? 3/9 Ducia +11 372, AMPS 405, 0.75U need help to monitor her jumpy BGs

Yesterday posts are here:

http://www.felinediabetes.com/FDMB/...2-3-306-5-96-6-65-6-5-75.174515/#post-1914598

Hello,
Ducia continues her 4th cycle on 0.75U dose.

Her overnight numbers were like this:

+2 BG 388, +3 BG 317, +6 BG 176, +9 BG 140, +11 BG 372.

No Yellows. Blue and Pink.

Earlier yesterday in the AM cycle we've seen some Greens, like BG 65 @+6 and after 1 Tbs LC BG 75 @6.5. It was close to the acceptable bottom. I am too inexperienced, only now beginning to understand and I panicked while monitoring her greens. Panicking makes me almost useless. I do my best to control it but it is difficult after the symptomatic hypo. That's why I ask that you please help me read her numbers thru the day and advise as to what to do. I am new to this.

She can go from Red to Green in 2 hours. She has shown big increases in 1 hour. I keep her SS updated.

This AMPS her BG was 405.

@AMPS she received Between 1/4 - 2/3 LC Friskie's Classic Pate, 19 ml water, Metranidazol 0.5 ml and Ringer's solution SQ 75 ml.

Thank you for being with us!

 

I inserted the wrong link earlier by mistake. It should OK now.

 

Looks like she bounced from the greens and now has to settle in to the lowered dose now that the depot has left. I'd get a +2.

 

Good Morning Tanya , it looks like Ducia is bouncing this morning from yesterday's greens and they could have been a result of the 1 unit depot . I am glad you got a ketone test and it was just a trace . Are you still giving her sub- q fluids?

The trick is going to be to get enough insulin into safely because to the ketones. Let's see how this cycle goes today to decide what's next.

 

I will post +2 later

 

I will

 

Yes, 0.75 ml SQ this AMPS. Vet said "daily". We are not sure for how long.

 

That is good because the fluids help to flush ketones.

 

What if to assume that on 02/28, the hypo day, she was accidetally OD with 10U. If so what with that depot?

 

We give SQF and do ketone test daily

 

That's an interesting question. That's a pretty big dose, but if that happened I would think the depot would still only take a few days to drain. I don't think there'd be any lingering effects now, other than the lingering effects of the hypo itself which might cause some increased sensitivity to insulin.

It is pretty tough to sort out all the different and overlapping forces (the depot, bounces) affecting BGs in a new diabetic under the best circumstances. You're doing a fantastic job collecting data to help with that task!

 

It is tough to read her.
+2 BG 437 is just in.
That's how it was yesterday AM cycle.
At this +2 time what does 1U do? Has start working already or not?
Is it her 1/4 - 2/3 Friskie 9% carbs AMPS meal interferes?

 

In addition to that possible OD, we also meddled mindlessly by switching doses and by skipping dose

 

Ducia's +2 is 437

 

Any depot from 10 units would be long gone, and you are starting to lose any 1 unit depot. The higher depot can influence 4-6 cycles. You should be starting to get a good picture of what the .75 unit dose can do.

She seems to start doing a big drop around +3. I might give an+2 or +2.5 snack of her regular low carb to see if you can slow the drop. Big drops can also cause bounces.

 

Well, that does add a little more complexity to the interpretation of the patterns because of the changing depot, but you can still see some major features like how she tends to bounce (some cats can bounce for up to three days, but Ducia seems to have much shorter ones!). And of course, the depot is now stabilizing, no matter what came before.

Lantus is usually thought to "onset" around +3, but it is possible to start seeing some effects earlier. The 437 isn't all that different from the pre-shot 405 so she's holding pretty steady so far, but I'd agree with Wendy that given Ducia's patterns of big early drops, it'd be good to try to anticipate and slow down any dive she has planned for today.

 

I have 1 Tbs Friskie 11% ready.
Is it "snack" size?
I will offer it at +2.5.

Or, I can give *5 Tbs.
Which one is better?

 

Her big drops worry me a lot. How to flatten it, how to make it smoother?

