Everything has been going really good with the cats... which is why there has been a lack in posting. I will say we have a hard time going on trips. We recently went on vacation and had someone lined up to watch the cats and give them shots and they bailed two days before we left so we had to scramble to find someone else to come over two times a day and give shots. We always pay people to watch them since they are hard to take care of. Pippin is now on 7 units of Prozinc, 1 Glipizide, 1 steroid in the morning and 1/4 Cerinia at night. Merry is on 6 units of Prozinc, 4 units of Vetsulin 1 glipizide pill.
I have noticed Merry has been limping a lot lately on his back left leg. I am pretty sure he has full blown arthritis now. I googled it, and it seems that there are a few ways to help this starting with medicine. Sigh... even more meds. It said either a NSAID or steroid depending on how bad it is. I am sure my vet will want to see him first before prescribing anything so there is $50 for that. I am going to give him this week and see if stays the same/gets better or wise. Hoping it goes away. So we'll see. I really don't want this to be the reason he dies. I had a golden retriever growing up and eventually we had to put him down because his hips gave out from arthritis. So sad. So here's hoping. Since Merry is overweight from all his other issues this makes his chances of having arthritis worse.
If you read the previous post on the blog you know we weren't able to clean Merry's teeth last week. He wasn't able to go under because he couldn't breath on his own. So this week my vet tried again using a different anesthesia. It was successful this time. Though it turned out quite expensive. When Merry went in the previous week my vet could tell he has a lose tooth, but that was all she could really see at the time. When I picked him up he had like 8 teeth pulled! I did have his teeth cleaned in May 2012 so I didn't think it had been that long and then 2 years before that. He has never had teeth pulled before now. I don't know how they got so bad. She did say that when a cat is diabetic their teeth will go bad... but that bad~!! He was under anesthesia for 50 minutes and so she didn't take xrays because he was under so long. Merry gets sooooo moody at the vet. I had to go in the back and move him into his carrier.
The vet did say she wants to see him in two weeks but she can't even get near him. I asked her how she would look at his mouth and she said from a distance. Well I am not going to pay $50 for her to stand away from him and say he looks good. I have been feeding him wet food for the week, and of course he is on all kinds of medication. I am going to start softening his diabetic dry food so he can eat that from now on. I think with all those teeth gone it's going to be too hard for him to eat normal hard food. His eyes also wigged out the night after his dental. One eye was fully dilated and the other was not. I googled this and of course this is a major sign of stroke. Luckily my vet will email after hours if you email her so I emailed her right away! She did say this was a symptom of coming down off morphine. But it was still very scary.
Be sure to get your cat's teeth cleaned. I had NO idea this is how bad his teeth were. I would've never know he was in pain. His breath did stink real bad so that's how I knew it was time. Plus my vet had 10% off this month for dentals so I saved a lot of money there too.
Merry's breath has not smelled good lately and it's been about 1 1/2 years since the last time he had his teeth cleaned. I think it's important to take care of your cat's teeth. Imagine a painful mouth! Cats can't tell you when their mouth hurts so I try to do it every now and then (I don't do it as often as recommended though). If your cat has bad breath though then it's time. Most likely there is plaque stuck somewhere in their teeth.
He fasted during the night but since he is diabetic he had to have a little food this morning. No shot though, no food or water during the night. After dropping him off I called and check on him a few hours later. Turns out he couldn't breath on his own while he was gassed so my vet decided to not do it today. She was able to get some plaque off some of his teeth, but went ahead and woke him back up. He does have one lose tooth so she wants to try again. Next week we will bring him in and she will use a different anesthetic. She said they would be able to tell before he is under whether or not he can breath. I am hoping it works because a lost tooth can be very painful and I am not sure what the next option will be for this tooth. This month is dental health month for pets so my vet also offers 10% off cleanings. I wasn't charged for today either which was really nice of them. I don't brush my cat's teeth though I should.. I do have a tooth brush and tooth paste for them for the vet but it is tough work. Be sure to get your cats teeth checked out especially if they are diabetic. I'll update next week about how that appointment goes.
