Was she part Bombay? The round eyes look like it.

You know when they told me that I assumed that’s the way all vets tested. Is it not?

 

When Saoirse went in for curves to the vets she was under at time of Dx they tested from the ears, the same way as we do (albeit clumsily). After we moved to our current practice, any time she was in with them for something they also would test from the ears.

I have no idea, Patty. I adopted Saoirse and Amadán, her brother, from a local rescue shelter and on their papers they were down as domestic shorthairs (moggies, in essence). Amadán was a tuxedo.

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Mogs, I couldn't help myself and tested Blue. He's at 66!!!

 

BTW, Saoirse was also out at two referral centres. They also tested from the ears.

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Wow! How long since his last insulin dose?

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And how big a dose did they give him?

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I think they gave it at 7 a.m. 1unit

 

How long ago was that (hours and minutes, please)?

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17 hours 12 minutes if they gave it on the dot

 

I fed him a little LC food. I'm not sure what else I should do.

 

Thanks, Patty.

Impossible to tell what's going on without recent readings and also the possible resolution of inflammation in the mix. We know that a 0.75IU dose with a bit of a depot built up is enough to take Blue down to the lower limit of the normal range. What worries me now is that we don't know whether Blue has been going lower earlier in the cycle on a 1IU dose than the 66 reading you just took. Bearing in mind that they set the 1IU dose in a situation where stress could have been elevating Blue's numbers, that's a concern.

I hope you can get the dosing information and BG readings from the vets tomorrow, Patty. I think you really need to see what has been happening to Blue's levels while he was at the clinic in order to be in a position to make properly informed, evidence-based decisions about how to proceed.

What do you think yourself?

BTW, if they say that the dose wears off after 18 hours, I'd suggest a spot check after that point to see how much Blue's BG might be rising.

(Sleep meds kicked in while I was in the middle of typing this. Sorry! )


Mogs