Another difficult diabetic....

Re: Another difficult diabetic....

Anthony Dennison — Tue, 10 Sep 2013 09:58:08 GMT

[quote user="Martin Atkinson"]what chance is there of training them to perform the curve at home? Also be aware that normal ranges for creatinine don't apply to old thin cats, you need to look as the IRIS recommendations and anything over 140 is high, a creatinine of 212 puts this ins stage 3/4 CKD. Your target phosphate range should then be 0.81-1.61mmol/l.[/quote]

Probably not much chance at all for a home curve, but it is something I might discuss with the owner when she comes in next month for fructosamine (If I tell owners you can get a starter pack that has enough to do at least 2 curves at home for less than it costs to do one here they usually try and give it a go!). I will try and get extra bloods for biochemisty and electrolytes at the same time. I was aware of the IRIS staging which is why I want to keep a close eye on it. Creatinine has increased by 60 in the past 12 months, so it is definitely worth keeping an eye on.

Many thanks for all your help and advice Martin, I do massively value your opinions on diabetic cats!

Re: Another difficult diabetic....

Martin Atkinson — Tue, 10 Sep 2013 09:42:05 GMT

[quote user="Anthony Dennison"]

He was on 2IU BID. 2 weeks previously a curve had been performed after 1IU insuling and the nadir was 16.3mmol/L. Despite the glucose not going very low, could it still be an overswing?

So I should encourage the owner to continue with grazing throughout the day? She has said she will get some new food when the current bag is running out, so I will encourage switching to a senior diet rather than the renal diet I initially recommended. The cat has lost approx 200g since May. The owner says that at some points during the day he is very very sleepy and hard to wake up; could this be related to the DM or just age?

I will ring the owner now to tell her to drop the dose rather than increase it

[/quote] These are huge changes in dose, 1 iu may not seem a lot but up to 2iu is 100% increase! I think this could still be overswinging so I would try 1.5 iu and try and replicate the cats normal feeding habits - what chance is there of training them to perform the curve at home? Also be aware that normal ranges for creatinine don't apply to old thin cats, you need to look as the IRIS recommendations and anything over 140 is high, a creatinine of 212 puts this ins stage 3/4 CKD. Your target phosphate range should then be 0.81-1.61mmol/l. Protein is not the critical factor in managing CKD, phosphate is, so as suggested to manage the DM better a senior diet plus a phosphate binder may be a better way than renal diet. Also are you measuring electrolytes? Low potassium is common in CKD and may need supplementing to maintain appetite. And yes, I'd let it continue to graze.

Re: Another difficult diabetic....

Anthony Dennison — Tue, 10 Sep 2013 09:02:09 GMT

[quote user="Martin Atkinson"]Anthony: you don't say what dose he was on when his nadir was 5mmol/l. [/quote]

He was on 2IU BID. 2 weeks previously a curve had been performed after 1IU insuling and the nadir was 16.3mmol/L. Despite the glucose not going very low, could it still be an overswing?

I will ring the owner now to tell her to drop the dose rather than increase it

Re: Another difficult diabetic....

Thomas Johnson — Tue, 10 Sep 2013 08:36:19 GMT

[quote user="Anthony Dennison"]

On admit this morning the owner confessed to feeding him mutliple times during the day, sometimes every couple of hours.

Curve done today; fed and 2IU insulin given @ 7.30am:

[/quote]

If the cat normally grazes through the day, which I'm not convinced is a problem with diabetic cats, but on the day of the curve only ate in the morning, then your curve may not be a true representation of its normal blood sugar levels as it hasn't eaten as much as it normally does.

Re: Another difficult diabetic....

Andrew Kent — Mon, 09 Sep 2013 20:50:30 GMT

I agree with Martin on this - cats are very different to dogs and do very well grazing through the day. They have much slower gastric emptying so don't get a significant post prandial hyperglycaemia like dogs.

Re: Another difficult diabetic....

