01/14 Casper AMPS 464 +7 57 Discharged from ER yesterday

Good evening almighty forum,

Newbie here, my baby-Casper was diagnosed with hyperglycemia last December and we went through quite a lot, just to brought him back from the death bed (3 vets actually told us to put him down and suggested his survival rate was only at most 25%). Casper was in critical care at the ER from 01/03 to 01/13.

Previously he was on vetsulin, we switch him to Lantus on 01/08. Casper responded to Lantus quite well in the first couple of days, his BG remained around 130-180 mg/dl until the 12th. He was on Lantus twice daily, 1 unit/dose; the vet changed to 1 unit/day (AM) on the 12th as his BG dropped to 26 on the 12th morning. He was then kept at the ER for one more night, discharged, and came home last night.

The vet is not sure why his BG is all over the place and 0.5 unit/dose for AM & PM didn't work either. Now we are really concerned as his unregulated BG is the initial cause that we had to rush him to the ER in the first place.

His morning AMPS reading is 464, 30 ML Forza10 Actiwet Diabetic food was then given; 30 mins later, I gave him 1 unit Lantus. I didn't test him until +7 at 4 PM (except for feeding him every 3 hours, I left him to rest.) Should I test him at +4/+6/+8? Any advice on how I should handle his critical case?

Many thanks!

Casper's Mom

 

You were giving 1 unit of insulin. That reading of 26 would have earned a decrease to 0.75 units, maybe even 0.5 units. Lantus is a depot insulin so any change in dose up or down will take a few cycles to readjust the depot. The high is because of the him going to low and not use to it so it creates a "bounce" an the hospital probably gave dextrose IV to get his sugar up. The bounce and the IV can take up to 6 cycles (12 hr periods) to clear and settle down. Going forward if you can get a +1 or +2 reading. It is a good indication of what the cycle will look like.

What food arae you giving? DM dry or wet?

 

Hi Yuling and Casper
What was Casper in hospital for so long with? Did he have DKA? Or something else?
Lantus needs to be given twice a day to get a cat regulated. Once a day won’t do that as it will leave a cat with 12 hours of no insulin.
I see you have a 57 at +7 today. Have you fed some high carb food and retested?. If not please do so as 57 is too low in the alphatrak meter.

You need to reduce the dose to 0.75 units twice a day
How often are you feeding him. Are you giving snacks during the cycle as well as before the shot?

 

Hi Olive, thanks for the reply. I will get his reading at +2, +4, +6 moving forward. We gave him Forza10 Actiwet Diabetic and Proplan DM wet.

 

Hi! I just wanted to re-iterate what those above (who have lots of experience!) said - that 1 unit of insulin is too much and not safe for Casper. You need to decrease by at least 0.25 and perhaps even 0.5 (or even more! you need to find a dose to give twice a day).

It looks like you shot 1unit again this morning so you will want to monitor closely. If Casper is below 68, you will want to intervene with a high carb wet food or even his regular food with some syrup. Here's a info on handling low numbers - it references a human meter number of 50 but since you are using Alphatrak, it's 68.

@tiffmaxee if you check in, perhaps you can comment too?

 

Hi Bron and Sheba,

Thanks for your reply. Casper was rushed to ER due to the complication of renal failures and unregulated diabetes. He had two blood transfusions, they had to work slowly to bring his sodium, potassium, kidney function, and other numbers back to normal. He was then discharged to come home with instruction of 1 unit/day only.

I planned to test him at +6 yesterday, as we were told that is when the Lantus insulin works at its peak. However, I had a really important meeting that went quite longer than I thought, so I tested him at +7. (My bad, I wouldn't do that again) When I saw his BG number at 57 at +7 (4 PM), I gave him 2 drops of honey, 10 ML cat milk right away, followed up 30 ML Forza10 Actiwet Diabetic food. Retested again 2 hours later, his BG number went up to 161 at 6 PM.

Regarding his PM dose, if the number is in range (like last night, 161 at 6 PM), do I still give him the PM dose? Should I start with the 0.75 unit tomorrow? And come back for your advice?

We feed him every 3 hours; always, always give him food and water before his shot. The freshly baked shrimp or Fancy Feast chicken fillet are also provided to him as snacks whenever he is out walking around.

 

Susanne is right. On the meter you are using any test under 68 calls for a .25 permanent reduction. Lantus is not dosed on the preshot. The highs you see are bounces from TOO MUCH insulin. Continuing to give too much insulin can lead to a symptomatic hypo which can be fatal. Sorry for being so blunt but I am worried about your cat. We can help you keep Casper safe.

