Diabetes Management - Advice

[Jo_]

Hello!
My name is Jo and I've adopted Dexter a little over 7 years ago. He's 9. He's a yellow, long-haired ball of fluff.
Last year (2023), in September, he started to lose a bit of weight and we took him to the vet. He was diagnosed with diabetes and even though we were caught off guard, we've been trying to do our very best to give Dexter the best treatment and care possible (it's not like he wasn't spoiled with care earlier ).
For a few years before this diagnosis, he was already a cat that required a bit more attention. We couldn't change food brands without him having episodes that the vet could not figure out if IBS or pancreatitis or something else, despite testing.

His diagnosis has been a roller coaster. Reflecting on the last year, we have never been entirely able to manage his diabetes. His vet was against monitoring, but we still do it with an Alphatrak3, mostly because of the support from other posts here, where we felt it would be wrong to just give insulin without any insight on how his glucose is doing.

Other than the occasional increase in the amount of insulin, the vet hasn't looked much further into his case. He's taking Lantus.

For a little over 1 week, he had been drinking more water than usual and his glucose has been SO high (always above 300 mg/dl, even with 4u 2x a day). He was more lethargic on Saturday, so we took him to the emergency. They found ketones in the urine so he had to be admitted in the ICU. They added a Freestyle Libre 2, did bloodwork, ultrasound, treated the glucose aggressively with fast acting insulin, worked on balancing the potassium and after 2 nights in the vet, we got our baby home. They even managed to reduce him o 2.5u while eating the food we gave them, since it's the one he tolerates well.
When he got home, his glucose was actually too low (that CGM is such a cool thing, wish I'd done it sooner). He was also very hungry. He ate and rested... Then his glucose spiked... And hasn't gone down from 20+ mmol since. Despite insulin (increased to 3u), despite playing with him and keeping him somewhat active (he was never the most active cat, he enjoys his naps).

We ever even more careful than usual administering his insulin, but to no avail.

I'm sorry for such a long vent... But I am starting to get desperate, because I want to help him as best as possible, but I am constantly worried about his levels not stabilizing and spiking so much and how much that arms may affect his quality of life moving forward.

I would really appreciate any advice.

 

[Tim & Pookey]

Hi Jo! Welcome to the group! It is great that you’re already home testing. That’s an important step. And you’re on a great insulin.

A more experienced member will stop by soon to offer support, they’ll probably mention getting your signature and spreadsheet up and running.

 

[Jo_]

Hi Jo! Welcome to the group! It is great that you’re already home testing. That’s an important step. And you’re on a great insulin.

A more experienced member will stop by soon to offer support, they’ll probably mention getting your signature and spreadsheet up and running.

Thank you for your reply! I just added the signature, hope it's correct.
I'll fill the spreadsheet asap.

 

[Jo_]

Also, I should be more specific.
I don't have a way yet to measure ketones in the blood or urine. My vet didn't suggest monitoring glucose so you can imagine, ketones was never brought up.

But, his glucose his crazy high. His Freestyle was set up to mmol (I'm used to mg/dl on AT). It hasn't lowered from 22, staying at 25 most of the time. We can't see any signs of the insulin with these results, but I am very confident we gave it.

He is tired, we can tell. But he hates going to the vet, and having spent 3 days there may have taken a toll on his energy.

Other than that, he is eating almost normally and drank water.
No vomiting or diarrhea.

 

[Tim & Pookey]

That’s good news about the clinical signs, but keep an eye on all those areas and report here if anything changes.

I would start researching how to measure ketones at home with him being in higher BG. Some folks use Ketostix and others use blood meters (I have a KetoBM blood meter).

 

[Bron and Sheba (GA)]

Hi Jo and Dexter and welcome to the forum.
Did Dexter have just ketones or did he also have DKA? If they were having to adjust the potassium levels it does sound more like DKA.
If the BG dropped low on the CGM (and they can be not accurate with BGs below 100 and it is worth while checking with a hand held meter with BGs below 200 for accuracy) he could be bouncing which would account for the higher numbers now. Explanation on bouncing at the end.

I am going to give you a list of things you need to be doing for Dexter because he has just had ketones/DKAnow that he is home with you.

