Xuxu 1/25/13 crashed yesterday, new test results

I think I almost killed him yesterday. I was so tired, no sleep the previous night, going in for foot surgery this morning and I think I forgot I gave a 2nd shot at 7:30 pm and gave a 3rd shot at midnight. These are all so routine that they seem to run together. But I vaguely remember pulling out a syringe after giving his medication at midnight. I was awaken to shallow rapid breathing at 4:30am as I was reaching for the snooze button. He didn't even have a swallow reflex, and for newbies, YES karo really absorbs fast through the gums. Within 60 sec, he did a small swallow. After that I was able to get more in via syringe feeding. At 5 min, he finally took a large deep breath and opened his eyes. It's so amazing how fast they can respond. I've learned to never give him up for dead, but this is definitely the closest he's gotten other than the very first. I was so afraid to give him a shot this morning, while I was in outpatient surgery because I was so afraid he might crash when no one was home. So he went 16 hours between shots. He seems ok today, although I slept for 4 hrs so don't have a reading between a lower one and back up to 720. I'll do a full curve tomorrow. I also decreased his dose to .25. That's hard on a U100 syringe, there is no satisfying push to feel on injecting. It feels like nothing is going in. If I have to go lower, then I'll have to get u40's and do the conversion.

His test results came back, I don't have a copy yet, but vet called me. All thyroid tests were normal, T4, T3, FT4. Hi eosinophils were up, the Antech results didn't agree with the in-house results, so they think their IDEXX maching may not be calibrated correctly. Vet talked to an Antech Consultant in CA who thinks we are full of Sh_t if I interpret my vet correctly. The Consultant said I was crazy to try Levemir because it's 7 times as dangerous as Lantus and I should switch back. She didn't listen to the idea that Lantus didn't seem to be working for Xuxu. She said I should not switch to Levemir until he was on 30 U of Lantus. 30U for a CAT! That sounds crazy. She said with the hi eosinophil and no IBS, that it's probably blood cancer. (I've read up on this and it's very rare). Recommended a continuous BG monitor and doing a radioactive scan. Never mind that they might have a continuous monitor in CA, but I've yet to find one on east coast. Not likely to be here other than maybe NY or FL. She did mention that parasites can cause hi eos. He hasn't been out of the house or sharing a litterbox with another cat for at least 10 years (time I've had him). It seems unlikely he'd have them when this problem only came up with neutering. But it's an easy thing to do so we are starting him on pracetamol (sp?) for 5 days. I've also heard that parasitic meds can shock the system and metabolism into working normal even if there are no parasites, so it's worth trying.

My vet wants me to go to an internal medicine specialist, she feels she's given me all the help she's able to as a general practioner, and she has given me tons of time after her regular appts, often talking until 2 hrs after closing. She's concerned about what these crashes are doing to his general organ status. I've been thinking the same thing, but haven't found anyone within 50 miles. I can't go running all over the country. She said she would try to find someone willing to do a remote consult with records for a fee. IF ANYONE HERE KNOWS OF AN INTERNAL MEDICINE BOARD CERTIFIED BETWEEN WASHINGTON DC AND RICHMOND VA, I'D APPRECIATE HEARING. Does Dr. R in Australia do remote consultations? I'd rather get an expert rather than a general internal medicine specialist that isn't particularly interested in DM.

In my research today I did stumble upon an article saying in people, there is some evidence that Lantus can CAUSE hi eosinophils. Wouldn't that be interesting. Couldn't find anything on small animals though.

On top of all this, his Levemir froze! Can't figure out why. Nothing else in small frig in my bedroom froze, not even the Lantus or a small bottle of water. Does Levemir freeze at a higher temp? I had to get the vet to call in a refill and made the pharmacy with 5 min before closing. Probably contributed to my forgetting if I'd given his shot.

I'm willing to consider any and all advice. I've learned more on this site than from these specialists we've been calling.

I just previewed this post and there were tons of mistakes, mostly substitutions. I love that Word thinks it knows more about what I want to say than I do. (frog for frig!) So if something doesn't make sense, let me know and I'll check, it might have left out or changed a word that I didn't catch. Plus, it's 1:15 am, and I'm on narcotics @-)

 

What's crazy about a 30u dose for a cat? One of my cats was up to 37u BID Lev, but I know of others on much higher doses.
I don't know what kind of 'consultant' says Lev is 7times as dangerous or some such nonsense, but it's obviously someone who doesn't know much about insulins.

I don't understand any of the rest of your posting, and don't know about Lev freezing, but you should be more cautious with giving your cat shots.

