? Ketones 2.0 on Precision Xtra. Help!

I'm lost, guys.

Hugo has not been evening out with his numbers. He's been too high or too low, and last night he didn't eat all his food like he usually does. I tested for ketones with a dipstick, and it came back trace. We then tested with our blood meter and it came back 1.7. I called the ER vet and they said to watch him and take him in to see our normal vet in the morning. We tested him this morning (he also didn't eat all his food, but most) and he was at a 2.0. Our vet doesn't open for another 15 minutes, and he's so blase about Hugo's levels, I don't know what I'm going to get. My boyfriend is now unemployed with all this COVID-19 stuff, and I dont know how I can afford to get him in the hospital. We've been giving him his shots, feeding him the low carb food, testing him, on time. What am I doing wrong? I'm so scared.

 

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Post in Feline Health: Ketones 2.0 on Precision Xtra. Help!

 

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Elle, first breathe. 2 on meter is okay but needs watching. Your signature says you using lantus correct?

Your ss suggests othetwise. Lantus likes consistency. Dose is based on the lowest glucose reading, not the preshot readings. It looks like you are dosing on the preshot.

Add a little extra water to each feeding. Hold the dose you gave this morming. If you are home because of virus, can you do the TR method? That's testing each preshot and one other time between cycles, like a before bed test at night and a test during day between +5-8? Then you can increase dose after 3 days.

You not doing anything wrong, just need to review the protocol and tweak a few things. It's a big learning curve. Gotta keep him eating, get the right amount of insulin in and some extra water. How are his teeth, litter box habits?

 

Yes, Lantus. What is the point of testing preshot then?

Teeth are fine, as far as I know. He pees and drinks a lot, but that hasn't been any different from when he was first diagnosed.

 

To make sure its safe to give insulin. How would you know if glucose is low and then you gave insulin.

 

I agree with Paula. The other reason that Lantus likes consistency is that every time you alter a dose, the depot is affected. The depot needs time to stabilize. If you don't let the depot catch up, you get wonky numbers. Also, Lantus is long-acting. You can't effectively use a long-acting, depot-type of insulin to "shoot down" high numbers. Because Lantus is gentle and not as potent as some of the short acting insulins (e.g., Humulin N or Vetsulin), it doesn't yank down high numbers in the way I think you may be anticipating.

The other thing you're seeing are "bounces." Hugo isn't really used to seeing those blue numbers. When he does, his system panics. This results in a stored form of glucose, along with counterregulatory hormones being released and the numbers spike back to those ugly ranges. It can take roughly 3 days for a bounce to clear. That 2.0u dose brought Hugo's numbers as low as 79. That's a good place for numbers! By skipping the dose then reducing to 1.5u, it's not a surprise that numbers were high again. Raising and lowering the dose based on the pre-shot number is also having an effect on the nadir and you keep having to play catch up with the depot. Since 3/31, you've changed the dose 5 times. There's no good way to predict what Hugo's numbers may be.

Probably the most frustrating part of using Lantus is that you have to be patient. It's a great insulin but you can't get the results you're hoping for if you are reacting to pre-shot numbers and destabilizing the depot. It's a tough learning curve because we all want our kitties to be better yesterday.

 

We had him on the 2 units for quite a while though which got him in the 300s. That was when our vet said to start him on 3 units which messed this whole thing up. I think the vet expects them to go lower immediately as well, and that's what I was expecting. How do we deal with such a low preshot number without messing with his levels? It gets too low, we reduce a little, and it skyrockets? Is that normal? Do I just ignore the low preshots and go with what we've been giving him?

 

Sienne gave an excellent explanation. First, dose changes should be done in 0.25 increments. A cat gets use to being in higher numbers, so when it drops and in some cats it can be just a little drop the cat isn't use to, so the body panics and dumps a bunch of glycogen into the system causing the numbers to skyrocket at you say. We call this bouncing. It can take 6 cycles for the bounce to clear. This can happen over and over again. Once the cat gets use to lower numbers the bounce becomes less frequent and shorter lasting and eventually levels out the glucoses.

Lantus is a depot insulin and will take up to 3 days to fill. Every time you decrease the dose the depot is interrupted. Then it takes another couple of cycles to stablize when raise it again, so right now there is no way of knowing what dose is actually in the cat. And to complicate things more, when you lower the dose, the higher dose is still active for a few cycles until the depot has drained.

Keep an eye on those ketones, they do bear watching. If you can get a test later that would be good. Make sure to add some water to his food.

If you are not sure what to do. Use the ? in the title bar and post for advice before doing anything.

