Just out of DKA hospitalization- vomiting/no appetite

Hi there- Long time lurker, first time poster (outside of my intro post just a min ago).

My big 12 year old boy Glenn Miller was just released from the hospital on Wednesday after his third round of DKA. He was stable (not regulated, of course) and looked great.

Little history- We check his BG morning and night, adjusting his dosage as necessary. He's generally on 2 units of Lantus, but if he dips below 200, we usually stick with 1.5 or 1. More often than not, he gets 2. The morning before he stopped eating before his hospitalization , his BG was 279. Alert, great coat, no signs of anything sinister. The DKA was a total shock, and I believe it was brought on my stress of having a very loud canine visitor that day. His BG continued to climb the following day (all the way to the mid 500s) untouched by the Lantus. I took him in to the emergency vet, where he continued to climb to the 600s. After a 4 day stay, he was discharged.

His BG has been all over the place since coming home, which I expected (the first night it was 40!). Now, the doctors gave me some uncomfortable discharge instructions, and I'd love to know what you guys think:

BG <250- No insulin
BG 250-350- 1.5 units
BG >350- 2 units
No eating/vomiting- 1 unit

I followed this loosely, as I know how fast things get out of control with him when he misses a shot... so when he was at 200, I gave him 1 unit.

He'd been doing relatively well, just very picky about food. When I got home last night (08/03), he was hiding under the bed and refused to eat. There was vomit in the room he was in, which I attribute to him...but I have 7 other cats, so I'm not 100% (...just 99.9). This morning, he seemed a little less nauseous and had a few licks of some "treat" wet food by Rachel Ray. He's normally on either Friskies or FF turkey pate. Pre-licks, his BG was 270. I gave him 1.5 units. He didn't eat much, so I applied Mirtaz to his ear (as I did yesterday and the day before). Several hours later, still no interest in food. I syringe fed him 5ml of Science Diet AD, very watered down. He threw up an hour or so later (this was more yellow liquid than anything). Two hours after that, I syringe fed him 10ml of Fancy Feast pureed in the blender. It hasn't come up yet, but he's drooling like nuts. His most recent BG (right before he threw up the first time) was 282.

He has now just thrown up the 10ml of Fancy Feast. He's not chugging water.

I'm at a loss. Any ideas? He had an ultrasound and endless bloodwork at the emergency vet, which generally came up fine outside of the kidneys looking rough upon admission (this cleared up as the DKA was treated).

His numbers post-discharge are in my spreadsheet (which is hopefully now in my signature). I can (and probably will) add his pre-hospitalization numbers a bit later.

Thank you so much for reading this novel!

 

What insulin? He needs food, but sounds like he's nauseated. Did they give you any anti-nausea meds?

Ok, re read your post..Lantus. Can you put more in the signature so this is all right at the bottom of your posts please?

kitty's name/age/date of diabetes diagnosis/insulin you're using and dosage amount /glucose meter you're using/what (s)he eats/any other meds or health issues (s)he has. You can add your name, and a geographic location (sometimes the country/time zone matters) Be sure to SAVE when you are finished.

@Wendy&Neko
@Sienne and Gabby (GA)
@Chris & China (GA)
@Bobbie And Bubba
@MrWorfMen's Mom
@AliceMeowliss&Cassandra
@Marje and Gracie

 

Are they sure it was DKA? were ketones present in the urine? at what level? I don't think DKA is caused by a stressful day, even with a strange dog. From info which I will provide a link for: Most times DKA occurs when infection is present. This usually causes the kitty to be anorexic and the infection itself can cause bg levels to rise because of the body's greater demand for energy to fight the infection.

Are you testing for ketones at home with urine dip sticks (Ketostix)?

http://www.felinediabetes.com/FDMB/...oacidosis-dka-and-blood-ketone-meters.135952/

 

Do you check his BG just before each injection, or do you check it in between the cycles as well?

My cat is not on lantus, but from what I’ve read on this forum since lantus is a depot insulin it does not work with a sliding scale like vetsulin does, so it’s important that you dose consistently instead of varying the dose. It would probably also be good to post on the lantus forum for dosing advice.

 

Wow, fast replies! Let me see if I can bang this all out:

-For anti-nausea he was prescribed Cirenia from the emergency vet, which he last got last night.

-I'm aware that one stressful day generally doesn't cause DKA, but I'm just not understanding how I've seen no other signs. Both other times, he was drinking incessantly for a week or so and his BG #s were all over the place. His appetite was great and we watch him like a hawk.

