Cody 2/20 need help ? next steps

Any comments on his ss? Are we getting anywhere?? Is this just the nature of the tumor? good days/bad days?
quick review :
FD dx 7-2007 continued unregulated mid 200's-400
acro dx 2-5-10
Vetsulin (long time)up to 13u eventually--->PZI (Nov09)---->Prozinc (Dec09) now at 9u
no hx ketones, no hx of a number under 140, gets enelapril, miralax & LRS daily
readings before 2-8-10 were with Freestyle meter, which tends to read lower; readings after 2-10-10 are w/Maxima reads approx 20-60 pts higher
2-12-10 vet suggested 2 unit increase because smaller increases made no impact. Nobody around to hold my hand that day, but we made it.
She wants a fructosamine after 2 weeks at 9u. I don't really see the point of that..... other than to see how our 2 week averages compare.
Food- canned, very consistent, same every day, spread out over 6 meal-snacks /24 hrs
Aspirin 2x/week may be related to 'better BG days", but not conclusive.

I realize we are close to taking the prize for "longest unregulated", but do other acrocats eventually get numbers below 200?

I am going in some day next week, maybe Thurs. Is it time to:
increase some more,
push her to support me using R
try a week of buprinex (SP)
other ideas? which one first and why?
I did restart tiny doses (250mcg) of methyl B12 every other day last week. I think it may help his bowel motility.
I'm not ready to change insulins yet as I have 1 1/2 vials left. Am I the only acro mom not using levimir?

 

hi nancy. i got your PM asking for some help tonight, so here i is.

okay i don't know you guys well so have a few questions...can you dose more often than 12/12? cause the first thing your SS says to me is that your kitty needs more insulin. that R would be a good idea too.

"I am going in some day next week, maybe Thurs. Is it time to:
increase some more, ~yes, more insulin needed here.
push her to support me using R ~yes, R in house is always a good idea for any acrocat
try a week of buprinex (SP)" ~yes, a pain trial is also a good idea. i don't know why you are using aspirin, but if it is for pain, there are better choices.

yes there will good days and bad days but the goal is a SS with as much blue as possible. and don't worry you will get there, just takes time and trying new things. i do not agree with vet having you stay at 9 units for 2 weeks here. don't see how that is magically going to give you the all blue SS you're after. you have given 9 units a week already, it has shown you all it has to give, pink and yellow, obviously not working.

what are you using for the chronic constipation issue that it looks like he has on SS? you still giving the LRS 75 mls bid?

 

Thanks so much! I think his history and meds are all up to date on the profile but here goes:
The aspirin is because he has an enlarged heart/heart disease. He takes 2.5 mg enelapril BID and asa 2x/week to decrease platelets. She thought his heart may be throwing clots which wiped out his colon motility, leading to megacolon. We've fought that for years and its the best its even been the last month (thank you FDMB) with
1/2t miralax/day,
approx 125-150 lRS QD,
120ml water added to food/day,
and 15ml orally whenever I think of it.
Lately, I added 250 mcg of methyl b12 tab every other day which might help motility a bit too. (vet is unaware I do this)
and I do warm water enema if things stop up more than 2 days.

Oh, and he takes 1 baytril everyday.

Can somebody tell me about buprenex? pill, dose, injection?

 

and yes I could dose 3x/day. He's a big job already, so Id rather increase dose 2x, but I could go to 3 if it was better.

Also tell me about purchasing R, I don't think I will get vet support on that.

 

Hi Nancy,
Forgive me for being so absent lately. Just kind of crazy at home these days. Mom still needing alot and lately 2 sick kitties. sigh....

Any chance you are interested in using a sliding scale with the Prozinc. Seeing it's very like the PZI Idexx - I think that could work well for Cody. And also IF you could dose at times more than every 12 hours. With the sliding scale you wouldn't give one set dose all the time. We would work out a scale that you give a dose based on cody's BG. It works really well with PZI type insulins. I think all of us who used PZI with our acrocats did/do this.

