My Cat the diabetic

We are. At least that's what my doctor told me. But then I have type 2 diabetes, so maybe we need different diets than type 1 diabetics.

Why would your cat's pancreas revolt? The pancreas reacts to the presence of glucose in the blood stream (blood sugar) by producing insulin which causes the liver to convert the glucose into glycogen. With low levels of glucose in the blood stream the pancreas produces glucagon. Glucagon causes the liver to convert stored glycogen to glucose (glycogenolysis), and then when those stores are depleted glucagon causes the liver to synthesize ketones from fat (ketosis), and glucose from proteins (gluconeogenesis). Because a diabetic either cannot produce sufficient levels of insulin (diabetes I), or is insulin resistant (diabetes II), the diabetic cannot effectively process glucose in the blood stream. Ketosis prevents high blood sugar levels by adapting the body to primarily utilize ketones for energy instead of glucose.

Remember, a cat's primordial diet was higher in fats and proteins than carbohydrates as opposed to todays processed pet foods.

The standard recommended high carbohydrate diet for diabetics smacks squarely against the very causes of diabetes itself--high blood sugar due to insufficient insulin production and or insulin resistance. These diets are aimed mainly at keeping diabetics on diabetes pharmaceuticals.

I'm strongly inclined to agree with that last paragraph. ADA used to promote fairly high carbohydrates, and use of insulin to maintain strict control. I believe they may have backed off this position recently, but I don't really follow ADA, anyway.

They're still pushing high carbs.
The ADA's Diabetes Food Pyramid

Click on the pic

What type of insulin is Screech on? Lente? Glargine?

High fat diets are contraindicated in patients with pancreatitis, which is suspected in Screech's case.

Pdawg's right - the cat has chronic pancreatitis. Fatty foods irritate the pancreas.

He's on PZI. I hear they're stopping production. So, I dunno what I'll do after the next 4-6 weeks when I run out.

Ohh, Ok.
Nevermind.

What? You didn't read the whole thread, did you? Tsk.

I've talked to a lot of cat owners who are very happy gith the glargine. Sustained release, supposedly peakless -- lower highs, higher lows.

THAT sounds good. Screech is a grazer. Any other name for it besides glargine?

"Lantus" is the trade name, though I've only known it as glargine.

I'm really not too in touch with commercial cost of stuff (shelters, school, not retail clinics), but according to these folks -- http://www.veterinarypartner.com/Content.plx?P=A&A=1812&S=1&SourceID=52 -- it shouldn't cost you any more than PZI (they say less).


Not sure how good a candidate your vet will consider Screech for glargine, though. We used it routinely at the vet school, but not-so-recent graduates may not have experience with it, and I don't know how much they've marketed this drug to veterinarians (probably not much, since it's a human product).

thanks Pdawg. I'll ask anyway. He had at shot time last night he had a BG of 567, this evening 3 hours until shot time he had a BG of 26! Christ. How is this supposed to even work at all? How has he not died before now - diabetic for 5 years. <muttermuttermutter>

I know it's probably back there somewhere, but how often is Screech getting dosed?

twice per day. The PZI is supposed to be a 24 hour, but that doesn't often pan out, I hear. He was good on the stuff for years - REALLY good. But, since his pancreas is starting to be a little more feisty, his eating is less predictable. Same thing since the weather got warmer, too. Some days he just sleeps at the wrong time and misses eating at the right time. I think a constant release formula would be better for him.

Plus, I think there's other stuff going on. He coughs and sneezes (has for some time). He had his teeth cleaned maybe a year ago, but his breath stinks (like stomach, maybe).

Can I pick your brain, pdawg? He's been to the vet for extensive tests twice in 5 months. The first really bad bout with pancreatitus was in Feb (he'd had mild ones before). They did blood work, xrays, an ultrasound. Kidneys aren't great, white blood cells up and he had a slightly elevated temp. He had loose stools too. So, they shot him with a strong antibiotic and sent me home with some he didn't eat and then some he did eat (chewable). He finished two rounds, I think.

Thing is that I thought they said that elevated white blood cells and temp could be either from an infection or the pancreatitus. I imagine the diarrhea too.

I can't keep dropping hundreds of dollars on tests. Last month I demanded they just top the cat off with subq fluids and let me leave with no tests. (they did it).

