4/7 Barsa PMPS 7.2 (130), +3 - 3.5 (63) How long will it keep going down?

Could anyone please have a look at my spreadsheet? What's happening with glucose? I do not understand how this insulin (Levemir ) works. I've increased the dose to 1.75 now. No result. I don't see any pattern. I feed Barsa twice in the morning and twice in the evening. Usually I give a food and a shot, then 2 hours later feed again. Ketones again today, above trace because I can't get BG under control. She's eating very well. Don;t know what else can be done..

 

I can't give advise on dosing but with the ketones try and give extra fluids and extra food. That is important to do that now. Hopefully someone will be along soon. You are doing well. Getting the kitties regulated is a slow process and can't be rushed. Concentrate on giving Barsa food and fluids until someone experienced comes along.

 

It might be an idea to edit your title and add "ketones, please help" to get the attention of people

 

I know there isn't much I can do about ketones. Been there before..less than a week ago actually. They've gone down and 2 days ago the test was negative. Now today - again pink strip, 1.5mmol. And it's because of elevated glucose levels. She's still 3kg, eating A lot but all that food is not assimilated because of high sugar.

I just wanted everyone who has time and knowledge to please try to analyze the spreadsheet. Maybe you see something I don't? Do I just wait and if nothing happens after 3-5 days increase the dose again? How does this Levemir work? I mean for my cat! I don't get it (

Thank you. Will appreciate any attempt to interpret the numbers.

 

Hi Vintry,
How is it going? Have you managed to get Barsa to take extra fluids or food?
I suppose your vet is not open today being Easter Monday. Did he tell you what to do if Barsa threw ketones again?
It is still early ( 7am) on the east coast of Canada and the U.S. where I think the people who helped you before live so it might be a while before they come online, so keep up with the fluids and food.
I will put a post on the main forum to see if there is someone to help you

 

Hi have just seen your post. Levemir is a really good insulin? It takes time for the depot to build and the insulin to do its work. I use levemir and I think it is a great.
I have had to learn a lot of patience with my cat as she has taken a long time to get near regulation. Some cats seem to be more prone to ketones and you just have to try and keep up the food and fluids and hopefully the insulin will start to bring down the blood sugars soon. Don't loose heart, you will get there. It can be frustrating and upsetting but there are a lot of people here to help and support you

 

Bron and Sheba, thank you.

Ok, but long is how long? I just don;t see any difference between doses reflected on the spreadsheet.. Maybe a little info on how this insulin works in your cats will help. Things like at which hour it starts lowering BG, nadir time, times fed, how long it lasts for your cat etc. Not the general info on Levemir, that one I've already read. I need specifics, individual approach because every cat is different.

 

Hi there. Couple questions: How much/what kind of food is she eating currently? Has the vet tested her white blood cell count recently? Has the vet tested a potassium level recently? If you can get a copy of labs and post them here, it might be helpful.

I have a suspicion that there is something else going on that is affecting her calorie needs and weight. She probably needs more calories than average to account for whatever it is. Until her BS are better and she is steadily gaining, I'd feed her Iams Max cal or another high calorie food (anything >230 cal/5.5oz can). I'd also increase her carbs since you have recurrent ketones.

Levemir has a way of hitting a "breakthough" level. You increase and it doesn't look like much is happening, and then that last increase gets everything in the normal range. Sometimes after that "breakthrough" you might even have to reduce a little bit too.

 

The BGs are not that high but recent except for 3/30 and 4/3 you are seeing little drop in BG between shots. The recent vomiting could indicate pancreatitis. How is Barsa eating/keeping it down now?
Are the ketone values fro a urine dipstick?
What does your vet think?

 

Sheba has been a diabetic for a number of years. Went into remission and came out of it after 2 years and has been hard to regulate this time around, which is apparently the case with cats the second time around. So even though I have been dealing with diabetes for a long time I haven't been on the forum that long and can't give dosing advise. But I am happy to tell you how I have found levemir.
As you know it is a slow acting insulin and had a depot which has to build up over a few days. Every time you change the dose upwards the same thing happens with the depot having to build up. Insulin is a hormone not a drug so doesn't act like a drug would giving a result from the beginning. It takes time for the cats body to get used to it. Every cats reaction to it is different. I used Glargine for a year before swapping to levemir. Sheba took a few weeks before I noticed a downward trend with the blood sugars once I did the swap.
And every day gives a different reaction. So it is not straight forward. Sheba Has an onset at about + 4 and a nadir around + 8 to + 10 depending on the day. Some days she is in pinks and some days she can be in green. Some preshots are red.
I feed Sheba at preshot and +3 both am and pm.
Please ask as many questions as you like. I hope this has helped

 

This is my reply from an earlier thread about food she's eating.

