Kitty who is prone to ketones... running out of options

Discussion in 'Feline Health - (The Main Forum)' started by CCG, Jun 12, 2019 at 12:51 PM.

  1. CCG

    CCG Member

    Joined:
    Wednesday
    Hi all,

    Thanks in advance for reading our story and offering advice.

    I am posting about my 11 year old baby, Ty, who was diagnosed with diabetes in February of this year (2019). We took him in after he suddenly was clumsy/unable to use his hind legs (which we now know is diabetic neuropathy).

    Ty has had two (4-5 day) stays in the emergency clinic because of DKA in the last two months. He is currently back home now and seemingly doing well, but I am posting to get advice. We are doing EVERYTHING we can to help him, and both veterinarians he has seen don't have much more information to offer us. I will now tell his story and am hoping that others have been in a similar situation and might be able to offer guidance. Between these two stays and his other visits/routine care, we have now spent over $10,000 in the last several months and financially we cannot afford for this to happen again. I can't stand the thought of putting my baby down if this happens again - especially for a theoretically "treatable" condition - so all thoughts are appreciated.

    Upon original diagnosis, our family vet recommended that he start on 1 unit of insulin 2x/day. We started on Humulin N. He had no ketones at the time of diagnosis. At this time I did not know that I could monitor his blood sugar, etc. at home, so we mainly monitored clinical symptoms (his neuropathy, frequency of urination, amount he was drinking and how much he was eating). He did not seem to be doing much better so the vet recommended we increase to 2 units 2x/day. We went on like this for awhile, seeing some? improvements (not many) until all of a sudden in late April. We left for a short, four-day vacation and one day into it our pet sitter called and said that Ty was lethargic, vomiting, and not eating. She took him into the vet office and they found that his ketones were high, so she immediately rushed him to an emergency clinic near us. He stayed for five days and the bill was nearly $6,000. But, his ketones were gone.

    After the emergency visit, an internist who started seeing him (works at the emergency hospital) made a few recommendations in conjunction with our family vet. First, we started him on Lantus (glargine) instead of Humulin. Second, we went back to 1 unit 2x/day. They suspected that Ty's glucose levels had been too high for too long and ultimately led to ketones. They also suspected that we were giving him TOO MUCH insulin and that his body was responding by spiking his blood sugar to try to avoid hypoglycemia. Ty seemed to be doing OK, but his clinical symptoms weren't significantly better. At this point, I also started checking his blood sugar at least 2x/day and testing for ketones once a week (urine strip). We did a glucose curve at home 14 days after he was released from the hospital and both of our veterinarians became slightly concerned that the "somogyi" effect was occurring -- same thing, that we were potentially giving him too much insulin. After this, we reduced his insulin dose to 1 unit, 1x/day (morning).

    After this reduction, Ty seemed to be doing much better. Drinking less, urinating less; his neuropathy wasn't gone, but improved. He wasn't totally back to his old self, but as close as we had seen him since diagnosis. My husband had even commented that he seemed much better.

    I tested for ketones last Sunday, and the test was negative. We had a normal week. Ty's blood glucose levels remained anywhere from high-200s to mid-400s. We were told this is OK as long as clinical symptoms seemed better. Then, out of nowhere, I woke up on Friday morning at 5am because he was vomiting bile. He seemed lethargic. He would still eat a bit and drink, but it was a very sudden shift in his behavior. I immediately suspected ketones and kept an eye on him throughout the day. I wanted to rush him in, but since we had just spent all of our savings, I decided to monitor for a little bit. He wasn't improving. By Saturday morning I was able to get a urine analysis done and his ketone levels were high. I took him into the hospital and he stayed until Tuesday. They were again able to reduce his ketone levels to negative, but we again paid close to $5,000 for his care. The veterinarians taking care of him have not been able to diagnose any underlying disease that could be leading to the rapid development of ketones -- he has a heart murmur, but no underlying heart failure, no kidney failure, no cancer. He had an abdominal ultrasound and his liver was slightly enlarged but they attributed that to the diabetes. They said it was possible that there was an acute case of pancreatitis, or some kind of GI flare-up that caused ketone development, but that was just speculation because they WEREN'T seeing anything else. But they couldn't offer much else and told us to keep doing what we are doing.

    All of that said, we cannot afford for this to happen again. Ty is my baby, and I want to do everything that I can to help him. I cannot stand the thought of putting him down, especially when he is only 11 years old and seemingly doesn't have anything else "more serious" going on than diabetes, which should, theoretically, be manageable. We are keeping our regimen as it is for now, but I am so worried about this happening again. Is there anything else that could be going on with him that I'm missing? Is there anything else that I could be doing to help him?

    Thank you.

