Newly diagnosed, 19 yo cat also has mild/moderate CRF

Hi all,
I just brought my 19 yo cat home yesterday from ICU where she has been since Monday, getting potassium supplemented fluids, nasogastric tube cause she wouldn't eat, and blood sugar checks after insulin. First insulin (Lantus) dose was one unit around 3pm, BG was 450 when she went in, dropped to 189 at 8 pm then 62 at midnight so night doctor started 2.5% dextrose, and it went back up over 400 but not much info from that ... so next they tried 1/2 unit of same insulin started around 2:30 pm when BG was again around 450, it dropped more slowly and lowest was 155 around midnight then by 4am it was back up to 273... again at 9 am they did 1/2 dose and then me home with her, she had been eating but then vomited so I don't know how that affected results but when I tested her BG at home it was 50. Which freaked me out and I thought maybe the glucometer was off so I tested myself and another cat (!). Then tested her again and at one point it said 34, so called vet and they said to do the karo syrup 1/2 cc. I was inpatient so gave her a little more than that over the next half hour. It went back up to around 400 so around 11:30 I gave a 1/2 unit, this time it dropped to 170 at around 4am then went back to 400 by noon today. Another 1/2 unit around 12:30 and now it's down to 211 so we'll see. I called and left message for vet because I am not really sure what I am supposed to be doing, isn't going up to 400 within 12 hours too high, but when we did a whole unit it dropped so fast, and I don't even know if I could do 3/4 unit it's such small difference ... I have been trying to make sure she eats as much as I can (any wet food) and she is eating fairly well, so maybe the BG will not go too low as it did when she first came home from the vet?

Anyway any advice on this would be welcome. My head is kind of spinning. She has only had the CRF until now, fairly mild, but she was very dehydryated when she went in so BUN and creatinine were pretty high and potassium very low but potassium was fine when she left the vet yesterday. I have only had her since she was about 13 when her owner went into a retirement home, I took her and her 2 children who were 12 at the time, they both died from cancer in the last couple years.

She also had a urinary tract infection so is on zenequin for that, and 100 cc LRS once daily with added potassium. What exactly is the relation between insulin, glucose & potassium? Vet said the insulin would make potassium go down and dextrose also pulls out potassium but I don't understand why. I know they also pee a lot out with the CRF.

Thanks for any advice/experience/suggestions/help.
Ellen & Mama

 

When you say you gave an additional 1/2 unit it is unclear of you are talking about the Karo or the Lantus. Lantus must not be given more often than 12 hours. Please clarify.

 

Hi Ellen. We can help you with Mama, and help to answers your questions, and give you support while you get used to the sugardance.
Lantus is normally given every 12 hours, and the dose should be as consistant as possible each time, unless she goes too low, then you would want to lower the dose.

There is a wealth of knowledge here. We have a lot of combined experience and are happy to help you and Mama.

Please be patient as we ask the questions and get the answers we need to best help you, and please ask as many questions as you have.

When you have time, go over to the Lantus forum and read the stickies at the top. It is a lot to learn and read and can be overwhelming with info. So, take your time.

Welcome :YMHUG:

 

OK is this the timeline?

• 3:00pm …..BG=450 …..1 unit Lantus
  8:00pm …..BG=189
  12:00am …..BG=62 …..2.55 dextrose
  ??????? …..BG=400+
  2:30pm …..BG=450 ……1/2unit Lantus
  12:00am …..BG=155
  4:00am …..BG=273
  9:00am …..BG= ??? …..1/2 unit Lantus and went home
  ??????? …..ate and vomited
  ??????? …..BG=50/34 retest …..1/2cc Karo plus a little more in 1/2 hour
  11:30 …..BG=400 …..1/2 unit Lantus
  4:00am …..BG=170
  noon …..BG=400 …..insulin?????
  4:3pm …..BG=211

is that right? When was the last insulin? just want to get this up for answers and I'll answer some of you questions.

 

I meant 1/2 unit of insulin. She has gotten it roughly every 12 hours since I have had her home, never more often than that, at the vet they did it less often. I don't have a set schedule yet but I have only given it to her twice myself so far, once at 11:30 last night and once at 12:30 today. The vet was thinking I would only be giving it once/day after the glucose dropped to 50 within 4 hours of the 1/2 unit being given, but when it rose back up to over 400 that night I thought she needed another dose. Does anyone give it every 24 hours or is it always every 12?