She's eating four times a day because she has good appetite. I wanted to split it into 3 meals in the morning and 3 in the evening but she's not happy with very small meals.

morning - meal 1 - 100g - 6.1% carbs - 105 calories
- meal 2 - 85g - 4.1 carbs - 66 calories
evening - meal 1 - 85g - 6.6% carbs - 98 calories
- meal 2 - 40g - 4.1% carbs - 33 calories

Total - 310g, 302 calories per day. Some days more 320-330calories and usually not less than 300g per day. She weighs 3.1kg

The food is mixed, some high in fat and some high in protein but all are under 10% carbohydrates. Some have over 100 calories per 100g

 

I would allow her to eat as much as she is able, so if she asks for more, give her more when she wants it. That she has ketones is one of 2 problems, not enough food or carbs, or not enough insulin. Given her size, she probably has a little of both going on. She might have a condition that increases her metabolism and so she requires a greater intake.

 

She had ketoacedosis a week ago and we were able to pull her out. Vet flushed all ketones out. After we came back home from vet, the urine strip test still showed ketones, at first above traces (1.5mmol) then after 2 days - no ketones. So I thought that's it, made it! Now I'll just let insulin do its job. Cat is eating, stool is fine, no ketones. But one thing remains unchanged - high BGs, that's above 13mmol (235) to me. So she's got ketones again because of that I presume.

 

Meya14, even if she's hungry all day long??? She will eat and eat and eat.. I was thinking..maybe it's thyroid problem? But that would show up on blood test. So far, vet said no other problems.

 

The thyroid would depend on what test they did. They should draw both a free t3 and T4 levels. Some vets don't do all the testing to save you $ so you can't be 100% sure. On average this is ok, but some oddball cases need the extra testing. If you can, go to your vet and ask for her most recent sets of labs and post them here. We might get a better idea of what is going on.

I had a cat years ago that weighed 3-4lbs full grown. We suspected dwarfism, but she had a HUGE calorie need. She would eat and eat and eat. One day I found she had torn open the food bag and was sitting in the food bag scarfing away. She would climb on the tables and lick our plates if we walked away for a second. She would knock over the garbage to get food, found her inside the garbage one day. She climbed into my freezer one day and was eating the frozen vegetables! We never could figure out the cause, probably some genetic thing. The people who gave her to us told us she was a kitten which was a lie.

As far as ketones, the high blood sugars really aren't the cause. You can have ketones when your BS is normal if you are starving. The ketones are produced when the body tries to break down fat stores instead of using the food you are eating. Insulin allows your body to use food as fuel and not fat stores. But if you are starving or have too high metabolism, your body will burn fat anyways and produce ketones. So that's why we say ketones = not enough food and not enough insulin.

 

To me and my Badger that is not high. Recently Badger had some PS BGs above 500 and even had one HI. This morning he gave me a 92. He gives me inconsistant BGs and has been doing that since I adopted him last July.

 

You can sometimes see a temporary increase in blood sugars after a dose increase. We call it New Dose Wonkiness (NDW), check out the second post here. It doesn't happen with all cats, and with Neko sometimes she gets it and sometimes she doesn't. It does take the depot of the new dose a few cycles to catch up to the increase. Paws crossed tonight you start seeing some action.

Neko is also on Levemir, and she does things a little later. Her onset is around +5 and nadir anywhere typically from +9 to +12. But it means her BG goes up for several hours after preshot before turning it around.

 

Tess is on Lev and she reacts a lot like Neko does. At least she did, things change and she seems to nadir earlier now, ECID and they vigorously maintain the right to mix things up just to confuse us. She was DKA a month ago from not eating. Since then she has been on daily sub-q fluids and it has helped a lot. They help to flush out the toxin that the kidneys can't handle. Ask you vet if he thinks that would help. It's a little unnerving at first, but both Tess and I got the hang of it very quickly.