    PS - Some additional details:
    -Ty eats Fancy Feast (classic pate) at 7am and 7pm. I have been giving him 1 1/2 to 2 cans per meal and he will usually eat all of it. He has never really been overweight and has lost a lot of weight because of the diabetes (he is down to 9.7 pounds; his healthy weight is probably in the 12-13 range).
    -I give Ty his insulin 20 minutes after breakfast every morning. He is a true trooper and is SO good about letting me check his sugars and give him his shot.
    -I have been checking for ketones every week, but am going to change that to every other day for now.
    -We have two other pets (a cat and a dog, both healthy) in the house. They all get along and have co-existed for years together.
     
  2. Sharon14

    Sharon14 Well-Known Member

    Joined:
    Aug 16, 2015
    Welcome! Sorry you and Ty are having such problems. I’m glad you are testing. Are you still giving Lantus once a day? If so, you need to switch to twice a day. 200’s to 400’s are not good levels and that may be the main reason for the ketones reoccurring. Also it’s fine to feed him more than twice a day. The calories can help to prevent ketones too. If you can set up our spreadsheet it will help us see what’s going on so we can better help you.
    http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/
    Let us know if you need help setting it up and we’ll do it for you.
     
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  3. CCG

    CCG Member

    Joined:
    Wednesday
    Thank you for your reply. I have my own spreadsheet for keeping track of his numbers, but I have copied this one and start putting his data in here, too.

    Yes, he is still getting Lantus once a day, per recommendation of both vets. They were concerned based on his blood glucose curve that he was actually getting too much insulin with 1 unit 2x/day, because there was a sharp decline in his blood glucose immediately following injection that shot up quickly into the 400s within several hours.
    I will also say that his numbers were even higher on average (300-500+) when we were giving Lantus twice a day.
     
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  4. Sharon14

    Sharon14 Well-Known Member

    Joined:
    Aug 16, 2015
    Instead of 1u once a day, you can give .5 u twice a day. It will help keep his glucose steady since insulin doesn’t last 24 hours. Dosing strategy will be easier once we can see his numbers in the spreadsheet. Here’s a link to the Lantus forum. Check out the yellow stickies at the top of the page.
     
  5. Sharon14

    Sharon14 Well-Known Member

    Joined:
    Aug 16, 2015
  6. CCG

    CCG Member

    Joined:
    Wednesday
    Thank you. I started to record his numbers on the spreadsheet.
     
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  7. Sharon14

    Sharon14 Well-Known Member

    Joined:
    Aug 16, 2015
    Great! Have you checked out the Lantus forum I linked above? Lots of great info and you can post there to get advice specific to Lantus. I’ll tag @AliceMeowliss&Cassandra as her kitty just had DKA, and is on Lantus, so maybe she has some ideas for you.
     
  8. CCG

    CCG Member

    Joined:
    Wednesday
    Reading now. And thank you :)

    I am so torn on how best to move forward. I keep thinking his numbers look too high, but the idea that more insulin could actually drive his numbers even higher makes me worried :(
     
  9. Sharon14

    Sharon14 Well-Known Member

    Joined:
    Aug 16, 2015
    Go ahead and post on the Lantus Forum. They are great at reading spreadsheets and advising on doses.
     
  10. AliceMeowliss&Cassandra

    AliceMeowliss&Cassandra Well-Known Member

    Joined:
    Jan 8, 2019
    Okay so Alice is just home recovering from surgery this evening so I will be brief for now compared to my usual verbosity.

    I tried to treat with NPH first (Novolin N, Humilin N). It was a major fail. I only achieved regulation on it after switching to 3x/day dosing.

    Alice had lost so much weight she was only about 60% of her usual weight. She was a walking skeleton.
    But since Lantus, frequent home testing, and lots of food, she gained back almost 3lbs in just a couple of months. :)

    Recipe for DKA: not enough insulin + not enough calories + infection or inflammation. Short version.

    Alice’s recovery has been best when I switched to Lantus because it lasts longer. I kept her high dose and have been simply feeding her way through it. Lots of food and lots of insulin helped her gain weight and she looked marvelous until surgery today.

    DO keep up kitty’s fluids. This will help flush any ketones. I mix a lot of water in with each feeding, and I feed Alice anytime she wants except the two hours prior to testing before her shot (so I can make sure it is safe to give her shot and that it is not a food-influenced number). Shooting higher can allow for you to feed more food, and if you test enough and feed enough you may be able to avoid those bounces. This is called..... feeding the curve...... perhaps someone else could give you more details as I am in caregiver mode extreme right now.

    I want to say thank you for your efforts, and your love. It takes a special person to spend $10,000 on their cat.

    Keep practicing testing blood sugar and start getting more data into that spreadsheet. You absolutely do want to do shots every twelve hours, so if you have to split the dose that is fine, 0.5u 2x/day will just be better.