With Merlin I was almost always able to keep him in the 100's - sometimes even in double digits. I used a mix of the PZI and R. It eventually got that no matter how much more of PZI added - it didn't affect his numbers so much. Then when I added in the R with it - I was able to get better control again. I don't know if you're interested but you can take a look at when I started doing that with him on his profile on catacro. It also helps with the cost in a way. You get to a point that no matter how much more you add in of the longer acting insulin - you need that shorter acting insulin to boost the longer acting one.

But yes - there are days that no matter what you do - you are going to have wonky numbers. Basically what we always talked about was to keep the BG below "renal threshhold" - where the kidneys spill sugar. The numbers vary slighly depending on what you read/who you talk to - but I tended to pick a BG of anything <250 being good. I knew Merlin never spilled sugar in his urine then.

I know that you want to work with your vet and I totally understand that. But truthfully - most of the vets really don't have much of an understanding of the acro. And I agree with JoJo that waiting 2 weeks isn't going to change anything.

Libby is still using PZI and happy with it. It's a matter of personal choice. I loved the PZI with Merlin but my life/work schedule made it possible to use it and shoot 3-4 times/day.

Also FWIW - with your glucometer - you can get a 2 week average of your BG readings - why does your vet want to do a fructosamine and charge you and that is what it's going to show. Just a little food for thought. When I adopted Boris - I was told his fructosamines showed he was well regulated . Well on Vetsulin his BG's went from 284 to 54 in 4 hours. An average of that is somewhere in the 100's. So if I had just been going with fructosamines I'd believe that he was just fine. You are hometesting and have more detailed BG results. The fructosamine seems like such a waste to me for your pocketbook.

And lastly - I found Buprenex to help Merlin alot. I know it's been awhile now since we lost Merlin - but I don't know that there is anything more that others really like. Because I knew towards the last year that it was more about quality of life - I added in Metacam too and even started Adequan. He had alot of spinal discomfort. I feel all of that helped make him more comfortable.

I know i've rambled on here - please forgive me for "talking" so much. I hope I've helped a little. If you are interested in the sliding scale or if there is anything I can give more info on - please let me know. I will check back in the morning.

 

just saw you posted while I was writing my saga....

In WA state - you can walk into any pharmacy and buy a vial of REGULAR insulin with no prescription needed. NOT NOvolog or Humalog. They are TOOOO fast acting. You want Humulin or Novolin REGULAR insulin.

edited to add:
Buprenex for me was sold in a "cartridge" type cylinder. I believe it was 1 ml. I dosed Merlin from that. He was 16.6lbs. I have to look up his dose as I've forgotten now. But I drew it up in a syringe and gave it to him orally altho it's listed as an IM/IV medication.

 

Come to think of it, thats what I did at the very beginning with humulin N I'm pretty sure; just asked for it at the pharmacy.

Is buprinex another injection or a pill? how long did it work? sliding scale is OK but I want something simple cause I probably won't have anyone holding my hand, day to day.

Patti, I hope your mom is doing OK. I know you've been swamped, and we've been trying to hold down the fort, but its not the same without you! Several kitties are being tested and should know next week.

 

Yeah, I agree on the fructosamine, they do one in house thats not tooo expensive, but I've been testing so much I can't imagine its really gonna tell us much. Cody is such a trooper in all this.

One thing I don't get about a sliding scale is that we haven't gotten anywhere near enough drop, ever, so why not keep going until we do? I guess thats the point, if we ever get lower, then you back off...

I need to sleep on all this. But I'll be back tomorrow.

 

cool patti stopped by too. (nancy PM'ed me cause she saw me on board and was lonely,lol).
i agree fwiw about sliding scale for PZI/prozinc. your vet probably won't but as patti said you are talking about an area that hardly any vets in the world have experience. the whole concept is easy, you just forget the clock and shoot after nadir (once numbers started back up). however i would suggest before you do that going out and getting the R asap and learning how your cat responds to R, you have to know what your cat's R onset/nadir/duration is to use it successfully, while still on 12/12 so as not to change too many tings at once. shouldn't take ya more than a week to get your understanding of R response in your cat down and then dropping the clock with the prozinc and going to sliding scale PRN dosing with R added in. i know it sounds complicated, but really it isn't, it is just see a number/shoot a number dosing. you do not need a script for R, just walk into any pharmacy and ask for it. you do need U-100 syringes for it. think you can get it tomorrow?
and yeah the fructosamine is totally a waste of $$ and stress on cat for unneeded vet trip/blood draw. like patti said, just use your meter's average, that is good enough. vets are not used to clients hometesting, the fructosamine test is for all their non-hometesting patients. however read below what i said about pain trial, you DO need a vet that works with you so if you can't talk your vet out of the fructosamine test sometimes people just have to play along, kwim?