 

I edited a little bit...

3:00pm …..BG=450 …..1 unit Lantus
8:00pm …..BG=189
12:00am …..BG=62 …..2.55 dextrose (throughout the night in fluids, plus they gave her some into the IV directly)
2:00 pm …..BG=400+
2:30pm …..BG=450 ……1/2 unit Lantus
12:00am …..BG=155
4:00am …..BG=273
9:00 am …..ate and vomited (while still at vet)
9:00am …..BG= ??? …..1/2 unit Lantus
(I don't know the order of this because I wasn't there and don't have the records yet, but it seems like she threw up and got the insulin around the same time and didn't really eat until I got her home later)
11:30 am went home from vet
1:00 pm …..BG=50/34 retest …..1/2cc Karo plus a little more in 1/2 hour
11:30 pm …..BG=400 …..1/2 unit Lantus
4:00am …..BG=170
12:30 pm …..BG=400 …..1/2 unit Lantus
4:3pm …..BG=211

 

There are exceptions to every rule and ECID (Every Cat Is Different) but Lantus is pretty much given every 12 hours as a standard.

Mama looks like she's responding to the insulin pretty well. Eventually, you may have to lower the dose, once the shed builds up. Are you generally home during the day to monitor her?

 

Just for folks to consider....is this a bounce number pmps and dose reduction in order. Mama did go pretty low and did bounce way up there.

 

I'll cross post in Lantus to try to get some eyes over here.

 

For cats Lantus needs to be dosed every 12 hours. In addition it is a depot (reserve forming) insulin so when you first start you need to do a consistent dose for a week to 5 days before all the insulin you are giving is available to the cat. Shifting the shot time can act as a decrease (shooting late) or an increase (shooting early). Every time the dose is changed the depot rebalances and it takes a couple of days to adjust. Sooooo…… it important to not vary the shot times by more than 15 minutes and to hold the dose until the depot can readjust. The exception is if the cat goes too low, then you reduce. That 50/34 may have been caused by the vomiting and no food on board when the Lantus kicked in, but may indicate even 1/2 unit is too much.

Many of us shoot micro doses. Syringes w/ half unit markings are available and you can squeeze outdrops for 3/4u and 1/4u. It is even possible to go in between by counting drops, but you have to be careful to be consistent.

Until the cat gets regulated those swing are not unusual. Part of the swings you are seeing is just the shed filling and a lot is from the varying shot times. Pick a time that you can shoot morning and evening and try to stick with it. I know there will be times when it will be impossible.

How was the dx made? A single blood test or a fructosamine? Vet stress can easily bounce a cat's BG into the diabetic range. The fructosamine show that there has been a build of of glucose over time and spilling into the urine. Infections and whatever she was in the ICu for can raise BGs too.

It is great that you are testing and that she is eating only canned food. Those are 2 big hurdles cleared right there.

 

If Mama is going below 50 on 1/2 unit while the shed is still being built up, it is probable too much. Even taking into account that one dose was basically w/out food.

"Bouncing" is when the liver detects low blood glucose and dumps hormones and a form of glucose, part of the survival instincts.

 

Oh, OK, I didn't know how important the same time was - I can pick a time and stick with it. So how much did I mess it up by doing it an hour different? The diagnosis was made cause she had the glucose in her urine and then 458 on her bloodwork, but the biggest problem was the low potassium and dehydration (and infection) and I know those things can affect the diabetes. We didn't do a fructosamine or any of that yet. We are supposed to recheck in a week. Vet does not think good prognosis because of her age and other problems and says she may be hard to regulate.

BG is 159 at 5:20. Am I testing too often? Isn't going up to 400 each time before the next dose, too high? Does that get better once the insulin is in their system a while?

I haven't left her for more than an hour or 2 since she has been home. I am kind of obsessed with checking her BG. I had another cat who became hypoglycemic and seizured, years ago, before I knew that could even happen, before I knew how to check BG, so I am very paranoid now. The vets don't really warn you how dangerous and complicated insulin is.