-Ketones were present in his urine at the vet, and I don't home test due to my other cats and extremely limited space.

-Depending on his behavior, I'll check between cycles-- but generally, no.

I'll edit my signature right now, thanks!

 

Meant to ask @Sarah&Soph (and anyone else)-- what are your thoughts on those recommendations from the vet in my orig post regarding dosage and BG?

 

Since you can't test his urine, would you consider buying a meter that tests ketones via blood sample, just like a glucometer? it's really important to know if he's throwing ketones and at what level.

 

This is a great idea and I'll look into it

 

I am not experienced with DKA, only know from reading how critical it is. Can you try getting baby food meat, no seasonings or ham, making soup and see if he will lap that up?

Beechnut is a good brand, no additives.

 

I’m hesitant to give dosing advice because I don’t personally have experience with lantus, and others might be hesitant too because of the lack of testing data, but I think it’s fairly important for cats that have recently had DKA to get insulin. Now how much insulin, I can’t say. Lou has tagged people who are experienced with it, so hopefully they will chime in soon!

In regards to testing, preshot tests are of course important, but it’s also important to test during the cycle as well so you can see how your cat is responding to the insulin.

Sophie gets pancreatitis and IBD flare ups which make her nauseous, and during those times all she will eat is dry food, which is of course not ideal, but bad food is better than no food. I’ve also heard of other cats that only want dry kibble when they’re nauseous as well (weird!). Flortiflora which is a probiotic also entices some cats to eat

 

Thank you for the dry food suggestion! I didn't know that about dry and nausea. I just put some down-- which is a big big treat for my other cats and they're thrilled. GM still looks miserable but maybe after some time...

I tested during the cycle fairly often after our 2nd round of DKA, then once he regulated (or so I thought), I eased off. How I wish I had a recent curve.


Right now I'm wondering if the Mirtazapine is playing a role is all this nausea and vomiting. I applied it Friday, yesterday and today (Sunday). I looked up that vomiting is a side effect, but it's also used as anti-nausea so...I just don't know.

His BG is rising (last read was mid 300s), but not like his DKA weekend (500s).

 

Hello and welcome to FDMB. Glad you have known about and visited FDMB for awhile but so sorry you and Glenn are having such difficulties now.

First of all I must echo the other members in that Lantus is not dosed the way the vet is suggesting you do it. It is a depot insulin and consistent dosing every 12 hours with the same dose is necessary to keep kitty on an even keel and to be able to determine the best dose for kitty.

I also echo the need for mid cycle testing when possible. When working full time, that can seem difficult but switching shot times so you can get an extra test before leaving for the day or when you get home from work helps immensely. Also grabbing a before bed test every night can fill in some of the blanks you now have in the big picture.

Right now you need to focus on getting enough food and water into Glenn so that insulin can be administered. If he likes higher carb food and will eat it that is fine. Anything cat appropriate is OK to feed right now. Insulin doses can be adjusted to accommodate food but it's imperative you get him eating.

I am not sure about giving Mirtazapine daily and hope someone else will chime in with more experience than me. What is the dose of mirtazapine that was prescribed? Seems to me transdermal dosing would be a bit more difficult to control than pills but I've never used the transdermal.

I noticed on your spreadsheet there is no insulin dose listed for this AM? Did you skip the shot this morning?

 

Hi and welcome to fdmb.
I agree with what others have said. It sounds as if Glenn is prone to getting ketones and DKA if this is his third episode.
I would also recommend you buy a blood ketone meter if you are able to, as it is a really good and easy way to monitor ketones and it will be something you will need to monitor on an ongoing basis. That way you will be able to deal with the ketones early and stop it going on to DKA.

With ketones and recovering for DKA it is really important Glenn gets insulin and you don't skip a dose if at all possible.....but of course you have to keep him safe. If the preshot is too low to shoot on an ongoing basis you may need to reduce the dose so you can shoot both cycles. If he is too low at preshot, stall for 20 minutes, don't feed and test again after 20 minutes to see if his BG level has come up. Post and ask for help and what you can do.
Food is really like a medicine for cats recovering from DKA as food and insulin helps ketones from developing. So feed him what ever he will eat. As @MrWorfMen's Mom said, we can work around the dose but food is very important.
Are you giving cerenia for nausea and vomiting on a regular basis?