as far as the health issues...
if you are having to give enemas then your miralax dose could prolly stand to be upped. i lived for many years with a megacolon cat, you want to keep the stool on soft side always. dosing the miralax twice or even 3 times a day is often needed. have you tried bid dosing with it? constipation med dosing is sorta like opposite insulin dosing. you find the right dose by giving too much, getting stools too soft, and then backing off dose. why? cause you cannot tell what is a good dose on a backed up colon.
and once you find a good dose for him that keeps litter box action nice, then that will be one less thing that is hurting BG numbers, being constipated to point of needed an enema can and will cause higher BG numbers in a cat.

so the aspirin is not for pain issue, but you have noticed an improvement in whole cat on those days leading you to believe there is a pain issue? sure a pain meds trial is called for then. bupe is a liquid, used as injection or absorbed through oral mucosa. injection is easier though. your vet has to be in on this, it is a controlled substance. at end of 3 days (usual length of a pain med trial) you report back to vet and if huge improvement is noted, then options are explored depending on what the source of pain is. (being acro we would suspect lumbar spine). adequan injections have provided relief for many cats for that. metacam is something you want to avoid if possible, depends on much much pain is interfering with QOL. (there is a time and place for it like how patti used it with merlin). but bupe is for short term use, it is not something you would want cody on forever.

the methylB, you can give that everyday, it can't hurt only help. is there problems with back legs?

why does he get a baytril everyday??

 

geez, 5 posts while i was typing? told ya i type slow. lol.

"One thing I don't get about a sliding scale is that we haven't gotten anywhere near enough drop, ever, so why not keep going until we do? I guess thats the point, if we ever get lower, then you back off..."

nancy see how a couple of days ago you had that 400 something AMPS and you instinctively wanted to give more insulin with that fat 9.0 units you gave? that is what a sliding scale will do for you, let you give more when number is higher. and yeah you have not gotten a drop cause 9 units is not enough, so your whole scale would be built on higher doses.

 

Ok I need to let this settle, Jojo you may actually out "night-owl" me, i'm fading. Sounds like maybe r or pain med tests should be first, then upping dose again. I still have u100 needles, but I dont think they were incrementally marked - ill check tomorrow. Yeah vet is pretty easy, and supports home testing. I think the variations in meters i've been frustrated with and told her about, is part of why she wants to have a comparison test.

I'm really fried - can I count on one of you for some r guidence ? when are you around? pm me if you need to

 

go to sleep. tomorrow is another day and there will be peeps around.
in morning if you can get the R that will get things started. (and can ask for a bag of U-100 syringes with 1/2 unit marking while at pharmacy if you don't have).
don't be scared okay? you can do this. your first shot of R is only gonna be 0.1 units. just a little drop to see how your cat reacts to it. not scary at all. :smile:

ni-ni!

 

Thank you thank you!
Sunday update:
overslept (duh) shot 1 hr late, cody mad about late food so he peed on the wall again (little s**t)(and he's been good for over a week w pos reinforcement treats when he uses the box)
added 1/4 can of Before Grain 100%chicken canned to his reg breakfast- is that OK stuff?
will buy R today and syringes, but today is family day, so that's all. I'm retired so I have all week.
AMPS 348
+1 1/4 329 purring loud and drinking - both very unusual

Notice how he dropped already? His onset is usually 2hrs and in full swing by 4-6. When am I gonna add the R?

Later and thanks

 

Dear Nancy,
I can promise you one thing - I WILL walk with you all the time if you want to use a sliding scale. Ask anyone I've worked with doing this and I'm right there with you all the time. I'll give you my phone number and you can call anytime too. What I've done in the past is figured out when you're going to shoot next and just planned on being there on line or wait for the phone call. Then you don't have to feel so alone.

