Still not sure.....

what to do about all these medication issues, and so far, Milk is still seizure free but very wobbly.

The urine bile acids test required a very small amount of urine. Results were reported practically the minute they got to Antech in New York. (Literally. The specimen was dropped off at the vet's about 1:30 PM on Monday, and the results were faxed back at 7:30 the next morning.)

Here's a copy of the results:

"Urine Bile Acid: Creatinine Ratio (USA-UCr)

Bile Acid (Urine) ******* 21.2 umol/L
Creatinine (Urine) ***** 400.6 mg/dL
UBA/UCr ************* 0.5 ********* reference range: <4.4


In order to permit measurements of bile acid in urine specimens collected at arbitrary times, urinary creatinine levels must also be obtained. The concentration of urinary bile acids in urine is calculated as follows:

the concentration of urinary bile acids (umol/L
------------------------------------------------ x10
the concentration of creatinine (mg/dL)

False positives may occur with specimens that contain elevated amounts of ascorbic acid."

So, this appears to say that bile acids are fine, but I guess the next project is to find out exactly how this test relates to the elevated blood ALT level from last week's bloodwork. I'm not sure if what the two tests measure is even related. It was my impression that the ALT can be a reflection of inflammation or stress anywhere in the body, but Dr. G. said that it's only a reflection of what's going on in the liver.

I feel a pressure to try to reduce both the keppra and phenobarb levels, but I'm not sure that's safe or reasonable to do. I certainly don't want to do them both at the same time. I feel more urgency to see if the phenobarbital can be reduced back to the dosage it had previously been at in August, (when it tested at 26) because I do think that the symptoms now - wobbliness and incoordination and erratic appetite - have typically been phenobarbital-related in Milkshake.

The Dilemma

I was afraid of this. The Keppra and phenobarb levels came back this afternoon from Auburn. The bad news is the phenobarbital levels are 33.8, and the Keppra levels are 52.7. While I'm not so surprised about the phenobarb numbers - not HAPPY about them, but they were somewhat expected, given the physical difficulties I've been noticing for a couple weeks - the Keppra levels were something of a unpleasant surprise. (The technician I talked to at Auburn last week said to make a note to Dr. Booth, who's apparently in charge of their lab, asking about whether they have developed feline levels, or if they are still using the human numbers. However, when I got to the vet with Milk on Tuesday, the technician had made her own copy of the form for Auburn, and I wonder if she copied my question to Dr. Booth on the one she made? At any rate, there was no response from Dr. Booth.) The odd thing is, I've been cutting back the Keppra for the last three weeks or so. Milk now gets 1/4 and approx. 1/8 of a 500mg pill TID. That's about 187 mg each dose, I think. Significantly less than before. (Or not, depending on the accuracy of the previous math.......)

In the end of August, '08, when Milk had that run of three or four seizures over the course of a little more than a week, we increased his phenobarb dosage from 1/2 of a 15/16mg pill in the AM and 3/4 of a 15/16mg pill in the PM to 3/4 at both times. It seemed to work, and even though he had a couple of seizures at the end of September/October, I didn't make any changes in the amount of phenobarb, and he's now made it for 141 days since the last seizure. And, in the real world, 33.8 isn't way out of whack for phenobarb levels. Except, as Dr. G. said, except for Milkshake. The combination of the pheno levels at almost 34 and the ALT in the 200's certainly seems to imply that something's going on with Milk's liver. I guess that makes doing another bile acids test imperative. (Have not seen this cat near the litter box ONCE since we decided to do that testing. NOT ONCE.) I think I'm also going to add another 1/2 or whole marin every day.

Dr. G. wondered when he called tonight with the results if we should send a copy of them to Dr. L - the IM vet I didn't care for at all, and who said that she'd never approve giving a cat more than 125 mg of Keppra unless their weight justified it - or to Dr. A, the neurologist in Ohio. He was a consultant, rather than a person who seemed to intend to have a long-term relationship as Milkshake's doctor. I think Dr. G. would appreciate having someone to consult with about this whole mess. Now that there's actually a neurologist in Pittsburgh, maybe I should ask for a referral? The trouble is, I don't want to have to go through the pressure to have an MRI again, or to put Milk through any number of unpleasant tests and appointments unless it's unavoidable.

