Cat with diabetes and hyerthyroidism

Re: Cat with diabetes and hyerthyroidism

Kate Richardson — Sun, 28 Apr 2013 14:33:27 GMT

Yes I think a home glucose curve definitely the best next step and sounds as though the owners are the best sort! Also check the urine for bacteria or simply give a course of antibiotics such as amoxyclav in case of concurrent bacterial infection contributing to the pupd. Ideally need to know renal values at this stage to know current status and for future monitoring especially with the hyperthyroidism. The other thing worth checking when you next have her in is her blood pressure if you have the means.

Diet wise, y/d isn't ideal given the diabetes and has been linked to development of diabetes in some cases in the US, but you are in a difficult position here as you need to control the thyroid as well but I wouldn't be scared of retrying oral meds. However you also have to take into account how the cat is doing and what the other options are, and I think gaining some clinical control and stability is probably the most important thing here so far and if in a couple of months time all is still going well you could consider longer term control of the thyroid with surgery or oral meds and changing to a more suitable diet. (assuming we are certain of the thyroid status by then and cat is stable). Take the time to explain all the options to the owners so that if they choose a less than ideal treatment plan then they will be aware of any pitfalls or future possible complications (doesn't mean they have chosen the wrong plan, may be the best plan for this cat at this point in time if you know what I mean) If the cat is doing well on y/d and you get her DM under control they may decide to just stick with it it the cat is happy and thats not necessarily the wrong thing to do.

Feel free to send me a message if you want at any time

Kate

Re: Cat with diabetes and hyerthyroidism

dachsie_4 — Sat, 27 Apr 2013 21:14:07 GMT

Dear Kate

The T4 dropped to 25 after being on 4 weeks of y/d, heart rate dropped from >220 to 160, cat looked really well on friday when I dropped more food off. Owners are very switched on, never thought of them doing glucose curve, they'll be chuffed if I suggest that. They already do regular urine glucose. Looks like she put a bit of weight on with increase of canisulin, but still pu/pd.

The reason they came to us for second opinion because they weren't happy with the previous vets management of the diabetes. I don't want to comment too much on other vetsmanagement, but there were a few unusual decisions, but then again this cat is not straight forward either.

Sorry cannot remember exact FT4D value, need to check on Monday

Thank you so much for discussion this case with me

Monika

Re: Cat with diabetes and hyerthyroidism

Kate Richardson — Fri, 26 Apr 2013 22:03:01 GMT

You're doing a great job! Difficulty is that the clinical signs of both diseases are similar. A T4 of 60 is certainly very suspicious of hyperthyroidism especially under the circumstances- you say the free T4 indicated hyperthyroidism to be a possible diagnosis- what was the value? Also can you palpate a goitre? Can be very difficult to be certain of hyperthyroidism in some cases but you certainly don't want to be taking the cat to surgery without a definite diagnosis. Referral for scintigraphy would give you an answer as well but may not feasible. I would also repeat the T4 and see if still robust. If still suspicious or diagnostic of hyperthyoidism, I would retry oral meds first.

Re the pancreatitis episode, certainly some of the side effects of the anti-thyroid meds would be the same as the signs of pancreatitis- but I wouldn't think the felimazole caused pancreatitis- the cat may have chronic recurrent pancreatitis- which may be why it has diabetes, and another differential for polyphagia would be exporine pancreatic insufficiency- extreme polyphagia is classic with this so could also explain your clinical signs. You mention diarrhoea- are the faeces also pale and smelly? However this can happen with hyperthyroidism as well as EPI!

I would definitely attempt a glucose curve as you may get some meaningful results or if the owner is really keen and on board, then teach her to do ear pricks and measure curve at home- but some glucose values will give you a much better idea of what is going on with the DM and if the clinical signs are related to the DM or not. Although the insulin dose is not that high, she is only tiny, so a somorgi effect is still possible, which would give you signs of instability with a high fructosamine but a dose reduction would be needed instead of an increase. Impossible to know without a glucose curve however. As a second opinion, how was her management prior to seeing you? Also what are her kidney values? (urea/creat/USG as minimum?)

Kate

Re: Cat with diabetes and hyerthyroidism

Martin Atkinson — Fri, 26 Apr 2013 13:17:27 GMT

[quote user="patrick murphy"]

I have been recently reading about hyper T and was surprised that 23% had ectopic tissue, after a friend of mine failed to locate either thyroid on a cat while I was 'borowing' his scanner. so 1 in 4 chance that a bilateral would fail?