Questions:
Can pancreatitus and an infection present the same way?
Should I put him back on antibiotics (I know he might be prone to infections given the diabetes)?
Can giving him subq fluids hurt him in any way? (he eats better after having the fluids)

Problems (as I'm seeing it)
Diabetes mellitus, poorly controlled recently
Poor appetite
Intermittent diarrhea
Bad breath
Elevated temperature with high white count (at least once)
Kidneys (assuming chronic renal disease)

My question: Does Screech vomit?

Your questions:
Yes.


If there's a good reason to (see below).


Not really (see below).

Pancreatitis
Certainly you have to think about chronic pancreatitis with these signs, especially if the diarrhea, fever, and high white blood cell count have been documented multiple times over the years. I don't know what test they ran for pancreatitis - the ones available on in-house analyzers (e.g., the older tests) aren't very reliable. There is a more reliable semi-quantitative test (fPLI) that's available in house now, and a quantitative fPLI can be sent out (results don't come back for a week or more). Given the signs and the presence of diabetes, though, Screech sounds pretty suspicious for pancreatitis.
That said, though, other conditions could give you these clinical signs as well.

Liver
You haven't said anything about Screech's liver values, so I assume they were normal when they were checked last. However, sometimes pancreatitis in cats appears together with liver disease (cholangiohepatitis) and inflammatory bowel disease (IBD), so if liver values were elevated, they might have been significant. (All three together is called "triaditis.") Liver disease on its own can look this way, too, as can IBD.

Upper respiratory disease
I wouldn't want to ignore the sneezing etc. Upper respiratory infection can do a number on a cat's appetite - cats don't like to eat what they can't smell. One of the biggest problems in shelters is that cats get URI, and then stop eating, and their health deteriorates. Unfortunately the most of upper respiratory infections in cats are viral in origin, and there's no effective treatment for the viral component of disease. However, bacterial infection can set in secondarily to the viral infection, and addressing it can make the cat feel a lot better. Of course, getting antibiotics into cats who don't eat is problematic…

Kidney disease
Cats in renal failure will have poor appetites as well, though advanced kidney disease patients usually are more remarkable for vomiting than diarrhea. Even if Screech's kidneys aren't a big problem for him yet, though, I'm sure you know that he's got to stay hydrated to protect his kidneys from further damage.

Bad breath
Like the upper respiratory disease, I wouldn't ignore this one. It could be pointing to another reason for Screech's loss of appetite. It's remarkable how much dental disease can affect a pet's appetite. Bad breath also can be a sign of problems further down (e.g., gastric ulcers associated with chronic renal disease or other diseases of the stomach) - but, again, a cat with severe gastric disease is probably going to vomit fairly regularly.

Fluids
If SQ fluids are helping, the benefits far outweigh the risks. Just make sure, if you're giving fluids at home, that you always use a fresh needle, and that you throw away the drip set (the line, the tube) with the bag when it's done. The biggest risk of SQ fluids is that you introduce infection, and this is pretty rare. Have you discussed giving fluids at home with your vet? It's not an uncommon practice, though it's not much fun for anyone.

Antibiotics
Personally, I wouldn't recommend antibiotics for their own sake. If there's no bacterial component what's going on, all you're doing is giving a drug that's likely to cause GI upset (unless an injectable is being given), that could cause increased burden on the liver and kidneys, and that could be encouraging bacterial resistance. (This excludes antibiotics like metronidazole that may be used for their reputed immunomodulatory properties in patients with unexplained diarrhea.)






Really, fluids would be at the top of my treatment list, especially if his kidney disease is at all advanced (e.g., creatinine consistently over 1.5 or 2). Mature cats with marginal kidneys can become old cats with terrible kidneys very quickly if they get dehydrated. And, of course, it improves his quality of life, which improves his appetite, which improves his health and helps manage his diabetes. Fluids are good, and giving them at home is not as difficult for most people as it might sound.

As for the pancreatitis -- if the choice is between Screech eating something that might aggravate his pancreas vs. not eating anything at all, I'd go with the risky food. Fasting is no good for a sick cat. (No good for a healthy cat, either.)

The other stuff -- well, Screech may have a dental problem, but dealing with it would require general anesthesia, and he's obviously not a good anesthetic candidate. Still, it's at least worth a look. If it's coming from south of the mouth -- well, then it's probably time to take another look at Screech's kidney function and at his GI tract, particularly if he's been vomiting. And I've said my spiel on respiratory disease already, and you haven't mentioned a history of elevated liver values, so that's that. I think I've gone on enough.

