In 1997, at the age of 8 months Tilly had a uterine infection (pyometra) which spread into her body cavity (secondary peritonitis). At the time, we were lucky to have an excellent vet and Tilly survived. Until she was diagnosed with diabetes, she occasionally had cystitis or a slight cold. Tilly also had inflamed gums since she was a kitten. Tilly received vaccinations annually which, according to new research, was too often.
January 2004: The Cortisone Injection
In January 2004, Tilly received a depot cortisone injection for an itchy spot on her ear. In March 2004, she was diagnosed with diabetes mellitus. In future I will exhaust all other treatment options before I give any one of my cats cortisone again.
March 2004: Diabetes and Caninsulin®/Vetsulin®
In the two months after receiving the cortisone injection, Tilly lost a lot of weight, she became apathetic, very thirsty, her fur looked terrible and the tips of her ears curled downwards. Just before she was finally diagnosed with diabetes, she began to vomit frequently.
The vet appeared not to know very much about diabetes. Tilly started with 4 IU (insulin units) Caninsulin/Vetsulin once per day. I was to bring her back to have the "nadir" (the lowest value in the blood glucose curve) measured at +8 hours (!). The first week was terrible. I figured out how to do home testing as quickly as possible and switched to "BID" (two injections per day), splitting the dose.
I was very unhappy with Caninsulin/Vetsulin: the "preshots" (blood glucose values just before injecting insulin in the mornings and evenings) were very high, the nadirs were sometimes, but not always, low.
Tilly looked horrible and she was still extremely thirsty. She also suffered from a voracious appetite (also called polyphagia), which is typically associated with poorly regulated diabetes: she ate 400g, 500g or more per day without gaining any weight.
The highest dose Tilly got on Caninsulin/Vetsulin was 3.5 IU BID. At low doses she developed ketones. When her blood glucose fell, it fell fast, and she only spent 2-3 hours of 12 under the "renal threshold" (the blood glucose concentration above which the kidneys begin to excrete glucose into the urine) of 200-220 mg/dl. The nadir was at +4 to +5 hours.
August 2004: New Vets and the "Low-Carb" Diet
In August we switched vets. I also began telephone consultations with a vet in Canada who specializes in internal medicine and has lots of experience with feline diabetes.
The first step in the new regimen was a blood panel including complete blood count (CBC) and serum biochemistry panel, including the thyroid function (T4). The purpose was to rule out complicating factors. Glucose, fructosamine and cholesterol were extremely elevated. Urea, GLDH, LDH, total triglycerides and eosinophil granulocytes were slightly elevated. The albumin/globulin ratio and the thrombocytes were slightly too low. All other results were normal.
The second step was to change Tilly's diet. No more kibbles, not even the expensive prescription diabetic dry cat food. The Canadian vet calls dry cat food "candy bars for cats". I was also told to avoid canned food with sauce, the manufacturers often use caramel for colouring. Also, no cheap grain by-products. Tilly was switched to high-quality canned cat food with meat and/or fish, plus smaller amounts of freshly cooked turkey or ground beef. I gave her extra taurine, because it is supposed to be good for human diabetics. Preshots of over 500, which were previously common, suddenly became rare.
November 2004: Ultratard®
Then we switched to Ultratard from Novo Nordisk (no longer being manufactured). This insulin was of the ultralente type and therefore had a much longer duration than Caninsulin/Vetsulin. Tilly's preshots were generally between 350 and 400, maximally 456. The nadir was mostly at +7 hours and Tilly was able to spend 4 to 5 hours in 12 under the renal threshold of 200. Insulins of this type are known to work variably in cats, and this was the case with Tilly.
Despite all of this, Tilly began to improve substantially: her thirst declined, her fur looked nice again and her excessive hunger slowly declined, she eventually began to eat normal amounts of about 200g per day again. She gained weight, going from 4.7 kg in November to 5.7-5.8 kg in February. Her maximum dose on Ultratard was 5 IU BID.
Tilly also had her teeth cleaned and several teeth extracted. Her gums surrounding her teeth have always been a bit inflamed, but during her illness it became much worse.
March 2005: Lantus® (Insulin Glargine) and Remission
On March 11, I finally switched Tilly to Lantus from Sanofi-Aventis because of the promising research that had just recently been published. I started conservatively with 0.25 IU/kg BID, the total dose was 1.5 IU BID. I had to reduce the dose very quickly and, amazingly, in less than one week she was in remission. Subsequently, Tilly's blood glucose values were almost always between 50 and 80.
In November 2005, I finally found out Tilly has FORL and most of her teeth were extracted. FORL is an illness which is very wide-spread in older cats. In January 2007, all Tilly's remaining teeth were removed.
January 2008: Triaditis and renewed Remission
In late January 2008, Tilly suffered from a sudden bout of triaditis. The major symptom was severe vomiting. Because triaditis also affects the pancreas, her blood glucose values spiked. I immediately started giving her small doses of Lantus in addition to her other medications. The triaditis was directly followed by an upper respiratory tract infection for which she also received treatment. In total, she received Lantus for 11 days and this was followed by a stable remission which lasted until the end of her life.
December 2009: Hyperthyroidism
Although her T4 has been in the middle of the normal range, it was slowly rising over the last few years. This in conjunction with a goiter and mild symptoms of hyperthyroidism indicated a problem. A trial with carbimazole in late 2009 failed due to elevated liver enzymes. Her goiter was partially removed surgically in January 2010. (The German oncology surgeon refused to remove more, as he was unconvinced that Tilly had hyperthyroidism, but subsequent scintigraphy confirmed it). The T4 continued to slowly rise during the summer of 2010 and Tilly lost even more weight. The fT4 finally tested above normal. In August 2010, we went to the University of Gent in Belgium for successful radioactive iodine treatment.
September 2010: Chronic Kidney Disease
We were aware, prior to radioactive iodine treatment, that Tilly probably had early stage renal disease but decided to go ahead with the treatment anyway. I had CBCs and blood chemistry panels done quarterly. Her chronic renal disease progressed only slowly over the next 1.5 years. She continued to receive low-carb canned food with lots of added water, phosphate binder, potassium, omega 3, taurine, macrogol, calcitriol and vitamin B12 injections. Food allergies also reoccured which led to adapting her diet. Despite all this, she made a healthy, happy impression and I was pleased with her bloodwork.
In April 2012, Tilly had advanced to IRIS Stage IV chronic renal disease and we did as much as possible to stabilize her condition, with diet, medications and subcutaneous infusions. The last months of her life we kept her weight up with assisted feeding. Despite all these unpleasent treatments, we were able to spend many wonderful hours together, especially in the sunny garden hunting sticks. Tilly was euthanized in September 2012 due to complications resulting from CKD (anemia), one month before her 16th birthday.
It is much darker
when a star is extinguished
than it would be
if it had never shone.
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