[/quote] I'm surprised that it isn't higher after all why do bilateral thyroiectomies not become hypothyroid? The accepted reason AFAIA was that most cats have some (possibly initially inactive) ectopic thyroid tissue which is activated in a state of hypothyroidism.

Re: Cat with diabetes and hyerthyroidism

patrick murphy — Fri, 26 Apr 2013 13:12:41 GMT

Re: Cat with diabetes and hyerthyroidism

dachsie_4 — Fri, 26 Apr 2013 08:53:50 GMT

The cat was seen for a second opinion as the diabetes just did not seem control, on first examination the cat was fractous, VERY polyphagic, heart rate of over 220bpm. So to get an idea of what was going on a full blood screen was taken. T4 at the time was 60 (18-65). Because of the high heart rate and possible euthyroid affect of the diabetes a FT4D was run which indicated hyperthyroidism to be a possible diagnosis on top of the diabetes. The cat was started on Felimazole 2.5mg bid and 7 days later was in hospital with pancreatitis which was diagnosed with a snap test. Some how this cat that looked on deaths door pulled through and was started on y/d after the diarrhoea was settled. Since then the cat has looked well, but is still pu/pd and eating well (better than other cat), but not eating food of the human plates anymore. She is only around 2kg and could gain a bit of weight and is on 1.5iu caninsulin bid. This has been increased to 2iu after the last fructosamine result. She is a DSH neutered female - age unsure as was a stray but guessing from the owner puts her at 9years. She does stress in the hospital so a glucose curve might not get a true result. If this cat would walk past me in the park my thoughts would be a slim cat with good coat condition - an elderly lady, she is not dehydrated and is well groomed, but because she is rather thin I worry that things can go wrong quickly if we don't keep thing under strictest control.

Monika

PS - thank you for all the input so far from everyone, much appreciated.

Re: Cat with diabetes and hyerthyroidism

Kate Richardson — Thu, 25 Apr 2013 21:38:34 GMT

Hi there

Can you give some more info? Assume 10Y + and female neutered- what breed? What came first- the DM or the hyperthyroidism? How high was the T4 initially? What dose of Felimazole was she on and how long for? How did you diagnose the pancreatitis? Are you basing her poor DM control on fructosamine only or on glucose curves and/or clinical signs as well? What dose of Caninsulin is she on currently? Is she bright happy and eating well? Sorry for all the questions but will help to advise you best way forward

Kate

Re: Cat with diabetes and hyerthyroidism

Martin Atkinson — Thu, 25 Apr 2013 17:56:13 GMT

[quote user="robloxley"]

[quote user="Martin Atkinson"] if its unilateral then saving the parathyroids isn't as critical, the other side usually rears its head but maybe not for 18 months[/quote]

So the cat does great after the 1st side but now maybe not the safest to do the second if you've removed half the PTs; hmmm, I'd go for preserving the cra PT on the 1st side (if possible), or at least reimplanting.

[/quote] Read again rob: 'if its unilateral then saving the parathyroids isn't as critical'. That doesn't say don't try and save the parathyroids just implies that if you're not the most confident surgeon then it is not the end of the world if you cock up. Heck there are those amongst us who say that even a bilateral thyroidectony with iatrognenic parathyroid damage will resolve itself. I consider myself an excellent soft tissue surgeon (and modest with it!) but I am rarely confident I've identified parathyroid tissue and reliably preserved it - good if you are but it 'aint that easy.

Re: Cat with diabetes and hyerthyroidism

Rob Loxley — Thu, 25 Apr 2013 17:42:20 GMT

[quote user="Martin Atkinson"] if its unilateral then saving the parathyroids isn't as critical, the other side usually rears its head but maybe not for 18 months[/quote]

Re: Cat with diabetes and hyerthyroidism

John Flynn — Thu, 25 Apr 2013 16:19:48 GMT

[quote user="Andrew Kent"]You need to be careful interpreting fructose mine in hyperthyroid cats. It changes the turnover of albumin which in turn makes fructose mine unreliable. I would be more inclined to look at glucose curves and urine - have you done either of these?[/quote]

Good point, Andrew. But I thought that the increased albumin turnover generally led to decreased fructosamine levels in (uncontrolled) hyperthyroid cats? Can you have elevated levels also and if so is there a proposed mechanism for this?

Assuming not anaemic, would you recommend glycated haemoglobin as an alternative?