I don't know, based on the 1/2 unit she got when I gave it and when I *watched* the vet tech give it vs the one time I didn't see them give it, I am wondering if they gave too much yesterday before I took her home. I don't fully trust them when I am not there. The 1/2 unit seemed to have the same results for me these last 2 times and also when she first got it in the hospital. So I'm wondering.

 

I thought she went back up because I gave her so much karo syrup, but vet said that doesn't last more than an hour in their system.

 

when the bg's go to low during the cycle you can end up with that 400+ number from a thing called 'rebound'
don't concern yourself with that right now.
the most important number is the low number of the day.
that is the number that will tell you if your dose is too high.
and it appears it may be.

 

OK I definitely need the smaller syringes, do I get them online ? Vet did not mention this option. At first they didn't want to do less than a unit, it was actually my idea to do the 1/2 unit.

 

well, unfortunatly "they" don't always know.
your testing...now YOU know.
when you say smaller syringes,...do you have one's with 1/2 unit markings on them?

 

:twisted: Welcome to the Vampire Club! I don't think you are testing too much, I test at least 6 to 8 times a day. Especially at the beginning the more data you can get , the easier it will be to advise you on dose. That big swing is unnerving, but not unheard of. As we said her liver is probably dumping sugar in a "panic". And yes once the shed is filled it should get better.

What you want are U100 insulin syringes, 3/10cc, w/ 5/16" 31g needles and half unit markings. These are what many of us use from ADW

I've tried at pharmacies and they tell me they don't exist. :roll: Some people have said they get the half unit marked syringes at Walmart, the house brand is Relion.

 

I have those BD 3/10 cc orange end syringes, but I don't think they have 1/2 unit markings on them. I just go between the last marking and the end of the syringe to do a 1/2 unit. It's like a drop. I don't know how I could do a 1/4 unit! I also have some that came from Walgreens that were donated to me, that are the same as the BD ones. 3/10, 5/16, 31 g. Oh, wait, the Walgreens are different from BD and actually do have little marks for 1/2 units. It's still gonna be hard to do 1/4 though. The Walgreens ones are Super Thin II Syringes Comfort Assured, and it even says 1/2 unit scale markings on the package. The BDs were the ones I had been using but I will use these now. I guess I have to get a prescription to get at Walgreens, it looks like whoever donated them had a script based on the label on the box.

My husband thinks I am bleeding Mama to death with all this testing and making her miserable for the last days of her life which is not very optimistic of him.

 

182 at 6:05
so the low is 159 about 5 hours after insulin shot?
Isn't that too high, or will it get lower in the next 2 weeks, or what?
It sounds like the insulin will have more of an effect as she is on it longer, yes? or am I not understanding that, is it only the duration that gets longer?

 

hey, would you share your name with us.
and this number is great. take it slow. it's not a sprint, it's a marathon.

 

Sorry it's Ellen. And Mama is the cat. I signed the first one but then I kinda forgot to sign my name.

 

Ellen, use those 1/2 unit markings and do lower your dose.
It is easier to raise dose as needed.
And................that low number you got today is good.
You go slow....your just a couple days in!
Your really don't want to see those 40 and 50s everyday.

 

and the idea is not duration so much as a nice curve, not too steep a drop, not to shallow.
and then you want to get to the point were you have lower pre shot numbers...and gradually lower dose....always according to your nadir (lowest number of the day)
lori

 

Hiya!! You've been given great info so far!! Welcome to the best place you wish you never had to be.

To address some of your most recent concerns...

Yay! on the 1/2u syringes. There are two ways to figure out 1/4u. Either you can place the black thingy exactly between the zero line and the 1/2u line, or you can fill the syringe to 1/2u and then slowly expel the insulin one drop at a time until there is none left. Lets say it is six drops. When it is shot time, you measure to the 1/2u line and then slowly expel 3 drops. Voila! 1/4u!

As for the pokes... the cats get used to them very quickly and some even are enthusiastic! The key? Low carb treats. Freeze dried chicken breast or shrimp works great... you can get Purebites brand at Petco (try the dog food aisle... same product but more economical packaging!). Boiled chicken breast is good too. Give a treat with each poke, whether the test is successful or not, and soon Mama will be much happier with the process.

Infection is something that can raise BG#s in cats, so as Mama's antibiotics kick in and do their job, you'll want to keep an eye on the BG#s as they could drop quickly.