On the Iams Max Calorie Plus, I called every vet in a 30 mile radius to try to get some to try out. No one here carried it, but i could order it on chewy .com . They say it is a prescription food, but you don't need a Rx to order it online.

 

I would also increase to 2U after the 6 cycles are done. Keep a close eye on her sugars.

 

Thank you for input. 1) Iams Max Calorie Plus in the UK is very hard to find it seems. 2) Sub-cutaneous fluids is what I wanted to do at home. That time when I was at emergency clinic, the vet there said I can't do it at home because it's not safe, that it's a lot of liquid to inject and if I do it wrong then it might go in the wrong place..'. So that was a NO to my initiative to do it. I really need to ask my regular vet! 3) I am thinking about 2 units too, plus everything .25 is soo difficult to draw in the syringe!

 

Giving fluids at home is safe once they train you and make sure you know the proper way to administer. Lot of people here do, and it really is helpful. You do have to make sure you get her electrolytes tested frequently if doing the subQs though, and the insulin and subQ shouldn't be injected into the same area.

Sorry I can't help with the food, I don't know what is available in the UK, basically anything >200-240cals/5.5oz can will help her get the calories.

Just make sure you keep a close eye on the blood sugars when you increase.

 

Hi Iryna! I have just a couple of thoughts:

A cat that is prone to ketones is prone to ketones - you can't relax on this until there's a lot more than a couple of days without any. I would encourage you to test twice a day for the next several weeks, even after it seems that she is fine. Ketones can go from small to large in just hours.

She's still not getting enough insulin, or you wouldn't be seeing ketones. If you need to give her constant high carb food in order to raise her insulin dose, then that's what she needs. The important thing is that ketones are connected to not enough insulin, not necessarily to high numbers.

I went back and looked at your last thread, which had a ton of good information about it on dealing with ketones. None of us has more experience than Jill - so I went first to see what she said:

I'd encourage you to go back and reread that thread from April 3rd - it really did have a lot of good info in it. I don't have personal experience with ketones so don't have anything to add that's helpful, but just want you to know that I am sending you lots of good luck!

 

Iryna, "if" Barsa continues to throw ketones by AMPS I would:

• Increase the dose to 2u and monitor carefully.
• If necessary, feed high carb food to prevent her from dropping too low.
  
• Feed as much and as often as she wants.
• Add as much water to her food as she'll tolerate.
  
• Test for ketones twice a day.
  
• Remain vigilant.

FWIW, that's what I would do in your shoes...

 

Thank you. I am back with an update. Numbers did go down last nigh and this morning too so I'm very happy. Ketones also down to traces. But as you said, situation can change very quickly so I am checking twice a day.

@Jill & Alex (GA) , just a couple of questions regarding your advice.
1) Increase the dose 2units. I wanted to. But this morning BG was at 3.2 the lowest, which is what I wished for. I think now it will bounce to a very high number again but I am yet to see that. Do you still think the dose should be increased to 2units taking into account the development?
2) Feed high carb food to prevent from dropping too low. What I did yesterday was feed her low-carb but higher than usual (6.6%, not 1-2%). Is it ok to continue feeding low carb if this food is high-calorie, high fat, high protein and she eats a lot of it? At the moment she can easily eat 350g per day, and up to 400calories.

 

In order to give the higher doses, you use the high carb food to steer the sugars. Reduce the amount of wet food by a little bit so she'll eat if needed and then if she starts to drop below about 120, give her a handful of kibble or mix a half of teaspoon of honey with the wet food you are feeding. You don't have to change all over to high carb food, but use it in order to give higher insulin doses. Sometimes it takes more then this to steer the sugar, ECID. For example, If it takes giving her straight honey to get the sugar up so you can give a higher dose, that's what you should do. With ketones, it's better to increase carbs then give less insulin.

Don't worry about carbs in the food so much until she's been clear of ketones for a while. You can use the insulin instead to control the sugars.

 

Barsa is looking great this morning. I don't know what anyone else would say about the dose, but I think you should hold at 1.75u for now. Barasa is having a great morning, and if she had gone below 50 it would have been time for some High Carb. And now it looks like she might be going into a bit of a bounce from the GREEN this morning.

 

Considering the numbers today, I'd hold the 1.75 too

Jill's concern in increasing to 2U was to get his numbers down to help with the fight against ketones, but with Barsa in normal numbers, I wouldn't increase

Just keep testing for the ketones since they can be produced even with cats with lower numbers and let's see how he does today.

