Darcy. Response from vet on Cabergoline. I'm just flipping out!!

Discussion in 'Lantus / Levemir / Biosimilars' started by Suzanne & Darcy, Feb 19, 2021.

  1. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

    Joined:
    Jun 4, 2020
    How can I upload a photo of a message from my vet?

    No... see below, I have typed up the whole email from the consulting vet... director of the UGA Veterinary Diabetic Clinic..
     
    Last edited: Feb 19, 2021
  2. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

    Joined:
    Jun 4, 2020
    Okay, I have typed below the response that I received today... not from my vet... but this is the typed response that she received when she requested a consultation from a vet at University of Georgia. I am flummoxed. What do do now. I'm ready to go off with all barrels loaded... so I really need to calm down. Calm down.... but this was from February 9 and I finally called today to see what was going on and the receptionist said she'd emailed me this and I never received it so she took a photo with her phone and I have transcribed the email below: here goes...

    "Sorry about your frustrating diabetic. While acromegaly is a possibility, there is not a ton of clinical evidence to support that diagnosis at the moment. Especially if the cat does not have weight gain in the face of poor diabetic control, obvious physical changes, or palpable organ enlargement on exam. While the iGF-1 is elevated, it is an imperfect test for this condition (but GH concentrations are not readily available for dynamic testing). Being given exogenous insulin alone can increase IGF-1 values. A recent study showed acromegalic cats with confirmed acromegaly having IGF-1 concentrations ranging between 890-2001ng/mL The insulin dose is also not too crazy, as an example the last acromegalic cat I managed was on 20 units of insulin twice daily. We often see complicated diabetic cats who require 5+ units of insulin twice daily through our diabetes clinic. So things like chronic pancreatitis or inflammatory disorders can reduce their insulin sensitivity as well.


    If there is a high clinical concern for hypersomatotropism, the next step would be to CT the cat and possibly plan for radiation therapy at the same time. Occasionally, an MRI is needed if the tumor is not obvious or easily demarcated on CT alone (though most are easily seen on CT).


    We do radiation for acromegaly at UGA. The treatment protocol would be 5 fractions given every other day. The cost would be around $3,000 – 3,500. There are other protocols that can also be done for les money but would be palliative and not targeting a definitive treatment.


    Oral medications involve things like octreotide or pasireotide have been shown to be effective in some but not all cats. Octreotide used to be very expensive, but generic formulations now exist (however I do not believe any studies have evaluated generic formulations in cats). It has been associated with diabetic remission in about 20% of cats though all of the other negative effects of GH excess can still persist (things like organ growth). I do not think pasireotide is available outside of a hospital setting, so it may require contacting a hospital to get if needed and I am unsure of cost. The last time I tried to see if it was available, most US hospitals hadn’t started stocking it routinely (but this was a couple of years ago). If there is a response to somatostatin analogues it is not always sustained long term, so we still usually recommend radiation therapy be considered. Cabergoline was recently shown to not be effective at improving insulin sensitivity, so I would probably avoid that therapy.


    Surgery is an option, but I am unsure of which hospitals in the US offer this as an option. I believe there is a surgeon in California performing this procedure, but otherwise it is mostly done in Utrecht, Netherlands."
     
  3. JanetNJ

    JanetNJ Well-Known Member

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    Jun 8, 2016
    Well I will say that is a really reasonable price for the radiation. The cheapest quote I got here in nj is $8500.
     
    Last edited: Feb 19, 2021
  4. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    Jun 4, 2020
    NC State lists $4500 to $6500 on their website, I believe. But they usually do the single day treatment in most cases (maybe that's why they have a range from 4500 to 6500).
     
  5. Wendy&Neko

    Wendy&Neko Senior Member Moderator

    Joined:
    Feb 28, 2012
    Boy, is that vet uneducated! :banghead::banghead::banghead: Might want to send that vet a copy of the paper in this post, see case 2, starting page 1092. (2020) Updates in Feline Diabetes Mellitus and Hypersomatrotropism

    A couple quotes from that paper "A serum IGF-1 concentration of greater than 130 nmol/L (>1000 ng/mL) has a positive predictive value of 95%" and "However, only a proportion of cats with HS-associated DM have noticeable acromegaly and its absence should not exclude the possibility of HS." This latter means, just because you have the tumour, doesn't mean there are clinical signs.