 

That's exactly what we're trying to do with the snacks now, even before she's started going down. Hopefully, by the time the insulin starts to work to bring her down, the effect of the food will already be in place to act in the other direction, smoothing things out.

 

Is 1 Tbs a snack size?

 

I would just give a tablespoon. Keep track of how much you feed. I used the Remarks section on the SS To record the amounts and it allows you to easily see the results. Based on that, then next time do more or less. I would do something under 10% to start. Trying to see what works requires experimenting, as each cat is different in how carb sensitive they are.

 

Thank you Wendy.She had a few bites out of 11% but switched to 9% right away. She eats. I am going to the SS Remarks section

 

I don't know if you have seen the post called Where Can I Find, but it's a good one to bookmark. In it is a post called Feeding the Curve, Tashie, that may help you understand how to slow down those fast drops.

 

I don't see this particular post at the moment but will check it right away. Thank you!

 

@Kris & Teasel @Nan & Amber @Bobbie And Bubba

@Tricia Cinco(GA) & Harvey @Wendy&Neko @tiffmaxee

@PumpkinsMom @rhiannon and shadow (GA) @Chris & China

For Ducia's sake, I can no longer bite my tongue. I'm jumping in on this thread with thoughts for consideration...

The basic recipe for developing DKA = an insufficient supply of insulin + inappetance + infection OR other systemic stresses.

Contrary to the apparent prevailing concept, ketones are not about the numbers. When dealing with ketones at home, we're dealing with an "exception"... not the norm. Throw the "usual" out the window!

To rid kitty of ketones it's not necessary to drop kitty into normal numbers. In fact, it can not only be dangerous, but taking this route can often make it harder on the caregiver because kitty has to be watched closely, 24/7, for fear of kitty bottoming out.

In fairness to all, sometimes getting some insulin, food, and fluids (oral + sub-q) into the cat is all it takes to get rid of ketones, BUT it's not happening here. Ducia continues to throw trace ketones. When kitty is throwing ketones we worry about DKA. In Ducia's case, she just came off of DKA, continues to throw ketones... and yet her dose has been reduced.

The fact that Ducia continues to throw ketones tells us she's not receiving enough insulin. I can already hear the objections! How can we possibly increase the dose, let alone hold it, when she's dropping so low? That takes us right back to ketones not being about the numbers.

When kitty is hospitalized for ketones and/or DKA they put kitty on a glucose drip. Why? Because they want to get as much insulin into the cat as they can without kitty dropping too low... going into hypoglycemia. Initially, they're not concerned with pulling down BG numbers into double digits (that comes later, after kitty is no longer throwing ketones). They're more likely to look for nadirs in the 100 - 200 mg/dL range. This provides a buffer of sorts.

When treating kitty at home for ketones/DKA, we don't have the luxury of putting kitty on a glucose drip. So what are our options? What can we do? We can continue as y'all have been and hope for the best OR we can feed kitty foods with a higher percentage of carbs in them... HC or MC or food mixed with karo, depending on the cat. Doing so will help kitty from bottoming out while allowing an increased dose or holding a dose (similar to the work of a glucose drip). Increasing the dose and/or holding a dose is what is needed when a cat continues to throw ketones.

Because Ducia likes to take those early dives, she may need HC to start the cycle and possibly MC continued for several hours. Forget the LC for now. It might take a little experimenting to figure out what works best for her.

With all due respect, please think about what I'm saying. It makes sense. Get rid of the ketones by providing a sufficient supply of insulin... then worry about pulling numbers down.


FWIW, just my thoughts.
And on that note, I have to finish packing for vacation.

@Meya14

 

I am just so confused about it all.


It's +4 time, I'll be back

 

Very interesting take.

 

+4 BG 313. Not dropped goes slowly. I will retest @+5

 

In what way?

 

Whenkitty is hospitalized for ketones and/or DKA they put kitty on a glucose drip. Why? Because they want to get as much insulin into the cat as they can without kitty dropping too low... going into hypoglycemia. Initially, they're not concerned with pulling down BG numbers into double digits (that comes later, after kitty is no longer throwing ketones). They're more likely to look for nadirs in the 100 - 200 mg/dL range. This provides a buffer of sorts.