 

We took him into the ER vet. They said he did have trace ketones and his blood was a little acidic. He was also a little dehydrated. They gave him subcutaneous fluid, cerenia, and told me to start using his appetite stimulant again. We're seeing his usual vet tomorrow. They're doing blood work and a urine culture. The ER vet wanted an ultrasound as well, but they had no appointments available for that, but it didn't seem to press her too much. She thinks something underlying might be triggering it. Either way, I'm glad I got him in, if not just for the fluids. Now, to write another novel-long email to our vet.

 

Does anyone have any dosing suggestions? Should we go back down to 2.25 and hold it for a while or keep it at 2.5?

 

How about checking glucose an hour before shot time and post for advice. Use the ? mark and put in title need help with dose. I don't know if 2.25 or 2.5 would be better, but you need to stick with one dose for at least 3 days unless he goes to low. He could just feel crappy because of the unstable dosing right now and that is why he isn't eating well.

 

You need to ask you vet for an antinausea medication such as cerenia or ondansetron. If Hugo is nauseated he won’t want to eat and you should not give an appetite stimulant if the cat is nauseated. Treat the nausea first then give the stimulant.
Food is very very important when it comes to ketones. So you need to make sure he is eating plenty so getting the nausea sorted out is paramount.

Also ask your vet if you can do SubQ fluids at home. I am concerned the ER said his blood was a little acidic.... please ask your vet to address that. That is also very important.

Keep testing for the ketones at least twice a day at this point.

 

He got a shot of cerenia. We just gave him the stimulant. I will ask about SubQs.

I'm worried about the acidic blood too. The paperwork says ph7.319. Serum ketones were trace. And hyperlactermia, 4.7, which I think means he was dehydrated. He also got 150ml of the SubQ fluids.

 

Your vet should give you some oral antinausea cerenia to continue after the injection wears off.
How is he eating?. At this point anything he will eat is ok. Even if it is higher carb or dry. The important thing is he eats. And eats as much as possible. The things that prevent ketones developing are enough food and enough insulin. And having any infection or inflammation addressed. Also making sure they are well hydrated is also important.

 

He doesn't seem to want to eat his food, but he'll gobble up some chicken. Does it have to be cat food?

 

Chicken is fine short term. Keep offering regular though in small amounts until he starts eating it. Put left over in fridge so it doesn't go bad.

Fancy Feast Savory Centers might appeal to him and it's low carb. Also baby food chicken, beef, ham that has no onions or garlic in it appeals to cats with decreased appetite.

 

Let him eat whatever he wants at thIs point. As long as it’s ok for cats to eat. If he’ll eat chicken , that’s great. Don’t put added salt on it

 

We boiled a chicken breast (no salt) for him a day or 2 ago, cause we ran out of his treats. It seems to have come in handy now.

I don't think I would be able to get my hands on that specific kind of Fancy Feast right now. Baby food, possibly.

 

Any sort of meat humans eat would also be ok, if he shows an interest such as beef, lamb. Just gently cook it in some water and he will probably drink the juice. Or he might like it fried.
With chicken breast if you gently boil it in some water... not a lot of water, the juice is great too. Serve it warm with some of the juice over it.

 

Has he had his insulin since this morning? Any tests?

 

List of things to try:

• Suggestions on How to Stimulate Kitty's Appetite
• Syringe/Assisted Feeding (Video and Tips)
• THE '~LIVER SHAKE~' FOR SICK CATS

Have you gotten any mid cycle tests today?

 

He ate a little bit after we gave him the appetite stimulant and he ate when we fed him his evening meal, though not nearly as much as he usually does, which scares me. Oddly enough, our other cat also isn't eating now, though he does that on occasion. I may give them both some leftover dry food we still have. Hugo was drinking a lot, luckily. We retested his ketones and they were down to 1.1. I'm hoping it keeps lowering.

 

I have not gotten any mid cycle tests, since he was mainly focused on hiding. His PMPS was 294.

 

He got his tests. BG was 294. Ketones were 1.1. We gave him 2 units tonight, which the vet suggested.

 

Can you update the SS please.

 

The preshot tells you if your kitty is on the way up or on the way down - very important when faced wiith a lower than you have seen before PS. Keep in mind that because Lantus is slow acting you aren’t shooting at your PS, you are shooting at a number 2-3 hours down the road, when Lantus onset occurs.

So you know, the recipe for ketone development is:
not enough insulin + not enough calories + infection/inflammation of some other systemic stress.

You see the way DKA works is that when there is not enough energy from food making it into the cells, the body will breakdown it’s own fat and protein to try and fulfill the need for more metabolic energy. The excessive breakdown of these stored reserves creates a toxic by-product - ketones. As ketones build up in the blood stream, the resulting pH and electrolyte imbalances can very quickly develop to life threatening levels , a state of DKA.

Along with using nadir to determine dose adjustments you should be checking for ketones at least once per cycle. I’ve been down the DKA path twice. Once my kitty BK went from ‘negative’ to ‘large’ in exactly 24 hours.