VERY nice to see no ketones and pretty green numbers for a change!!

 

Yes how quickly things can change! One day it's the worst, next day it's the best. I now have to worry about BG going too low!

 

Just fed her again. Please look at my spreadsheet. I have 9 hours until morning. Going to watch her all night. What to do in the morning? Reduce dose to 1.5? And what is happening? I cannot understand anything. It keeps falling and falling..for over 12 hours now I think.. When does it start? When does it stop? Need to make some sense out of it.

 

Which meter do you use? If it's NOT the AlphaTrak, those are GREAT numbers!! As long as she's above 50, she's in good, pancreas healing numbers. She wouldn't earn a decrease unless she went below 50 on a human meter (68 on the AlphaTrak)

I'd just give her a little of her regular low carb food and test again in about an hour

 

Low numbers don't mean that ketones can't form or will go away. A cat can have DKA when in normal numbers. The cause ultimately is still not enough insulin, even if she is going low in her numbers. I know it seems counter intuitive.

I work with a lot of diabetic people at work, and when a person is in DKA, the standard of treatment is to put them on a dextrose (sugar water) IV so you can give them enough insulin to change their metabolism away from burning the fat. This is called "substrate". You have to have enough carb "substrate" to allow the insulin to do it's job. Right now you cat does not. This is dangerous. You need to increase her carb intake.

Don't reduce the insulin. Try to keep her blood sugars around 150-200. Use honey/dry food to keep it there if you have to. Only after 2 weeks with no ketones, I'd relax everything a little.

 

I use Freestyle glucometer. The thing is I don't let her go below 50. I saw that she went down to 3.5 (63) only 3 hours after shot so I panicked that she will go even lower into the night and gave her more food - 50g high carb (actually 12.4% is not so high-carb). Measured again at +4, it's gone up a bit, not much - 4mmol (72).

 

OK, Meya14 what % carbs? Is 12-13% high enough?

Basa had traces this morning but in the afternoon I tested and no ketones I'm not relaxing of course and will continue testing twice a day.

 

Usually what we'll suggest is just giving a teaspoon or two of their usual low carb food....Most of the time that's enough to stop them from dropping and get them "surfing" (staying in the same basic numbers)

Since she's up to 72 now, I'd just retest in an hour and make sure she doesn't drop back down. We want them to stay in the 50-120 range as much as possible because at those numbers, the pancreas can heal and maybe even start producing it's own insulin again

What's been suggested in the past (because of the ketones) is to feed her higher carb food if necessary so you can get more insulin into her to get her numbers down....since for now, they are in the normal range, I'd just stick with the low carb food and stay at the dose she's at now.

It's great that she's testing negative for ketones too!!

 

Oh one more thing! Meya14, you said the cause of KDA is lack of insulin. From previous threads I learnt it is also due to lack of food and/or infection. Now, do you think it's possible that my cat is getting enough insulin (or maybe even too much now) but ketones resurface because she's severely underweight - 3.1kg? She's eating loads but of course weight gain won't happen overnight.

 

Chris, the insulin isn't about getting her numbers down but to convert her metabolism from burning fat to burning carbs and getting the metabolism normalized. This can take a few days with no ketones to correct the dehydration that goes along with it. A cat in the midst of DKA is not the same as a healthy cat.

https://edenseffort.files.wordpress.com/2014/04/dka-graphic.jpg

Vintry, the graphic above kinda explains the process. With your cat, you are right. In the graphic, your cat isn't doing step #2 because she probably has little to no reserves for her liver to produce sugar and dump it into the blood stream. Euglycemic (normal sugar) DKA or DKA with only slightly elevated sugars can be caused by starvation. I would stick to the dose you are on now, increase the carbs, and if in 4 cycles her blood sugars are >200, then increase.

What is causing starvation in your cat? That's the problem, there many reasons and she might be prone to ketones again unless she gains some weight. Also when the vet says, "Everything else looks fine" that really means, "the things I chose to look for were fine". No vet ever tests for every disease, and a lot of problems they will only see on a test if they chose to test for that specific thing.

Here's my short list of causes of weight loss - maybe others can add to it:
insufficient insulin (might just be from diabetes)
Pancreatic insufficiency
Hypothyroidism (cause they stop eating)
Hyperthyroidism (increase metabolism)
Cancer
IBD
Worms/Parasites
Chronic infection
Liver disease
CHF
CKD

If you can get printouts of the labwork your vet did, and post them, we might be able to point you in a better direction.