 

If you look at his ss, you'll see he's been problematic from the beginning. I am very cautious about giving his shots, but he's very unpredictable plus he regularly goes to 750 and then down to 20, which has everyone puzzled. We have been dropping his dose trying to avoid the crashes, but haven't hit a good protocol. Yes I may have screwed up Wed, but I was dead tired, in pain and just in general fuzzy, it's the first time I've doubled up on shots. The rest of the post was because we finally did a scattershot blood test looking for some hidden problem as primary, making the DM a secondary condition. Please don't make judgements until you know the situation. (plus you don't need the copy the whole message, everyone can read the original).

 

Just reposted his SS. He was going up as expected, but just went back down at 11th hr. I don't think I can risk giving his shot on schedule when he's gone from 400's to 20's just as much as from 750's even with a reduced dose. He definitely isn't feeling well, hasn't eaten since last night, has a bit of sneezing, but we though the Zithro was taking care of that. Can anyone tell me what is going on with his BG going down so late?

I've read the descriptions of rebounding and it sounds like the descriptions of Somogyi effect, although my vet says that has to happen in the first 30 min after injection, and that isn't true with Xuxu. His seems to start down at 2-3 hrs. So what is the difference?

 

Levemir usually doesn't kick in until 2-3 hours after the shot and sometimes even later...with Autumn she doesn't start dropping until +4. To me he looks exactly like he is in Somogyi...To the point I'm almost wondering if he needs insulin at all. Just gut instinct here but I have to wonder if those really high highs are coming from those really low lows. That if he was just left alone his body would bring him back down once the counterreglatory hormones clear his system. Because that rollercoaster ride can't feel good.

But that's just my 2 cents worth.

Mel, Maxwell, Autumn & The Fur Gang

 

Deb,

I know this is frustrating - and scary. And it isn't making Xuxu better. I still think that he needs little or no insulin and that the 700s are from rebound.

Frankly, his BG can not go higher than 700s with no insulin shots even if his pancreas is not making any insulin. If he were my cat, I would stop insulin for 3-5 days and keep testing to see what happens. I would check for ketones every chance I could and I would make sure he was eating only low carb canned food, or meat only baby food.

And HUGE WARNING!!! You can't use u40 syringes and a conversion with u100 insulins. 1u on a u40 syringe is = 2.5u of u100 insulin, so it actually would make things more difficult - plus you do not want to risk an overdose, not with things going the way they are with him. (as an aside - using u100 syringes with u40 insulin works beautifully - just not the other way around).

Also, Dr. Lisa Pierson, DVM (catinfo.org) used to do phone consults. I don't know if she still does, but she has an email on the very bottom of her home page (and its a long page so scroll all the way down).

 

if you give a shot and the cat's BG drops from 400s to 20s, you are giving too much insulin.... and you may be giving insulin that's not even needed. The 20s could well put the cat in a coma or worse.

You are not seeing Somogyi.

And Levemir takes hours, sometimes as many as 5hrs, to kick in for some cats, like my own Oliver.
Oliver's nadir was quite often as late as his next shot time, but your cat's just getting too much insulin...

 

My vet talked with an internal medicine doc. His eosinophils are 2783 (range 0-1000). She said to follow that, the cause of the high level is the source of his problem. That might be simple, and it might be complex. One cause is parasites. It doesn't seem likely since he's not been out of the house nor shared a litter box with another cat in 10 years. He hasn't been tested for heartworms, but a mosquito would have to fly a really long distance through 4 rooms and down a closed stairway to reach him. Not impossible, but not likely. Anyway, that's the cheapest way to go at first, so he's on Panacur for 10 days to see if that helps. If not, then we'll test for heartworms. After that it gets complicated, like a bone marrow biopsy.

This specialist said the same thing as the other. Levemir is considered gentler in humans than Lantus. But in animals, it's considered more dangerous. I'll let the rest of you using it argue the point. As I said earlier, I found an article that indicated Lantus might raised eosinophils in humans, nothing on pets.

As far as the rebound and need for insulin, I don't know what to do. Down to .25, he's only going down to 281 and feeling much better. I might try to stop the insulin halfway through the Panacur treatment to see how he does. But his original presentation and dx was with DKA, nearly dead. DM seemed to be the only dx reasonable, especially with the pancreatic inflammation on ultrasound. But that may have healed fully by now. I can easily see when he's high, he sits with his chin resting on the water bowl rim, so it wouldn't be hard to see if the high levels were continuing without a lot of testing. I do have the ketone strips to test.

