Avoiding Ketones vs Rebound?

Hello, I have just joined and am so appreciative of everyone who offers their time here to help others, thank you!

My 18 year old cat Henry was diagnosed 4 years ago, and thanks to Dr. Pierson's website & a forum I found back then I was able to keep him well regulated for years. Due to recent travel, a Kidney Disease diagnosis and managing the related constipation, he has become unregulated. I am starting from scratch and have forgotten so much of what I initially learned about getting his levels under control.

He is on Prozinc and eats either Dr Pierson's homemade recipe or one of the low carb canned foods from her list. I use an AgaMatrix meter & sticks. He gets subQ fluids twice a week (for CKD) and I recently added Miralax because he was very constipated. The vet gave me Laxatone the day I brought him in, which contains corn syrup. Because it was close to becoming an emergency I gave it to him for a couple f days until things got moving. His BG seemed fairly stable at the time, but I think it was about a week later I started to regularly see crazy numbers in the 500-600s. Everything I read on Miralax says it's fine for diabetics, but I am concerned that might be the problem.

A few months ago he had high numbers (400s) that I think were rebound and I reduced his dose and got it back under control again. For years he used to rarely go over 200 and I would give him an average of 1U or less twice a day (always after testing). He would occasionally get off track a little bit and I could get him back, but at the moment I am really struggling.

I will start a spreadsheet and pick up some Ketone sticks, but in the meantime, I have a general question about choosing a dose and if it's more important to avoid rebound or avoid ketones:
With these high numbers should I try to only bring him down by 50% at nadir to avoid rebound, or should I try getting him closer to 100? I haven't thought about ketones until now as he was never consistently high before. How do I prevent ketoacidosis if I don't try to get him lower ASAP?

Until I get my spreadsheet up, here are a few numbers from today and yesterday:
Yesterday he was 424 and I dosed 1.2U (3U draw in a 100U needle) and he got to 166/+5, 177/+6, 217/+7.
Last night he was 565 and I dosed 1.4U and he was 378 at +3 but I fell asleep & missed the nadir
This morning he was at 411, I dosed 1.2U and he is at 233/+5.5

Should I try 1.6 tonight? I saw the Prozinc protocol says to keep the same dose for 3 cycles, but I have already been sticking to 1.2U for the past few days, afraid to increase and create a rebound.

Thanks!

 

Hi and welcome,
to answer to your title - Avoiding Ketones vs Rebound?
I 'd say avoid ketones development at any cost. The ketone bodies presence does not mean DKA but anything above the Trace level is a vet visit.
To prevent from developing give extra water - mix into his food and keep testing his urine daily. Make sure he has eaten his foods and increase the insulin doses as needed. Watch for any signs of being unwell or off - anything that might make think "infection" .

@Kris & Teasel is good at ProZ dosing - I am tagging her for help.

 

Avoiding ketones is top of the list! Dealing with bouncing requires a bit of dosing finesse.
If your kitty is a bouncer (and he can become one even if he wasn't before) it's best to gently "nudge" numbers down with careful increases. Bouncers often have a tendency to soar high and get stuck up there, building up glucose toxicity and losing responsiveness to a dose - ask me how I know?!

Your best defenses against ketones are (as Tanya suggested):

• adding extra water to all wet food meals for good hydration
• testing his urine for ketones as often as you can manage when numbers are high (daily is best)
• keeping an eye out for any signs of illness, pain, etc.
• getting BG under decent control.

Action plan for now:

• set up your spreadsheet: http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/
• start up a structured testing routine (see below)
• start urine ketone testing ASAP
• post on the ProZinc forum for advice.

______________________________________________________________________________________________
Here's the basic testing routine we recommend:

1. test every day AM and PM before feeding and injecting (no food at least 2 hours before) to see if the planned dose is safe
2. test at least once near mid cycle or at bedtime daily to see how low the BG goes
3. do extra tests on days off to fill in the response picture
4. if indicated by consistently high numbers on your spreadsheet, increase the dose by no more than 0.25 u at a time so you don't accidentally go right past a good dose
5. post here for advice whenever you're confused or unsure of what to do.

Here are some tips on how to do urine ketone testing (VERY important if BG is high and kitty isn't eating well!):

• put the end of the test strip right in his urine stream as he's peeing
• slip a shallow, long handled spoon under his backside to catch a little pee - you don't need much
• put a double layer of plastic wrap over his favourite part of the litter box and poke some depressions in it too catch pee.

Most test strips have to be dipped and allowed to develop for 15 seconds before viewing the colour change in very good light.

Re recent numbers: the drop you got on the 1.2 u dose yesterday was pretty good but the nadir is a bit high. I suggest to start with that and stay there for a couple of days to get SS dat for us to look at.

I hope this helps.

 

Thanks @Tanya and Ducia Just when I thought I was done learning about cat conditions, something new to study, Ketones!
He's usually great about being stuck with lancets & needles, but I just tried to sniff his breath and appear to have crossed a line
Heading to go get the sticks now.
So with high numbers are they just at risk of developing Ketones? It's not a direct correlation? I'll have to go do some reading.
He has a mildly inflamed tooth that concerns me, but with his age & CKD the vet & I are reluctant to put him under to pull it. He had a normal WBC at his last visit 2 weeks ago.

 

the recipe for DKA is not enough calories+not enough insulin+infection of any kind, or an inflammation.

Good on WBC!
Then just watch his BG numbers, if remain high - do increases regularly.
We have plenty of people with experience here - you 'll get help.

I 've been here for over a year and the only thing I can say with certainty is that I learnt enough so far to understand well how little I know and how much more is too learn...

 

Thanks @Kris & Teasel! I'll get the spreadsheet going later today.
He got fluids yesterday (at home) and drinks quite a lot of water himself. I used to worry about that, but with the CKD now I'm grateful.

 

Slightly better numbers for this evening's PMPS test, but not dropping much. Could he be fighting the insulin? I have to get to bed, so I'll check the nadir again tomorrow.

I've been doing some reading in the forum and refreshing my memory on the protocol I started out using, which was Tight Regulation. I think the forum I started with was Your Diabetic Cat. I see a few people on here aren't so keen on using TR with Prozinc & YDC, just wondering if you have any thoughts on that?.

I found TR was almost impossible to juggle with 3 other cats to take care of, going out of town frequently and starting a business though, so I ended up settling into a twice-daily routine that kept him stable. I'm hoping I can get there again without having to go back to TR.

 

The people here on FDMB don't do TR with ProZinc. It's an accepted protocol for Lantus and I know it has been done with ProZinc. It still is elsewhere in other groups. I suggest you post on the ProZinc forum for help.

 

I'll be able to get one more (a +7) test in today before I have to head out for a few hours. He was back in the black this am and only coming down to purple at +6. If he is in black or red for the PMPS would it be ok to try 1.6U, and if yellow 1.4U? I have tried 3 cycles at 1.2U
I started him back on a supplement that I think used to help keep his BG stable (Petandim, an herbal supplement to reduce oxidative stress, safe for cats) but I gave up as he sometimes would refuse the food with it in. I am trying it in pill pockets this time, which I gave at around +1 or +2, which might be affecting that +3 number.

 

I'm not the best person to advise about varying the dose in response to PSs. I suggest you post on the ProZinc forum. @Djamila is better with that than I am.

 

Will do, thank you!

 

She might not reply right away if she's at work. Actually, I just remembered that she's travelling for work this week. You could try those little dose tweaks yourself to see what happens.