The worst feeling is when you and your significant other don't communicate right on who is giving the meds and shots and the cats miss it. This morning we both thought the other one was going to do it and then no one did it. Then becomes the debate... when to give the shots/pills. Right away or wait a couple hours and get them back on schedule right away. I feel terrible thinking that they don't feel good right now because of our mistake. This has only happened twice in the 2 1/2 years since they have been diabetic but it's AWFUL!
Well.... surprisingly things are going well here. Thought I would let you know... we tried a few different meds on Pippin and they seem to be working. Merry even dropped down a unit on his insulin!! So he is doing really well. I am quite pleased with the cats. Merry has puked a couple times this week and he never does... but I am hoping that it's nothing. Usually it's Pippin's puke I am cleaning. Merry also decided to pee for me today.. I put him in a box since he loves them and he got so excited he just peed. The joys of diabetic cats.. they just can't hold it in!
So Pippin had a little episode of puke last night. He couldn't hold his food down this morning either. I called the vet and told them there was just no way I could have another $1000 day and that we keep going in and doing tests to only find out that his pancreas isn't doing good.. and same old same old. She told me to bring him in and that she would do an ultra sound for free to see how he is doing inside. When I called today I also told her we would probably have to put him to sleep. I picked him up this evening and turns out that of course his pancreas is still bad and has a lot of scaring in it. The gallbladder still has sludge in it too. The only organ that doesn't have any issues right now is the liver.. which will probably eventually will be going soon. This is called Triaditis.
So we talked about what is next. She said there is really nothing left to do, the pancreas will not get better but can be managed. We are going to try that route... so Pippin will get a steroid twice a day, and nausea meds twice a day along with his insulin. She did say if this doesn't work we'll have to put him down. I asked about them putting him down after hours.. but they said for some clients they will come to your house and do it. Since we have been long time clients they will come to my house, I am quite happy about this.
Having a good vet even if they are pricey can really been a good decision in your pet's life. Today all the procedures and medicine I was sent up with were all free. That isn't something you get if you don't have a relationship with your vet. Even if you have a healthy cat be sure to do their check-ups and teeth cleanings and get to know your vet.
EDIT: It is now February 18th, 2014 and Pippin is doing really well. The mix of pills has turned his pancreas around. He takes a steroid, 1/2 nausea pill, and his diabetes medicine everyday.
Glucose readings are tough. We don't take them everyday. I know that some people out there do. My vet has doing the curve every two weeks. The numbers are looking fantastic lately. I thought though I would give you a glimpse of what we do.
On the weekends we will go and poke their little ears. The reading can be all over the place so be ready the first few times you do this. It might just make you worry and panic. Never fear though! Keep honey and Karo syrup on hand at all time. If your kitty goes under 65 then put this on their gums. Make sure they eat if they are this low and give them some treats.
OK... so one things that is probably important is to keep a log on the days when you do this. We mark it with the time the cats received their shots, which ear we poked (very important because you probably will forget through out the day and you want to rotate which ear), the time you took the reading, and the name of the cats (if you happen to have more then one cat with diabetes like me).
This is a great video on how to take a reading. We use One Touch Ultra for our glucose reader. I will say that my vet told me NOT to use the type of needle used in the video to poke my cat. This is because the needle in the video will go right through your cats ear. We use BD PrecisionGlide Needle REF 305122. This allows you to just poke the vein on the outside... though.... lets be honest. We have pierced the cats ears a couple of times. One time we poked Merry and he moved and the needle was hanging through his ear! I was totally panicked. He acted like nothing though. So I was more scared then he was.
The cats do know when it's time. We get out our little bag of cat medicine goodies and then hold them down!
So here is today's readings:
Merry 7 units of Prozinc, 3 units of vetsulin, 5mg glipizide Pippin 4 units of Prozinc, 5 MG glipizide, and 1 whole steroid at night (tomorrow we start half a steroid).
