Sebastian has moderate ketones

Okay, Vetsulin is garbage. Just tested him and he's showing moderate ketones. I'm not sure what to do. No vet is open right now. Do I give him some Lantus?

 

I found an emergency clinic that's open and I'm taking him there now.

 

Hi, don't panic just yet, is he eating?
How is he behaving?

I see you went with the vets suggestion of dropping the insulin back as well.
Taking back his dose by such a large amount is likely contributing to the situation.

Sebastians previous post
http://www.felinediabetes.com/FDMB/posts/2337601/

 

I'm going to try and contact some of the members that have a lot of experience in dealing with DKA. Stay in touch.

 

He ate a little bit, maybe a 1/3 of what he usually eats.
He's behaving relatively normal.

Yeah, per the vet's suggestion we went to 2u of Vetsulin.

 

Do you have sub-q fluids you can give?

 

Problem is I don't what the timespan is from when ketones show up to when it's a problem. This happened a couple weeks ago too when we tried the Vetsulin and were messing with his diet. Ketones weren't quite as high, but we went back to his regular food and Lantus that night and by the next day they were gone.

I'm kicking myself right now. You guys knew better, my gut told me not to trust the Vetsulin, and I did it anyways.

 

No. My local vet that's around the corner opens at noon and they do.

 

I know I'm sorry you got some bad advice from the vet, I can understand wanting to believe them.

I do think that you should go back to Lantus and the dose he was at, as we know that not enough insulin, combined with inappetance/not enough calories and some other systemic stress, could trigger another episode of DKA.
I've sent an SOS out with it being the weekend I'm not sure who is about, I hope that someone will get to you soon.

Getting some extra fluids is a good idea as it can help flush out the system, keeping kitty hydrated is important.

Keep monitoring that, offer him some more food a little later, making sure he gets enough calories into him is important at this stage.

 

You just shot the Vetsulin, so you would need to wait until you can be sure that it is out of his system before you shoot Lantus again. I'd be concerned about nadirs overlapping and BG dropping to low for you. I'm not sure what the usual nadir/duration of Vetsulin is.

 

Are you testing blood or urine for ketones?

 

Will he drink water? Try and offer him a mixture of water and tuna water and see if you can get some extra into him.

Gizmo loved clam juice. Again diluted. Just enough for them to taste it

 

Vetsulin usually lasts about 7-8 hours in the system (sometimes up to 10, but not with this low dose) with a nadir around 4-6 hours.

 

That 209 to yesterday isn't terrible.... Before today when was the last time you tested ketones?

 

Urine testing for ketones. The reading came back at moderate (50).

He is drinking, he's made a few trips to the water fountain so far today. Just now in fact. And he is eating. He only picked at his normal food but if I break out the treats and put a few in his bowl he'll eat them up and a little more of the food.

 

The last time I checked the ketones was either thursday or friday. Either right before or right after we switched to the Vetsulin.

 

It's good he is drinking and encouraging him to eat is a good plan for now.

I'm not sure if you know, but there is also a food transition in the mix from a high carb kibble to Dr Elseys LC kibble. Just so you are also aware. So it's unknnown if it's the kibble transition, or the vetsulin, also with the large dose of lantus that Sebastian was on the depot will possibly also be influencing that cycle with the 209. The previous DKA incident was a result of a similar suggestion by another vet, Sebastians dose was dropped and insulin swapped, this resulted in DKA two weeks later, so I think that's why Sebastians dad is worried.

 

So I just mixed up a batch of tuna water for him. And I gave him the can with the scraps and he's currently licking every molecule out of it.

That timeline on the DKA is a little off. We did drop the dosage down to 3u per vet suggestion, this being after they tried us at 3, 4, and 5u with no change in BG, but it was still Lantus. Were at that level for a couple months and then the p'titis and DKA set in. The Vetsulin switch was recent, first attempt was 1/30 and we did that for a couple days until his ketone levels started to rise and we switched back to Lantus.

 

So should I still go to the vet and get a sub-q shot or is the fact that he's drinking on his own and still eating a bit enough? I was planning on going tomorrow to get the blood draws for the IGF and IAA tests so I need to make a trip anyways, just wondering if going today and getting the shot is a good idea.