An FYI for CRF, one of the keys I know is keeping the phosphorus intake low, especially if you aren't using phosphorus binders. Both Merrick Before Grain (BG) Turkey and Blue Wilderness Duck are both FD friendly (each under 3% carbohydrate) and are also low in phosphorus. With Mama's numbers, you're also going to want to stock up on some cans of high carb food (look for gravy in the title!) as you may need to use those to steer numbers. We like to start with high carb food when cats go low but aren't showing symptoms of hypoglycemia. The carbs in the food will help the numbers rise, but the food itself allows those numbers to stay up longer, whereas, as your vet pointed out, karo gets numbers up fast but is processed and out of the system very quickly, leaving a cat vulnerable to crashing again.

Finally, Lantus works in long-acting manner because it builds up crystals under the surface of the skin that slowly dissolve to help bring BG#s down. To work optimally, the cat's body has a certain amount it needs in reserves. We call that the shed. So, imagine that Mama has a little shed in the back yard. When she was just starting out, she took most of her shot out to the shed for storage, then used a little to help her BG#s. After 3-5 days, her shed is full, so each shot just tops it off, and the remaining insulin goes towards the BG#s. That is why a consistent 12 hour cycle is important... we don't mama to have to go to the shed to get more insulin to keep her BG#s in check. It sounds like her pancreas is likely doing it's job on some level, but probably needs support for a bit longer, and she'll be attending Liver Training School (LTS) as well. Right now, Mama perceives numbers in the 400s as "normal" (as opposed to 50-120 on a human meter, which is typically where non-diabetic cats hang out). So when the insulin does its job and takes her numbers lower, her liver freaks out and thinks it is in danger of hypoglycemia. In response, it releases stored glucose and hormones to bring the numbers up to what it perceives to be normal. In LTS, Mama's liver will gradually recalibrate its sense of normal so that it doesn't have those reactions. When that happens, you'll see a nice, flat curve as opposed to extreme highs and lows. LTS has many classrooms here... some kitties are in the advance class (where I suspect Mama will be!), while others have to repeat the remedial level. :lol: :lol: :lol:

Okay, that's probably enough info for one post... don't want to overload you!

Welcome again, Ellen. Please continue to ask questions as you have them!

 

It is possible and you will get it. I have been shooting .1u for the last 3 months, but I do have a very geeky and powerful magnifying visor. :lol: :lol:

Cat's ears don't have a lot of nerve endings so it is not as painful and that's why we test there. Tess just sits and purrs while we test, waiting for her treat.

I never looked at Walgreen's, I'll have to check. I didn't think that you needed a script for syringes in CA.

Mid blue is not bad at this point. You need to get the shed established and then the next step is to get the bounces under control. THEN you start working to get the overall BG down.

You said Mama is eating canned. What? Any dry at all? That is very high in carbs and not good for diabetics. There is a list we use to find out the carb 5 in catfood. Janet & Binky's List Diabetic cats should be fed food less than 10% carbs and many of us try to keep it around 4 or 55.

 

Hi and welcome,

You're getting some great help so I'm not going to get into the numbers and things, but you asked about potassium, insulin and CRF. I'm not very technical and don't now the correct medical terms, but did a lot of research when Tucker had potassium defiency.

Many cats with kidney failure do have potassium loss. Part of this is the increased urine output, potassium gets flushed out too quickly. In mild cases of low potassium you might see inappetance, lethargy some muscle weakness.

Then there are diabetics who when just diagnosed the increased insulin in their system from the shot we give can cause potassium loss.

Insulin increases the body's ability to draw potassium and glucose into cells lowering the amount of potassium(K) in the blood stream leading to potassium deficiency. If potassium levels in the blood stream are already low from the CRF, the insulin drawing K into the cells could cause a condition called hypokalemia.

Potassium defiency can also cause decreased insulin resistance which could be why you are getting these low numbers on the low dose of Lantus.

Maybe you could give the fluids 2X per day, at 50 cc so your kitty could get the extra potassium twice a day instead of all at once and possibly flush that out too soon. If it were my cat, I'd want to get the potassium up, keep kitty hydrated with the fluids and hopefully once hydrated and K is in normal range, appetite might come back and the insulin given might not give such dramatic highs and lows.

I know I'm not good at explaining this, hopefully others with low K experience could better explain this.