Martin Atkinson — Mon, 09 Sep 2013 19:09:07 GMT

Anthony: you don't say what dose he was on when his nadir was 5mmol/l. That is in my mind too low, there is not enough room for manoeuvre if the cat doesn't eat properly, vomits or gets stressed. If the dose has remained the same and the cat has lost weight I think your latest curve is over-swinging there is not much else would make it shoot up to higher than the start point in less than 12 hours. You should tread very warily before increasing the dose, indeed I would be reducing it first to see if the curve gets better or worse As said in my previous post your high fructosamine is as likely due to this as under-dosage. I also disagree about the feeding regime, I think he is better being fed small amounts throughout the day he will have much smaller swings once stabilised regardless though you've got to test him on his normal feeding regime. One further complication though is if he has to go on a low protein diet for the CKD as this is higher in carbohydrate it may increase his insulin demand so a senior diet with a phosphate binder may be a better way forward.

Re: Another difficult diabetic....

Anthony Dennison — Mon, 09 Sep 2013 18:32:40 GMT

Another confusing diabetic cat case - I'm afraid I really need to brush up on my endocrinology!

20yr old MN DSH, has been on insulin long term. Last glucose curve done in January showed good control (Nadir 5mmol/L half way through the curve). Has lost a little weight recently and drinking a bit more, so decided to do a fructosamine which cam back just over the poorly controlled mark (608; >600 poorly controlled).

On admit this morning the owner confessed to feeding him mutliple times during the day, sometimes every couple of hours. I told her that isn't really ideal as does mess with glucose and insulin. However, this is how she's always done it and he has been well controlled previously. PABs were taken at the same time, BUN was 18.2 (5.7-12.9) and Creatinine 212 (ref 71-212). These renal parameters have slightly increased since bloods taken last July (Creatinine 147).

Curve done today; fed and 2IU insulin given @ 7.30am:

9.30am: 14mmol/L

10.39am: 10.3mmol/L

11.30am: 11.7mmol/L

12.30pm: 12.2mmol/L

1.30pm: 11.4mmol/L

2.30pm: 12.8mmol/L

3.30pm: 25.6mmol/L

4.30pm: 30.9mmol/L

5.30pm: 29.1mmol/L

The curve is telling me that the insulin isn't being as effective as previously was, so I've increased to 2.5IU. But it doesn't seem to be lasting long enough either, would switching to Glargine be beneficial here? Or is it just because the cat is used to being fed so regularly the liver is just kicking in to pump out some fresh glucose? Cat not stressed at all, in fact was sleeping between samples!

Re: Another difficult diabetic....

Martin Atkinson — Mon, 09 Sep 2013 16:38:59 GMT

[quote user="Richard Carter"]I find fructosamine gives a more consistent representative and repeatable result than a glucose reading.[/quote] If they are in the 'well controlled' range you may be in danger of over-dosing on a day the cat doesn't eat properly or vomits and if its high you don't know if its high because you're under-dosing or because its over-swinging. I reiterate that IMO and IME it is useful only to conform the original diagnosis.

Re: Another difficult diabetic....

Richard Carter — Mon, 09 Sep 2013 14:06:22 GMT

yes and I find fructosamine gives a more consistent representative and repeatable result than a glucose reading. Cats dead in 18 months?? What are people doing?

Have had 2 cats in last month come off insulin altogether so of course repeat testing essential.

Re: Another difficult diabetic....

Martin Atkinson — Sat, 07 Sep 2013 11:44:34 GMT

[quote user="Richard Carter"]assess polydipsia, weight and appetite rather than try fit the glucose between 2 levels may be the better approach [/quote] Whilst I don't think one should give up trying to find the holy grail of the perfectly stabilised cat I think we have to accept that it is almost impossible to achieve. However there is a sweet spot between thinking of a dose and continuing without regular monitoring and an obsessive chasing of numbers. There is no doubt in my mind that the more effort the vet/client put into trying to seek perfection the longer the cat will live. In the bad old days when dinovet did a couple of blood glucose tests, the insulin was issued on a wing and a prayer and the cat seen once in a blue moon and the odd spot glucose or urine test performed, these cats would be dead within 18 months. With my current approach of as regular as practical glucose curves and micro-adjusting insulin doses along with good client education on injection technique and diet they have a normal life expectancy. I don't bust a gut chasing numbers but equally one has to keep ones eye on the ball.

