Using R insulin as bolus for high #s and ketones?

My new foster kitty Yoda turns out is battling with very high levels of ketones. I later found out he was on the verge of DKA when I got him on Wednesday and I am having to feed him every 2 to 3 hours (FF grain free) mixed with about a 1/4 cup of water each time to keep the ketones at bay. I've got the levels down to 'elevated' today. His glucose numbers on 1.5u of ProZinc are in the mid 300's to low 400's. He just started insulin on Thursday of this past week. It has been suggested to me to try using R insulin as a bolus with the ProZinc I am already giving him in order to get his numbers down to a level where the ProZinc will work better. We are trying to avoid the expense of having to go to the vet just for them to do the same thing. We are hoping lower glucose levels will also help to keep the ketones down.

Does anyone have experience with using R insulin as a bolus at home? Any suggestions or knowledge as to what to expect?

I can get a vial at walmart without a script for $25.

Yoda's story and pictures can be found on the PZI forum here: viewtopic.php?f=24&t=17053

 

Re: Using R insulin as bolus for high #s and ketones kitty

He really needs to be seen by a vet. His electrolyte levels need to be evaluated before making any additional changes in his treatment. The vet will do more than just lower his glucose levels.

 

Re: Using R insulin as bolus for high #s and ketones kitty

I understand that the vet can help with electrolytes, fluids, etc. If you were to look at this cat and spend time with him, you wouldn't know that his ketones are so high. He is very alert, walks around, jumps on counters, eats and drinks like a horse .... I am just trying to keep him from getting into the situation where we would need to worry about electrolytes and treating for DKA.

 

Re: Using R insulin as bolus for high #s and ketones kitty

And Boo looked just fine one afternoon and then spent the next 4 days in ICU for DKA treatment. It can happen that quickly. He needs vet care ASAP.

 

I understand your concerns. We are prepared to take him in tomorrow morning if his ketones spike back up. I am really looking for advice from anyone that has used R in conjunction with their regular insulin in order to bring down the overall numbers.

 

Kelly
I'm sorry, I have never used R. I know it is a short acting insulin, something like 4-6 hours and gone, and the main thing is to avoid nadir hitting at the same time as the prozinc. ( Prozinc nadir typically is at + 4-9 which I think you know)

If you decide to wait until monday morning to see the vet, I would be giving sub q fluids to flush the ketones right now. Quantity of fluids are based on weight of kitty. Maintenance fluid for a 11 lb cat is around 330ml. Since you are giving a lot of oral water, and there is water in food, you give something less than 330ml. I have given tf and cody as much as 250ml, but normally I give 150ml/day. If he's dehydrated, then "maintenance" won't correct the deficit. If his sugar is high, he's peeing out excess water trying to lower the sugar.

I haven't looked at the ss, but could you up the prozinc? I dont know, but I've heard it's easier to treat hypo, than DKA.

 

R is a very fast acting bolus insulin. Onset is within 1 hour or less and you should be very conservative on dose, no more than .5U to start. If anyone else feels differently on that dose based on the potential for DKA, please step in. I am only going by my use of R during the period I used it for Gandalf. He would drop 150-200 points in 2 hours on .1U of R. Some cats may be very sensitive to it.

Some examples can be found in the 2008 page of Gandalf's spreadsheet, which should be the "Entire Spreadsheet" link in signature.

I know that some use R on a continuing basis, especially on the longer acting basal insulins, Lantus or Levemir. R should not be necessary however if the optimal dose of basal insulin is achieved. R should be used in situations such as yours, where the cat is ketonic. So consider this a temporary situation and don't get dependent on it to bring numbers down quickly. I did that and was warned by a teaching hospital vet that R is emergency use only and although members here have used it effectively and some Acro cats need it to supplement their basal insulin, I caution its use in even a semi-regulated cat because it impedes proper regulation with the basal insulin. Gandalf's '08 spreadsheet is an example of that. It has lots of varying colors!

Good luck and Deanie is right - they can crash in a very short period. Trying to deal with ketones at home is commendable, but perhaps foolhardy for even very experienced caregivers.

 

When somewhat new to FD, I used R as a bolus to BCP PZI basal to get Max's numbers down to a range that the PZI could be effective. Ketones were not an issue with Max.

On New Year's Eve 2008, I treated a friend's cat that had been hospitalized for a week with DKA. The day after Romeo came home from the ER ketone free and with a $5K bill, he went lethargic again and was running HI. We had no urine to test for ketones, no way to test blood ketones, and Romeo's beans were not able to afford another DKA bill. Their choices were (a) PTS and (b) me and my bag of fluids, bottle of R, and test strips. They chose me. It took about 10 hours of testing every 30 minutes, injecting R every couple of hours, and giving SubQ fluids until the HI broke and Romeo could be effectively treated with a basal insulin. We opted not to use the Vetsulin the vet had sent him home with and put him on my cat's Levemir. Romeo came quickly back to health.

When Stefani brought foster Ahi home from the shelter he was in very lousy shape and running HI. I suggested she try R to bring him down. It worked for Ahi.