Eating is important. The ideal to aim for is 1.5x the calories required to maintain ideal body weight.

 

I would continue to offer him small amounts of food throughout the cycle and try and get a couple of tests in around +4 to +7 so we can see how low the insulin is taking him.

 

Done.

 

I'm worried that the stressor that kicked this off was getting tested more. Though I'm sure our changing his doses so much really did it. I'm worried there's some other thing going on.

I'm just worried about everything.

 

He's definitely still interested in food, somewhat.

 

I doubt the testing would have caused the problem. But it is easy to start worrying about everything when things go wrong. But you have definitely come to the best place for help with a kitty with ketones.
He looks like he is interested in the pizza! Nice photo!

You have a plan now:

• Test every cycle for ketones and post result.
• Stay with the same dose of insulin unless it drops below 90 (SLGS) or 50 (TR), or ketones increase, in which case post and ask for advice on increasing the dose.
• Try and feed as much as he will eat (@Sandy and Black Kitty explained why that is so important. Feed small amounts often
• Encourage fluids
• Ask the vet for oral cerenia medication, doing subQ fluids at home and to address the issues raised by the blood test (acidic etc)..
• Keep us posted.......we care!

 

+4 was 204. I dont know if I'll be able to remain awake for a +6 or 7. I'm exhausted.

 

Go to sleep. He's not dropping fast enough to go anyplace dangerous tonight. Make sure he has some food in case he wants some.

 

Well done getting the +4

 

Good morning. Hugo ate a fair amount this morning. I feel like I can tell that he's feeling like crap. His AMPS was 220 and we havent been able to get enough blood out of his ear to get the ketone test yet. His appointment is at 10:15, so we might just wait for the vet to check.

 

Vet wouldn't give me fluids or anti nausea meds. Said we needed to wait until results from the tests to come back on Tuesday! He said just keep feeding him and he should be fine. He suggested either switching insulins or seeing an internist. Kinda sounded like he was done with dealing with me. I'm limited with the vets in my area that take my pet plan. I just don't know anymore.

 

arghhh. How frustrating.

 

I still wasn't able to get a blood ketone test, but I was able to get a dipstick, that seemed like it might be trace? We're really beating the **** out of his poor ears trying to get the amount of blood we need for that dumb ketone meter. I put an extra bowl of water in our bedroom to encourage him to drink more water, which he seems to like. He is acting better though, and eating more food.

 

I'm sure you likely already know the tricks for getting that precious blood droplet but I'll just review a few things I've learned since being here:

1. heating the ear with a rice sock or pill tube filled with warm water
2. massaging the ear to increase blood flow
3. hitting the 'sweet spot' of the ear
4. using the lancet free hand to prick the ear
5. "waving' the ear with both hands to encourage blood flow
6. test while kitty is having a treat or eating his meal
7. use a new lancet every single time
8. if freehanding with the lancet, ensuring the beveled tip of the lancet is facing up toward the ceiling.
9. if freehanding the lancet, prick on an angle
10. if using the lancet device hold flat
11. using vaseline on the ear will help the blood form a blood droplet
12. scoop up the blood droplet with a fingernail or credit card
13. make 2 pricks side by side to get more blood

The more times he's pricked the more capillaries are produced in his ears and it becomes easier to get more blood.

 

If you prick them 2x side by side, don't you have to use a new lancet for each poke?

 

For 2 pokes side by side I think you would be fine. You don't want to be using the same lancet numerous times because the tip gets deformed and dull.

 

from a sticky in the Q & A

I'm following the instructions faithfully, but I still can't get blood from my cat's ear.

A4.6. In addition to the excellent tips in the above links, here are some extra suggestions:

• Jerri & Opie's Rice Sock: Warm the ear using a sock filled with uncooked regular rice, barley or oatmeal which has been warmed in the microwave (test on wrist to ensure it's not too hot).
• Alternatively, use a small jar filled with hot water - kitty's ear may fit neatly around this curve, or a ziploc baggie with wet paper towel inside warmed in the microwave, or a heat lamp behind the cat's ear to keep it warm (not too close!).
• Or just massage the ear a bit to get the blood flowing.

• Hold something solid against the back of the ear to hold it in place. (A flashlight can serve double-duty here.)
• Get as close to the edge of the ear as possible.

• If using a lancet device, use the middle depth setting on the lancet device if adjustable. You can adjust depth up or down as needed with experience - you do not want to pierce through the ear although this is not harmful.
• Hold lancet device firmly against the ear.
• If doing a manual ear prick, be sure to prick the ear at a shallow (45-degree) angle, not straight down.

• Fold the ear over the wound, or pinch the ear gently on either side, to help the blood well up.
• If the drop is not forming properly, gently "milk" the ear on either side of the prick by stroking towards the prick, bringing the blood to that area.
• You may attempt to add more warmth to increase size of blood drop depending on your heating method.