Re: Another difficult diabetic....

Dagmar Steele — Sat, 07 Sep 2013 08:38:14 GMT

[quote user="John Flynn"]

[quote user="Dagmar Steele"]John, I'm in Germany where rules are quite strict and politicians are tightening the rules even more at the moment. Plus we have no ability to be as laid back as the Irish are, it just doesn't come to us naturally ;-)[/quote]

To be sure, to be sure

Does sound like bureaucracy creep to me though.

Effectively what they're saying to you is that you can't be trusted to make an independent professional judgement (or offer fully informed consent even) on the best choice of medicine for a patient/owner if left to your own devices.

I'd be intrigued to know what their philosophy behind this is? Presumably they must believe that you will, either through ignorance or maliciousness, prescribe medicines that are either ineffective or present a public/environmental risk unless they legislate a clumsy formulaic mechanism which you must follow to arrive at your medicine choice.

I'm not sure where this line of thinking ends?

Presumably your choice of suture materials need also be spoken for.

Indeed proscribed surgical techniques would be the only way to stop you mutilating animals I assume, but I guess no-one profits from your choice of surgical technique... or do they... there's nothing to stop further bureaucracy creep as long as someone can profit from it. A licensed TPLO procedure would presumably prevent you from performing extracapsular repairs in the same way that licensed insulin prevents you using glargine?

And why stop at treatment? If the drugs that you must use for treatment of congestive heart failure are set out, then surely the tests that you must perform to reach that diagnosis must also be set out (all in the interests of the patient's welfare no doubt ). I assume money wouldn't be considered an issue, so that would entail a pretty decent echo exam (with an expensive vet-licensed machine) I would hope - no drugs allowed unless it's done.

[/quote] The cynic within me tends to think that this has all been set up in the monetary interest of pharmaceutical industry! The Cascade says you're not allowed to use any human medicine as long as there is a licensed veterinary medicine for this condition this kind of animal. If there isn't you can use the veterinary licensed medicine for another animal and only if there isn't anything such you can use human medicine. Of course the pharmaceutical industry has decided now that it is time to get some old fashioned well used human medicine licensed for the veterinary market. Usually that makes them a lot more expensive and it is down to us to explain that to the customer. We are having a lot of fun. On the other hand some of the well used and very good vet products have been taken off the market lately, a combination of penicillin and streptomycin comes to mind. Other products have to been thrown away once you stick a needle in the bottle the same day!

Re: Another difficult diabetic....

John Flynn — Fri, 06 Sep 2013 20:19:14 GMT

To be sure, to be sure

Does sound like bureaucracy creep to me though.

I'm not sure where this line of thinking ends?

Presumably your choice of suture materials need also be spoken for.

Re: Another difficult diabetic....

Richard Carter — Fri, 06 Sep 2013 18:53:48 GMT

quite a few vets at CPD events have commented on the poor results of glucose curves in cats and given that diet etc cannot be restricted in a cat that has access to outdoors, fructosamine levels and a slow approach to stabilising - pick a dose, continue for 10 - 14 days or longer, assess polydipsia, weight and appetite rather than try fit the glucose between 2 levels may be the better approach than terrorise kitty with a blood sample every hour. Also had a chat with a medic and apparently human diabetics are not expected to be stabilised in the space of a few weeks.

I am also constantly amazed by how well cats respond even on the first tentative dose level even when you know the glucose is not controlled. May have something to do with being usually type 2 DM? Today have had a second test on diabetic that originally showed very poor body condition and raised hepatic and renal enzymes and other mineral imbalances. 2 weeks later, glucose still >20mmol but drinking down to 100ml/d, strength returning with defecation normal (had been showing constipation signs) and other muscle condition and hepatic and renal enzymes back to normal. Will see kitty in 2 weeks again on slightly higher dose to do fructosamine.

Re: Another difficult diabetic....