 

I can't stay on I have to go out now, I hope that someone with experience can offer some advice soon.
In the meantime if you can grab another ketone test at some point then that might be a good idea, just incase reading was off or you can monitor any increase or decrease in their prescence.
If he stops eating, acts lethargic or seems off, then I would definitely be taking him to the ER.
Symptoms of DKA to watch out for
Taken from the feline health sticky
http://www.felinediabetes.com/FDMB/...oacidosis-dka-and-blood-ketone-meters.135952/

Signs of Diabetic Ketoacidosis (DKA)

• • Drinking excessive amounts of water OR no water
  • Excessive urination
  • Diminished activity
  • Not eating for over 12 hours
  • Vomiting
  • Lethargy and depression
  • Weakness
  • Breathing very fast
  • Dehydration
  • Ketone odor on breath (smells like nail-polish remover or fruit)

Pet Diabetes Wiki "Ketoacidosis": What is it? Is it dangerous? When to go to the vet? How do you test for it?
Please go to the link to read all about ketones and diabetic ketoacidosis.

Thanks for clarifying, I must have got the two mixed in my head when I read through all the condos yesterday.

 

Thanks for all the info and getting others involved. And yeah, it's been a roller coaster.

 

I don't know, it's promising that he's drinking and eating, perhaps if you can grab another ketostix test that might sway you one way or another. I'd be inclined to go to the vet if it was still reading moderate or rising, and monitor if it was just showing trace. I may be erring on the side of caution with that since I have no personal experience of dealing with DKA/Ketones, but I have seen them develop very fast on other kitties here on the board.

The link above on Pet Diabetes may help you decide what's best.

My concern is that he is likely not getting enough insulin the last few days, he's dropping weight so he's not getting enough calories, if he had any other systemic stress or infection then that could turn out to be the perfect storm.

I'm sorry I can't be more help.

 

Generally, when a cat is hospitalized, they use a short acting insulin (e..g, Humulin R) to manage the ketones. This means the cat can be dosed as often as every 4 hours. Your vet's suggestion to drop the dose from 7.5u to 2u was not a well informed recommendation in a ketone prone cat. Personally, I would get Sebastian back on his usual dose of Lantus as soon as you can.

Gill is correct in that ketones can develop quickly but you may need more of an intervention than you can provide at home if the moderate level is accurate. Are you using a blood or urine test? I'm assuming it's a urine test since your reading is "moderate" rather than a number. It's hard to know how variable the ketone situation is with a urine test. The vet should have a blood ketone meter or a way to test the blood for ketones.

We urge people to get their cat to a vet if the ketones are above a trace level. You should expect a vet to put Sebastian on fluids and run lab tests to see if his electrolyte values are out of normal range.

 

Another question, when I switch him back to Lantus tonight, how much should I give him? This is one thing I haven't been able to wrap my head around, his BG numbers are basically the same whether it's 3u, 5u, or 7u. Prior to the p'titis we did about a month each at 3, 4, and 5 and it didn't have any effect on his weight or BG. The past couple months we changed dosage quickly so I didn't get a good sense but his weight always started to climb back up at 7u, even though he's still well below ideal weight. He was at 7.5u Lantus before we switched to the 2u Vetsulin Thursday evening.

On my way out to the vet now to get some sub-q fluids and have them check his blood.

 

When I switched insulin from Vetsulin to lantus the peeps here said it was okay to start at next regular shot time. You have to remember it will also take time to re-establish the depot.

You do need to keep him eating and subq fluids (it's NOT just a shot) will be a big help to flush his system and keep him hydrated. It giving 50-100 cc just under the skin where it forms a bubble) that's absorbed over time. It takes 10-20 minutes if kitty cooperates nicely. Is that something you can do daily for awhile? Does he have any heart related diagnosis that could contradict fluids? That's important, you don't want to over load the heart.

I would call your local vet, he will probably want to see him, but then they can show you how to do subqs, hopefully draw the other tests you want then you won't have to make another trip tomorrow.

 

Bubba threw moderate ketones while he was in the 200's also. Luckily, he continued to eat and I added as much water into his food as he would tolerate as the water will help flush the ketones. His ketones came and went from day to day and soon when I got enough insulin into him, his numbers started to come down.

As Gil said, the recipe for a DKA event is : Not enough insulin, in appetence and infection or systemic stress.

When Bubba had the moderate ketones we were using Lantus and with the help of very knowledgeable peeps here we also used Novolin R, a short acting in/out insulin, to help grab the numbers down and break through the insulin resistance. It might be something to consider with help .


ETA: I too am glad you went to the vet for a current ketone reading and sub q fluids. We also went to the vet when Bubba was throwing the ketones. I invested in a blood/ketone meter so I had a instant snapshot of what was happening in the blood right now. When using ketone urine sticks, it can take up to 8 hours for the ketones to show in the urine. A urine test might tell you negative ketones when in fact they have them. With a kitty who has had DKA, time is important.