• you need to give one and a half times as many calories as Dexter normally eats. Offer snacks every couple of hours during the day and evening as well as the 2 main meals. Food is like a medicine and helps keep ketones away. If your kitty won’t eat the low carb food, feed him whatever he will eat as eating any food is better than not eating,
• Don’t skip any doses of insulin as insulin helps keep ketones away. If the BG is not high enough to give the dose…stall, dont feed and test again in 20 minutes and post and ask for help.
• Test daily for ketones. Put the results of the tests into the remarks column of the SS so we can see. Please report any trace ketones at all. You can either use Ketostix to test the urine …get at a pharmacy or get ablood ketone meter. Both are ok but please start testing daily for ketones. It is very important we know if there are any ketones present.
• Give antinausea medication if needed. Cerenia or andansetron. It is common for cats to be nauseated after DKA
• Give appetite stimulant if needed after the antinausea medication
• Give extra fluids. If kitty will tolerate warm water in the food, put a teaspoon into each snack..
• Ask the vet about subQ fluids
• Set up a spreadsheet and test the BG frequently. This is really important. We need to see the BG data to be able to help with the insulin dose.
• Post daily with updates and ask for help as often as needed.

Information on bouncing

• Bouncing - Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles).

 

[Jo_]

Thank you so much for the helpful advice. Greatly appreciated! Truly.

I just double checked his report from the emergency episode and they mention DKA. Here for reference:

"Dexter was treated at our clinic, where diabetic ketoacidosis was diagnosed along with sonographic signs of pancreatitis. Dexter responded well to therapy, which included infusion, initially short-acting insulin foliowed by a switch back to Lantus, pain medication, and potassium supplementation. He has been eating well in recent days
Therapy:
- Lantus 2.5 IU, once in the morning and once in the evening
- Buprenorphine 0.15ml, 2-3 times daily directly into the mouth (pain medication) for approximately 3 more days, as needed
- Kaminox 2ml, twice daily with food or directly into the mouth

Glucose Monitoring: Continuous glucose measurement via Freestyle as long as the measurements are possible. If the glucose monitor no longer works, wait before removing it, as it will fall off by itself."

He's currently at 390 and I just gave him 3u.
He ate. A bit less than usual, but he's also preferring to eat the one food that is a bit more caloric (still LC Wet Food). Happy to provide some treats throughout the day.

This is really great to know as no such info was given to us by any of the vets that have seen Dexter and all this is really unfamiliar territory.

 

[Bron and Sheba (GA)]

Keep the snacks up during the evening/ night as well. We need him to be eating lots. The snacks are not treats. They should be low carb food.
Can you get the spreadsheet set up please?If not I can ask @Bandit's Mom to do it for you. She can do it in a couple of minutes. We need to know how low the dose is taking him. And if you can get either Ketostix or a blood ketone meter to test for ketones asap please. It’s really important to know if there are any ketones present

 

[Jo_]

I just added the spreadsheet to my signature. I also added there links to the Freestyle graphs we've been getting from the sensor.
Sorry, I meant "treats", as food, not just treats. We'll make sure we really prioritize him eating

Thank you ♥︎

 

[Jo_]

We just measured, and it's at 329, which is still high, but in the grand scheme of things, makes our hearts skip a beat!

 

[Sienne and Gabby (GA)]

Welcome to FDMB!

You have been doing a great job. Being alert to lethargy is a good response and it was a wise move to get Dexter to the vet. It also sounds like you've got a great emergency vet practice nearby.

Just so you're aware, we are very aggressive about coaching so you stay on top of managing ketones. Kitties who have experienced DKA may be more prone to future episodes. The basic recipe for ketones is an underlying infection/inflammation + not enough insulin + not enough calories. DKA is serious and hospital stays are expensive. We want to prevent both. Either getting Ketostix (urine ketone test strips) or a blood ketone meter (e.g., PrecisionXtra, KetoMojo) are a good investment. The down side of the urine test strips is that you need to stalk your cat to the litter box in order to get a fresh sample. In addition, urine tests give you a result that's hours old -- it takes time for the body to produce, collect, and excrete urine. The strips for a ketone meter are about the same cost as AlphaTrack strips and like a blood glucose meter, give you an up to the minute result. And, of course, we have a Primer on Ketones.