Time Merry Pippin
7 am 215 277 9 am 159 243 11 am 74 125 1 pm 52 97
630 PM 81 321
As you can see Merry is very low. The vet has us switching him to 6 units of Prozinc and 1/2 a pill of glipizide starting tomorrow. We will do the results again in two weeks. These numbers are very good for Pippin and Merry. We are finally getting them under control. Luckily... our vet will monitor these readings for free. We email in the readings and she usually responds in a couple of days.... sometimes she responds right away. Hopefully you can find a vet who will also do this. Make sure your vet uses a glucose reader that pokes the ear. The first vet we went to actually made us bring in the cats and actually drew blood from their legs. There is no reason for this and only causes more stress to the cat.
You really should invest in buying a glucose reader yourself and just do it at home. You can find readers for like $40! Don't buy your reader from your vet. Go to Amazon.com and get a great deal on one. You can use any reader.
This month I have had my two kitties for TEN years! I adopted them both from a no-kill shelter called No More Homeless pets in Utah in 2003. Merry was already 3 1/3 and Pippin was 6 months. I almost didn't get two cats but my mom was there with me and when I went to adopt Pippin my mom was like "he needs a friend"! The guy working there told me he and Merry got a long so that is how Merry came home also.
I did learn one thing that I would like to share. When adopting a microchipped animal, which mine were, MAKE SURE THE AGENCY CHANGES THE ADDRESS! I turned in a piece of paper with my address and they were supposed to change it for me. I just assumed they did. Then years and years later when we moved I called the microchip company to change it and they said I had to pay like $100 a cat to change it because it wasn't a change of address but a change of owner now. (The company told me they are still registered under No More Homeless Pets).
I tried to call the agency that I adopted my cats from who of course by now had changed names they are now Best Friends Animal Society... no one would email me back or call me. Hell I was even willing to pay the $15 fee (that was included in my $165 fee that I had paid to adopt both of them) to simply change the address (I need them to do it though) 10 years later I still have all the adoption paperwork too, so I could prove I adopted them from this agency (which I did say on the messages I left them). So in the end .. I don't have $200 to switch owners for the microchip. I think the cats suffer because this adoption agency won't step up and help me. I know that it is a non-profit so I was willing to do what I could on my end, I just need them to call since they are technically the "owners". I mean... if they get lost does this agency still have the paperwork with who adopted them? I doubt it. So please if you adopt your pet and it is microchipped included check with the company of the chip to make sure the address is updated.
So now that we know that Merry has Acromegaly... then you probably know I decided to treat him by giving him 2 insulins and controlling it that way. My vet and I discussed the radiation therapy but I chose to not go in that direction. I asked my vet the other day what will happen when it's the end of his life. How will I know when the disease is too much. She told me that he will start having seizures. I am pretty scared about that. I just hope it isn't bad and that I make the decision to put him down when the time is right. Sometimes I wish I was one of the lucky people who come home and find that their cats have passed away and they don't have to make the decision about when the time is right to put them down. Anyways...
My vet gave me their new magazine Veterinary Medicine which has an excellent article on Acromegaly.
That is a link to the article but incase someone finds this post out
there in the world of the internet and it is gone I would like to repost
it here for information. I don't have permission to do this but hope
that the magazine doesn't mind so we can spread the information out
(just incase the link is ever pulled).
Feline acromegaly: Treatment options
Somatostatin analogues, dopamine
agonists, and growth hormone receptor antagonists are commonly used to
treat people with acromegaly. Should you be giving them to your
patients?
Feline
acromegaly is a disease characterized by excessive growth hormone
released from a functional pituitary adenoma, resulting
in a wide array of clinical signs and, commonly,
insulin-resistant diabetes. For information on the pathophysiology,
clinical
signs, and diagnosis of feline acromegaly, see
the article on page 467. This article provides an overview of the many
treatment
options for this disease.
MEDICAL TREATMENT Medical options
for treating acromegaly range from increasing a patient's insulin dosage
to manage the diabetogenic effects
of acromegaly to instituting treatment with a
somatostatin analogue, dopamine agonist, or growth hormone receptor
antagonist.
Several of these treatments are common in human
medicine but have not been studied widely in veterinary medicine.