 

Meya, that was a VERY good explanation, Thank you! Food for thought and action.

 

Oh about the question for carbs. 10-15% will probably be good to start with. You'll have to figure out how her sugars respond. At this time you want her to be a little higher to ensure she has "substrate" for the insulin, around 150-200.

 

You know what I notice with these ketones? They go away when BG goes lower than 14-15 (252) and stays there. Also, you asked about starvation. She's lost so much weight after I lost control of blood glucose because of somogii effect first, then resistance to caninsulin, then change to levemir. All that time sugar was high and I couldn't manage bringing it down so she lost weight and then at the lowest she's ever been (3kg) developed ketones. That's the long story short. I will still ask my vet to email me test results.

 

4 hours left for me to stay up (yawn). Then at 4 my mum will take over. It looks like she's going up but I just can't allow myself to go to bed. What if I wake up and..you know. Can't do that.

 

Yeah, the weight loss might have been simply due to the insulin/diabetes and she may start gaining once she gets stable. Insulin allows fat cells to be able to uptake and store sugar as fat. Without enough, weight loss happens. Max lost a few pounds and looked bony when he was first diagnosed, and gained it all back and then some, but he's a big cat. Your cat didn't have a lot to lose to begin with. The weight loss can be hard on the liver though, which can make it into a cycle.

Lantus/Levemir are a much better insulins for ketone prone cats.

 

YES! Levemir is impressive. I have to sit all night today of course but the fact is my cat has been in good numbers (under 200) for 27! hours now. Caninsulin, shame on you!

 

Hi Vintry,
Sheba only once showed a trace of ketones in her blood and she was quite ill and at the vet at the time, about 12 months ago. So I don't have much experience of ketones but I know how scary they are.
Sheba was in high numbers for months early on and she lost weight and struggled to put any weight at all on until her BSL came down. She went down to 4.8kgm and she is now 6kgm. She is a big cat and was looking very skinny at the time. Just right now.
This weight loss is because the body can't use the food properly when the blood sugars are higher than normal, so even though you are feeding her enough for a normal cat her size, because of the diabetes she is only able to use part of it. So Meya is right. You need to feed her all she will eat.
Good luck. You are doing a great job

 

@Meya14 thank you for that great explanation of what's going on with the ketones. I appreciate both your description and the graphic - and will hang on to both for the next person in this position.

Iryna, take a look at the subject lines for some of the other cats on Lantus and Lev - you can see them from the main page. The Tight Reg Protocol sets 50 as the number we intervene at with high carbs under normal circumstances, for a newly diagnosed (less than 1 year) cat. For cats who have been diabetic longer than a year, based upon experience on FDMB, the line is set for reductions to occur once the cat dips under 40.

My only point is that for a person who is monitoring, a cat isn't in danger just by going below 50. There is time to take action, give carbs, and bring the cat's blood sugar back up. I just don't want you to feel like you need to panic at 63, for example. We don't want them lingering under 50, of course - but it's not a crisis. You're doing great - I just wanted to reassure you a little bit on that part.

She's looking better and I'm celebrating no ketones in your last test!

 

Wow, you have been on quite a roller coaster. Great that the ketones are gone with your last test and I hope it stays that way. I know how scary it is to see the low numbers. When Max first dipped under 40 it was the middle of the night and I was a mess. The first time my meter said lo I ran for the karo and hc fast. It turned out to be a bad strip I think because he came up fast and stayed up. Now if I get an unlikely high or low number I retest before rushing, yes rushing if low, for the food. Once you see how to bring your cat back up it isn't as scary but you still take notice and feed accordingly.

 

So her BS increased (from the increased carbs), I'd continue feeding the same foods as you did this cycle and wait another day and see where she's at. If her BS at the nadir is >200, then increase to 2U, and monitor her sugars very carefully. If she starts to go low at 2U use honey to keep her in the 150-200 range. Hold this dose for a few days and continue the higher carbs. Continue to check for ketones.

If in 2 weeks she's free of ketones, you can consider backing off on the higher carb food and the insulin carefully, however extra carbs and a higher insulin dose might help her gain a little weight if you stick with that for a couple extra weeks. If you choose to back off insulin, you should test for ketones 2x/day.