I did finally pick up when looking at the conversion chart for syringes that you can't go 100 to 40. I didn't pick up on that at first. Thanks for the warning. But my vet had showed me a while ago a syringe with a very small bore that was much easier to read. She just wanted to make sure I was reading the intervals correctly. I had assumed it was a u40 when I heard of them. It may have been just a regular syringe for small amounts. I guess it wouldn't work since it's mls not units.

I didn't give his insulin this morning and he's did finally go back up to nearly 750. I've posted his latest.

 

Frankly, I would not use any syringe with a u100 insulin except a u100 syringe. I am certain that if a smaller syringe, with easier to read numbers existed that could be used with some conversion method, everyone here would know about it.

I am not going to "debate" the safety of lev for cats. Any vet that says it is dangerous for use in cats is just plain wrong. Period. The proof of that statement are the thousands of cats on lev that are fine, regulated, or already off insulin after using lev. I am sure that lev saved Beau's life. Coudl lantus have also worked? Who knows and I don't care. Lev was perfect for him.

As a reminder, it will take days for somogyi rebound to clear his system, so seeing a 700 now doesn't surprise me.

Can you put the "crash" numbers from the other morning in his SS? Even if you just add a row below the day's regular row, merge all the cells and write in it as notes, that would be very helpful for those of us trying to guide you. You will want those numbers to refer back to later as well.

 

I gave him less than .25, I couldn't tell there was any fluid in there at all, but he still crashed. So Levemir is a moot point for Xuxu. I spoke with my vet and we decided to put him back on R. I'll just give him .5u when he's showing signs of sitting at his water bowl, and test for ketones every time he pees. We are just hoping for enough time for the Panacur to work if it is going to. After that, it's on to the really serious testing, bone marrow aspiration, etc.

I've been on a number of these type of support group/boards for my own health, and I do agree that many times a collective group of the afflicted know more than their doctors. It usually takes a doctor who is afflicted themselves to get one that truely knows what is going on and can interpret the signs correctly. So I'm not arguing with anyone that Levemir is dangerous in cats. But it's obviously dangerous for Xuxu, and the Lantus wasn't good for him either. For now it's a race to figure out what his real problem is.

I didn't do a lot of testing this time, I pretty well know the dance steps for him and can judge by his reactions where he is. I didn't catch him this time because my pain meds put me to sleep, plus he crawled under the bed so I didn't hear him seizing. It was bad, he was tied up in a knot with muscle tightness. But again, it's amazing how fast some karo on the gums can work. If you look at the 2nd 1/20/13 line on his ss, that was testing every 15 min after a crash. It didn't seem necessary this time, plus I've run through $100 of these strips in a couple of weeks and need to ration until I can get some more.

My vet says I've got so much invested in Xuxu that I can't give up. That's true to a certain extent, but it's also that I see him for at least part of the day up walking around, purring and wanting to play. It's hard to put a cat down that can still do that. Yet I do feel he is really suffering everytime he goes into a crash. How much can I put him through. But I'm getting the horrible feeling in the pit of my stomach that we are only going to figure this out on necropsy.

My vet said since we started down the pancreatitis trak, she didn't really think of Cushings. But he would be non-typical for that too. She was still going to do some more reading to see if that might be any possibility. Those would be tests she could do in house instead of dragging him up to Vienna, Va.

 

I do not know what you think you will accomplish by giving .5u R instead of a .25u of Lev.
The R is much harsher than Lev, so if .25u of Lev is causing a crash, the .5uR is likely to put your cat in ER and not survive.

You speak of a crash and mention that Levemir is dangerous but when asked for test numbers to show that a crash happened, you have no numbers.

I am not quite sure why you continue to post and refuse to follow any suggestions given. It does not seem to matter what anyone posts, you just ignore or do the opposite.

Nobody waters insulins, yet you were and when told it was not to be done, you continued.
Everyone here knows that R is very harsh, yet you claim the opposite.

I don't think the insulins are a danger to your cat, unless you are giving insulin to the cat when it's not needed, and if that's the case, it would seem that it is you who is the danger.

 

Deb, I beg of you to stop giving ANY insulin for 3-5 days. Please. He doesn't need insulin. To me it is the most obvious next step when .25u dose has such an effect on him. It isn't the lev. It isn't the lantus. It isn't the R, even. He doesn't NEED insulin. Please.

There are cases where stress (life changes, meds, surgery, etc.) can cause transient diabetes. Since he is "crashing" on a very small dose of insulin (any insulin) and doing it from as high as 750 he is getting a significant response from that small dose.

He should not have insulin. Not until you get some new BG tests showing what is truly happening with no insulin - and that will take 3-5 days to clear all the hormones that circulate during rebound. During that time his BG will swing, but then it should start to come down.

Gayle is right that R is much more harsh that lev and .5u may indeed kill him.