Somatostatin analoguesSomatostatin is a
hypothalamic hormone that acts on the pituitary gland to inhibit growth
hormone release. Somatostatin analogues
are commonly administered in people with
acromegaly and have efficacy rates of 50% to 60%. In addition to acting
centrally
by suppressing growth hormone release and
peripherally by interfering with growth hormone receptor binding on
hepatocytes,
somatostatin analogues are also thought to
result in tumor shrinkage of pituitary adenomas by promoting apoptosis.1 The somatostatin
analogue octreotide has been evaluated in a few cats with acromegaly
with limited success. In a study of
four cats with acromegaly, no change in serum
growth hormone concentration was noted after treatment with octreotide.2 Another study, which measured the short-term effects of octreotide in five cats with acromegaly, found a decrease in growth
hormone concentrations for up to 90 minutes after octreotide administration.3 However, a recent study evaluating a long-acting somatostatin analogue (Sandostatin LAR Depot—Novartis) showed no benefit
in cats treated for three to six months.4 The failure of
these drugs to inhibit growth hormone release may be related to
differences in somatostatin receptor subtypes
found on pituitary adenomas. Future studies to
identify the somatostatin receptor subtypes in feline growth
hormone-secreting
pituitary tumors are required to determine if
these subtypes are similar to the ones found in people and if human
somatostatin
analogue therapy, at least in theory, may be
beneficial in cats with acromegaly.
Dopamine agonists and growth hormone receptor antagonists Dopamine agonists and, more recently, growth hormone receptor antagonists are also given to people to treat acromegaly. Growth hormone receptor antagonist therapy has not been reported in cats, but in people, response rates have been reported
to be as high as 90%.1 However, it has been noted that these medications have no effect on tumor size (do not result in tumor shrinkage) and, thus,
would not benefit patients with neurologic signs. A single case study on the treatment of feline acromegaly with a dopamine agonist (L-deprenyl) showed that the medication
had no effect on reducing insulin requirements or clinical signs of disease.5 In people, dopamine agonists are typically only 10% to 20% effective but are often combined with other medications.1 Increasing insulin Increasing the
dosage of insulin to improve glycemic control and clinical signs of
diabetes is the most conservative—and most
common—method for managing insulin-resistant
diabetic acromegalic cats. While helping to control the clinical signs
of the
diabetes, raising the insulin dose has no effect
on growth hormone secretion, progression of the clinical signs of
acromegaly,
or continued growth of the pituitary tumor. In addition, some patients treated with high doses of insulin unpredictably and inexplicably become sensitized to the effect
of the insulin, resulting in hypoglycemic crises.6,7 The timing of the insulin sensitization and occurrence of hypoglycemic episodes was extremely variable. In one study, several
acromegalic cats were euthanized after experiencing hypoglycemic comas.6
SURGICAL TREATMENT Surgically removing
the pituitary tumor (adenectomy) is the treatment of choice in people
with acromegaly. The procedure can
be performed in cats and dogs but typically results
in the complete removal of the pituitary gland (hypophysectomy).
Complications
associated with the surgery include hemorrhage and
incision dehiscence. After surgery, patients require treatment with
cortisone,
L-thyroxine, with or without desmopressin, to
compensate for the loss of pituitary function. Because of this, only
patients
that are easily medicated should be considered for
this procedure. Few case reports
exist for the treatment of feline acromegaly with transsphenoidal
hypophysectomy. In one case, a patient
was receiving 25 U of insulin detemir (Levemir—Novo
Nordisk) four times a day before surgery, and three weeks after
surgery,
the patient no longer required insulin therapy.8 Up to one year later, the patient's insulin-like growth factor-1 (IGF-1) and growth hormone concentrations remained normal.
In a case we
treated at VCA West Los Angeles Animal Hospital, a 13-year-old castrated
male domestic shorthaired cat with acromegaly
underwent transsphenoidal hypophysectomy. The
patient had a history of insulin-resistant diabetes mellitus and was
receiving
15 U of insulin glargine every 12 hours. The
patient's diabetes mellitus resolved two weeks after the surgery and
remained
in remission for eight months, at which time the
cat was euthanized for an unrelated issue. Availability of this
procedure is limited in the United States, and as of this writing, the
procedure is only available at
the VCA West Los Angeles Animal Hospital, although
other institutions may soon be able to offer this option.