Sorry. I wrote this before you responded.

 

Susanne is right. On the meter you are using any test under 68 calls for a .25 permanent reduction. Lantus is not dosed on the preshot. The highs you see are bounces from TOO MUCH insulin.
Thanks for getting back to us. When you test tonight, stall, don’t feed, and post asking for dosing advice. Your next dose when safe to give will be no more than 0.75 and possibly less. We want to find a dose he can handle every 12 hours. Did the ER mention DKA or ketones? Do you have a copy of the labs and discharge directions? Since he has been in hypo territory he might be more sensitive to insulin and need even less than .75.

 

Thank you, Susanne, Tiff, and JaxBenji! I will reduce his dose immediately, will give him the next shot at 0.75 U.

I am extremely frustrated as the doctor first instructed us to go with 1 Unit/dose, AM & PM; then to 0.5 Unit/dose, AM & PM; then to 1 Unit/dose, AM only. Aren't they paid to figure out a safe dose for him? I feel I've been more educated about how to care for Casper here with all of you than those vets! I think that's what made him really sick last December and we had to rush him to the ER on 01/03.

How should I handle his number if the BG reads below 200 before his PM shot? Please advise, thank you!

Casper's Mom

 

You don’t need to worry about him dropping under 200 during the cycle. If he drops under 100 it’s still fine but you want to feed a little food to prevent a drop under 68. Get a +3 and post the results. What is your feeding routine? Most cats do well getting 3 mini meals each cycle.

 

Hi Tiff, that's what we are doing right now, skipped his PM dose as his BG reads below 200 in the evening. But that leads to a high number in the morning. Or maybe once we adjust his dose to 0.75U, we should see a change?

I just tested him +2, his number is still at 684, the same as for AMPS. I feed him every 2 or 3 hours, depends on his status. If he is awake and walking around, I give him 30 ML diabetic wet food (syringe feed, he hates those). Normally he finishes 1 can a day, by 6 PM, he would pretty much finish the diabetic food; then we make him fresh-baked shrimp and Fancy Feast chicken fillet for his dinner and late-night snacks.

 

Hi Tiffmaxee, please see the attached clinical summary from one of the ER that brought him back from the death bed. I don't have the latest reports, requested multiple times, but not yet received.
The vet did mention DKA, according to the lab tests, there is no trace of Ketones. I tested him yesterday, the test strip results in negative. I Will test him daily and report to the group whenever I see a trace.
I will come back to the group for instruction in the PM. Thank you all! You are his saviors!

Casper's mom

 

Simple answer: Vets don't know much about feline diabetes. They come off sounding authoritarian and wise...when in fact they learned little in college and likely have had no time to become well versed in the nuances of this disease. When you think about it, you can hardly blame them. FD is a complicated disease and requires a lot of reading/information to figure out the intricacies of blood glucose regulation in cats. They just don't have time to keep up with all the literature...and most likely have to treat a lot of different animals for a lot of different things.

Stay tuned to this forum for lots more information and support than you'll ever get from your vet ...and most vets fall into this category - although there are Endocrinology vets and specialists for FD...but they're few and far between.

You're in the right place....and have already gotten some great advice today.

 

Were you told that he was anemic when hospitalized? I don’t know if that has changed since dus barged but 18% HCT is very low. Are his gums pink and moist or pale and tacky? With DKA you don’t want to be skipping doses which is more reason to find a dose that can be given every 12 hours.

We are neighbors. I’m on the west side.

 

Yeah, we were told about his anemic situation, he had two blood transfusions, once on 01/05, once on 01/11. The vets stated it caused by the fluid given to his body, on the night he came home, we asked his vet specifically about this. His response is not to worry, we need to give Casper and his body time to recover, let him eat, drink, and rest.
I've been monitoring his gum yesterday and today, almost no change, a little bit pink with pale. The vet did not give us any meds to take home or giving any instruction on what to look for or monitoring his HCT number.

 

When was the HCT last tested? If it’s due to CKD and stays under 20% he will need Aranesp or Epogen. If it’s back up over 20% it needs to be monitored.

 

His last test should be done on the 12th or the 13th. I will be able to tell when I got the reports on hand. I believe the tech said his HCT was at 24 after the transfusion, but without the data in hands, I am not certain.
I just tested him at +6, BG reads 694.

 

Take a break from testing until pmps.