Wow! THANKS! He had his kidney values checked twice in the last 5 months. They were all within normal except for one was slightly elevated. I unfortunately don't know which one. Maybe I have a record of the results (* I checked, I don't have any records of results). No one mentioned anything with his liver, I also expect it's fine. I figure I could take him in for subq fluids once every 2 weeks. That seems it would be enough. But, if it was a more than once per week thing, I'd attempt it at home. He's even used to me pricking his ear for blood. Good cat.

He always eats something (except for that bad bout in Feb). I think we all pretty much decided it was chronic panc. There was minor inflammation showing on his xrays, ultrasound found the same. They said the same about food - get him to eat. When he stops, I give him anything he wants (almost) like chicken broth, cooked eggs, baked turkey, canned foods including the big guns: kitten food. He loves fat free cheese and low fat tofu turkey. I found freeze-dried chicken and salmon which he will eat ANYTIME, but which have very few carbs. I drizzle them with cane syrup when his BG tanks.

vomiting: Yes he does vomit. More than the average cat (as if there's an average vomit factor). Bile comes up, most often - only occasionally cat hair or leaf parts. I'd say it happens anywhere from once a week to once every couple months. Renal is kidney? Or liver?

So, I shouldn't ignore a URI or digestive disease. What should I expect if I bring him in to the vet?

Don't forget to send me a bill!

Renal is kidney (sorry, it's the word that's in my head now).

If you ever see a coffee ground appearance in the vomit, that's a sure sign of ulcer. Bile could be any number of things (including ulcers, if they're not really big).

If Screech only needs fluids every couple of weeks, he's doing pretty well! I've known cats who get fluids every day at home.

Question -- how often do you check Screech's blood glucose? I've never seen a diabetic cat or dog managed with regular checks. The clinicans I've known just put them on a regimen and bring them back for a glucose curve after a couple of weeks, then after a couple of months, then once or twice a year as long as things seem to be well-managed (e.g., the curves are going well and there are no clinical signs or recurrent problems in between curves).

That value of 26 really does seem odd to me -- I'd expect Screech to be comatose or having a seizure at that point. And to have a really low value 9 hours after the previous dose (and after a reading over 500). Hard to make sense of that unless something really dramatic was happening that day.

Traditionally we did glucose checks just as you describe in your last post. We went to fructosamine because he was well regulated and didn't curve well at the vet (wouldn't eat). His fructosamines have been ok. But as I understand, they are just sort of averages. If he's swinging from 500 to 26, can he get a good fructosamine?

It drives me crazy.

Memorial Day weekend, a vet was on the Cape with us (bro-in-law's brother). He introduced me to the BG kit. I got a little test happy and the vet told me to chill out. The plan was that I'd stablize him at 1 unti twice per day and then curve him myself. I did a partial curve (every 4 hours, or so, rather than every 2 hours). He was clearly not getting enough insulin, so I bumped him up. But he keeps having these periodic low glucose issues, so the dosage doesn't stay constant for a week for the next curve.

So, no, I don't do BG checks regularly. I test him before I give him insulin to be sure he's not too low (what happened this evening). Or I test him mid-day (he peaks 8 or 9 hours into a dose) to check his lows. His ears aren't very forgiving, so I sometimes have to prick him several times to get any blood. I feel badly.

At 26 (and I have checked with second strips and/or the testing fluid when I've gotten those low numbers) he walks, makes eye contact, does NOT have dilated eyes, does NOT act drunk or confused. He has less of a response to me when I talk to him, but that is not a very good indicator.

I had a friend who was diabetic (he still is, we just aren't friends anymore) who didn't treat himself well. He became low-glucose desensitized - he couldn't feel the glucose low coming until it hit him full force and at that point he was so addled he barely knew how to help himself. Scary to see.

Fructosamine is an indicator of how much time an animal is hyperglycemic, period. If your blood glucose is high, fructosamine goes up. If it's low, it doesn't change (that is, it doesn't go down).

If Screech's fructosamine levels were within the "normal range," then he was receiving too much insulin. If you give a cat enough insulin to prevent it from ever having high blood glucose, then there are going to be long periods when the glucose is low. So, it's not really an average, it's a gauge of the extent of hyperglycemia only. For a diabetic cat, you actually want to see mildly elevated fructosamine levels -- measurements within the normal range suggest that insulin doses have been too high. (Which is probably the result your vet was getting.)

2 units twice a day is a pretty high dose for a cat, though. Is Screech a big guy?