When treating kitty at home for ketones/DKA, we don't have the luxury of putting kitty on a glucose drip. So what are our options? What can we do? We can continue as y'all have been and hope for the best OR we can feed kitty foods with a higher percentage of carbs in them... HC or MC or food mixed with karo, depending on the cat. Doing so will help kitty from bottoming out while allowing an increased dose or holding a dose (similar to the work of a glucose drip). Increasing the dose and/or holding a dose is what is needed when a cat continues to throw ketones.
It kinda makes sense. Why wouldn't we treat with more insulin and steer with higher carbs. I wondered about this a few times.

 

Sounds like a plan!

Hopefully the extra snacks is helping to slow her down-- she's dropping, but not as fast as previous days.

 

The steering which I started to learn/understand this morning is too risky because
1. My inexperience
2. In case of emergency I have no car and no one to drive us to ER until late afternoon
3. I cannot afford it. Card maxed out. Cash very limited.
4. Yesterday AM during drop my hands were shacking, it was difficult to take tests. I cannot help the hands yet.
5. During recent hypo I was so shocked that I could barely understand the help I was getting from the Board. English is not my language.

 

Jill, I appreciate your chiming in at this point. I agree with everything you say. Just for the record, some of us have tried to encourage Tanya to hold the dose and feed higher carbs, but because of the very scary hypo event Ducia had recently, Tanya has been very reluctant to follow those suggestions. She has been more concerned about another hypo than a DKA.

 

Can you please check us out @+5?
She was lowering at around +5 for 4 am cycles.

 

Jill, I was wondering what vet treats this way? I have paid the bills for dozens of cats in DKA and have treatment plans and invoices for each and no vets do simultaneous glucose and insulin. Simultaneous glucose and insulin hasn't been used, to the best of my knowledge, in at least 8 years. It's only currently used to treat severe hyperkalemia.

 

That is because she is at or nearing her nadir. This is what is supposed to happen. She's safe, Tanya.

 

Not exactly so.
Her habitual drops may mean that her body tells me the dose of 1 is too much.
Hypo is important factor to consider not solely because of my fears but also because during the day I have no car and no ,oney to go to ER.
Keeping Ducia on honey with shaky hands resulted her going in to convulsions very fast. The BG readings were inaccurate because honey was everywhere.
I do worry about DKA.
I think and hope that stabilizing her within blue yellow BG range, urine test, SQf administering will help with ketones.

 

This is true, she definitely has a pattern of dropping very quickly around this time-- as Tricia says, that's the typical action of the Lantus (although Ducia's drops have been more dramatic than many cats).

Looks like the last snack she got was at +2.5-- is that true? Let's see what she is at +5 today-- if she's dropped a lot, then (first) I think we want to give her some food to try to slow her down today, but then going forward we can do more snacks in the mid-morning to try to smooth out her patterns more.

 

Her reg feeding time is between +4 and +5. No show of appetite so far.
Last snack at +2.5

 

OK, let's see where she is at the +5 then. She may not be hungry because of the +2.5 snack. That may have been enough to slow her down today, or else we may have to experiment with the timing and carb content of the snack. I agree with Jill that more AM carbs may be a good strategy for keeping Ducia safe from both hypo and DKA (because it will allow you to keep giving enough insulin without fear of hypo).

 

+5 BG 257 12 min after 1 teaspoon snack and 2.2 hours sinse +2.5 larger snack.
She wasn't hungry around her reg feeding time.
I am going to offer it now.
Is that right what I am doing?
This AMPS she got larger portion of about 2/3 8%.

 

@PumpkinsMom

I'm sorry, I don't have a whole lot of time to look for multiple sources at the moment. I now realize I should have worded my post better. I probably should have used the word "dextrose" instead of "glucose". Dextrose is commonly added to fluids to avoid hypos.

Dextrose: the dextrorotatory form of glucose (and the predominant naturally occurring form).