 

The dm wet food is ok if it's the pate food. I don't know about the other food you mention. You do want to keep the food less than 10% in carbs. You won't find carbs listed on label. Most people here use friskies or fancy feast pate foods. There are others I'm sure people can suggest. The food list is to outdated at this point. A lot of the new foods are not on it.

 

Copy!

 

Hi Olive & Paula,
Yes, the Proplan DM he has is pate. Before he started having issues, he's had Fancy Feast pate all his life. He hates ProPlan DM, so we got Forza10 just as an alternative (label reads below):

• CRUDE PROTEIN 8.5% min
• CRUDE FAT 8.0% min
• CRUDE FIBER 0.6% max
• MOISTURE 80% max
• CRUDE ASH 2.0% max
• OMEGA-3 FATTY ACIDS 0.8% min
• OMEGA-6 FATTY ACIDS 0.5% min
• STARCH 0.05%
• TOTAL SUGAR 0.09%

We also have Royal Canin Aging can, Tiki Succulent Chicken (I believe the protein is 16%).

 

Another more recent food chart can be found at Tanya’scrf. The order she lists the foods is low to high phosphorus but carbs are included.

 

Okay, +11 BG reads: 382 mg/dl. 9PM should be his PM dose. Should I give him 0.5 unit/0.75 unit or just skip and follow up tomorrow morning?

 

Don’t skip. Let’s see the PMPS. He’s still coming down but high enough to shoot. Will you be able to monitor? Can you set alarms to test?

 

Got it!
I can also get up at 3 AM to check on his BG when insulin PM dose works at it's peak (+6, correct?). What I am worried is the repeat situations the vets were having, give him two doses, his BG dropped way low (lowest at 26).

 

I think you should probably shoot .50 or even a token .25. Let’s see the PMPS.

 

The low point, nadir can happen at any point in the cycle. Fir many it’s at +5-7 but sine nadir at the end of the cycle.

 

Shall we go 0.25 or 0.5 just on the safe side? I can test any time required, just feel bad for him, almost like he barely gets any rest.

 

Let’s see the PMPS. It will be either ,5 or .25. Then start with a +1 and +2. I’ll stay with you for at least the +2 and will have someone else help you when I leave.

 

So, I need to poke him again in 10 mins for BG reading then give him the shot? Sorry, my bad, thought we are making the decision based on his +11 number as his PMPS.

 

A lot can happen in an hour. Sometimes a cat drops between +12 and the preshot. Depending on the bg sometimes you have to stall at preshot, don’t feed, and see if the bg comes up on its own. So if any doubt, always post and ask for advice. You always need to get a AMPS and PMPS, even if you get a +11.

 

Got it! Sorry, I normally follow the routine of: test, feed, 30 mins later then shot. I will test again now

 

You need to test, feed, shoot all in about 10 minutes. With Lantus you dint wait 30 minutes to feed. The onset, when it starts working, is usually around +2.

 

552 mg/dl PMPS. Last eat: 7PM

 

Ordinarily I would say shoot .75 but given the big drop I think you should shoot .50 and get another test at +2.

 

Copy! 0.5 it is. Thanks Tiffmaxee!

 

See you at+2.

 

When you get a chance add to your signature that he was DKA , has CKD and anemic. Add any medications he’s taking. Did they send him home with sub-q fluids? Thanks.

 

And renal failure too, Eise?

 

No meds, no sub fluid.
According to the vet, his body really needs a good recovery process: as long as he is eating and drinking, no vomit or diarrhea, keep him on insulin as instructed (1-unit a day only). Of course, we are now fine tuning that dose.

 

Are you adding water to his food? Is he drinking much?

 

Yes, we always add water to his food.
He is drinking well, always asks for warm water to drink when the weather is chill. I am not certain about exact volume he drinks each time, but at least 3-4 tbsps each time and he asks for water at least 4-5 times a day. In the night, he drinks from his fountain. We always give our cats Primo water, and we clean the fountain, change the water every day.

 

I’ve just looked through his report from the vet. The vet says he’s in there for DKA but the urine sample showed no ketones....so a bit strange. I’m going to ask @Marje and Gracie if she can shed some light on the path exults as it is quite lengthy. Marje the clinical summary in in post12 above, thank you..

If he did have DKA, he needs to be having as much as 1 1/2 times as much food as normal.........how is his food intake atm?
And as @tiffmaxee said...don’t skip any doses of insulin and please give it 12 hourly. We need to find a dose that you can safely give every 12 hours and which also keeps away the ketones.
I’m really glad you are testing daily for the ketones, that’s really important.