I think there is a place for using a small amount of R in Yoda's current situation. I agree with Vicky's cautions about a low dose to start (I would recommend .25U of less) and not using it with any regularity. I also agree with Nancy's caution about the timing of the nadirs. The first time I gave Max R, I didn't understand that point and made the mistake of timing the basal and bolus so that the nadirs might have coincided. The few times I used R after that, I always shot it at the same time I shot the PZI so that the R was clearing Max's system as the PZI was starting onset.

One thing with Max that is not the same with Yoda is that Max got a huge food spike in the morning. This was 5 years ago when conventional wisdom was BID feeding. Max would hog out on breakfast. Over time, I learned I could flatten Max's curve with small, frequent meals. You already are doing frequent feedings.

I understand the concerns of those who have been through DKA that immediate treatment by a vet is needed. However, I'm not sure they are fully aware of how Yoda came into your care and the limited resources that are available to treat him. And you make a very good point that he is not appearing to be affected by the ketones that are presenting in the blood tests you are doing.

I have never tested blood for ketones, and I don't know how reliable those tests are. I think most here are accustomed to urine testing. If the question were one of whether Yoda should be seen and treated immediately by an ER vet, I come back to my story of Romeo. There are sadly just some situations in which that is not a viable option, and this is one. But then, I also don't see the need, given the very apt care you are giving him with the resources you have available and him having no symptoms of a ketonic state.

 

Thank you for explaining so much Venita :smile:

I did a lot of research about testing for ketones since Oscar is so difficult to catch in the litter box (he must have a bladder the size of texas because he only pees like twice a day for like 3 min at a time lol) ... Either way, I needed some way to test his ketones that didn't involve camping out by the litter box all day. Testing by blood tests for the most acidic type of ketone (there are 3 - ketostixs test the other 2 types) and is the most used way of testing in the ER for humans. It also shows a more real time result of ketones rather than waiting for it to reach the urine. More info can be found on page 2 of this article: http://www.diabetesselfmanagement.com/a ... cidosis/2/ I get the test strips on ebay at a fraction of the retail cost, which makes it more affordable.

I do not think that an ER visit is needed right now really. I will make the judgment about a regular vet visit tomorrow morning when I take his ketones reading again. What stinks is I will have to see the regular vet which I am not absolutely fond of.... my favorite vet is only at that practice on Fridays.

I gave him a 0.25u dose of R with 1.5u of prozinc this evening at 6:15pm. There was a food spike at +1, but he came down 70 points by +3. I'll test again at +5 and see where we are at.

 

I am very glad to hear you are ready to take the cat to the vet because it is very scary and risky to try to treat a cat with ketones. Getting a day of intensive treatment might save multiple days of hospitalization later. Yet I can certainly understand financial constraints and what you are trying to do. The fact that you have the skills and tools to do frequent blood testing for glucose and ketones is great. Without that I think vet care would be truly critical.

R is normally fast onset, giving a fast drop in blood glucose, and gone relatively quickly. However, I have heard of a cat that had a late onset with R and extended impact. So as always ECID. I echo the caution of a low starting dose of R.

For my acrocat Cole, I have used R to add more "punch" to the primary insulin of basal long-acting levemir, and on occasion still do (400+ BG). I think many would say using R tends to cloud what is going on with the primary insulin.

Since Prozinc is supposed to act similar to PZI, I wonder how TID dosing might work if Yoda is not getting enough 12 hour coverage. I did TID scaled dosing of PZI with Danny early on since he couldn't get enough duration on PZI. It was a lot of testing, a lot of work -- but I then switched to Levemir for the extended duration and life was a lot easier. But Yoda's so new that I don't think you could have an understanding of how Yoda reacts to Prozinc yet either? So either with more frequent Prozinc, or adding R, you run the risk of concurrent nadirs since you don't know the insulin's profile of action in this particular cat. Not a comfortable situation to be in! Yet I am sure you have your hypo tools at hands, and it looks like you are testing frequently, feeding frequently and watching Yoda very closely.

As an aside, if you want to get Yoda onto Levemir, I will donate a new pen.

laur

 

That would be wonderful. We have 1 donated Levemir pen through DCIN that should be shipped to us on Monday, but we will need donations for his on-going treatment.

I have tried TID with Oscar a few short weeks ago, but he is a bit of a conundrum and we may be switching to another insulin soon because of this. ProZinc usually does not become predictable until around the 30 to 45 day mark, so I might be hesitant to try TID so early.

I am very prepared for a hypo situation - I have had a few scares with Oscar even though he didn't show any hypo symptoms. It also helps that Yoda is getting food every 3 hours at minimum, so he always has food in his system.

Even if we do not go to the vet tomorrow, I will still be contacting a few people about getting fluids through donation. I already have someone that has offered IV needles and IV sets.

 

[quote="Kelly & Oscar
I am very prepared for a hypo situation

 

Glucose at +5 is 355

Temperature (rectal) is an even 101

Hopefully his ketones are lower by tomorrow morning. If not, then I will make an appointment for tomorrow afternoon.

