Sally, recent DKA, AMPS 61

Yesterday's thread: http://www.felinediabetes.com/FDMB/threads/sally-recent-dka-amps-91-6-326-pms-253.197771/
Sally's bg is 61 this am. I think I did this in the wrong order. We fed her and my husband is going to test in a little while and see if we can give her the .25. I think we need to do that because of her recent dka, keep a good amount of insulin and not skip a shot. I think we could also do a smaller amount of insulin too at some point but I 'd rather try to get the .25 in. I don't think this will be the new norm we are still working off the depot built up from the .50. I might be rambling, still waking up and have to get going to work. Am I thinking correctly or should we have waited to feed her?

 

I just looked at the SS and it looks like you did shoot 0.25u and +1 was 122, correct? Usually with the AT2 meter, we wouldn't have shot below 68. It's hard with the DKA in picture. I will tag some experts.
@Wendy&Neko
@Chris & China
@Marje and Gracie
@Sandy and Black Kitty
@Gill & George
@Jill & Alex (GA)

 

Thanks! It was tough this morning, my husband is home with her. Normally we wouldn't have given an injection...

 

When did you actually shoot? At the 61 or the 122?

 

My husband is home with her and he shot at the 122. I'm sorry so long responding I'm checking while at work. Her +3 was 159.

 

Shooting the 122 was fine, though that number now needs to go in the amps slot, and in theory, you should have shot 12hrs after that, so it should have seen you of schedule by an hour at pmps.
That said as she was on the rise at +11(the number you have in the pmps slot) it was ok to shoot early.

In theory when you get a number below 68, you should stall for 20min or so without feeding, or you can give them a tiny LC snack maybe a teaspoon, to see if that bumps thrm up to over 68. If you give a full meal as you did, the test at +13 (122) is food influenced so you can't say for sure if the BG is on the rise, and it's safe to shoot.

But it all turned out alright anyways.

 

The headache with feeding before shooting is that your end up artificially bumping up the numbers due to food. (This is why we suggest that people do not feed their kitty 2 hours prior to shot time.) If you were following TR, shooting a number like the 61 isn't an issue. With SLGS, it's a bit more of a challenge. Like Chris noted, stalling without feeding and then re-testing is an option.

The bigger issue is the recent DKA. I absolutely agree that you need to get insulin into Sally. Fundamentally, with a cat that is post-DKA, the dosing methods go out the window until the kitty is recovered and stable. I would also strongly urge you to get PM cycle tests. Even if the only test you get is a "before bed" test, it can help you to know that Sally is in safe numbers. In addition, without any PM tests, you are missing half of your data.

To be frank, I disagree with your vet. Shooting using a sliding scale is a good method with Prozinc. It is not a good strategy with depot type insulin like Lantus or Lev. Depot insulin works best if the dose is consistent unless an increase or reduction is indicated.

I'm not sure how you want to proceed. Since you noted that you're following SLGS, the drop into the 60s indicates you need to reduce Sally's dose. I'm a veteran TR person, so I wouldn't have a problem with your holding the dose but that's a decision you need to wrestle with especially with recent DKA in the equation.

And additional thought... How do you feed Sally? I also had a cat who was prone to early dives into low numbers. Rather than feed her an entire meal at AM/PMPS, I spread out her food into 3 - 4 installments over the first 3 - 4 hours of the cycle. By front loading the cycle with food, it helped to keep the numbers bumped up given Gabby's early insulin onset.

 

I also disagree with the vet. It was the ER vet consulting with the internal med dr at the hospital who came up with that plan. We believed from past experience with .50 bid it was too high for her. They supposedly devised this plan for her based on what they did in the hospital and our ss. When we got her home we were too scared to do anything else. Then some sense creeped into us and we decided to rethink all that, but we're till petrified of doing the wrong thing. The ER dr was great, her area of expertise is in treating DKA cats however that is totally different from day to day.....I really believe we helped to put her into the DKA, we had followed rdvm advice to try off insulin for a few days, and this is what happened.
We were trying to feed her a few times per day, 1/2 can each time, till she went into the hospital. They fed 4 times/day, but for some reason I guess because my husband had mentioned the twice a day feedings they sent us home saying to feed her twice a day. We would like to feed her a few times a day. We are now so exhausted....if there was any money we could pay to have someone devise a plan that works, we would pay it. I know that's not possible. She is getting back to herself, really needs to gain weight, but appetite is normal.
We are testing daily for ketones, yesterday's numbers looked so good to us but I think they need to level out, yesterday was the first test I remember being glucose free in her urine. So we really would like to keep the dose at the .25.
This whole thing has just been so disheartening. Especially since you really can't find a vet who really knows what they are talking about....and even worse because my being in the profession exposes me to many vets....it is scary. Scary to know that even we in our desperation to do the best nearly cost her her life.
We are so very grateful to all of you who have been here to advise.

 

(((Terri)))
In fairness to all veterinary professionals, yourself included, I think you all have a next to impossible task. Most vet practices are treating dogs, cats, hamsters, snakes, iguanas, and maybe an alpaca or two. I don't know how anyone can be an expert across so many species. Most vets don't get a huge amount of training in diabetes -- it's probably one lecture in a unit on endocrinology and that lecture is likely across species. Even needing to keep up with continuing ed, how many vets are taking the courses on FD? Part of the different here is that all we eat, breathe, and talk about is FD. Many of us have access to medical and veterinary libraries and we trade articles. There are also many of us who have cats that have survived DKA and have coached other members and their cats through DKA.

If you need a sounding board, put the question in your thread and a note in the subject line and people will reply. There are times that I research someone's questions (because I'm one of those people who has access to a medical/veterinary library).

From looking at Sally's SS, I don't know if the 0.5u dose was too much. The numbers are difficult to decipher due to not giving a PM shot. I'm going to sound like a broken record but please try to get at least one PM test every evening.

 

Thank you so much.