I think that a worry about DKA is not the priority here. Yes, DKA is serious and can kill, but maybe that wasn't what happened the first time. I had a cat that had a very bad response to anesthesia and nearly died. She was dehydrated, not eating, lethargic. All she needed was fluids for about a week. These are similar symptoms and treatments for DKA. Ketones can build up during dehydration. Blood sugar can climb because of stress from pain, surgery, being at the vet etc. Blood sugar can be falsely high from rebound. Perhaps his DKA was more a bad response to anesthesia, coupled with not eating for a few days and dehydration. Treatment was given that included R and his BG started to drop and climb.

DKA will not kill as fast as a hypo/seizure from an insulin overdose.

If you are already thinking about putting him down, then you can at least stop insulin and see if it helps. You have nothing to lose. Maybe he does have a rare blood cancer, but maybe all the odd labs are from his body struggling to fight off hypo after hypo.

Also, you might want to get a human meter, like a Bayer Contour or Walmart Relion. the strips are much cheaper and you can test more ofter. Many of us use the Contour and have regulated or gotten our cats off insulin.

 

I am going to join in the begging.

Before you start R, please please please please please try stopping insulin for a few days.​

The numbers might be ugly for a few days while the counterregulatory hormones clear out, but then the numbers will probably come down. If it turns out that he does need insulin, then start at 0.1 units or less, but please stop insulin for at least 2-3 days before giving ANY insulin of ANY kind. Test for ketones, just in case, but please stop insulin.

Please. I know you don't trust us as much as you trust your vets, but your vets have not seen this response before and we have. Cats go off insulin all the time, and we have also seen some that DO need insulin but only a very very tiny amount (just a drop). Please consider those possibilities before doing something even more dangerous.

 

I'm going to join in with the chorus. I am very, very, very scared for your cat. When I read the notes on your spreadsheet -- "lo but not comatose" -- all I can think is what more indication do you need that Xuxu is getting too much insulin? How many more seizures can he survive? And this isn't the first time your kitty has been close to dead from hypoglycemia. You have absolutely nothing to lose by stopping insulin. You risk losing your cat by continuing doing what you're doing.

With long-acting, depot-type insulin, the emphasis is NOT on the pre-shot numbers. You're focusing on Xuxu''s body's response to extremely low numbers. Every mammal has this built in means of protecting itself: numbers drop into low ranges and the liver and pancreas go into action by dumping glycogen and counterregulatory hormones to get BG out of the basement. Stop focusing on the highs -- focus on the lows. These low numbers can kill. The highs are just inconvenient.

I'm sorry if I'm being blunt. I'm terrified on Xuxu's behalf.

 

oh boy! sorry if it feels like you're being ganged up on, but for xuxu's sake... i have to chime in with the others by begging you to stop insulin for 3 - 5 days and continue checking for ketones daily... twice a day if you can manage it.

it can take up to 3 - 5 days for the counterregulatory hormones to clear out before you'll see the numbers come down on their own.

as the others have said, judging by xuxu's response it's very, very possible he no longer needs insulin. very possible. we've seen this happen over and over again on the FDMB. "we" recognize the possible signs even if your vet doesn't.

i beg you NOT to administer 0.5 unit of R insulin! R is an extremely potent insulin and can be dangerous if not used properly. a tenth of a unit of R has been known to drop kitties rapidly and should not be used with an insulin sensitive kitty under normal circumstances.

"if" after several days it becomes apparent he does require insulin, i strongly urge you to consider administering 0.1 unit of insulin... after posting to ask for thoughts, suggestions, and opinions.

deb, you don't "know" us, but i can tell you the people responding on this thread are worried and scared for your precious kitty. between us, we have more collective years of experience with lantus and levemir than the majority of vets out there.

please take what we have to say seriously... for xuxu's sake. i know you want only the best for him.
please.

 

I'm going to wholeheartedly agree with these very knowledgable ladies. If you are monitoring his ketones closely, you have nothing to lose by stopping all insulins as suggested and everything to gain if it turns out he does not need any insulin.

And although it is not the really urgent issue here, the other thing that struck me as odd is the eosinophil issue. All of my cats, except Gracie, have had high eosinophils at one time or another. My 17 year old cat has rarely had a normal eosinophil level. His is usually in the 1300-2700 range. Every vet that has seen him has attributed it to allergies. Other common causes of high eosinophils are asthma and parasites but rarely, cancer. Oddly, one of my cats that did have parasites as a kitten, did not have high eosinophils.