Bron has provided a large amount of information along with some homework for you. I'm going to add to the homework. Since your vet hasn't taken the time to educate you about managing Dexter's diabetes with Lantus, I'm going to direct you to a ton of information. (We're very good at adding to information overload!!) At the top of the Lantus board are a series of "sticky" notes. These notes will provide background on the way Lantus works, dosing methods, and other information that will be useful such as using U100 syringes that are calibrated in half unit increments.

I'm glad Bron provided some of the basics about bouncing. It was my first thought when I read your introduction. The only thing that I would add is that it's not just the stored form of glucose that causes numbers to spike. It's also the counterregulatory hormones. Hormones are steroids and steroids raise blood glucose levels and can keep them elevated longer than the glucose that is dumped by the liver and pancreas. It's why many cats experience higher levels at the vet's office -- they get stressed and the stress hormones raise their levels. Just an observation -- with the drop in Dexter's numbers from the 400s to his +6, it's possible that he will bounce again.

Since Dexter was also diagnosed with pancreatitis, I'm going to add to your reading. This is our Primer on Pancreatitis. One thing to keep in mind is that pancreatitis can be quite painful. Pain will also raise blood glucose numbers. If Dexter looks uncomfortable, do not hesitate to use the buprenorphine. It's a very good drug for managing pain.

Please let us know if you have questions or how we can help.

 

[Jo_]

We are more than happy to be informed! So any and all information and experience is very welcomed!

We're getting the Ketostix. I know it's not as good as a blood meter, but with the holidays, I can't get one for a few weeks (I live in Europe and most of the sources I find take a while to ship). It's better to measure something now instead of just waiting for the monitor (which we're also getting).

Pardon my inexperience here. When the vet sent him home, they did so with the painkiller you mentioned and we've been giving it since. They also sent us home with a Potassium supplement (2ml 2x/day).
For further context, due to the holidays, we had to take him to a different vet, since ours wasn't available last Saturday. This one is open 24h hours and our experience has been very positive so far. But currently they are running on emergency services only which makes it a bit harder to get information.

In the event that he bounces again, besides monitoring for symptoms, checking glucose, feeding and testing for ketones, what would your advice be? Is it advisable to give him a bit of time at home with a very close eye or take him to the ER? Our concern is that despite being the sweetest of kitties at home and letting us do everything to him, he's not so friendly at the vet, which stresses him and usually results in a suggestion for sedation (which in the past led him to stop breathing and requiring intubation).

Quick update: we keep seeing a (slow) downward trend. He's appetite is actually quite good and he's much more aware and awake today.
We're just hoping it's not too slow.

 

[Sienne and Gabby (GA)]

Bounces are normal. They are very annoying to us but not dangerous to your cat. Very few members here have any idea when their cat became diabetic. As a result, your cat may have been in high numbers for quite some time until you observed symptoms. Since you mentioned that he's been in high numbers even since he was diagnosed, it may take a while to get him to stop bouncing. His body needs time to get used to being in closer to normal numbers again. Unless you see that he isn't eating, is hiding, is becoming quite lethargic, it's not really necessary to get him to the ER/vet unless you have a reading of moderate ketones or larger on the ketone strips. It can also take several days for a bounce to clear.

If you're not familiar with buprenorphine, it's an opiate. It may cause Dexter to be sedated or a bit loopy.

In the US, ketone meters are available through Amazon. You could check with local pharmacies later in the week to see if they stock ketone meters. A human meter is fine. They have become quite popular with people who are going on keto diets.

 

[Bron and Sheba (GA)]

I’m glad @Sienne and Gabby (GA) has been helping you and answering your questions while I’ve been asleep.
I used to freak out with the high BGs until I was told about bouncing.
Thanks for adding all that information to the remarks column of the SS. It is very useful to have that besides the BG numbers.
I’m glad he is wanting to eat. That is often one of the battles with post DKA kitties. They can be nauseated and not want to eat. If he is eating one food more readily let him have that. It is good if it is higher in calories. That is what we want him to have…extra calories to help stop the ketones.
Can you put any ketone results into the remarks column of the SS please and also post them here?
As Sienne says, we are quite aggressive with suggestions and care of post DKA and ketones kitties to keep the ketones at bay.