Martin Atkinson — Fri, 06 Sep 2013 13:35:28 GMT

Notwithstanding an apparent lack of response to original dose of 2iu, am I the only one to spot that the curve demonstrating the best response was the one on 2.5iu thus suggesting overswing on the higher doses? I would go with 2.5iu Caninusilin bid and let it settle down then repeat curve but do it every hour at least for the first 4-6 hrs or you may miss an overswing.. Either get the cat in and give the insulin yourself for the curve day or watch the owner giving it, I never cease to be amazed by the ways they can get it wrong + make sure they're changing the injection site. If its a stressy cat teach the owner how to take tests and try and get them to do the curve at home, you can get a near 24 hr curve that way as well. The high fructosamine could occur with overswing as well as underdosage I think it is of little value other than at original diagnosis. By all means get a growth hormone test for acromegaly at least you can eliminate it if nothing else. Another fan here for Lantus glargine.

Re: Another difficult diabetic....

Dagmar Steele — Fri, 06 Sep 2013 13:21:43 GMT

John, I'm in Germany where rules are quite strict and politicians are tightening the rules even more at the moment. Plus we have no ability to be as laid back as the Irish are, it just doesn't come to us naturally ;-)

Re: Another difficult diabetic....

Anthony Dennison — Fri, 06 Sep 2013 13:06:44 GMT

I'm having a similar problem with a diabetic cat - she was quite overweight so we combined insulin therapy (Caninsulin) with RCW Satiety Support to help her lose weight. She has lost just over 1kg in the past 3 months, so nice and controlled weight loss. At first she was ok to do a curve on, but we had her in yesterday to do another and had to abandon it mid-morning because she became almost untouchable.

Fructosamine when first diagnosed was 604. A blood sample last week gave a Fructosamine of 900!! Generally curves have been creeping higher, but we start them 2-3 hours after the owners give the insulin, so dont see that 1st important period. We tried to do it yesterday, but things didn't go our way!

The owners may be willing to do a curve at home, is this what others would recommend to rule out somogyi? Or just go straight for the glargine?

(Sorry for hijacking the question!)

Re: Another difficult diabetic....

John Flynn — Fri, 06 Sep 2013 12:19:29 GMT

[quote user="Dagmar Steele"]I'd rather us glargine in cats than Caninsulin... BUT... I think I can't first line under the cascade. Given that there are studies that more cats treated with glargine go into remission plus it works much better in my hands this is a real nuisance. What are the glargine fans out there do? Do you ignore the cascade?[/quote]

I think the approach to bureaucracy and the results of political lobbying by Big Pharma differs markedly between EU states.

I'm in Ireland where we treat non-food producing animals with whatever we think (as independent free-thinking professionals) is the best compromise between clinical efficacy and cost for that patient/owner unless there is a concern re public/environmental safety.

A vet from Spain that was visiting confirmed a similar approach there,

My understanding (from a vet in the North) is that in the UK there are rules which if followed would mean (for instance) treating malassezia otitis externa with a product containing antibacterials and other such crazies (but these may be greatly exaggerated rumours!) - I really doubt any UK practitioner actually follows all these rules if they truly are such, but I don't know their details really.

Where are you in Europe? I guess you follow the prevailing culture or local rules with respect to medicine prescription.

Re: Another difficult diabetic....

Andrew Kent — Fri, 06 Sep 2013 10:51:50 GMT

[quote user="Rebecca Benge"]

[quote user="Andrew Kent"]So a few other thoughts:

I suspect from your 2.5IU of the lente that the bg is rising again at 5pm so this dose twice daily may be more effective. .

[/quote]

See, now this is what I thought!!! I've not really used lente myself before but thought it was twice daily dosing looking at the formulary. But my boss who started this cat off was sure it should just be once daily. I even asked him again the other day about dosing twice daily and he said no and that we should perhaps be thinking about other things like acromegaly.

So obviously we've screwed things up a bit now, the cat has just started on 5IU SID. Should we go back down to 2.5IU but do it BID and see how that goes?