 

Any reading above ‘trace’ warrants a call to the vet. Glad to hear you are taking him in.

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.

Keep us updated

 

So I still don't understand why he throws ketones on the Vetsulin but not on the Lantus. His BG has been the same on both but only the Vetsulin causes problems. That's causing me to completely not understand what is going on with his treatment.

We got back from the vet. They took the blood for the IGF and IAA tests, they did not do a blood ketone check and just did a physical exam, so I'm going to go get a meter and do it myself. They recommended we stick to the Vetsulin and just increase the dosage from 2 to 3u. They did not give him a sub-q. Until we got into the lobby for checkout and he started vomitting. Then we took him back and they gave him an anti-nausea and sub-q bag, but nothing else.

At this point I'm pretty much done with both these vets and am going to setup a consultation with another local vet. I'm also going to put him back on the Lantus at 7u tonight until they're able to provide me an adequate explanation for why the Vetsulin would be preferable and why he's getting sick on it and not the Lantus. To me it's completely absurd that their solution to insulin resistance is to switch to a different insulin, at 25% of the volume, without even bothering to test for things that could cause the resistance or give an a reason why.

 

Sounds like a plan. Is it possible the vetsulin itself is making him vomit? I guess it's possible he reacts to it but I don't know for sure.

 

I think the issue is that he is not getting enough insulin. If you had reduced the dose to 2u of Lantus, my feeling is that you would have found yourself in the same predicament, this is what happened last time when you said they got you to try various lower doses of Lantus. You might start to see the BG move some once you complete the transition to LC completely. We've had numerous cats develop IAA or glucose toxicity and basically they eventually hit a break through dose which sees them in better numbers and start coming down the dosing scale. It has not been necessary to swap insulin. I suspect your vets are not familiar with Lantus and are just going back to something they feel more comfortable with.
Your observation that his weight is stable on the 7u of Lantus and he's not sick is also a telling factor. My Cat lost quite a lot of weight just before diagnosis, he leveled out once I started insulin therapy, but it wasn't until he was in much better numbers did his weight and body condition come back to normal.

I'm speechless, given his history and the fact he was presenting with ketones in the urine. Good plan on getting a meter, hope you can get one today.

I'm glad that he got some Subq but sorry that he had to start vomiting in order to get it. How is he doing since you got home? Are you still managing to get him to eat and drink? If he stops eating you may need to consider assist feeding.

I think that is a reasonable plan, my only worry is that because of the way lantus works, being a depot insulin, it takes a number of cycles for the dose to reach it's full potential therefore this may not address the problem quickly enough to prevent Sebastian from having another DKA episode.
I think that the vets you have spoken to are not really up to date with FD, vetsulin, is typically too fast acting and doesn't have enough duration for cats, Lantus and Lev, are much longer acting and slower to onset and dosed twice a day a lot of folk eventually manage to get their kitties spending significant time below the renal threshold.

That's good, will you be able to see someone today? or is it going to be tomorrow?

 

He's been good since he got home. He ate a bit and drank some more tuna water and has just been resting on his "boat" with no more vomiting. Overall I think he looks okay. Having been DKA twice now I know what the critical stage looks like and he's definitely not there so hopefully we get the Lantus back in him and he turns around.

Blood ketone meter won't get here until tomorrow but I'll continue to urine test him as I'm able and keep an eye on his eating and drinking. I work from home so I'm fortunate in being able to keep a close eye on him. Got the Lantus too, after much wrangling of both vet and Walgreens. I swear none of these people know what they're doing. Walgreens had the wrong fax number for the vet so they just deleted the Rx. I mean, really?

I'm going to check out the new vet tomorrow and try to get a consultation scheduled ASAP. I want to really grill them on what they know before I commit. Otherwise I'll just pay lip-service to the current vet to keep getting his Lantus and whatever tests he needs and rely on you all for actual dosage guidelines.

Again, thanks everyone. From my wife also, she's been skimming the forums too to keep up-to-date on what's going on and we both really appreciate everything you all are doing.

 

You might find this link interesting if you are interviewing a new vet.
http://www.felinediabetes.com/FDMB/threads/vet-interview-screening-topics-check-list.156663/

This is a strategy that quite a number of us have followed.

 

Cute picture.

 

I hope you find a more suitable vet. Keep those subq fluids going. I'd find out what's safe to give on a daily basis once you see those ketones disappear. I brought Ming in for daily subq fluids once when he was having a p'titis attack.