Nothing's ever simple, and sometimes it really stinks.

Bloodwork

I've been concerned about the increasing wobbliness Milk's been showing, and it's been about 5 months since his last phenobarb levels were done, so, I've decided to combine the phenobarb and Keppra testing, and have the vet do his local office testing for a regular CBC. My poor little white cat - he was quivering so hard it was visible the entire time we were in the office. And, while the vet did attempt to get the blood from Milk's thigh, he couldn't get enough. So, now Milk's got the shaved neck. I can't imagine what it must be like to see some total stranger coming toward your neck with a syringe, while another total stranger is holding you so you can't move. Poor cats.

Anyway, Dr. G. just called - didn't give me all the results, but I will ask for a copy the next time I'm down there. I had told him that I was interested in liver function results, and it turns out that the ALT was in the 200's - normal goes up to around a hundred. He suggested that, if I'm concerned, we could do a bile acids test; the original one, when Milk was diagnosed, was not done fasting, and we didn't do the preprandial/postprandial version. I told him that Antech can now do the urine Bile Acids test, which I would prefer. So, I think when they let me know how much they need, I'll have to devote myself to collecting a specimen. I am almost certain that a sterile test (using cystocentesis) isn't necessary, which would be nice; I'd rather not have to take Milk anywhere for as long as possible. (Turns out they need just a teeny 1 ml of urine - I asked Dr. G how much that is - no head for metric measurement - and he said a teaspoon is 2.5ml. I'm a little out of practice for catching urine since Scruffy's been off insulin, but I think I can probably do it, although Milkshake's not nearly the carefree pee-er that Scruffy was, and he doesn't seem as regular about it.

I have kind of wondered about the phenobarb levels. Before, whenever his levels were around 26, he usually started eating on his own again. So, I've been going along, thinking that, since he's eating with a degree of enthusiasm, his phenobarb levels must be okay.....Not necessarily true, I suppose. Rats.

Well, another 60 dollars for the urine bile acids test, which is worth doing, I guess. I've been giving him 1 Marin pill a day; I could increase it, after we see what the phenobarb levels are. I just don't think that reducing or removing phenobarbital is possible for Milkshake. Not without setting off a whole cascade of seizures, I'm afraid. And undoing all the seizure-free times he's had in the last six months.

I have a vague memory that ALT is responsive to stress and infection somewhere in the body - maybe the stress of today's visit, or the beginning gingivitis might have had an influence?

Dr. G. asked me how and what Milk is eating these days, and when I said he's eating enthusiastically for the first time in three years, and he's getting half Fancy Feast and half raw, Dr. G sort of collapsed in shock against the wall and started stuttering about salmonella and e coli. (When he asked if there was a less disease-prone animal than chicken to feed raw, I said, "Well, yeah, they've got rabbit and now there's frozen ground mouse." It was cruel; I shouldn't have done it.

The third adoption anniversary

Well, the good news is, no tears this year.. The bad news is, I completely forgot about the anniversary until about five minutes ago. Which doesn't, of course, mean that I don't care about the milestone. I just have a really lousy memory and not much interest in the calendar. Plus, I actually finally managed to get Milk trained to show up when I jiggle his tupperware container of TempTations. Thank goodness.

I have been a little concerned about him in the last couple weeks. Milk seems wobblier than he's been for quite a while. He is eating fairly enthusiastically, which is wonderful. He even gained an ounce since last month. Still, there are small but noticeable balance issues, for instance. God forbid he should decide to shake his head when he's in any position but lying down. I have an appointment to do phenobarb and keppra level bloodwork. Anyway, I have dropped the second chunk of Keppra with his 2AM set of pills, and it doesn't seem to have made any negative impact. I'm just afraid to take the chance of setting off a whole wave of uncontrollable seizures, when things have been going so well for so long.

On a happier note, as the picture above shows, Milk has finally gotten semi-close to Cinnaminnie. Not touching her, but in the vicinity. Not much chance of his ever accomplishing that with Tootle, though....