? What to do with post-DKA kitty with low numbers?

I'm relatively new to this so please be patient with me. My girl was diagnosed in late Jan. 2017. As we were trying to get her dosing correct she got DKA. She ended up in the hospital. We took her home and apparently the DKA wasn't clear and we took her to an ER cling 3 days later. She has been out for ten days now. She is on Lantus, 2 units and eats FF.

Four days ago Millie started getting low BG readings. Unknowingly we had moved her shots up an hour, then we had daylight savings time as well. I wasn't sure what the readings meant and posted on here (I will be asking for help setting up a spreadsheet). Here is a breakdown of the last four days:

3/14 8:00am bg 79 (2u) 7:30pm bg 479 (2u)

3/15 7:35am bg 408 (2u) 7:15pm bg 70 (2u)

3/16 7:30am bg 535 (2u) 5:00pm bg 61 7:40 bg 62 No Lantus given

3/17 7:30am bg 540 (1.5 u)

Note: Millie has been receiving 2 units of Lantus in AM & PM until today, I gave her 1.5 U

She has been negative for ketones
Appetite has been good. Drinking more in the last two days

We have a vet appointment today at noon. She will be getting a fructosamine test. I will ask the vet to retest BG and to give fluids.

Is there anything else I need to be aware of moving forward.

Can someone help me set up a spreadsheet?

 

@Marje and Gracie is the member that helped me set up mine. She is awesome. I taged her so hopefully she will see this.

 

I'm glad you posted here. I have to go out until early afternoon EST but there are many excellent advisors here with a lot more experience than I have.

@Marje and Gracie is the spreadsheet/tech guru here.

 

Thank you.

 

Hi, and good luck at the vet today, too. I'm not experienced enough with the issues you described. But I'll tag @Marje and Gracie and @Tricia Cinco(GA) & Harvey for starters. They are both among the very experienced members here and Marje can also help you get your spreadsheet set up.

I'm also including here the link to your most recent condo (thread) to make it easier for others to refer to.

http://www.felinediabetes.com/FDMB/threads/dka-kitty-back-in-hospital-please-help.174309/

 

Thanks for the help!

 

Hi and welcome. There's not enough information here for me to give dosing advice but I have a few comments.

Lantus is dosed based upon the nadir, the lowest point in a cycle. You listed only listed ambg and pmbg which are important only to know if it's safe to shoot. Have you done any midcycle tests? Most cats hit nadir between +4-7 but some nadir late and others early. Many cats drop lower at night. I had one of those.

If you get a +2 test which is often when lantus onsets you will get a heads up as to whether it will be an active cycle. By that I mean if it's the same or lower than the amps/pmps be prepared to test more often so you can feed to avoid a hypo.

We increase and decrease based on nadir in .25 increments so as not to miss a good dose. Have you read the two protocols to see which you want to follow, SLGS or TR? Read the stickies for detailed info on them. This also will determine dosing changes. Basically SLGS requires a curve once a week and you decrease if the nadir is ever under 90 with a human meter and a little higher with AT. Most of us use human meters because the strips are so much cheaper and the protocols were done with them but some use the AT. With TR you would decrease if your cats drops under 68 on the AT.

These are just a few quick thoughts.

Would you please remove the 911 which is reserved for a real emergency such as a hypo and change it to a question mark please?

 

Giving you a bump up to the top of the column and sending vines....

 

Sorry about the 911, I originally had a ? Thanks for letting me know.

 

We went to the vet. Millie's 12:15 BG was 484. This was there hours after her A.M. insulin shot. We are going to test her before then 4, 8 and 12 hours after her shot tomorrow to get more info. Are these good times to do additional testing?

If anyone is available over the weekend to help me set up a spreadsheet, I'd really appreciate it.

 

@Marje and Gracie is the go to techie here. She's been tagged a couple of times and I'm sure she'll respond as soon as she can. Where does 12:15 fall relative to the time you gave her shot - ie., how many hours? The readings they get at the clinic could be higher if she's stressed.

 

It was three hours after the insulin shot.

 

Sorry....I wasn't on earlier today and am just checking in. I will send you a private message regarding the spreadsheet so please click on "inbox" in the upper right corner when you see a number on it in a few minutes. I'll do that first as I will need some info and then I'll come back and read the thread about dosing suggestions.

 

I'm glad you reduced her dose because she was getting too low on the AT. Shooting a 70 (AT) with 2u is something our experienced members do after they have built some data. She might have gone lower that cycle. While I might have suggested you just reduce to 1.75u to start with, now that you have her at 1.5u, let's try and build some data as quickly as we can so we can determine the best dose.

What you are seeing with the high and low numbers is what we call bouncing. Bouncing is a normal response from the liver. When our kitties are diagnosed, they might have been at higher numbers for a while and the body acclimated to those numbers. When we start insulin therapy and the BG comes down lower (and it might not be low...just lower than what the liver is used to) or it comes down quickly, then it triggers the liver and pancreas to release counterregulatory hormones and glucagon into the bloodstream and the numbers rise, sometimes quickly, to where the liver believes is normal.

