Saturday, September 29, 2007

Hamlet - Another Life Used Up!

Last fall, when Max started to deteriorate quite rapidly, Hamlet was noticing the small changes, and along with the move we had made the previous fall which meant he had to learn to walk on slippery hardwood floors with his slight neuropathy, and the year of backhoes, dump trucks, jack hammers, chain saws, and other renovation noises, he regressed back to needing insulin. We had a slight reprieve from that during the months of October and November where we had a slight hypoglycemic episode, (the only one he has had), but after Max died in mid December, Hamlet went into the most grievous decline a cat could, with an extremely high fructosamine at 659.
Hamlet's numbers were not improving with insulin, and as we didn't want him to have the added stress of hanging around dogs, we made the choice to ask Margie Scherk for some pointers on feline diabetes. She has a less stressful 'cat only' practice.
During the initial period we did a number of glucose curves to establish how the Caninsulin was, or wasn't working for Hamlet, and, had periferal issues to address as his appetite had also becom poorly. He was placed on a small dose of periactin, (aka cyproheptidine), which also reduced his asthma that develops late winter/early spring, every year. Slowly we increased the insulin dosage until it was around seven units, b.i.d., when the fructosamine reduced slightly. It appeared that Hamlet's body takes time to adjust to each new dosage of insulin, as the improvements we first saw didn't happen for about a month on the high dose of insulin, and then we had to start reducing it at a fairly regular rate, until I made a very serious judgement error.

From the start, the curve of Hamlet's delta, (glucose curve), went deeper as we gained control, but the apex of his curve, at shot time, was remaining high. His numbers remained quite extreme for most of this past year, once we started managing to pull down the nadir of his curve. In fact, one morning when I was about to start a curve, Hamlet was reading 3.5 before his shot, so I panicked. In previous tests, he had dropped so low at nadir that the glucometer was reading "LO", and we had given him Karo Syrop to prevent hypoglycemic episodes, just as a precaution. On this day, I didn't give him his insulin at all, and was having trouble contacting any vet, (it was a holiday weekend), so I held back until the next morning when his apex was again very high.

Previous to this, my understanding of hypoglycemia in humans had led me to believe that recovery from this was simple in that one just went back to a more appropriate dose of insulin, and everything would be fine. When one is dealing with an unstable feline diabetic, this is not the case, and we regressed right back to Hamlet having a fructosamine of 639, with apeces that read too high for the glucometer, and yet he was 'seeing' the insulin well enough to spend part of each day in normal range. It took another three months to give the pancreas time to heal enough that we could bring the apex of the curve back down to more reasonable numbers, without also taking him too low, as he has been having such deep deltas throughout the process, once the insulin was starting to have good effect on his system.
We went through one more time with a low apex again, that made me extremely nervous as I 'bit the bullet' and gave Hamlet a lower dose of insulin, but didn't drop it completely. That worked.
During all the above, Hamlet had been free fed, as all cats are naturally intended to be, and when the temperature became warm, I often had to rouse Hamlet and encourage him to eat just a little, every once in a while, as this was found to be the reason his glucose numbers would go so low at times, and we had the added complication in that it seemed, according to the patterns of the curves, that the Caninsulin would sometimes be effective for longer than the twelve hours between shots, and so was overlapping, particularly if he hadn't eaten recently.

A month ago, we had managed to bring Hamlet's fructosamine in at 405, even though his apex was still going quite high, and while I agree with Margie, and all those who have more education than I do in this area, that cats should free feed, Hamlet's performance, along with a weight gain of a pound within a couple of months, persuaded her that possibly, in this case, he needed a timed feeder.

This past month or so, Hamlet has been getting 18 Royal Canin Diabetic DS 44 every two hours, night and day, and his nadir has consistantly been between 1.6 and 2.3 throughout, at 3.5-4 hours after his shot. Over the past couple of weeks I have gradually introduced five Wellness CORE into each serving, and reduced the Royal Canin portion by six crunchies, so he is now getting 17 crunchies per serving, total. I do not think we have managed weight reduction with this, however, the glucose readings are most important for long term pancreatic health, as is a healthy appetite in his case, which we are achieving. The peracitin/cyproheptidine has been reduced to 1/4 tablet once per day.

It has been great to be able to allow Hamlet to have a little more variety with the Wellness CORE, but I don't know if this will be a long term possibility.........we are hoping, for his enjoyment of life. His urine deposits have reduced from being enough to fill a grocery store bread bag per day, to about two cups, (maximum), and stickiness of those lumps have receded dramatically. In the past couple of months we have also noted more and more interaction between Hamlet and Thumper, (who doesn't know how to play but is learning), with Hamlet being the initiator. His activity level has been increasing, and I expect that to continue with the colder weather causing less need for long naps in the sun or shade.
.............and, this household is very much looking forward to the fructosamine being done next week to see if we managed to reduce it to even lower numbers......wish us luck!

Hamlet dosing on the garden swing - who could blame him for not wanting to go out on the hot deck to get to his food, when slumber had him in its grasp?

Hamlet had just had a lion cut before this photo, and the weather went cold right after this, for at least a month. This is not too much of an issue for Hamlet as he has a collection of polar fleece blankets, of varying colors and sizes to fit his mood.

There is an example of the type of interaction we hope to see develop between Thumper and Hamlet, about two thirds of the way down the page where Hamlet and Max were 'getting into it'.
The above shows us, in our own experience, that there are a lot of variables governing the wellbeing of our diabetic felines, even without the fact that causes of the onset of disease can vary.

  • How stable and frequent is the eating pattern for steady glucose levels? (We are feeding every two hours.)

  • Type of food being served. (I agree with veterinary professionals that Royal Canin Diabetic DS 44, with its low caloric content, and lack of 'trendy' additives is best for cats that may develop kidney issues when useless ingredients tax the digestive system.)

  • What type of insulin is being used? (Here we are lucky enough to have access to Caninsulin, which is a long acting, dependable insulin for pets.)

  • How well is the cat's body seeing the insulin being used? (Hamlet's delta is fairly fast and deep, meaning he is seeing the insulin well at this point in time.)

  • Emotional stress of the cat. (Moving, fear, loss, hidden simple carbohydrates are a number of possible contributors to the emotional side of the scale that balances feline diabetes control.)

  • Physical activity, pollution, and weather conditions. (All these affect how Hamlet is treated, or monitored as he has weight issues, and tendancies toward asthma.)
The method of therapy that we are trying to follow, as is happening with more aggressive treatments in humans is found here.