If you can make sure the spreadsheet is kept up to date all the time, that will help us help you, as we look at the SS every time we help you. Are you able to get any tests in during the pm cycle?
There is no dose in the AMPS this morning. Did you give him insulin?
Lantus works best when you stick with the same dose (unless you are increasing or decreasing the dose). Sliding scale does not work well with Lantus as it is a depot insulin and itlikes consistency.
Getting plenty of fluids will help as well.
Are you feeding him during the cycle as well as before the shots.?
Ask lots of questions, we are happy to help.
Bron

 

I thought you only take Mirtazapine once every 3 days. My cat Buddy has had like the worst pancreatitis ever and until his evening the only thing he would eat is dry food, pancreatitis makes you nauseous.

 

Have you ever thought of assist or force feeding Glenn Miller. You will need a syringe and watered down wet food. If you are close to the 24 hr. vet or any vet should have a syringe. Hill's A/D is a good wet food to use and must be bought at the vet. Maybe someone else would know of other foods that could be used if you are not close to the vet.

 

I thought the dosing of Mirtazapine was only every few days. If they prescribed it on a daily basis, that may be contributing to the lack of appetite rather than stimulating it as it's meant to. That said, perhaps the dosing is different with the transdermal type. @Teresa & Buddy , were you dosing with pills or transdermally?

 

Thank you so much!

He absolutely will not touch any food at this point... he's drooling on and off and is just generally nauseated.

Whoops- good catch on the spreadsheet. I gave him 1.5 units this AM.

 

Thank you!!

After dealing with this for so long (had diabetic kitties most of my childhood), I'm disappointed I was trying so hard to follow those discharge instructions. They felt wrong and I knew it.

He's not eating on his own at all. I gave him another dose of Cerenia about 2 hours ago. He received it last night as well, but before that, his last dose was at the vet on Wednesday.

I did give him insulin this morning...somehow missed that on the spreadsheet, sorry! I gave him 1.5.

His usual schedule is 2x daily feedings, both before his shot. Since he's been home from his hospitalization, I've let him graze throughout the day with 2 main meals morning & night.

 

Ask the vet for some ondansetron for the nausea. It works differently to cerenia and may help. It can be given every 8 hours if necessary.
It’s imperative that Glenn eats so you may have to force feed him. But try the ondansetron. I found it very good and can be given at the same time as cerenia.

 

My discharge instructions and the container it came in both say every 24 hours-- not that I'm trusting that, but that's what it says. His pancreas looked a little out of wack at the vet, but they didn't think it was too bad. I'll give my home vet a call in the AM about it.

 

At this point feed him throughout the day and night. Cats on Lantus can eat during the day as well as at Preshot. When recovering from DKA the more food he will eat the better it is for him.

 

I syringe fed him 15 ml of the Hill's (thought it was Science Diet) AD food about an hour ago, gave him his shot about 30 min ago, and he's just thrown everything up.

I gave him Cerenia a couple of hours ago.

Just not winning today.

 

With pills.

 

Try some dry food, sometimes just the smell of the wet food can make them nauseous. I have never dealt with DKA and I hope I never do.

 

You will need to test the BGLevel throughout the cycle if he’s not eating much. Keep trying with the food. Any cat friendly food at this point is ok. Very important he eats.
You are doing well. It must be very difficult!

 

Hi there- He could not eat...he was too nauseous. He's now back at the emergency vet with severe DKA. I appreciate all the help and support... hopefully I'll have some good news to report in the AM.

 

Oh no! I am so sorry.
Sending all good wishes for a speedy recovery.

 

Poor baby, please keep us updated, keeping GM in my prayers

 

I'm so sorry to hear Glenn had to go back to hospital.
If Glenn doesn't start not eating on his own, the vet can put in a feeding tube which, when Glenn gets home, would make it much easier for both you and Glenn. Sounds like Glenn could be battling pancreatitis as well as DKA too so make sure they look at that aspect. Pancreatitis is painful so pain meds may be needed along with the anti-nausea/appetite stimulant to get Glenn eating on his own again and keeping his food down.
Sending healing vines to Glenn and hugs for you.

 

Hope Glenn comes out of this and soon, I miss my Buddy when he is in the hospital. Wonder why this vet released him to begin with. DKA is serious business and they need to be in the hospital.