Take a look at Merlin's sliding scale and see how it helped him:
http://catacromegaly.com/acmb/viewtopic.php?f=9&t=475
Yes - I know it's not a spreadsheet - lol
but you can see how I gradually had to increase the insulin doses to account for his numbers. Also on 10/5/2007 I tested Regular insulin on him and started using it on him with his PZI - you can watch after that how it worked together.

You can do the R how Jojoj suggests OR there is another way with the Prozinc to do it how we did with the pZI. That's where you can see how we did it on Merlin and all the other acrocats on PZI.

Sorry Jojoj - don't mean to change what you say but it does work a ltitle different than with the Levemir and Lantus so she can do it differently here.

I'm sending you a PM with my number.

 

Ok just thought I'd cut/paste this so everyone could see:

Here's how I tested R on Merlin:
12:30pm(+5.5) = 226 (12.6)...1unit R given and fed 2 oz FP
1:30pm (+1) = 237 (13.2)
2:30pm (+2) = 180 (10)
3:30pm (+3) = 192 (10.7)...1.5units R given
4:30pm (+1) = 163 (9.1)
5:30pm (+2) = 120 (6.7)
6:30pm (+3) = 143 (8 )...2units R given
7:30pm (+1) = 147 (8.2)
8:30pm (+2) = 103 (5.7) and ate 2 oz FP
9:30pm (+3) = 91 (5.1)
10:30pm(+4) = 117 (6.5)...8units PZI

Regular insulin with PZI typically only lasts 3 hours and peaks at 2 hours. What I had done was held my PZI dose when it was due and then started testing my R so you need a day when you can do this. Then I set a BG level where I would add R into the scale and for me that was whenever Merlin was >250.

Here is an example of a day I used R:

2am (+5) = 213 (11.8 )...9.5units and 1unit R
8am (+6) = 207 (11.5)...9.5units and 1unit R
fed 2 oz FP @ 9am
fed 2 oz FP @ 1pm
2pm (+6) = 232 (12.9)...10.5units and 1 unit R
fed 2 oz FP @ 5pm
7pm (+5) = 197 (10.9)...9units
fed 2 oz FP @ 9pm
12MN(+5)= 156 (8.7)...8.5units

 

Patty - Buprenex dose

Your bup dose was probably .1ml -- 1ml would have been about 10 times what I give Leo

Thanks for helping out Nancy, you're a dear!

 

Patti, Jojo (and everybody)
I appreciate your data and I'm really studying it, and have to say, you are really brave (Patti). I think for me to really understand what you were doing I need to see what a normal full curve on your PZI might have looked like , because from what you have given me, I don't think it acted like Prozinc does in Cody. When we started PZI 1x/day it lasted way more than 12 hours.

The other variable that kind of worries me is that I'm feeling like my current vial is not acting like the first vial and I'm wondering if all this freezing weather during shipping has changed how it is acting (or is just Acro cody?) I'll tell you next fall I'll be ordering enough to get through the winter. This adds uncertainty to the next vial and I hate these variables!

With this vial it does seem to poop out sooner (+10?), but then maybe it is because I started adding meals every 4 hours and the combination makes his BG rise steeper during hours +8-12. Since I noticed this, I now make the +7/+8 meal more of a snack, but the others (PS and +3/+4) are big meals. He has been much more content and less sneaky since we've done this (and increased the quantity;better QOL). I know doing this levels out the nadir, but Cody gets a bit panicky for food when his BG gets below 250. He's been here for YEARS and its where he's comfortable. I'm not saying thats good, but it IS true.

So I'm all about, whats the next single (easiest) logical step, because I've attacked this very methodically with lots of data.(food mania, bowel issues, insulin choices, acro dx) and he is a much happier kitty, so we're moving forward.

I took the pain med names you both mentioned and did a bit of research. Not very encouraging, unless the adequan helps. Metacam is out of the question, and Bup being narcotic (not for chronic use) is much less interesting now. I didn't see any downside of adequan but wonder with his bowel and heart issues if its still OK. Ideas? :?:

Here are things I'm considering next:
1) to up the 12/12 dose. Yesterday, I noticed that 9.25u suddenly dropped his number over 100 pts (and it was right as I'm headed out to church) which freaked me out so i gave him his 2nd meal early and left. Later his numbers were still good.