 

Update: 7:10 pm now BG is 145 (was 182 and hour ago, 159 2 hours ago)). So that means I haven't hit the low yet? Should i be worried that it is still dropping 7 hours later or is this good? Very confused.

Thanks for all the info. I have used Wilderness Chicken esp for cats that tend to put on weight, is that also low in phos like the duck? I feed her whatever she will eat, right now she is not wanting to eat much but usually likes those Fancy Feast appetizers (tender tongol tuna I think?) I try to do grain free for any chubby cats I have - Mama actually only weighs about 5 lbs but I don't know what she was like in her heydey with previous owner (who ironically was diabetic herself when she went into the assisted living home). Mama doesn't eat dry right now but I did feed her KD dry for a while and that probably isn't a great idea for diabetes, sometimes I would feed her kitten kibble just to get her to eat it so she would put on some weight... but now she will only eat wet anyway, so I give her whatever I can get her to eat.

 

I'm not going to say you should be worried...but I will say you DON"T want to shoot a still dropping number. Not this early in the dance.
Hope I got to you in time...If the number is still dropping you can test again in 1/2 hours. If still dropping I might skip the dose....or shoot a micro dose. But since you are so new to this...I think it might be smarter to skip dose and see what she is doing in the morning.

 

just wanted to stop in and say hi - you're doing great. not sure what time you're giving shots but i can see you're on the US west coast time, same as me & Ann, not sure who else. so if you haven't given the shot yet tonight and want input on it, just post again. check mama's BG right before and then post it.

it gets easier - and yes, it's a marathon - it will take a while for her to settle in with the lantus and it will take a while for you to learn how it all works, but it's do-able and it definitely gets easier. a little bit of information goes a long ways towards making you feel more in control!

with lantus, the numbers that are most important are right before giving a shot to make sure they are high enough to be safe to give the shot, and mid-cycle to make sure they aren't going too low. i test preshots and then every 3 hours after that from 7am til 10pm unless punkin's looking like i have to check him during the night or more often. routinely i check him 6 times a day. not everyone does that and some people do even more - it will depend on your life and how mama responds.

she won't bleed to death. you can reassure your husband! :lol:

 

One thing that will help us better answer questions about BG#s is if you can put it into a universal time format:

AMPS-- AM Pre-Shot Test
+1-- one hour after, and so on...
PMPS PM Pre-Shot Test

If you are giving a shot late or are stalling waiting for numbers to rise, you would keep counting... for example, if it is 12 hours after your last shot but for whatever reason, you're reporting numbers having not given a shot, it will be +12, +12.5, +13, etc. until you shoot, at which point you would use the PS designator.

We have folks on these boards from all over the world, and keeping track of time zones just proves to be too difficult. By reporting your numbers in the fashion, people can clearly see where you're at in the cycle and give advice accordingly.

This is another chart created by a member that has the values of many of the premium brand foods. There is a column for phosphorus that you can use to determine appropriate foods for Mama. The Wellness isn't the lowest phosphorus option, but it isn't the highest either. You should probably aim to avoid seafood varieties of cat food as they tend to be the highest... though for some crazy reason, Merrick BG Chicken and Quail is CRAZY high as well! My Willie has shockingly good kidneys for pushing 15, and I'm doing my best to keep them that way!

 

Please let us know how things are going. What time are you going to shoot 12:30?

12:30= PMPS~400 ….1/2 unit
4:30 = +4~211
5:00 = +4.5~159
6:00 = +5.5~182
7:10 = +6.5~145

About 6 or 7 hours after the shot is not an unusual nadir. When she ate in relation to the tests could explain the dip and bump up, but this is a very nice curve. I don't think she should keep dropping too much longer. but I agree w/ Lori that if she continues to go down until the preshot , you should skip the shot. You don't have enough info to shoot that type of number yet. I like to do a test an hour before the preshot so I know which way Tess's numbers are going at the shot time. Also be sure to take up any food 2 hours before the shot to get a more accurate test.

Tomorrow morning start a new thread w. the date, Mama's name and her AMPS in the subject. We do one thread (we call them condos 'cause we live here :lol: )per day w/ a link to the previous day, that way it is easier to keep track. We'll explain how to link and update and a million other things you never thought you would need to know. Ni Ni, I am toast.