If it were me, I'd focus on getting him off insulin and see how he does. Once you know where he stands with that, you can determine if there are any clinical issues that need to be addressed. If he has parasites, believe me, his poo will be so disgustedly stinky that you can't stand it and it will be very soft off and on.

 

and i wholeheartedly agree with the above. alex is another cat whose eosinophil levels run high due to allergies... in the 2700 range during allergy season or if she's been bitten by fleas. it's not uncommon.

 

I know you all have the best of intentions, but please read what I wrote and don't just repeat it back to me. I said I was going to stop the Levemir, test his ketones whenever he pees and only give R when showing signs of DKA. He's gone DKA 3 times, so it's not just crashing that is the problem. He can just as easily die from DKA coma, which was what happened the first time when he was Dx.

 

Gabby has had the same experience with elevated eosinophils and allergies.

 

yes, we do have the best intentions and we have read what you've written. unfortunately, several of us also have hands on experience with DKA.
DKA can result in death, but not as quickly as crashing from an insulin (any insulin) overdose.

administering 0.5u of R can be very dangerous in an insulin sensitive kitty like xuxu... heck, for the first time in any kitty... without knowing what kind of response that particular cat may have to R. "if" he were to start throwing ketones, you'd want to start out with administering 0.1u of R and then monitoring every hour for the next 4 - 5 hours. you want to start with a tiny dose, collect data, and then go from there based on his response. we can help you with using R if it comes to that.

we're all on the same side, deb. just trying to help...

(((hugs)))

 

I know you don't know me either, but I too agree with the ladies advising you, and I too am scared for your cat and am joining in on the begging for you to please try to stop all insulin for 3 to 5 days to see how Xuxu does, and of course please then check for ketones daily.

And, if you could go out to WalMart and get the cheaper ReliOn meter and test strips, then you can test more, and don't have to ration your test strips.

As far as R goes, that is a very potent and dangerous insulin to use. I can not believe your vet suggested to switch Xuxu from 0.25 of levemir to 0.50 units of R.
My cat is on 0.50 units of levemir, and just 1 drop of R, measured to the zero line, can bring him down fast, really really fast, and can set up another round of sky high bounces. I think if you were to give R to your cat with the way he crashes, that Xuxu would be in extreme danger, and you may not have time to get him to the ER in time.

Please, please listen to these very experienced and knowledgable ladies!

 

Deb, we are not ignoring what you wrote. I clearly read that you were stopping lev and the vet told you to give .5u of R instead, and you wrote:

You can't judge if he needs insulin by him sitting at his water dish. Only a blood sugar test can tell you if his BG is high - and that is not an indicator that he (or any cat) needs insulin as long as there are rebound hormones circulating.

Poor Xuxu is fighting for his life AGAINST all the insulin you are giving. I know you are trying to help him and doing what the vet is suggesting, but your vet is missing the big picture. Xuxu can't keep suffering these hypos and seizures.

We all want what is best for Xuxu. I don't want to see him die because your vet told you to do something that was dangerous. That would be a tragedy.

If you are overwhelmed and feel like you can't keep treating him then please, ask one of us to take him instead of putting him down.

 

Deb,
You don't know me from Adam, although I did post in some of your threads in Health. I just read thru this whole condo, and I just have to say this.

You have been advised by some incredible people here. Of all the voices that have chimed in, you have heard the collective wisdom of literally decades of experience in dealing successfully with feline diabetes. Every person in this thread has had at least one cat go into remission since joining here. I've never met any of them in person, but i have corresponded with every one of them at some point during the past 18 months. There isn't an insulin used on cats that at least one of them hasn't used. They have dealt with many cats directly, and with thousands of cats indirectly.
Simply put, and I don't use terms like expert loosely... their collective expertise exceeds that of any of the specialists you've dealt with. They have more hands on experience than any single vet will have in a lifetime of treating FD cats.

There isn't a single person who has offered advice in this thread that I would not put either of my cats' lives in their hands without blinking.

I am 100% certain that the primary thing in your heart and mind is that Xuxu get better and remain safe. Us too. The overwhelmingly top priority of anyone who advises on this board is the safety of the kitties, and all I am reading here is exactly that. Please, please, listen to them regarding using R. My cat was DKA too. I understand the terror associated with that. Bob was as close to dead as he could get.
But please, give "no insulin" a try. Xuxu is nothing close to what we normally see here. A one-of-a-kind as far as what I've seen here. There's something unique going on with him. If this were Bob, I would put my trust in these ladies to try to figure out the mystery.

Carl

 

Deb,
Sheila mentioned dr. Lisa and as far as I know she does still do phone consults. If you go to catinfo.org, you'll find her email, and I think you arrange for the consult by way of email.

Carl