Over time, we work with the dosing to get the liver used to lower numbers and try to flatten out the curve a bit. Some cats will experience bouncing for a while; others bounce only briefly and there is no way to predict which cats will do what.

In order to figure out the correct dose, we do need some mid cycle tests. I would recommend that, instead of +4 and +8, you focus on getting a few more random tests. Think of the SS as a puzzle and we have to put the pieces in the right spots to identify the picture.

You should always get a preshot test so kudos to you for doing that. I would suggest that you get a +2, +4, +6 and a +10 in tomorrow's a.m. cycle so we can see exactly how much she drops when she onsets. It is extremely important that we put this puzzle together for her because of the DKA. We need to be sure she is getting the insulin she needs but not more than what she needs.

Are you testing her urine ketones every day? It's very important that you do. You can pick up urine ketone test strips at Walmart or any pharmacy. It's also very important that you let us know if she starts being fussy about eating. The recipe for DKA is:

Infection + not enough insulin + not enough food/water

So if she starts to act like she doesn't want to eat, we need to know immediately, ok? Also, if you get even "trace" on the ketone strips, we need to know.

It's also important that we get her to a dose that you can shoot insulin every cycle for the time being. Skipping shots is not the best thing for a cat with a history of DKA but you were right to not shoot the 60s.

However, the next time she gives you a number 150 or below for a preshot, I would recommend you not feed her but immediately post. Be sure and tell the people helping you that she has had DKA. We can help you decide what is ok to shoot and whether you should shoot on time, stall, or shoot a reduced dose.

The priority right now is to test a little more, as I suggested, so we can make sure we get the dose right. At night, if you test at PMPS (p.m. Preshot), +2, and before bed, that will help. Depending on where her BG is, we might also suggest you test at other times (e.g. if her BG is running low).

I would suggest you read the "New to the Group" sticky at the top of this page and equate yourself with the terms "onset", "nadir", and "duration" as they are very important. As you build data, you will learn how they apply to Millie and that will help manage her diabetes.

Also, please be sure you keep high carb food/gravy, Karo/honey, and lots of test strips handy for when she drops low again.

Please let me know any questions you have about what I have written. This is a group of caring folks who will do all they can to answer your questions and help Millie.

 

I just took a guess at the dose. I am testing for ketones, so far she's negative. I will be sure to not feed, etc if she's under 150 and post here instead (is there anything in particular I should write in the title of my post for this?).

I have Nutracal and honey in the house. Last night we gave both. Just bought some FF Gravy Lovers to also have on hand for when she runs low.

I initially read new to the group but will definitely do that again, I'm sure it will make more sense now.

Thank you for all the information.

 

This will all get easier and more routine - I guarantee it! You're in the right place now to get a lot of help.

 

Where do I purchase strips for the AlphaTrak?

 

If you bought it through your vet you should be able to buy them there. They're very expensive (about a dollar a strip in the US) which is why many people switch to a human meter eventually.

 

Which human meter is used?

 

Put the little question mark in the subject like you have now, some good words would be "Stalling - Dose advice?" Stalling is what we call it when it is shot time, but numbers are a little low and we stall for a few minutes and re-test without feeding.

It does get easier, I was overwhelmed at first, but as time went on it became easier and like with most things repetition helped things stick.

The Relion meters from Walmart are very popular. There are 2 different ones, the Relion prime strips are a little cheaper, but take a little more blood. The Relion Micro/confirm are a little more expensive, but take the tiniest drop of blood. The Prime strips are about $17/100, the confirm strips are $38/100. Either meter is under $20, and while you are there pick up some of the Relion lancets ($2 / 100 ). I'm not a Walmart fan, honestly try to avoid it, but for diabetic supplies they are hard to beat.

 

We don't have a Walmart in the city. I'm not a fan either but would buy if I could. I am going to call my pharmacist to see if he can help.

 

There are Walmart ReliOn clones available at regular pharmacies - Arkray is one that's been mentioned on here.

 

Check out American Diabetes Wholesale for meters such as the Arkray Glucocard 01 (free meter and 200 strips right now) which requires the same sample size as the AT. I also bought my Alpha Trak 2 test strips at ADW.

Or you can order a ReliOn Micro or Confirm and test strips from Walmart. I'm not a Walmart fan either but that's where I got mine and was very happy with it.

 

I just realized we only have 6 strips left for the meter. I need to pick up a new meter tomorrow locally. Is the True Matrix a good meter to use with cats?

 

I’ve never heard of it. The Bayer Contour is a good meter as is the Accu Chek Aviva is also good. Here is the consumer review report for 2016 on meters.

Target also makes a fairly decent meter....the Up and Up.