    From the email you got
    Oh contrare, starting exogenous insulin can reduce IGF-1 values, and if IGF-1 testing is done within 73 days of starting insulin, 1/3 of acros had false negatives.
    Where to start! That 890-2001 mg/mL is for measurements in the UK, the United States measure in nmol/L. And actual though it says 130 above in the quote from the paper, MSU suggests above 92. Just because 1 acrocat is on 20 units, does not mean all acros will be on 20 units (not that 17 and not budging is far away from that). I've seen untreated acros on as low as 4 units and up to 90+ units. Chronic pancreatitis and other inflammatory orders do cause insulin resistance, but how many of those cats they had on 5+ units were on low carb food, and more importantly, how many of them had their IGF-1 tested? And those inflammatory disorders do not make such a large difference in dose needed, maybe max 3 units. Dry food has a worse effect.

    The article I pointed to also has some words about CT scans and even MRI's not being definitive. When I was at CSU (first time), they had a cat that had SRT whose tumour was so small it did not show on either CT or MRI.
    Nope, there are studies showing that's not true either for octreotide. One study was done at CSU. Would love to see any papers they have referring to success in cats. Pasireotide pricing is literally out of this world. Oh, and the paper above mentions cabergoline as a possible treatment. Surgery is done at AMC in New York, the surgery was done many years ago in Los Angeles and very briefly Spokane, Washington - but they didn't have a great track record, don't think they are doing it anymore. You do want to have the surgery with someone who has a proven track record - it's a risky surgery. And well, there is always London England, Royal Veterinary Clinic who has done over 50 of these surgeries. That vet really has not looked at recent research at all. RVC authors are on most of the current articles, including the one I linked.

    Done now, I could say more. You need to try elsewhere. The "consultant" was clearly trying to sell their inferior radiation therapy (not SRT) too. Or maybe you pass the paper onto your vet, with the hint that you think the UGA vet is a little out of date. If you like your vet, maybe they'll be willing to treat and work with you.
     
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  6. Olive & Paula

    Olive & Paula Well-Known Member

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    Sep 6, 2015
    I can't help with SRT treatment. AMC in NY does the removal surgery. I do not know the cost as when I checked into it there was a grant that covered the surgery but it is no longer available. I chose not to go that route. Octreotide is cost effective when I looked into it but not effective if given alone, if given with cabergoline there is consensus is its an option but no real studies on it. Cabergoline can be effective in controlling symptoms of acro (Ollie was my proof of success with cabergoline). HOWEVER, removal is the best guaranteed treatment for remission of diabetes and even then, I know of one cat who is back on insulin after 1 yr. Dr is correct that there isn't a ton of trials on the medications for acro. A cat does not have to have obvious physical changes (normally vet say broad face, weight gain is what they seem to go by since they can "see" it). Ollie was up to 9 units of levemir when diagnosed. Cats do not have to be on super high doses to have symptoms. There can be bone, soft tissue overgrowth, stridor, hcm, problems walking because of bone and tissue overgrowth, general body pain, headaches, light sensitivity, hard to regulate with insulin. My Ollie had all of these and more. Although some kits have gone into remission on cabergoline, I didn't use remission as the reason to try it with Ollie.

    Wendy posted before I finished. Keep trying elsewhere if you really want to give it a try. Nothing to lose. Darcy has everything to gain by trying. If it doesn't help, you stop.
     
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  7. Wendy&Neko

    Wendy&Neko Senior Member Moderator

    Joined:
    Feb 28, 2012
    Paula is an excellent example of keep trying new vets until you find one willing to work with you and prescribe cabergoline. Honestly, all the treatments except it will set you back many thousands.
     
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  8. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

    Joined:
    Jun 4, 2020
    Thank you to everyone who responded! I am going to read and process all of this and make my move forward.
     

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