 

[Jo_]

Hello,

Thank you both for your responses! This forum has been super helpful to us by keeping our kitty safe and our nerves under control

We have ordered yesterday a blood meter for the ketones, we found one that should arrive tomorrow.
Today we are picking up the ketostix from a pharmacy to sample his urine. We know the results will be a few hours old, but its better than being blind.

Also we see his glucose levels are stabilizing a bit more and coming closer to the "safe" level. We hope he doesn't have another bounce, but we are keeping a very close eye on him for the next few days.
We will keep the spreadsheet up to date and we will add the ketones values as soon as we get the monitoring tools.

Again, thank you so much ♥︎

 

[Bron and Sheba (GA)]

Looks like he is coming down off the bounce. This is his 6th cycle so keep an eye on the BGs.
Up until the ketone meters came into being a few years ago we only ever had the urine strips. And many people still use them. How is his appetite?

 

[Jo_]

Yeah, it seems like a great tool. It's just that in a 2 cat household we're expecting the normal challenges

He is eating well. A bit suspicious of us insisting more than usual for him to eat, because we are giving a bit more calories and the snacking more often than usual

 

[Jo_]

Update: we finally managed to use the Ketostix, and there are no signs of ketones in the urine (no color change on the strip). The Ketostix also measures glucose, and as to be expected with his high BG levels, there is glucose in the urine.

He was a bit grog this morning with a bit less appetite, but he took a long nap and woke up with appetite and with more energy.
The glucose is still a bit higher than we would like/expect, but on average, lower than yesterday and the day the before.

 

[Jo_]

Dexter is eating better, he's more energetic and attentive to play time.

He's BG was slowly coming down but now is gone down quite a bit. He ate ~50 minutes before his 109 measurement.
I am fearful of this drop, would prefer to see it happening slowly.

I am not sure on how to proceed.
I am going to keep a very close eye to check if it keeps dropping and act if that happens. And I'll also double check with AT because it was mentioned before that Freestyle doesn't do well with low values.

 

[Bron and Sheba (GA)]

Update: we finally managed to use the Ketostix, and there are no signs of ketones in the urine (no color change on the strip

Excellent! Keep testing daily and putting result into the remarks column of the SS which I can see you did for todays result, thank you.

Dexter is eating better, he's more energetic and attentive to play time.

He's BG was slowly coming down but now is gone down quite a bit. He ate ~50 minutes before his 109 measurement.
I am fearful of this drop, would prefer to see it happening slowly.
I am not sure on how to proceed.
I am going to keep a very close eye to check if it keeps dropping and act if that happens. And I'll also double check with AT because it was mentioned before that Freestyle doesn't do well with low values.

Don’t be fearful of the drop. You are in control with hometesting and can intervene with food if necessary. I am very happy to see the BG 109.
As you are seeing a couple of blue BG with the current dose, you need to stay at that dose for 10 cycles unless the BG drops under 50 or ketones reappear.
Keep feeding lots of food and fluids
Can you have a look at the two dosing methods for Lantus and choose one please?. At the moment it would be better to be doing TR ( tight regulation) because of the DKA.
DOSING METHODS

 

[Jo_]

Update: we had a scare tonight with Dexter. His values on the Freestyle continued to drop. We reacted by giving him a small amount of diabetic dry food to see if his levels would improve. According to FS, it still dropped to 52.
We then compared with the AT which at its lowest, recorded 112.... Which by itself wouldn't have prompted us to give him the dry food.

We kept a close eye on him.
As expected, the values spiked in the meantime, but are slowly going down already.
He seems ok and with energy.

As for the TR, if possible, I would ask for a hand on this.
When he was in the ER, he was being given 2.5u, but he's been on 3u for 7 cycles because of his really high levels. With this amount, the values already dropped to more acceptable numbers. We're keeping an eye to see if it continues to lower.
So 3 more cycles, before lowering, if values do not drop, right?