• Sometimes it helps to make 2 pricks side by side one after the other to ensure you get enough blood from one or both.
• Try using the other ear.

• To prevent bruising, apply firm pressure on the ear prick with a tissue while waiting for the meter to count down.

Be sure to give your cat a hug and/or a treat afterward to reinforce the idea that this can be a pleasant experience!

http://www.felinediabetes.com/fdmb-faq.htm

 

His +6 BG is 391. We went through 4 more lancets to get blood for the ketone meter, and none of them got enough.

My guess is his BG is so high because he's eaten a bunch. I don't know what to do. Stay on 2 units? Go back to the 2.25? Isn't this what got me here in the first place?

Also, the vet gave me options about Hugo's numbers. He said if they're still bad, we could try switching to a different insulin or he could send me to an internist to look at my info and see what they suggest. I know the specialists around here cost at least $125-150 to even get in the door.

Any ideas?

 

Hey Ella!

It helps to remember that with Lantus, your dose is based on the nadir -- the lowest number in the cycle and not on the pre-shot numbers. Let me further that statement. Any time you make a dose adjustment, you need to hold the dose for several days. Since you're following SLGS as your dosing method, that means you hold the dose for a week unless numbers drop below 90 which means. you reduce the dose, hold the new dose and go from there. The only thing that disrupts the week of holding the dose is if a dose reduction is warranted. Because Lantus is a depot-type of insulin, if you don't let the depot catch up with a dose, you end up with wonky numbers. You've been making dose adjustments almost every cycle since 3/30. I'd strongly encourage you to decide on a dose and hold it for a week.

IMHO, at this point, a change in insulin or an internal medicine consultation is premature given my above observations. If you want to be more aggressive about dosing, how about reading over the Tight Regulation Protocol? It will allow you to increase the dose more frequently. I also don't think Hugo's numbers are that bad. Yes, he's seeing some high numbers but they look to me to be bounces from from of the low blues. It can take roughly 3 days for bounces to clear (which is another reason to not tinker with the dose until you really know how low a dose is taking the numbers).

That's my 2 cents.

If I could ask a favor. On this forum, we ask members to open a new thread each day. You link your previous day's thread to the new post for continuity. This prevents the threads from getting overly long and makes it easier to find information you (or other members) may be looking for.

 

I can’t believe the vet would not give you anti nausea meds. That is disgraceful when you are battling ketones and Hugo is nauseated.
Would the ER give you some oral cerenia, do you think?
Is there no other local vet you could go to?

What size lancet are you using? The best sizes are 26 and 28 gauge if you are having issues.
Is there an adjustment on the lancet device for you to change the depth of the prick?

Are you holding the ear after you get the blood for a minute after you get the blood to stop bruising?
Are you using both ears? You can also use both sides of each ear.

I see that Sienne has just posted and I agree....I would not go to an internist or change insulins at the moment.
I would also look at the TR method....it will give you more options which you need if you are dealing with ketones.
Keep offering food. (Except for the 2 hours before you test for the preshot BG)and test the urine for ketones when you can...at least once every cycle. If you can get a blood ketone reading that would be good too.

How is his appetite today?

 

I could call the ER and see if we could get some oral cerenia from them, but Hugo seems to be eating better with the appetite stimulant. He's also hugging the water bowl. We're using 28 gauge. There is an adjustment, and we have made it deeper, but I think I'll have to try it on my own tonight, since the last time we tried it, my boyfriend and I got very frustrated with it and he swore he would never use it again. I do hold the ear after and we do use both ears. It seems like they bruise fairly easy though. I didn't know you could use the non-sweet spot part of the ear though, thank you.

 

When I was testing Sheba a lot I used all the edges of the ear to get blood to give the other areas a rest. It may not bleed as well.
If you hold a torch behind the ear, you can see a vein running around the whole ear. You need to try and get between that vein and the edge of the ear.
Do you have the neosporin pain relief ointment to put on the ear after pricks? That can be helpful..make sure it is ointment not cream.

If you think Hugo is eating ok without the cerenia, you may not need it. You are there so you need to make a judgement call on that.
I’m glad he is eating better. Remember that food is like a medicine when ketones are involved.
What food are you feeding him? Is he eating low carb or are you having to tempt him with higher carb food?

 

I'm feeding him his regular Friskies pate with a fair amount of boiled chicken.

 

Ella, I’d start a new thread and link this thread to it if you can, by copying and pasting the URL of this thread onto the new one. If you can’t do it I’ll do it for you, no problem.
Call the new thread something like......4/4 Hugo AMPS 220, +6 391 Ketones
Putting the ketones in the subject line will help identify you as needing help.

 

Thank you! Sorry!