 

Thank you guys so much! I have a little update:

Glenn Miller is now stable at the vet, which blows my mind because I thought he had died before I took him Sunday night-- it was that fast of a crash. He ate on his own this morning and is acting totally normal, so they're starting him back on his Lantus this AM. They performed a repeat ultrasound and still didn't find anything overly alarming outside of slightly thickened intestines and a slightly out of the ordinary pancreas (but still did not appear to be pancreatitis). I okayed an additional test to be sent out to Texas A&M that could confirm pancreatitis if it was missed on the ultrasound, of which there is a 1/3 chance. They recommended starting him on steroid therapy for the thickened intestines to treat for possible IBD or low grade lymphoma, neither of which they could confirm and it's honestly just a guess at this point. I okayed this because I just don't have any answers for these fast DKA crashes and neither do they. $10k later, it's very frustrating and my credit is running out.

I'll have a meter for ketones ready for him when he comes out, and I'm looking into the probiotics. I ordered a Feliway diffuser (has anyone tried that?) out of desperation. Any other ideas?

I still think I was given terrible discharge instructions in the first place and I wonder how he'd be if I hadn't followed them. Maybe in the exact same place, who knows.

 

Oh goodness, poor Glenn Miller! So glad to hear he’s doing better.

My kitty also has IBD/lymphoma and chronic pancreatitis, which did not show up on the ultrasound but was confirmed when I insisted that they do a GI panel and send it to A&M. Luckily she is well managed so far with a novel protein diet so we haven’t had to use steroids. But just be aware that depending on the kind of steroids, they can make the diabetes more difficult to manage.

 

This is great to know! I'll ask about the protein diet when I go in to visit him. Thank you!

 

Many cats with IBD have food intolerances that can make flare ups worse and often times it’s chicken or beef. The vets sell hydrolyzed protein diets, but they’re often not diabetic friendly, so I just switched her to a wet food that ONLY has rabbit as the protein

 

check out Northwest Naturals -- nw-naturals.net -- they sell freeze dried raw treats and foods, some of which are indeed novel proteins, SINGLE proteins
plant is in Portland OR but website says your local retailer can special order from them if no one in your vicinity carries their products

ETA -- Catcat loves their freeze dry whitefish treats

 

Maybe it's just me but putting a diabetic cat on steroids for "suspected" IBD seems a little extreme. There are other alternatives for treating IBD that would not affect the diabetes to nearly the same degree if at all. Steroids should be a last resort for any diabetic cat. I'd inquire about budesonide if they are that sure about the IBD.

ETA So happy to hear Glenn is feeling better!

 

That's wonderful news about GM, I hope each day he gets better and better

 

I am happy to hear Glenn Miller is feeling better. I agree about the instructions you were given.

 

I’m so glad to hear Glenn has improved.
Make sure he is getting enough insulin and enough food and fluids. Feed him all he will eat. Post and ask for help if you are concerned about shooting a lower number. It’s really important you don’t skip doses of insulin if at all possible.
You can feed some higher carb food if needed to keep the blood glucose level up so you can shoot. Does that make sense?
I’m glad you have the blood ketone Meter. That is great. Test every day at the moment. If you could document in the remarks column of the SS all the ketone test results please, that would be very helpful for helpers.
Ask lots of questions. We are happy to help.

 

Hi there- Little bit more of an update:

I visited GM tonight and he looked great. My most recent conversation with the main vet who is working on him was a bit deflating... they still can't give me any answers and are now leaning away from actual DKA in the first place. This baffles me. Could a stressful event trigger IBD which would kick in some sort of acute DKA and throw ketones? As I said before (and I've been telling the vet the whole time), he did not exhibit the symptoms of DKA as he had the previous times, and his BG readings had been consistently good pre-hospitalization, up until the day before he was admitted.

They started him on a low dose steroid tonight, and he will switch to the softer steroid (starts with a B but it didn't sound like the budesonide-- will confirm tomorrow) tomorrow night with hopes of managing with a novel protein diet (like the rabbit) very soon. I hope to bring him home tomorrow.

Thank you again for all the help!!

 

I'm so happy to hear GM is doing much better, he must have been so happy to see you. I hope they can figure out what's wrong with him. He such a handsome boy

 

Did the vet give any reason why they did not start with the softer steroid in the first place?

 

Flat out because they don't carry it-- which is bizarre.

He's staying one more night there, and I'll pick up the prescription from the drugstore (I'm assuming) tomorrow.

 

Glad, to hear he is doing much better. It is so hard on you when they are in the hospital, I hope everything goes well for you and Glenn Miller.