She was 4.45kg when she first came to us on 24th July and she was last weighed on Tuesday where she was 3.7kg. I can't see a weight on the previous vets notes. Urine dipstick never shows any signs of UTI but obviously comes up +ve for glucose. I have discussed urine culture with them, but it's not something we've done yet.

[/quote]

Going to 2 or 2.5IU of lente twice daily would seem reasonable. Hypurin is, however, a much more expensive way to manage cats long term compared to other insulins.

I think you have 2 options - try twice daily lente for a few weeks and see if you can stabilise, or go for glargine. As others have said there is an increasing body of evidence that glargine may be the 'best' insulin for cats in terms of percentage of cats that stabilise on it.

Re: Another difficult diabetic....

Dagmar Steele — Fri, 06 Sep 2013 10:38:41 GMT

I'd rather us glargine in cats than Caninsulin... BUT... I think I can't first line under the cascade. Given that there are studies that more cats treated with glargine go into remission plus it works much better in my hands this is a real nuisance. What are the glargine fans out there do? Do you ignore the cascade?

Re: Another difficult diabetic....

John Flynn — Fri, 06 Sep 2013 10:32:39 GMT

[quote user="David Mills"]This cat needs glargine. Without wishing to sound like an anecdote-obsessed practitioner[/quote]

+1 in the glargine fan-club.

I'm a believer (for now anyway) that starting diabetic cats on glargine is the way to go.

http://www.uq.edu.au/ccah/docs/diabetesinfo/link5.pdf

http://www.uq.edu.au/ccah/docs/diabetesinfo/link3.pdf

Having said that, I'm sure it's quite possible to stabilise this cat on other forms of insulin.

Is the Hill's m/d a dry food? I try to go for a wet food as get lower carb content, though I looked up (http://catinfo.org/docs/FoodChartPublic9-22-12.pdf) and think the m/d has about 14% calories from carbs and I've heard it reported that anything less than 15% is probably OK and getting really low levels now essential at all. (see e.g. http://www.felinediabetes.com/diet.htm)

I may have missed what weight the cat is and whether significantly obese or not?

Re: Another difficult diabetic....

Rebecca MacMillan — Fri, 06 Sep 2013 08:58:38 GMT

[quote user="Andrew Kent"]So a few other thoughts:

I suspect from your 2.5IU of the lente that the bg is rising again at 5pm so this dose twice daily may be more effective. .

[/quote]

So obviously we've screwed things up a bit now, the cat has just started on 5IU SID. Should we go back down to 2.5IU but do it BID and see how that goes?

Re: Another difficult diabetic....

Mark Hedberg — Fri, 06 Sep 2013 08:55:15 GMT

[quote user="David Mills"]

Re above: yes, Herrtage. Email the meds dept at Cambridge to obtain protocol. David Church at RVC is the other diabetes don whose advice I'd take by rote. Both contactable and helpful IME.

[/quote]

Thanks, I was pretty sure it was him but I was having a brain fart and couldn't be sure!

Re: Another difficult diabetic....

Miriam Lodewyks — Thu, 05 Sep 2013 23:55:59 GMT

I second acromegaly and Glargine. Have diagnosed acromegaly in a female cat myself... she stabilised (clinically, at least) on around 12-15 IU. Good luck!

Re: Another difficult diabetic....

Rob Loxley — Thu, 05 Sep 2013 23:50:36 GMT

[quote user="Robin Grimmer"]AFAIK Acromegaly is almost exclusively seen in male cats[/quote]

I'm pretty sure the cat of ours the RVC is seeing for hypophysectomy is called Penelope...

Re: Another difficult diabetic....

David Mills — Thu, 05 Sep 2013 23:01:59 GMT

Re above: yes, Herrtage. Email the meds dept at Cambridge to obtain protocol. David Church at RVC is the other diabetes don whose advice I'd take by rote. Both contactable and helpful IME.

This cat needs glargine. Without wishing to sound like an anecdote-obsessed practitioner, I have zero faith in caninsulin, whatsoever, for cats. Possibly my cases have just been unlucky (n=22, the earliest to stabilise was at 12 weeks(!) ). Dogs - great. Cats- glargine. Sometimes, I think its dangerous not to.