(I appreciate fructosamine might not be that useful in cats at the best of times anyway other than to help with diagnosis in first place)

If looking to follow up with a fructosamine later, you get a FREE fructosamine (+ triglycerides, cholesterol and IGF-1)h if you submit the case via http://www.rvc.ac.uk/CIC/documents/GHsubmissionformV1328Jan10DL.pdf (one per case only unless recently diagnosed I think) and get to contribute to the body of scientific knowledge at the same time - bonus

Re: Cat with diabetes and hyerthyroidism

Martin Atkinson — Thu, 25 Apr 2013 10:20:03 GMT

I agree with thyroidectomy if you're a confident surgeon, if its unilateral then saving the parathyroids isn't as critical, the other side usually rears its head but maybe not for 18 months. I tend to put my diabetic cats on kitten food - moist Purina as this has (had last time i looked anyway) the lowest carbohydrate content. I'm a also a fan of Lantus glargine for unstable diabetics but you don't say if you've done glucose curves and thus given Caninsulin a fair crack and as Andrew intimated, you can't draw too many conclusions from fructosamine. The issue with glucose curves in the clinic with cats is stress so if you can train the owner and lend them a glucometer they may be able to perform them at home but then you have to rely on them doing it properly which you can't always be certain about.

Re: Cat with diabetes and hyerthyroidism

Andrew Kent — Thu, 25 Apr 2013 09:38:42 GMT

You need to be careful interpreting fructose mine in hyperthyroid cats. It changes the turnover of albumin which in turn makes fructose mine unreliable. I would be more inclined to look at glucose curves and urine - have you done either of these?

Re: Cat with diabetes and hyerthyroidism

John Flynn — Thu, 25 Apr 2013 07:38:51 GMT

http://catinfo.org/docs/FoodChartPublic9-22-12.pdf

Anything less than 15% carb by calories should be fine (less than 5% is achievable with supermarket brand diets, I'm just not sure is necessary). Look at Science Diet Adult for an example of something you wouldn't want to feed a diabetic cat!

http://www.felinediabetes.com/ is a good site also

Re: Cat with diabetes and hyerthyroidism

John Flynn — Thu, 25 Apr 2013 07:30:08 GMT

Wet foods tend to have much lo0wer carb contents, so I normally switch diabetic cats to one of these if fed on dry food, but in the case of y/d I think the wet actually has slightly higher carb content?

With a carb content of almost 30% I don't think you'll get a diabetic cat well-stabilised no matter how much or what type of insuolin you give.

I'd go for thyroidectomy along with canned wet food (commercial brand fine) and insulin (glargine by preference) and aim for remission - I think the diet aspect of that regimen is crucial to achieve remission, but I don't personally see the dizzy heights of 80% success reached.

Regarding the thyroidectomy, it really depends on your experience and level of confidence as to what to do, but I've seen a fair few cats benefit from an extremely non-technical lumpectomy of the largest thyroid gland available which is a 5 min job and at least halves the T4 production, even if you're not confident dissecting out parathyroid glands etc (and you can cut them off your lumpectomy and stick them back in a neck strap muscle after if wanted).

Re: Cat with diabetes and hyerthyroidism

David Mills — Wed, 24 Apr 2013 23:29:41 GMT

I'm not sure Hills y/d will be the best for DM as its carb content is quite high. There's a nice review of its contents here:

http://endocrinevet.blogspot.co.uk/2011/09/is-hills-yd-nutritious-diet-for.html

You have a few options. I assume renal function is OK.

1. Thyroidectomy (is there bilat or unilat goitre?) - I'd go for unilateral if its just one side - then concentrate on the DM.

2. Vidalta + diabetes diet - m/d or similar.

3. Continue as is but use something actually effective against feline DM - I'd be hitting the glargine about now.

4. Thyroidectomy + glargine.

If it were I, I'd go for 4). How long been a diabetic? 80% of cats will have resolved DM within 6wks of starting glargine (if relatively recently diagnosed).

Re: Cat with diabetes and hyerthyroidism

Michael Woodhouse — Wed, 24 Apr 2013 22:42:29 GMT

Hills have a great helpline - have you asked them about the suitability of the food in diabetics? I have no idea as I haven't used it.

Think in this case I'd push for Sx and then only have one endocrine disease to worry about.

Re: Cat with diabetes and hyerthyroidism

Gillian Mostyn — Wed, 24 Apr 2013 22:35:27 GMT

Welcome to Vetsurgeon!

I'll leave the advice to someone who knows more about DM than me......not my strong point!