2) try to shoot 3x/day, every 8 hrs whenever possible.

3) Add a drop of R to the backside of the daytime 12/12 cycle,( for example at +9,) if the BG is over some number like 300 (for starters and dropping as he adjusts to lower numbers.)

4) learning more and discussing adequan with his vet. Do you have to do a bup trial first? , or is that best ? Is this a standard vet practice or am I teaching her something else?

I don't think I like the random shooting whenever idea. I think Prozinc is a longer acting insulin and that could get me into trouble. Maybe I just don't understand where Merlins nadir was but I did have trouble with getting your example.

I'm really confused what to do next. Whenever I feel this way, I know I need more information. Hang in there guys, I will be back

Oh and to answer a couple questions from earlier:
Baytril- every time I try to wean him off the baytril he gets a mucousy left nostril, which I think stems from possibly aspirating mineral oil the 1 time I tried it. his body can't break it down so it just sits there and festers I guess.

Methyl B12 it says on the bottle "supports red blood cells". He's on aspirin to decrease platelets (wh if I remember correctly are broken bits of RBC's) The vet asked me to stop giving it when we discovered his heart issues, and he still can jump onto a 36" countertop, but may walk a little funny and seems to get tired easily, rarely comes upstairs. I know everything says its water soluable and safe, but I'm still a bit nervous giving it. Any cardiologists out there? :?:

As for the miralax,/ enemas. In Jan we did exactly what you (Jojo) described (thanks FDMB- Carolyn i think it was), giving too much and backing off and things are good. Just need to keep him out of the dog food, :evil: that set us back 10 days at least. No enemas in awhile, (just a messy butt much of the time) I do add it to ALL of his food. I make a batch of food every 12 hrs and divide it into meals for later.

I'm starting to get p****. I called the vet Sat and this AM and left a message and she hasn't called back. All my guys love her and don't mind going to see her so ........ :shock: I guess I must be patient.

 

:shock: :shock: :shock: :shock: :shock: :shock: :shock: :shock: :shock: :shock: :shock: :shock:

Just got a message back from vet through some new girl. "Come back in 3 weeks for the fructosamine" and "yes keep the dose the same."
cat(2)_steam cat(2)_steam cat(2)_steam cat(2)_steam cat(2)_steam cat(2)_steam cat(2)_steam cat(2)_steam

I'm going for a walk to cool off :shock:

 

Hi Nancy,
Checking in from work here.

Sorry - I picked a day from Merlin after we'd been at things for over 2 years. I was just trying to explain about using the R and it seemed easier to show you how I did it than trying to word everything.

With Merlin - in the beginning - I got longer durations at first but over time - the durations varied and often I had to shoot every 6 hours but even that could vary. It all is due to the tumor. And yes - to the various insulins. I just didn't want to bore you with ALL the numbers I had here! @-)

In order to set up a sliding scale we would definitely need a curve and then always you wouldn't shoot if he wasn't <150. However with Merlin I learned that if I didn't shoot when he was around 100 oftentimes - he would skyrocket. Again - this was all learned overtime. And his sliding scale was changed numerous times. But yes we would need to learn Cody's nadir with his insulin. And setting up his first sliding scale we would be conservative. We would take into account how the prozinc works and how low he goes with each dose of the prozinc. It would be great if we could find a nice balance and keep him somewhere in the 100's but remember too that a cat's normal BG is somewhere in the 50-120 range depending on what reference you read. altho it's scary to ever see that number after you've been used to hi numbers for so long. And yes - when starting to use R - you pick a number that you want to start adding the R in at. For me it was anything >250. But again - I'd been at it a long time by the time I started using it.