Here's one source I found quite easily from NAVC - AAHA VetFolio:

Understanding and Treating Diabetic Ketoacidosis
Scroll down to "Insulin Therapy" --- "Insulin therapy should be administered in such a way as to lower the blood glucose gradually (50 mg/dl/hr) to 200 to 250 mg/dl over 6 to 10 hours.2 This slow, steady decrease prevents the osmolarity from changing too rapidly.2 Once the blood glucose level has reached 200 to 250 mg/dl, 2.5% to 5% dextrose should be supplemented in the fluids to avoid hypoglycemia while the ketosis resolves.2,5"


Have to get back to work, but will check back later in case there are more questions...

 

I vaguely remember conversations (quite a while back) about sub-q fluids causing the insulin to "kick in faster"???? I apologize - I don't remember all of the details, and I don't know if it's even relevant in this case. I'm just thinking about those fast drops and wondered if the timing of the fluids is somehow playing a role. Hoping someone with experience can chime in.

 

Please do, or we will have to keep giving it every AM.
There is no one to give SQF during the day Pacific time 7am to 6pm.

 

Thank you for bringing my attention to it.
So far we give it in the time convenient for us but can move to another time, late PM or night.

 

I hope you didn't misunderstand. I'm not saying not to give SQ fluids. I just vaguely remember some tip or trick about giving fluids and insulin together.

 

Shelly & Jersey,
I got it. We will keep giving 75 ml SQf @AMPS every 24 hours.

 

Sorry, posted the reply in the wrong place again. Here it is:
I got it. We will keep giving 75 ml SQf @AMPS every 24 hours.

 

I'm also curious about this, it would be good to know if there was evidence for that kind of interaction between sub-Q and insulin. The only thing I've been told is that they should be separated by at least 45mins-1hr.

 

I think I found what I was looking for, but I'm still hoping experienced users can help determine if this is even a factor here to consider. This is something @Amy&TrixieCat posted in another member's thread:

 

We can give SQf first, an hour before AMPS , and then do the usual routine @AMPS. I wish someone knows details and will post them here.

 

Thank you Shelly,
the SQF goes above the shoulder but the Insulin shot on either one of her sides.
But still I hope someone who knows better will post

 

Hmmm... I hadn't heard of that kind of reaction, but if Ducia is like Amy's cat Trixie, it could explain a lot. Had you given sub-Q on the morning of the hypo event?

I know you got a ketone test in this morning and have been getting several each day (yay!), but if her appetite is still a little off, please do make sure to get another test whenever you have the opportunity.

 

I honestly don't know what to say about this. We're valiantly trying to guide Tanya through a maze that she's still in after she's had to deal with both DKA and a hypo episode in a kitty who responds dramatically. I understand that if there are ketones in the picture sufficient insulin is needed. The recent hypo event needed measures at odds with that. It would seem that the simplest remedy to address both at home is to feed a high carb diet for now and raise the dose of insulin (1 u? more?). The BG has to be monitored and kept at a higher value at nadir for as long as it takes to have many readings of negative ketones.

Just thinking out loud and trying to mentally sort out the variety of concerns addressed over the last few days. We're doing the best we can as non medical people in a complex medical situation that's happening outside a clinic setting.

 

No, we didn't give SQ on the hypo day.
I try to take ketones test as often as I can. Ducia 's been cooperative in that regard.

 

What exactly is nadir? The lowest BG during the day? Ducia can be on very low numbers, safe green lows, for several hours in a row. Check the SS. Can nadir be as long as several hours? Forgive my ignorance

 

Nadir is the lowest BG of the cycle and it can last a while sometimes as well as moving to different times in different cycles.

 

Both of these statements can be true... it depends on the cat. Every cat is different. For example, I could give Alex sub-q fluids in one shoulder and then immediately test, feed, and shoot in the other shoulder... as long as the fluids and insulin shot were given on separate sides of her body. One of the perks is that some cats tend to be hungry/eat immediately after fluids. Aex was one of them so I took advantage of it when she wasn't eating. Amy found otherwise with Trixie. This is simply another one of those "Know thy cat" things.