RADIATION Radiation therapy is
another option for the treatment of feline acromegaly, especially if
the tumor is inoperable or surgical
treatment is not available in the area. In human
medicine, radiation therapy is regarded as a second-line treatment since
beneficial effects may take years to develop and
patients typically experience undesired late-term central nervous system
radiation effects. Most studies that
have been performed in veterinary medicine focus on radiation treatment
of pituitary masses regardless of
functional status. There is no standard treatment
protocol for pituitary masses, and varying methods have been used,
including
both single- and multiple-dose fractions,
administering total doses from 1,500 to 4,500 cGY.9-14 Most of the cats included in these studies had insulin-resistant diabetes (suspected acromegaly or Cushing's disease) or
neurologic signs. Radiation therapy
has been shown in these studies to be successful in improving both
insulin resistance and neurologic signs.
Neurologic improvement was generally seen within
weeks to months. Improved insulin response was seen within the first
month;
however, most patients still required insulin
therapy. In cases in which repeat imaging was available, a decrease in
tumor
size was also noted. Disadvantages of radiation therapy are the early and delayed effects of radiation, repeated anesthesia, and expense. Early
effects from radiation therapy include hair loss, skin pigmentation, and otitis externa.12,14 Reported late-term side effects include brain necrosis, tumor regrowth, loss of vision, and hearing impairment.11,12 In one study, 12 cats with pituitary tumors were treated with a coarse fractionated radiation protocol, delivering a total
dose of 37 Gy in five once-weekly doses.9
Eight of these cats had insulin-resistant diabetes mellitus secondary
to acromegaly. After radiation therapy, five of the
eight cats no longer required insulin therapy, two
became stable diabetics, and one required less insulin. In addition,
three
of four cats had improved neurologic signs. The
mean survival time of cats in this study was about 18 months. In another study, 14 cats with confirmed acromegaly and insulin-resistant diabetes mellitus were treated with a total dose
of 3,700 cGy divided into 10 fractions (three a week).10
Thirteen of the 14 cats had improved insulin responses, with an
average insulin dosage reduction of about 75%. Six of the
cats went into complete diabetic remission, and
three of the six remained in remission at the time of this writing. The
median
survival time of cats in this study was 28 months.
CONCLUSION Many options exist
for treating feline acromegaly. However, clinical studies on their
long-term safety and efficacy are limited
and often lack controls. Until more work is done
evaluating medical treatments such as somatostatin analogues and growth
hormone
antagonists, most patients are best treated with
radiation therapy or surgery to control growth hormone concentrations
and
neurologic signs, or with increased insulin doses
to improve glycemic control. When making your
recommendation regarding treatment, be sure to consider the patient's
clinical status (state of diabetes
control, any coexisting diseases, whether or not it
is a candidate for anesthesia), the availability of treatments in your
area, and the advantages and disadvantages of each
treatment modality. Justin Wakayama, DVM Department of Veterinary Clinical Sciences College of Veterinary Medicine University of Minnesota St.
Paul, MN 55108 David S. Bruyette, DVM, DACVIM VCA West Los Angeles Animal Hospital 1900 S. Sepulveda Blvd. West Los Angeles, CA 90025 Veterinary Diagnostic Investigation and Consultation 26205 Fairside Road Malibu, CA 90256
Recently when I went into the vet for my crazy cat Pippin (who is doing well after being on all the meds but tonight he eye looks crazy.. what's next???), the vet gave me their new magazine Veterinary Medicine which has an excellent article on Acromegaly. That is a link to the article but incase someone finds this post out there in the world of the internet and it is gone I would like to repost it here for information. I don't have permission to do this but hope that the magazine doesn't mind so we can spread the information out (just incase the link is pulled). In my next post... I'll post what they say about treatments so be sure to look for that.