 

Casper has been a picky eater all his life. If it's not what he wants, we have to syringe feed him. Now he takes 1 can to 1.5 cans per day. In the past two nights, we gave him shrimp and chicken fillet for dinner/late-night snack.

I picked up some Tiki succulent chicken for him today, high in protein as well, all white meat; legend says it will help him gain some weight and promotes kidney function too he smelled, put his nose in the air

I just tested the ketones, negative. He might think I am crazy, always follow him into the litter box.

 

It is hard when they won’t eat!
Great no ketones!

 

579 mg/dl. +2, 11 PM PDT.

 

Still bouncing

 

Hi Bandit's mom, I think the renal function got corrected by the treatments at the ER. Thought that was the issue caused by toxins with unregulated diabetes. Do I also need to update that?

 

@Bron and Sheba (GA) Do you think she should have shot .75? I was worried about a big drop like earlier.

 

Don’t add that now since it could have been a temporary or even an acute attack that will correct itself. You won’t know until the next set of labs.

 

Yes, Ma'am!

 

Casper technically earned a reduction down to 0.75 and with DKA in the history we don’t want to drop the insulin too low, but in saying that the SS is incomplete and has only two readings in the PM cycle so we don’t really know what is happening for half the story. He’s bouncing big time from something and I don’t think it’s only those three lime green numbers.
So I think erring on the side of caution and safety was a reasonable call.
And Casper tested negative for ketones which is good.
Yuling now needs to get some tests in during the pm cycles so we can see what is happening at the moment.
It’s hard to work out how long the bounces are lasting and if it is only low numbers that are triggering the bounces or if Casper is also dropping fast (like he did on 12/27.)
@Yuling & Casper do you think you could put a blank line inbetween the 1/3 and 1/14 please, so we can see they were not consecutive days?

 

Done.

 

Agree with Bron. I think your suggestion on the dose tonight is correct. Since his numbers are all over the place, it's safer to go with that route.

 

Thanks. Much easier to understand!

 

Thank you!

419 mg/dl at +4.
Should I continue at 3AM or actually give him a break tonight?

 

That’s a big drop in 2 hours....160 points
Did you give a snack?
I don’t know when 3am is (I am in Australia) but I think I’d get a test around +8 or +9 just to see if he’s going to drop low. And it’s good data.
Would that be ok?

 

No, he didn't have any snack. His PM shot was at 9PM PDT. He had 30ML food 5 mins before the shot and had some water after +2, +4 tests.
I can do +8 reading, will report back to you tomorrow morning. Thanks for your time and support tonight!

 

I probably won’t be online in your morning as it will be the middle of the night for me, but I’ll look when I get up.
One way to stop fast drops is to feed the curve. So as you gather data you will see when he is most likely to drop and if you give him a snack before that drop you will hopefully be able to slow it down.
I would give him a snack before you go to bed. You have I hope you can get some sleep in between the tests. That’s important.

 

No worries, we will talk more tomorrow when you got time. I let Casper sleep for now, will check on him at +6. If he is still sleeping at that time, I wouldn't bother him but will check on him at +8 for a BG reading.

 

Casper just had some chicken, now he is all curled up in bed again.

 

Yuling --

First, welcome to the board.

I've done a pretty rapid skim of the posts above. You've gotten some great suggestions. I want to add a few housekeeping notes and thoughts.

For today (Saturday), please start a new thread. We typically suggest one condo (aka thread) per cat per day. You'll want to copy and paste the link from this thread into the new thread. That makes it easier to backtrack for information as well as not having to read tons of posts from an aging condo.

With a cat that is recently post-DKA, you want to do what you can to not skip shots. DKA arises as a result of an infection or inflammation + not enough calories + not enough insulin. Some cats are very sensitive to any variation in that combination of factors and we don't want Casper back for another hospitalization if it can be avoided. If catching a urine sample to test for ketones is inconvenient, there are blood ketone meters. The ones that have historically been used ar the Precision Xtra and NovaMax. However, in recent years with the Keto Diet becoming popular, there are lots of ketone meters around. The strips are expensive -- about the cost of the AlphaTrack strips -- but you don't need to use as many.

If you get a pre-shot number that's lower than expected, please post and ask for help. (You will want to put a note in your subject line that you need input.) Again, this is because you really don't want to skip a shot due to Casper being on the recovery from DKA.