There was only one hypo event. It *sounds like* it was was an over dose of 10u given on 02/28. On 03/08, the dose was reduced from 1u to 0.75u after a low number event, not a hypo. There is a difference. Between excellent coaching and Tanya's steering, Ducia never came close to earning a reduction. One can expect to have to steer numbers with food when treating ketones at home. The reason being one has to address the issue of an "insufficient amount of insulin" to get rid of ketones... one way or another.

This is what I was trying to get across last Sunday. Feeding high carb food may allow for dosing a sufficient amount of insulin, but Tanya was told not to feed HC except for when steering low numbers.

Tanya, here's some terms that we use a lot. They refer to a kitty's response to insulin (you can click on the links in blue font):

• Onset - the length of time before insulin reaches the bloodstream & begins lowering blood glucose
• Peak/Nadir - the lowest point in the cycle
• Duration - the length of time insulin continues to lower blood glucose

• Carryover - insulin effects lasting past the insulin's official duration
• Overlap - the period of time when the effect of one insulin shot is diminishing and the next insulin shot is taking effect

Hope this helps a little bit...

 

Boy, I am so glad that you weighed in @Jill & Alex (GA) as I feel so out of my league giving any advice with the DKA issue and fear of hypo . I hope that there will be some veteran peeps to help guide Tanya with dosing from this point forward .

And I hope you have an nice vacation

 

I agree with your post.
However, we have seen some Blues in her PM cycle yesterday on 0.75U. Her ketones are regularly checked and keep at Trace.
I understand how bad for DKA insufficient insulin is but I think I didn't give 0.75 dose enough time to be observed. Too many Why?s in her numbers for me. That's why I appreciate every post in here.

 

Jill,
Thank you for caring.
I really do not know what to tell you.
At the moment I don't know what will we do.
But I am grateful you shared it here and gave us food for thoughts.
In the past weeks we made so many mistakes so all I truly want is to see her stable withing acceptable range. No extremes of green to red. Yes, it is true that I am scared of hypo and very low numbers and that that fear might have played role in the reduction decision. But there are also some positives in 0.75U.

 

You're welcome, Tanya. I'm trying to help without adding more confusion.
I wish you the best!

 

No one is more confused than me at the moment>
I am really too new to all of it to have sound judgement on the matter. I didn't mean you caused it, I was being confused ever since Ducia was diagnosed.

 

Tanya, it is a very big learning curve with Feline Diabetes alone and when you throw DKA into the mix and a hypo, things get tricky . But the info Jill gave you about DKA supersedes a hypo event without a doubt. You now know how to handle the hpyo event and what was proposed for Ducia who has fast early drops was giving HC food right out of the starting gate ( or in the very beginning of the cycle ) that will allow you to get more insulin into Ducia to rid the ketones and prevent a hypo event .

I hope you will consider the method and I will tell you this : My Bubba had ketones and had I not followed the great advice from Jill, I am sure my cat would not have made it. For what ever it's worth......

 

Most likely we will increase tomorrow AMPS.
Can you recommend good pate style HC canned food that I can make into a slurry for the tube use?
Something easily available at night?

 

Most HC wet foods are chunks in gravy. If you have a blender you could puree the food and then add enough water to make it the right consistency for the feeding tube.

 

Hi Tanya,

I see a note on your SS about ketones being negative at the vet's. How are things going?

 

Also hoping for an update-- hope things are going well for you guys!

 

Hi Tanya, hope all is going well with you and Ducia. When you get a chance, could you please give us an update? How is Ducia doing with eating, now? From what I could see on her spreadsheet, it doesn't look like she is eating very much. Is she eating on her own or are you still using the e-tube?

 

Since most of the carbs in gravy food os in the gravy, you could buy a chunky gravy food (like fancy feast gravy lovers) pop the top and push down to squeeze out the gravy and just feed that. If it's too thick you could dilute with a little water for etube feeding.

 

Hello,
I posted an update on Ducia here:

http://www.felinediabetes.com/FDMB/threads/3-11-update-on-ducia.174711/

 

She is far better today, eats all she is expected and on time. I posted an update her:

http://www.felinediabetes.com/FDMB/threads/3-11-update-on-ducia.174711/