Feline acromegaly: The keys to diagnosis
Caused by excessive growth hormone
secretion, this likely underdiagnosed endocrinopathy may be lurking in
your feline patients—especially older, poorly controlled diabetic males.
Here's a look at which diagnostic tests can help you detect it.
Feline
acromegaly is a disease characterized by excessive growth hormone
secretion, leading to a wide array of clinical signs
caused by the hormone's effects on multiple
organ systems. These effects can be divided into two major classes:
catabolic
and anabolic. The catabolic actions of growth
hormone include insulin antagonism and lipolysis, with the net effect of
promoting
hyperglycemia. The slow anabolic (or
hypertrophic) effects of growth hormone are mediated by insulin-like
growth factors.
Growth hormone
stimulates the production of insulin-like growth factors in several
tissues throughout the body. Insulin-like
growth factor-1 (IGF-1), which is produced in
the liver, is thought to be the key factor that facilitates the anabolic
effects
of growth hormone that are responsible for the
characteristic appearance of people, dogs, and cats with acromegaly. Similar to its etiology in people, acromegaly in cats is the result of a functional adenoma of the pituitary gland that releases
excessive growth hormone despite negative feedback.1
ANATOMY AND PHYSIOLOGYGrowth hormone is produced in an anterior lobe of the pituitary gland, specifically by cells called somatotrophs.
The regulation of growth hormone is complex, and many factors—both
environmental and endogenous—are responsible for its
control. The two most important regulators of
growth hormone production and release are growth hormone-releasing
hormone (GHRH)
and somatostatin, which are produced in the
hypothalamus. While growth hormone release is stimulated by GHRH, it is
inhibited
by somatostatin as well as by negative feedback
from itself and IGF-1.1 SIGNALMENT Feline acromegaly
is an uncommon disease, although it is thought to be underdiagnosed. It
most commonly affects middle-aged
and older, male castrated cats. In one study, 13
of 14 cats with acromegaly were males, with an average age of 10.2
years.2 This association may be biased, however, as most
cats in which acromegaly is diagnosed are presented for complications
associated
with diabetes mellitus, which is also common in
older, male castrated cats. Based on available data, no known breed
association
for feline acromegaly exists.
CLINICAL SIGNS
1.
This domestic shorthaired cat with presumptive acromegaly is exhibiting
a broadened face, a physical change commonly associated
with feline acromegaly. The cat was
presented for unregulated diabetes.
Cats with acromegaly are commonly presented for insulin-resistant diabetes mellitus (insulin doses dependent on insulin type)
with concurrent weight gain rather than weight loss.2 Other clinical signs vary because of the wide range of effects the disease has on the body.
Physical changes associated with feline acromegaly include increased body weight, a broadened face, enlarged feet, protrusion
of the mandible (prognathia inferior), increased interdental spacing, organomegaly, and a poor coat (Figures 1-3).
2. The same cat as in Figure 1 exhibiting another physical change associated with feline acromegaly—protrusion of the mandible.
Respiratory
disease may result from excessive growth of the soft palate and
laryngeal tissues, leading to stertorous breathing
and even upper airway obstruction.
Cardiovascular signs include the presence of a heart murmur,
hypertension, arrhythmia,
and congestive heart failure associated with
hypertrophic cardiomyopathy.3Neurologic
disease associated with feline acromegaly is uncommon but can occur with
large pituitary adenomas. Neurologic signs
that have been observed with acromegaly include
dullness, lethargy, abnormal behavior, circling, and blindness.
3.
This close-up of the cat's teeth (the same cat as in Figures 1 & 2)
highlights increased interdental spacing, another physical
change associated with feline
acromegaly.
Glomerulopathy
and secondary renal failure have also been associated with feline
acromegaly. Histologic evaluation of the
kidneys of cats with acromegaly has revealed
thickening of the glomerular basement membrane and Bowman's capsule,
periglomerular
fibrosis, and degeneration of the renal tubules.2Because of an associated degenerative arthropathy and peripheral (diabetic) neuropathy, lameness has also been noted in cats
with acromegaly.