 

For us Prozinc lasted about 10-11 hours, and the onset started about +1.5 or 2 hours. The nadir moved around between +4 to +8, and was tough to predict. If I was ever going to try R with Prozinc, I would have used it at PZIR+10, so that it was cleared and gone by the Pzir +4, when the prozinc is in full swing. If you give it at the same time you could see some overlap i'm afraid,at +2 through +5.

You never said if you have access to Lactated ringers. If you can get a prescription tomorrow, Sams sells a case for about $25, and you can reuse the tubing several times. Needles cost about $8/100 I think.

 

I do not have access to fluids since I need a prescription. Getting my vet to write a script for LRS is like pulling teeth really. I haven't been able to get it for Oscar even when he was running with ketones in the 0.6mmol range (while in the mid 200's for glucose). Gator has offered to give me some needles and sets since he is in the Indy region right now. Still working on acquiring fluids.

 

how is Yoda acting?

Listen, I don't know how much you've been on the board. I've been around a couple years and there are certain people, that when they speak, I listen. One of them is Deanie. When I hear her say treating Yoda at home is a "big risk", that increases my worry factor enormously. I knew electrolytes were important but I didn't bring it up in my post, shame on me.

Please take what Deanie says very, very seriously.

laur

 

> What stinks is I will have to see the regular vet which I am not absolutely fond of.... my favorite vet is
> only at that practice on Fridays.

Is your favorite vet working at a different practice on Mondays? If so, could you try calling that practice and seeing if they'll fit you in with an appointment there?

 

Yoda is acting well. He moves around from the first floor to the second floor a couple of times a day. I got him to play with a toy mouse on a string today for about 5 min. He is eating about 3oz of FF every 3 hours or so. He is still a bit dehydrated, but significantly better than he was on Wednesday and Thursday. He's been begging to go outside, so I took him out today on Oscar's harness and a leash. We maybe spent 15 min outside today together. He seemed to enjoy that a lot.

I do take all suggestions very seriously. The problem is when I am responsible for spending someone else's money. Especially a foundation that helps so many and has limited funds. I want to try to do what I can at home (within limits) before I spend the money on a vet visit. With all respect I can give - If I wasn't considering taking him to the vet on Monday if things are unchanged, then I wouldn't have mentioned it at all :smile:

 

She is the ER vet at the emergency/specialty clinic in Indianapolis. It would involve paying an ER fee and driving an hour to see her. :sad:

 

Any chance he would let you syringe warm water onto his upper gums? It might help get him through the night. Or might he drink chicken or tuna flavored water?

I'm not saying "just treat at home"- I'm just trying to help you deal with the difficult situation you are in to get through to the morning.

Did you understand what I suggested about the timing of the R insulin ?
Keep prozinc on a strict 12/12, and give the R at +10 (on a rising number)

 

Yes, thank you Nancy for that suggestion. I will try that timing for his evening shot and see where that brings us. Ketones are down even further today! They were 1.4 on Saturday, 0.7 yesterday, and 0.5 this morning (trace) dancing_cat

I will try tuna flavored water today to try to get more fluids in him.

Thank you everyone for your help!!!!! As a safety plug - I would NOT recommend anyone brand new to diabetes try to treat ketones at home by themselves unless ABSOLUTELY necessary. This thread should not serve as your reason to not take your cat to the vet if you are able to.

 

Kelly,

I had to give Angel an R bolus with Prozinc for the Prozinc to work right. I gave them at the same time. With the R bolus, I got very nice, gentle, 10-12 hour curves, but without it and only Prozinc, her BG would gradually climb. That said, I was giving her TINY doses of R, like 0.05 - 0.1 U or less, with about 0.5 U of Prozinc. I don't know whether her response was typical or not, as she was impossible to regulate on anything, but this combo of R and Prozinc worked better for her than anything else. I only wish we'd tried it sooner, because the vet only thought about it 2-3 weeks before Angel had to be PTS. :sad:

As for the ketones, etc., I hope Yoda is doing better now. I always would give Angel SQF for her trace ketones, and if I couldn't do it at home, I would have taken her to the vet for them. I'd be very hesitant to stay with a vet who wouldn't allow SQF at home. Do you have any prospects for other vets that you could use instead?

 

Thank you for writing about your experiences Heather - it really helps to hear others experiences with this method!

We have actually been thinking about switching vets anyway since the vet practitioner that we like is no longer coming in on Fridays and may be starting her own practice up in Indianapolis. Venita just spoke with a person at my current vet today to set up things for Yoda to be seen on Thursday and she was told that I was one of those people that 'complicate things' by home testing and trying to regulate on my own rather than relying on vet glucose curves and fructosamine tests ... and on top of that, she had never heard of Levemir being used for cats and wanted to know who prescribed it to me for Yoda :roll: So I have a line up of vet journal articles detailing the use of Levemir and the advocacy of home testing to bring in to support what I am doing. Depending on how that goes - we definitely will be looking for a different vet.

Good thing is that Gator (Justin) donated a few bags of fluids and IV sets/needles to me yesterday and we have started giving Yoda fluids as of last night. We started with 50ml because he was squirmy, but we may add a second session to that tonight and give a total of 100ml and see how that goes.

 

if you arent, try warming them in a pitcher of hot water for 5 min, until it feels warm to the back of your hand- gotta run