And wait minimum 3 days, but at least 10 to 14 cycles.
If it then grants another reduction, we would repeat the process of gradually reducing, until we find his sweetspot.

Is this correct? We would appreciate your advice on how to proceed in terms of units of insulin and to what it should be reduced after these 10 cycles.

 

[Bron and Sheba (GA)]

The FS is unreliable with BGs under 100 so always test with one of the hand held meters.
Instead of giving dry food when the A bags are lower, have a look and get some of the higher carb canned foods. The gravy lovers fancy feast are high carb and suitable for giving if the BG drops low. And always have some honey or Karo on hand in case of low numbers. We can help you with what ever dosing method you choose.
At the moment I would stay with the 3 units.
If you choose TR you would drop the dose by 0.25 units if the BG dropped under 50 ( on a human meter) or 68 (on the AT).
We can help you with dosing until you feel confident to do it on your own. Many people stay months here to get help. Keep asking questions.

 

[Jo_]

I'll look into other canned foods to have on hand.
It's just that Dexter has a tendency to develop IBD or other issues (the vet wasn't able to proper diagnose this episodes) whenever we give new foods.
This means that we are limited to 2 brands of wet food, one is higher in carbs than the other, but that is already the one we are giving him this days because of DKA and bouncing.
And then we have a brand of diabetic dry food that he tolerates (but we never give him, because he stays on LC wet food). That's why we resorted to it.

Our vet had explained that honey should only be given if he has a seizure, so we have on hand, but haven't used it.

We'll stick to 3 then, and monitor frequently. We have both the AT and AccuCheck Guide, so we'll use the human meter to help stick to the levels mentioned in the post.

Thank you so much for all the help!!

 

[Bron and Sheba (GA)]

And then we have a brand of diabetic dry food that he tolerates (but we never give him, because he stays on LC wet food). That's why we resorted to it.

I understand. Have you looked at a novel protein for him?
Do you know what foods make the IBD worse?
If you are giving dry food you can’t do TR.

Our vet had explained that honey should only be given if he has a seizure, so we have on hand, but haven't used it.

That is simply not true. I have no idea where he got that from. It is certainly good to give if the cat has a seizure but it can be given for low BGs as well. And hopefully with hometesting you will not get any seizures. I used to give Sheba honey instead of high carb food often when her BG dropped too low. A couple of drops makes a big difference.
The accucheck is a good meter so I would use that over the AT. And it’s cheaper.

 

[Sienne and Gabby (GA)]

Not to contradict your vet, my diabetic kitty was sensitive to gluten and most of the "gravy" foods contain gluten. It may be easier on your cat's GI tract if you use either a drop or two (literally) of honey, corn syrup, or other high carb sweetener to bump up low numbers. I did this for years with no ill effects on Gabby.

 

[Jo_]

Don't mean to take away from any of the kitties that need help at the moment!

Would just appreciate your insights on this.
So, our ketone blood meter arrived today. The second it arrived, we read instructions, set everything up and measured. It shows 0.1 mmol/l. I'm almost certain this doesn't qualify as traces, but I'm still new to this and wanted to be extra sure.
We've been using the urine test strips, that show no signs of ketones... But I'm always afraid that I may misinterpret or something

Other than that, Dexter is ocasionally having some blue results, but his spreadsheet is still mostly at yellow, which coming from so many pinks and reds, we're taking as a small victory.

Also, we have a small suspicion that the insulin we got from our vet is not ok. Not cloudy or anything, but even long before his DKA episode, one thing we saw over and over is that Dexter sometimes has little to no reaction to the insulin. Before foing to the ER, we tried a new pen (from the same vet) and still, not effect, though at that point, everything was a bit out of control.
The team on the ER sent him home with the rest of his vial (lantus same as pen but just the glass part). Whenever we use it, we see effect, but the other day (02.01.24 AM), we used the other pen, since it had been opened before his vial and again, hard to see a clear sign of insulin.
The reason we are considering that this may be the case is because since august, Dexter has done multiple curves, we measure often and still, we were not seeing effects of insulin. The vet checked with us how we're administering, what we were doing, but we never discussed the insulin pens and their efficacy...

We are still assuming that we were doing something incorrectly, but wondered if this is something you'd come accross before.