 

Just another update that at this point, they have no idea what's going on with him. They say he's showing signs of remission, and although I see where they're coming from, I don't think that's where he's headed. His BG was 60 this morning, so they held off on the shot. They gave him a half unit last night when he was at 200.

They want to keep him as a medical boarder for a few more days and talking to me about inserting a Freestyle Libre. I have no idea what to do.

Any thoughts??

 

Any readings you get will no doubt be more accurate if GM is at home so if medically he is ready to come home, I would bring him home. Chances are good he is at least a bit stressed being out of his normal environment which almost always leads to elevated BG.

As for the Freestyle Libre, a number of folks have tried them with mixed results. The benefits are that you can take a reading at any time and get a graph to see what the whole curve for a period of time looks like without having to poke kitty. The readings seem to be a bit hit or miss in some cases (some report high readings, some low) and sometimes the sensor doesn't stay in place properly for the whole 2 week life of the sensor. I think they definitely are beneficial for anyone having issues home testing their cat but they are not IMHO the holy grail we all wish for. While GM's BG may have been low this morning after a 0.5u dose of insulin, I wouldn't jump to the conclusion that he is in remission on the basis of one "normal" BG reading. When did he last eat? How much? Perhaps this in indicative that a dose reduction to 0.25u is in order.

The Freestyle Libre will give you more data to assess the situation than manually testing. I think I'd be inclined to say OK to that but bring GM home if feasible to make sure the data you get from it is as close to his current "normal" as possible. Hopefully others will chime in.

 

Avoiding steroids if at all possible... please
Hang in there... you are doing the very best, you know how to do

 

I agree with everything Linda (@MrWorfMen's Mom) is suggesting ... -

 

Hey there, I see many have responded. Could you start posting over in the Lantus forum where all the peeps that are familiar with that insulin can offer support and advice.

The link for the Lantus forum is Here

See you there!

 

Thanks Bobbie!
Great idea

 

Hi there- Last update before I move over to the Lantus forum.

Glenn Miller came home Thursday evening with a smorgasbord of meds including the steroids, a potassium supplement, Clavamox, Zofran (oral AND injectable), oral Mirtazapine, Cerenia, and my favorite part- fluids! I'm pumped to have the fluids on hand. They still wanted to keep him on the sliding scale for his insulin but... no.

I finally received a call today with answers- the GI panel sent to A&M was positive for pancreatitis. The vet said to continue our current regimen and he'll most likely come off the steroids in a week.

He's not looking so hot tonight. He ate dinner and there's been no vomiting, but his energy is very low and he seems a little depressed. I know he's probably exhausted from all this hospitalization, but I'm watching him closely.

(As if I wouldn't be anyway... lol)

Final note- he did get the FreeStyle Libre! Two days in and I love it, but I am still very apprehensive.

Thanks again for all the help. I really appreciate it.

 

I know that part of me was SO relieved when I got that A&M GI panel back and it showed Sophie had pancreatitis, because at least then I knew what to treat! Hope the meds help GM start feeling better and get back on track!

 

You are welcome!
Thanks for the update
I’ll be keepin an eye on Glenn Miller and you!

 

Thanks for the update on Glenn Miller.
Did you end up getting the ketone meter? If he has been throwing ketones, even if it's not recently gone on to be DKA, I would still test for them as it's important to keep them in check.
Otherwise it sounds as if you are set up well.
Sending many vines for improvement. Please keep us updated

 

So happy GM is home, wishing you and GM all the best and please keep us updated on his progress

 

Glad that there is some good news and you have your boy back home

If GM has never had Clavamox before...know that It has made a couple of our kitties look and feel just *awful*, and also it negatively affected their appetite unfortunately. You have meds to combat nausea,vomiting and to increase appetite, I know, but that antibiotic could still be knocking him for a loop. I haven't dealt with pancreatitis personally, but I just re-reviewed http://www.felinediabetes.com/FDMB/threads/a-primer-on-pancreatitis.83108/ and it says that antibiotics are not usually prescribed. Was that just a Hail Mary on their part since they aren't sure? I won't recommend it removing it, but I would be curious to know if that is the culprit if the blood work didn't seem to have indications of an infection. But maybe there is an infection, and it is what is making him feel bad. If only they could talk, right?!?!

All 10 fingers and 10 toes, and all 23 paws here are crossed that GM just continues to see improvements every day