It's so frustrating that you have to get an rx for insulin and "convince" vets to give you it.

 

Caring for a kitty that is battling ketones requires intensive care. I’ve been there.

I think using humulin R, a fast acting insulin, along with the Lantus can help. That’s how my Black Kitty survived.

It’s not something you should attempt without the help of an experienced R user. Also know that close BG monitoring , both AM and PM cycles, is a must.
Please let us know if you are interested and we can make sure to have folks with experience guide you. Do not attempt it alone.

Working from home is a huge advantage. Is your wife able to test Sebastian as well?

 

Unfortunately, without lab tests you don't know if Sebastian was throwing ketones or was in DKA. His electrolytes would need to be off in order to diagnose DKA.

The basics:

• Add as much water to Sebastian's food as you can
• Make sure he's getting a sufficient number of calories
• Stick with the Lantus. Sandy's suggestion about using R may be helpful. You will need an experienced user to help you with this type of insulin.

The likely reason that Sebastian is developing ketones with Vetsulin is the recent dose is too small. Dropping from 7u to 2u was at best, ill advised, at worst, stupid. The other reason is that Vetsulin does to have the duration that Lantus does. You have several hours of the cycle where there is no Vetsulin at work.

 

Yes, using R is a really good idea as I mentioned on your 2/15 thread . And my Walmart still sales it for 24.95

 

Is the Humulin R something I can get over the counter or will I need a script for that too? I have a feeling that's what we'll wind up needing to do. Even at the 7.5u he was still in the 300-400s, with that last day being in the 500s even, so I feel like we'll need a little extra push to get through. I want to wait until the IAA and IGF results come back before we do anything like that just to see where we're at though.

I think Sebastian is doing pretty well today. Waiting for him to go pee or the blood meter to get here so I can check ketones, but he looks better. I put out a bunch of different foods overnight and have been keeping him topped up on tuna water and he's eating and drinking really well. I'd say he's back to eating his normal volume of food and hasn't vomited again. And he said good morning to me when I got up and came to see what I was doing in the kitchen instead of just hanging out on his boat like he was last night.

 

Nevermind, I see in that 2/15 thread you said "The Novolin R can be purchase at Walmart Pharmacy with no RX necessary for around 25 bucks". So I'll keep that in mind, like I said we'll wait for all the tests to come back before we do anything different, in the meantime we'll just keep on the Lantus and continue working on the transition to LC wet.

 

Good Morning, the Humulin R and Novolin R are the same insulin just different manufacturers. I ask specially about the Novolin R when I called Walmart. There could be a price difference between the two since they are coming from different manufacturers.


ETA: How is he doing today. What was his BG this morning and how much insulin did you give?

 

I'm glad he's eating and drinking well.

If you start the R insulin, you'll want to set up a time when someone with experience with R insulin can be with you and guide you. R insuliin is very potent and there are certain guidelines like how much to give and when to give and when not to give.

I hope your blood ketone meter comes today. When I needed test strips for mine, I called around to a bunch of local pharmacies and although they didn't have the test strips in stock, a couple of them said they could get them in within 24 hours.

You test pretty often, which is great. Keep it up today, too, even though his Lantus depot needs to build up again, you are going from 2 units of insulin to 7? and that's a sizable increase.

Good luck with the Lantus, and no ketones vines are headed Sebastian's way.

 

Glad he is eating well again. Home ketones stay away.

 

I'm glad that he's eating and drinking and behaving like himself, those are all good signs.
Paws crossed the ketone meter arrives soon.

I second Dyana, once you have your results back if you want to give R a try do ask for help with that, there are a number of experienced users that can guide you with that so that it can be done safely. As Dyana says it is very potent, and there are a number of things you need to take into consideration to ensure it's safe use.

ETA it would make sense to add that you detected ketones at moderate levels again at yesterday numbers.

 

Glad Sebastian is eating and feeling better today.

I recommend you get the R to have on hand. No reason to wait for the high dose test results.
Keeping ketones from developing is most important. Him having IAA or Acro is a separate issue.

 

As Bobbie said, Walmart has Novolin-R and no script needed. Vials are about $25 and located in the pharmacy refrigerator.

 

Have you tested for ketones recently?

Really glad to read he is eating and drinking better.

I feel your pain with finding a vet to work with you. I had a wonderful vet that I loved and really worked with us to get through multiple issues but she left the practice to pursue a completely different line of work. I found another but wasn't as open to my research and queries.

When trying to find a new vet I actually interviewed them and flat out asked if they were prepared to take on a cat with multiple issues and work with me to best care for Gizmo.