Here's one of Merlin's first SS from Aug 2006:
141-170 = 1 unit
171-185 = 1.5 units
186-200 = 2 units
201-220 = 2.5 units
221-250 = 3 units
251-290 = 3.5 units
291-350 = 4 units
351-410 = 4.5 units
468 = 5 units

Here is an example of his SS from Aug 2007:
August to December 2007
Scale from Aug 9th/2007 I've been using
90-115 = 7.2
116-139 = 7.5
140-149 = 7.8
150-170 = 8
171-185 = 8.2
186-200 = 8.5
201-220 = 9
221-250 = 10
251-270 = 11.5
271-290 = 12
291-310 = 12.2
311-350 = 12.5
351-410 = 12.8
411-450 = 14
>451 = 14.5

raised scale starting 10/1 by 0.5units across the board as Merlin's numbers have been steadily running higher
new scale
90-115 = 7.6
116-139 = 8
140-149 = 8.2
150-170 = 8.5
171-185 = 8.6
186-200 = 9
201-220 = 9.5
221-250 = 10.5
251-270 = 12
271-290 = 12.5
291-310 = 12.8
311-350 = 13
351-410 = 13.2
411-450 = 14.5
>451 = 15


and here is an example later Oct 2008:
new scale
90-115 = 7
116-139 = 7.5
140-149 = 7.8
150-170 = 8
171-185 = 8.2
186-200 = 8.5
201-220 = 9
221-250 = 10
251-270 = 11.5
271-290 = 12
291-310 = 12.5
311-350 = 12.8
351-410 = 13
411-450 = 14
>451 = 15

As far as the pain meds go: Adequan is supposed to have little to no side effects or so it's said. I wish I had thought to start it earlier for Merlin. Also there should be NO reason you have to do a buprenex trial before starting adequan. They are two different drugs. And I still used both for Merlin. The Adequan takes a bit to build up in the system to work. You start by giving it every week and then eventually every few weeks. Another drug to think about for pain is Gabapentin. I don't have the link here at work but at home I do so I can get that for you later. I have articles on pain control.

Lastly Methyl B12. Another good thing to offer your kitty. It's a water soluble vitamin B. all kitties (and people) with heart disease could use this. There should be no contraindications for Cody to take this. The aspirin prevents a certain phase in the coagulation cascade. Please don't ask me to explain it all - that's where I fail. But I work with open heart kids and they are on aspirin too. Platelets are a part of the blood that helps blood clot. You don't want clots to build up in the heart tho when you have heart disease. Platelets aren't part of your RBC's tho. Something else you might consider adding is a little fish oil to his diet also. Good for the heart!

Hmm - have I answered everything. Or just made more questions. When I get home tonight I will give the link for pain control. Let me know what you think about my lengthy saga once again. laptop_smiley

 

Oh Nancy
Just saw your post -

Forgive me if I upset you at all....

sometimes with kitties like ours - eventually - you more or less have to start treating the diabetes how YOU want to. I know that's a hard thing to do and I don't mean to upset you or rock the boat or anything. I LOVED my vet but when I realized that we were getting nowhere after about 8 months and I just knew something else was going on - that's when I started doing the sliding scale and moving off on my own and seeking more advice from here and another site.

I hope I haven't upset you. I know your vet means well - she's just not experienced with the acro so doesn't know really how to improve on things for you.

 

Patti ,
You didn't upset me! I appreciate your help.

 

SOOOOOO Nancy - how are you and Cody doing???????? :YMHUG:

 

I know we need it for the R insulin, so I tried to find his nadir today by testing a lot and not feeding much during the day. He was either so mad by dinner time, or he rebound because it went down to 215, that his number right after eating was 370. I wasted 2 strips trying to test before dinner, but he was having none of that.

Looking back over his many weeks of data I still couldn't tell you his nadir...

 

Patti,
I wrote a PM to you Tues which evaporated- SORRY. and another last night, in my outbox.

-After getting over my "mad" at the vet, I decided I have to keep a working relationship, so brief pause until 2+ weeks is up.
-Going out of town (W/Cody) for DH's mom's 80th b'day this weekend, so bad time to start something new. (DH bday also and no gift ideas???)
-my "other life" outside the kitty world is feeling neglected and needs some Nancy/mom/daughter attention

Patti, the turkey/giblet thing is very scary. Please give us an update on how your guys are doing. :?: nailbite_smile You have your hands full now
and this (Cody & I) can/have to wait.

I started a barely used, (donated to me) vial today and I'm a bit nervous myself. I backed off 1 unit to 8.

How do you judge the nadir, when 1 day its +4 and another day its much later? Look back at my last 4 weeks and feel free to comment...

Thanks everyone! day at a time-we'll keep at it :smile: