? Jag: Not eating, losing weight, vet visit

[chrisb3127]

I'm hoping someone has experience what to do with this situation.

Last Friday, I increased Jag's Lantus to 4U, from 3U, per the vet. He seemed fine, and was eating normally.

Then, this past Monday, he started to refuse food. He would take a few licks, and that's it. So I couldn't do any shots.

On Wednesday, he's fully refusing to eat at all. He ate some tuna flakes as a treat, but that was mostly it. I did shoot him in the AM because he ate a little bit, but not very much. Maybe less than 1/4 of a 3oz can of food.

I took him to the vet Friday. He was drinking so much water, that the litter box would be full by afternoon, and he would urinate outside of it because it was completely full of his urine. His urine is practically clear, very diluted, and no odor at all.

He also lost about 3 pounds. He was 21lbs, now he's just over 18. I was shocked that a cat can lose this much in a week's time not even.

The vet ran blood work (see spreadsheet) and ran a pancreas snap test which came out normal.

They said he is dehydrated (sticky gums, blood test electrolytes) and that I need to admit him. Since it's a holiday weekend in the US, they said he wouldn't go home probably until Tuesday. They will administer IV fluids, along with Famotidine, Ampicillin (if needed), X-ray (if needed), Buprenex (if needed), and Cerenia.

They also mentioned possible diabetic ketoacidosis due to the fact he has trace ketones? He's had trace levels ever since he was diagnosed last month. I tested his urine several times per week at home, and it never budged from Trace. Initial urine test at vet also showed Trace in April.

My concerns are:

- Is keeping him admitted to the vet a good idea? They aren't a 24/7 facility, and during the holiday weekend, will only most likely have a vet check him once in morning each day.

- If he suddenly stopped eating after several 4U doses of Lantus, could the insulin be a potential cause for this problem?

- Is this the best course of action? By keeping him admitted to the vet until next week?

- Why would his water intake suddenly go through the roof? He never drank and urinated like he did this week.


Hoping someone has some experience with these sudden issues! He seemed to be doing fine until Monday, when everything seems to be going in the wrong direction.

 

[Tricia Cinco(GA) & Harvey]

Hi,

This is my first visit to one of your threads, so please forgive me if I ask a question you have previously answered. I notice very few tests in the middle of the cycle on the spreadsheet. Is this because you are not at home to test during the day? Just having the preshot tests is like trying to figure out the picture in a jigsaw puzzle with just the outer edges filled in. What we don't know is why Jag's BGs are so high. I just went back and read your previous thread. If you are still not testing because of what your vet said, please ignore that advice! Just look at my two spreadsheets. I was a bonafide testaholic, and neither of my cats ever got an infection. Forgive me, but your vet does not sound very familiar with FD.

I personally do not agree with your vet's raising the dose to 4 units. Here we change doses by .25 unit increments. A whole unit is a lot for a cat, especially one with so little data. Lantus dosing is based on how low the BGs go during the cycle, with consideration given to the preshot number. You cannot determine whether a change is needed by just looking at the preshot numbers. That is asking for trouble. I know I sound very critical, and I am sorry - I don't mean to. I just want you to know that this isn't a good way to use Lantus. You mentioned having only one unit syringes. Walmart carries syringes with 1/2 unit markings, and you eyeball the .25.

We have pictures of how to measure small doses here.

- Is keeping him admitted to the vet a good idea? They aren't a 24/7 facility, and during the holiday weekend, will only most likely have a vet check him once in morning each day.

If there is no one there to watch him for long stretches and they are giving insulin - especially that high of a dose, I wouldn't do it with my cat. Your vet can show you how to give subcutaneous fluids at home. If the urine test showed only trace ketones, I don't know if it is possible for him to have DKA. In case you don't know, DKA is caused by not enough calories, not enough insulin and some kind of infection or inflammation. Since he hasn't been eating, and you therefore skipped some shots, that can certainly lead to DKA. Especially if the reason he stopped eating is an infection of some kind.

It sounds like he stopped eating because he was nauseated. I'm glad they are going to give him Cerenia. They can send him home with some, either tablets or injectible if he is throwing up, and you can give it to him yourself.

If he suddenly stopped eating after several 4U doses of Lantus, could the insulin be a potential cause for this problem?

Unlikely, but not impossible. Chances are something else made him feel unwell. Just having a high BG can make a cat (or a person) feel crummy. So can large swings in the BG.

Why would his water intake suddenly go through the roof? He never drank and urinated like he did this week.

Did they check him for a urinary tract or kidney infection? This can cause increased water consumption and nausea. So can DKA, and several other issues.

I'm going to ask some other veterans to stop by, and to look at the labs, and see what they think. Please keep us posted on how Jag is doing. We care.

 

[chrisb3127]

I personally do not agree with your vet's raising the dose to 4 units. Here we change doses by .25 unit increments. A whole unit is a lot for a cat, especially one with so little data.

Thanks for the reply! You are not being too critical -- this is very helpful information! I basically got yelled at after I sent the spreadsheet to the vet last time. She said that's too much pricking, and can lead to infection because it's constant poking, and said I need to stop doing that. I didn't agree with that, because would a human shoot blind? Their definition of a curve is to test twice weekly at +5/6. Doesn't seem right to me... not enough data like you mentioned.

I will go through my meter and see if I'm missing any data, and update if needed. I think that is all of the readings though. Since they were saying not to poke so much, I shouldn't have listened and kept doing what I was doing when he was first diagnosed by checking more often.

If there is no one there to watch him for long stretches and they are giving insulin - especially that high of a dose, I wouldn't do it with my cat.

I believe they only have staff go in at 7:30am on days they are closed to check admitted animals. I'm going to confirm this when I go there at 8am today. They want me to bring the Lantus so they don't have to open a new one. If they really only check once a day, I am not really comfortable with that. I'd rather get the medicine and SubQ to do at home. Plus he would probably be happier/in a better mood if he was in familiar surroundings. I'm going to push them on letting me take Jag home with the supplies I would need.

I was reading other threads how you can feed via syringe by turning the wet food into a puree. I would be willing to do this too. He's usually a laid back cat, so I think I can handle it.

Just having a high BG can make a cat (or a person) feel crummy. So can large swings in the BG.

I'm thinking this too, especially with skipping so many shots this week. His numbers dropped into the 100s (I think this is when the depot of the increase to 4U took effect) then went right back up due to no shots.

Is it normal if they aren't eating to have the BG skyrocket back to 400-500?

Did they check him for a urinary tract or kidney infection?

They took urine and are sending it out for a urinalysis and culture. What concerned me most was how watery his urine was, and how it had no smell. I caught him sitting at the water bowl drinking non-stop for minutes at a time. It's like he replaced eating with drinking water only.

They tried feeling his kidneys, but since he's a bigger cat, they said they may need to x-ray him for that, or refer out to a specialized vet for an ultrasound.

I'm going to ask some other veterans to stop by, and to look at the labs, and see what they think. Please keep us posted on how Jag is doing. We care.

Thank you! I will post an update later today once I get back from the vet. I'm hoping they can let me do the care at home until they're back in on Tuesday. It just doesn't make sense to leave him there if they only come in once a day in the morning on closed days.

 

[Gill & George]

One other thought if they are only going in once a day are they only going to shoot once a day??

At this stage probably not advisable to be skipping insulin shots, if there are ketones and concerns over dka, as Tricia already mentioned not enough insulin is one of the 'ingredients' that can lead to dka.

 

[chrisb3127]

Here's the 8am update:

- Jag ate a little bit overnight. Not a whole lot, but did eat. He gained 5oz from being on the IV fluids for 12 hours so far.

- He is getting small amount of pain meds?

- His BG dropped 200 points overnight (from 686 taken at vet yesterday) They will dose 2U insulin to start the regimen again.

- They've been giving him Cerenia (1 injection/day) and Pepcid for acid control due to no food in stomach.

- They did not start an appetite medicine yet, but may. They said they don't use Cypro anymore since it's an older drug that can affect the heart. They said they would use "Entyce" which is more like a supplement with little to no side effects. I have to look that one up.

- They corrected the info yesterday about being told only 1 check at 7:30am. They only have the doctor there at 7:30am, but vet techs come in at morning, mid-day, and evening, to check/feed/etc. So he will be able to be checked and get insulin at regular times.


It looks like a step in the right direction so far. Hopefully he'll begin to eat since that's the biggest thing right now. They said if he doesn't eat, or they feel he needs closer watch, he would have to go to a specialized facility. Hoping that doesn't happen.. I believe that if we can get him on the anti-nausea and appetite medicines, he would begin eating more normally.

If all goes well, hopefully they will let me take him home Tuesday, and give me these medicines to use at home if needed, to avoid having to go through this again if he doesn't eat.

 

[Sienne and Gabby (GA)]

Great news that Jag ate a bit.

I couldn't agree more with the information Tricia posted.

I'm also concerned about kidney issues. Your observation is one that should concern your vet -- your cat's urine is dilute. Hopefully, the vet sent out the lab work and you'll get an SDMA test result back. (This is a test that helps to predict kidney disease.) The sodium, potassium and BUN/creatinine ratio are outside of normal values. While this could be due, in part, to the not eating and whether fluids were started prior to their drawing the labs (fluids will dilute sodium and potassium), I would be very insistent about their investigating kidney related issues. Unfortunately, a kidney infection (vs a urinary tract infection) can be challenging to diagnose.

To be honest, I don't know of anyone here who's cat has developed an infection due to testing. I have 6.5 years of test data on Gabby and, like Tricia, I was a testaholic. If you don't re-use a lancet, the chances of infection are minimal.

I also don't know where your vet came up with the information on cyproheptadine. My vet is a cat specialist and uses crypto The only heart issue with the med is if it's used with heart failure patients. I did a little bit of research on Entyce. I would urge you to discuss it's use with your vet if, in fact, kidney issues are present. Entyce is excreted both through the liver (via the cytochrome p450 system) and the kidneys. With the liver system, this same system is used by many drugs so the vet needs to be aware of whether there are other drugs that are also excreted by this system. If so, there's competition for the site and blood levels of one medication or the other(s) can be effected. With the kidneys, if there is a concern with kidney function, again, levels can be effected or the drug may be hard on the kidneys. The reality is that no drug is perfect.

 

[chrisb3127]

Hopefully, the vet sent out the lab work and you'll get an SDMA test result back.

Thanks for the info! They ran the blood test in-house, only urine was sent away. They took the blood before fluids or any treatments. I don't believe they ordered a SDMA test. It sounds like they will re-draw bloodwork in a day or two once he is re-hydrated. Vet said since it hasn't been eating, it's like a cascading effect on how everything else is all out of normal. Once he eats and gets insulin normally again, they will probably redo all the labs to get a better idea of what's going on.

I also don't know where your vet came up with the information on cyproheptadine. My vet is a cat specialist and uses crypto

Yeah, I've been reading here alot overnight, and Cypro seems to be the go-to for appetite. Vet seemed not to want to consider this one at all, and use Entyce instead. I will followup on kidney/liver concerns if they end up prescribing it. I will have to learn to pushback better. Everyone on these boards seem to be well educated, since everyone has first hand experience with diabetic cats.

 

[Tricia Cinco(GA) & Harvey]

Hi Chris,

Sorry I haven't been online all day and just checked on you and Jag now. I'm glad to hear he ate something last night. Do you have a report from today? I take it you decided on leaving him there? It sounds better that they will be checking on him at least three times a day, but I hate that there would be no BG checks overnight. I think if your vet persists in the silly notion that testing could cause infection, I would ask him/her for the data on that. I'll bet there is none to be produced.

Everyone on these boards seem to be well educated, since everyone has first hand experience with diabetic cats.

We have had to become educated to advocate properly for our cats. The sad fact is that vet students only get about five hours of training on diabetes in vet school, and that includes both cats and dogs - even though the two species handle the disease very differently. Unless they get a lot of FD patients and pursue more education on the subject, they only know the basics, and often their information is very outdated. Then, too, many owners simply put their cat to sleep upon diagnosis, so most vets don't expect their clients to want to treat it aggressively. Because you came here and are doing your research, it's obvious you are not one of those people. Welcome to our family! Many of us have learned to try to keep the peace as much as possible with our vet by smiling and nodding when they give FD advice, then continue to use what we have learned elsewhere (mostly here) to deal with the disease. After all, you need your vet for other issues and to write the insulin prescription, so it is important to keep a good relationship with them. Once they are presented with the good results of your efforts, they often come around, or at least leave you to it.

Vet said since it hasn't been eating, it's like a cascading effect on how everything else is all out of normal.

I do agree with this. Not eating causes all kinds of problems in a cat, especially a diabetic one. I also agree with Sienne that you should pursue the kidney disease angle - ask them to do an SDMA when they redo the labs.

I've never heard of Entyce, but I trust Sienne's research - she's very good at that kind of thing and knows her stuff. Cypro is the appetite stimulant of choice around here, although many vets like to prescribe Mirtazapine. Some people here use it, too. I personally don't like it because it made my cat very hyper, plus you can't give it as often as Cypro.

Please start a new thread the next time you post, and link this one to it so people can go back and get caught up. If you aren't sure how to do that, just ask.

BTW, when you have time, please check out this post, if you haven't already. It helps newer members navigate the forum a bit and explains some stuff we say or do that may seem confusing. Above all, keep doing your homework, and keep asking questions! I'll be watching for your next update, and I hope it's good news.

 

[Sienne and Gabby (GA)]

None of us started out well educated. We were just like you -- we read like crazy and took advantage of the information that people here routinely pass forward. I've been hanging around for 6.5 years. If I hadn't learned anything over that period of time, I'd be embarrassed!

FYI - you are probably the first person to mention Entyce. It looked like it has an indication for dogs but not for cats yet.

 

[Olive & Paula]

I have seen a few people ask about Entyce. But I don't know if it was on the FB site or different group altogether. I gather its a new drug and not much is known. I have not heard anyone reporting back with their experience.

 

[Wendy&Neko]

I am glad things are starting to improve a big with Jag. I hope you will be able to take him home soon.

We did have one other member try Entyce with her kitty Maggie. From her experience it raised the cats's blood sugar but didn't do much for the appetite. Not surprising on the blood sugar cause it also increases the level of growth hormone cirulating. Growth hormone stimulates the production of IGF-1 (insuln growth factor), which blocks the cells from letting in insulin. It's the reason that cats with acromegaly become diabetics. Mirtazapine is another alternative, and to avoid the hyper symptoms Tricia mentions, get it in transdermal form which is much more slowly absorbed.

 

[chrisb3127]

Here's an update that is from yesterday (Sunday), I will post another update later today once I get more info.

Yesterday, Sunday, the vet called and said he continues to not eat. He also moved around too much, causing the IV fluids to shut off halfway overnight, so he didn't get the full amount of them. He also continues to drink non-stop and his urine continues to look like water. The vet said his BG was 230, but they can't really give him much insulin since he's not eating.

They gave him Entyce to try and make him eat. He still wouldn't eat, and they said he needs to be transferred to a specialty facility that can be more hands-on with him. That they could not properly manage it there since they don't have the proper insulin needed as well as staffing to be checking him frequently.

However, when I got to the vet to pick him up, he was sitting in the cage in the corner, facing the wall. I put my hand in the cage for him to smell me, and he immediately sat up and then walked over to the food and started to eat! Then, when we got in the car, I decided to try feeding him again. He ate about 90% of a full can of food. It seems like the Entyce worked, but he was refusing to eat due to being in a stress environment away from familiar faces.

I took him to the specialty vet, and they said this is definitely DKA. They also said his diabetes is not being managed properly, and they first need to get him fully hydrated and eating. His "serum ketones" turned moderate on Sunday, was Trace prior. The specialty vet wants to use a fast-acting insulin, so that he can get the BG under control more quickly, as Lantus is no good for that purpose due to how it builds itself up over doses. (Regular vet was only using the Lantus I brought to them)

The plan is to hydrate him, monitor BG constantly, and they will dose with fast-acting insulin most likely every 2 hours. But he needs to eat, and get rid of the ketones. They said they would only release him if he's eating (otherwise he gets a tube), and when the ketones are negative.

They also are planning to do an ultrasound to eliminate any internal issues, particularly with the liver and kidneys, and just do a general organ check to make sure nothing looks out of the ordinary.

Been a stressful weekend. But this specialty vet implied that his management was not optimal, and they suggested to use them to manage his diabetes. For appetite, they said Entyce is too new of a drug and he advised against using it. They prefer the appetite drug that starts with M. They said they have specialists who only deal with this disease, and he would get better management and control over what's going on.

I am waiting for an update this morning. They said to expect a call sometime around 10am with what's going on, and what to expect next.

My worry is the eating -- if he ate for me, and won't eat for them, I will need to go down there and try to feed him myself. From the fluids alone, he already gained back a pound. So now he's roughly 1 to 2 pounds short of what he weighed in at a month ago. The not eating for several days took away weight very quickly.

What is interesting to me, is he was always acting fine and eating. It seems like he only started getting worse once they upped him to 4U twice a day. After that depot built up of 4U, he deteriorated very quickly.

 

[Tricia Cinco(GA) & Harvey]

Hooray for eating! That's wonderful! Sounds like the specialty clinic is the place for him right now, although he would probably eat better at home with you. The M is Mirtazapine. It's a good appetite stimulant, but it makes some kitties hyper - we call it Meowzapine! It's better than an unknown like Entyce, though. You might ask about Cyproheptadine instead, although they probably only use Mirtz. It would be great if you were able to visit once or twice a day and feed him.

The fast acting insulin is probably what we call R - Regular insulin. That's what is often used to bring the numbers down in a hurry. Lantus doesn't do that - it's much slower. R is usually only used in situations like the one Jag is in, by vets to bring the numbers down quickly, and sometimes by very experienced owners when they have a cat that is constantly in high numbers.

I would definitely ask to talk to their diabetes specialist and get his/her opinion about the dosing. Find out if he/she is familiar with the Tight Regulation protocol and would he/she be amenable to your following that protocol once Jag is out of the woods. Don't let them talk you into any prescription foods. There are plenty of perfectly good foods for diabetics available in pet stores and supermarkets for much less.

Please keep us posted on how Jag is doing.

 

[chrisb3127]

Alright, Jag is now home! It's been a crazy week running around. He came home yesterday afternoon.

Here's what they said:

- He was dehydrated and in a DKA state. He had potassium deficiency, unbalanced electrolytes, and poorly managed insulin.

- They did an ultrasound and found inflammation in his bile ducts. They prescribed Clavamox to be taken 2 times a day, for 30 days.

- They said he has a slight heart murmur and slight galloping. Never heard this before from the vet.

- They prescribed Cerenia and Mirtazapine, to be given as needed. I'm glad I have these tools to get him eating if needed, but they only gave me like 8 pills of each. (The Mirtazapine should last longer, since it's given in 1/4 of a pill dose)

- They prescribed a potassium supplement to put into food, twice a day, until told to stop.

- Insulin was reduced from 4U twice a day to 3U twice a day.

- They recommended regular monitoring(!) and said to do a full curve after a week. They do not recommend bringing him in for curves, due to the way the numbers will be artificially inflated due to being in a stress environment.

- They want me to regularly test urine for ketones and glucose. Had to get the dual strips to test both, but was already testing ketones at home at least once a week.


Hopefully he will continue to improve. He's been eating, but still seems like less than usual. Water intake and urinating is still high, but they told me to ignore this for right now, since he will eventually balance out as the days go on.

The old vet wasted no time in billing my card $1,500 for doing really nothing other than IV fluids and re-running bloodwork. (They didn't even give me a run-down of that $1500 yet since it doesn't match the initial estimate) I went there to see if they could help me out any with the bill, since the specialty vet was over $3,000. They were very annoyed with me that I was complaining about the bill, and said he was already improving before he was transferred? That was not the impression I got on Sunday, when the vet called and said I needed to get him out of there immediately for better treatment.. I think it's time to find a new regular vet. They definitely do not like to be confronted with concerns, and don't like when you're slightly educated with diabetes. (I got yelled at for testing his glucose more than 1 time twice a week..haha) They said they'd call me this morning to discuss how they could help the bill, but have yet to hear a peep from them.

As I was typing this, they just called and offered to take $225 off the bill..so I guess it's better than nothing.


Hopefully Jag will continue to get better! The eating is my biggest concern, that was scary when he would refuse all food.

 

[Sean & Rufus]

Get better soon, Jag! Sounds like he's on his way to feeling better.

 

[Olive & Paula]

So glad he is home. One thing is popping out at me. Did they suggest any follow up for the murmur and gallop heartbeat with a cardiologist? Or said to be careful if fluids are being given.

 

[Tracey&Jones (GA)]

The heart comment stood out for me as well. Jones showed a murmur when he was in the ER but it hasn't been noticed since. I always ask though.

I am glad he is home now and it sound like this IM vet is way more on the ball for what is needed for management. Especially for a kitty with a DKA history.

I hope that Jag continues to eat for you. If you want some specific feed back in regards to dosing and DKA considerations... Sandy and Black Kitty can be a great resource. Don't be afraid to tag her.

 

[Bellasmom]

So glad Jag is back home with you and doing better

 

[Kathy and TiTi]

Alright, Jag is now home! It's been a crazy week running around. He came home yesterday afternoon.

Here's what they said:

- He was dehydrated and in a DKA state. He had potassium deficiency, unbalanced electrolytes, and poorly managed insulin.

- They did an ultrasound and found inflammation in his bile ducts. They prescribed Clavamox to be taken 2 times a day, for 30 days.

- They said he has a slight heart murmur and slight galloping. Never heard this before from the vet.


I would not credit any heart diagnosis until Jag's got his potassium balanced. Low potassium leads to the heart acting up.

 

[Tricia Cinco(GA) & Harvey]

Hi Chris,

Sorry I haven't been on the Board the past couple of days, so I missed your update. I'm so glad Jag is home and doing better.

Sounds that that specialist knows FD! I love that they want you to monitor and NOT to bring him in for a curve! I agree it's a good idea to stay on top of the heart issues, and make sure your new vet, when you find one, knows about it before they give fluids.

Kathy makes a good point about the potassium issue. When that's out of whack, all kinds of things can go wrong.

I hope you will continue to post here so we can watch Jag's progress. Next time you post, please start a new thread. You can put a link to this thread in the next one so anyone that needs go can go back and review what's gone on before.

 

[Sienne and Gabby (GA)]

What great news! I like the specialty vet. It's great to hear that they understand the value of home testing and are supportive. Personally, I would let the old vet know that the specialty clinic indicated that Jag's FD was being poorly managed and, given their inadequate care, they should consider reducing the costs further. They clearly didn't know how to treat DKA or their inadequate care pushed him into DKA. This is especially the case since they managed to not get his fluid line properly situated and Jag disconnected it. The standard treatment is fluids and a fast acting insulin along with blood tests to determine if electrolytes are out of whack. Most vets will also do additional testing to try to figure out why the cat is in DKA -- they are usually looking for a source of infection or inflammation. (And if they do not reduce the bill further, consider a post on a social media source like Yelp.)

Just an FYI, urine glucose testing is not generally helpful compared to blood glucose testing. When you test blood, you get a the to the second value for where the BG level is. When you test urine, the value is hours old -- it takes much longer for food to be metabolized, waste products to make their way through the kidneys and to the bladder, and enough urine to accumulate for your cat to need to use the litter box. In addition, the urine glucose test strips really only tell you mid-range values.They will not tell you if glucose values are so low that you need to intervene. So, ignore the urine glucose testing and test blood glucose. It will keep Jag much safer..

The same is true for ketones but you have greater bandwidth in that you start to be attentive if you see more than trace amounts. You can always get a blood ketone meter but the strips are pricey.

 

[JeffJ]

I am glad to hear that Jag is back at home.

If possible, I highly recommend more regular mid-point nadir tests. They are highly useful to determine dosages.

If my vet told to stop testing, I would either stop going to that vet, or I would simply not talk about it with them. But both of my behaviors would probably cause me to go to a vet who would work more closely with me on dosing guidelines.

In general, cat emergency services can be very expensive. One thing we do now is get an estimate and then we cancel specific services they are going to do if we do not believe they are necessary.