    Something someone said that helped me u sweat and this whole crazy process better—we first think of insulin like medicine. You give it and things get better. But that’s not how hormones work. They are just way more complicated and make you want to bash your head into a wall sometimes. :banghead:

    @CCG , I am glad you found this group, because the one thing I can tell you for sure: I would not have Alice today without FDMB and everything they have helped me learn and helped us overcome. There is so much support and information. Best wishes to Ty-cat going forward. You are welcome to tag me in your posts in the future with any questions or just to share something. You can do this by typing the @ symbol and then start typing my username. :)
     
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  11. Bron and Sheba

    Bron and Sheba Well-Known Member

    Joined:
    Feb 21, 2015
    Hi @CCG and Ty and welcome to the forum. You have been given great advice from @Sharon14 and @AliceMeowliss&Cassandra .
    I honestly don't think that you have been given the best advice going forward after DKA and ketones...from the vets. Once a day Lantus is not enough for any diabetic kitty and with a DKA kitty it is imperative that they get the insulin twice a day to stop the ketones reforming.. And the urine ketones need monitoring daily after DKA. It is much easier to turn ketones around when they are small, than it is when they are full blown.....this is not your fault........you should have been advised better.

    I am glad you have swapped to twice a day insulin. If the BSLs (blood sugar levels ) dont start to come down, you will need to increase to 0.75 units twice a day as it is really important that your kitty is getting enough insulin to keep the ketones at bay.
    Make sure you have some high carb food and honey at home in case of low BSLs at all times. Test before every shot and again during the cycle if you can..
    I would also feed him some more food. Food is very important when a kitty has had ketones and DKA. It is almost like a medicine and it helps stop the ketones reforming. We recommend feeding at preshot and then again around +3 and +5 or 6 both cycles. It is better for the pancreas than just two meals.

    Also give him as much fluid as he will allow you to put in the food.
    And I would be testing the urine for ketones every day at the is point.
    Keep asking questions. We can help you get Ty well again. :bighug:
     
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  12. CCG

    CCG Member

    Joined:
    Wednesday
    @AliceMeowliss&Cassandra - thank you very much for such a thoughtful reply and the helpful tips, especially while your own furbaby is recovering. I hope she is doing well today post-surgery.

    Will definitely mix water into his food -- that is a great tip. I'm so torn on how to move forward with the insulin and feeding, just because the vets have so strongly recommended the 12 hour schedule, and confusingly, have said that it should be OK to do 1 unit 1x/day (I agree with you that it makes so much more sense to do a 12 hour schedule for the insulin). It seems like such a delicate combination of feeding + insulin that we just can't seem to get right.

    It does worry me to start giving him more insulin based on what happened when we were doing 2 units 2x/day -- he went into ketosis. And when we were doing 1 unit 2x/day his glucose levels were ever higher than they are now.

    He is our family and we want to do right by him. It's just so tough. I really like your medicine/hormone analogy. I wish he could just tell us how he was feeling!
     
  13. CCG

    CCG Member

    Joined:
    Wednesday
    @Bron and Sheba - thank you for the welcome and the helpful note.

    Maybe I should take Ty in for a different opinion somewhere else? I know that our initial vet wanted to be cautious in avoiding hypoglycemia. But that doesn't explain why they want to keep him on a low dose now. I just found this...
    https://www.aaha.org/guidelines/diabetes_guidelines/monitoring_algorithm.aspx any sense of how reputable this organization is?
    Ty is nowhere near 2U BID and is still exhibiting symptoms.
    So much conflicting information :(

    I will give him more food and loved the recommendation above to mix water in, which I did last night and today.
    I tried to test for ketones this morning but he scraped the small amount of litter I had in the box (he won't go in without it) in such a way that it absorbed all of his urine before I could test :-/. Will come home early and try this afternoon again.
     
  14. CandyH and Catcat

    CandyH and Catcat Member

    Joined:
    Apr 23, 2019
    might it be worthwhile to replace the litter temporarily with either lentils or aquarium gravel? --or put some crinkled up plastic wrap in the litter box to catch some pee?

    some have been able to slide a long handled spoon/ladle underneath, if you notice or catch him in the box
     
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  15. CCG

    CCG Member

    Joined:
    Wednesday
    Thanks for the suggestions. I could try aquarium gravel. I’ve tried the small rubber pellets and catching his urine in the past and he just wouldn’t have it. He’s picky.
     
  16. Sharon14

    Sharon14 Well-Known Member

    Joined:
    Aug 16, 2015
    Do you have these readings? You went from 1u to 2u which is too big a jump. We recommend you only increase by .25u at a time and only after at least 3 cycles at one dose to allow the Lantus depot to stabilize. Please go to the Lantus Forum and post for dosing help. They have a lot of experience with that insulin and will be able to help you. While you definitely don’t want a hypo, you do need to get Ty’s glucose down into normal range to help stave off the ketones.
    Candy gave you some good suggestions on the ketone testing. Good luck and keep us posted!
     
  17. CCG

    CCG Member

    Joined:
    Wednesday
    Thanks. I am working on putting in his past readings in his spreadsheet. I've put them in from when he was on 1U 2x/day.
    When I am finished with the rest I will post on the Lantus forum to get their feedback.

    Thank you!
     
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