2/15 new member needs reassurance! Uncontrolled BG since April.

Hi (warning, long intro message)

So much good info and knowledge here and in the Facebook group! Hope this is the right place to post.

I'm getting stressed and overwhelmed that we can't get Minnie's numbers down, and that I can't see any other spreadsheets like ours. I have yellow/blue envy. But mostly I'm afraid we'll be back in the ER for the 4th time since diagnosis in April with another DKA.

Minnie was Dx in April, started on Lantus (up to 4u) without success. Levemir transition in work (now at 2.5) but it doesn't seem to be having any effect yet either. She eats Purina Wet DM Selects, was getting some W/D kibble for treats but I stopped that completely last week. Vet recommends waiting to adjust diet, after we get the insulin sorted out.

I'll talk to the vet when she's back in tomorrow and imagine she will propose another 1/2u increase to 3u after 2 days with nothing in the 100-200 range.

Can you help calm me down by pointing me to another spreadsheet that looks as black and red for as long as ours? (ideally that has successfully improved) How long should I prepare for this to continue?

Thanks so much and sorry for the essay!
Elizabeth

HISTORY

• Apr: Minnie was diagnosed when I took her to ER for loss of appetite/sweet smelling breath. One day at home then back in for a UTI. They started her on Lantus and we worked up to 4u 2x/day monitored with Freestyle Libre. Never got below 300s.
  
• Aug: Back in hospital because loss of appetite - DKA and UTI, 10 day stay. (New internal medicine vet) restarted low dose Lantus.
• Oct: Worked back up to 3 units in Oct. Minnie finally chewed off Libre #5. Dr said to check in after couple months.
• Dec: applied new Libre with Minnie in pj's/collar so she couldn't remove it. Primary vet thinks she developed allergic reaction to adhesive. Increased to 3.5u Lantus. Internal med vet had suggested Levemir as next option, I said let's do that instead of increasing Lantus to 4 again as it hadn't worked before.
• Jan: Started Levemir at 0.5 > 1.0 >1.5 then Libre stopped working. No more Libre due to allergic reaction, vet recommended Alphatrak. Back to ER for slightly decreased appetite, sweet smelling breath (Sunday), ketones in urine. Vet said didn't need to bring her in until they reached moderate (Weds).
  
• Feb: Another 4 days in hospital. DK, became acidotic. She got to 98 nadir after 2u Levemir, so she came home. I joined this group, bought the Relion and Alphatrak. [Sticking with AT due to issues getting blood even with rice sock, warm cloth, vaseline and 26gauge lancets. If anything, less blood than when I started]

 

Hi Liz, the other experienced folks will chime in soon, I’m sure. First...you are doing what you can and you found a great home on the forum!! So many people have helped me and given me confidence that I could figure out how to help Mr. Howie. He is a medical mystery. It sounds like your pretty Minnie has given you some scary/stressful times. I know from reading other people’s advice that you didn’t need to start back from ground zero when switching to Levemir. So that might be part of it. Being a depot insulin, you’re not building up his depot with such small doses (compared to where you were with Lantus). Howie was on ProZinc and I switched him to Levemir last fall. I’m really glad I did as his BGs don’t have so many peaks and valleys. I may also suggest switching to TR instead of SLGS. I had better luck in getting him in line as I was doing enough testing like you are. The biggest thing is to not sit on a dose more than 6 cycles if you’re not seeing improvement. But please listen to the experienced folks! Also, you may get quicker responses if you post in the Lantus/Levemir forum.

Just know we’re all here with open arms and big hugs!

 

Dear Liz,

welcome on the forum, it has been a Godsend to us, all the information and help we got. We are new here and i can’t really give any advice since i am still searching for answers as well, just wanted to let you know that we are here with you and bump your message higher for the experienced people to notice and have a chance to answer.

i was looking at Minnie’s spreadsheet and it is a bit confusing, are these all data from 2021 or 2020? You said she was diagnosed in Apr 2020, it would be best to fill in the as much history there. It looks like you are measuring her BG at home, is this the case?

it is very frustrating when we dont see the progress we would like to in our beloved kitties but we have to take each day at a time. You are doing great by following Minnie so thoroughly, keep up the good work and i am sure you will see light at the end of the tunnel

 

Thank you both for your kind words of welcome and support!

Minnie's spreadsheet has 2021 data only starting when we transitioned to Levemir and joined this group at the end of Jan. I am measuring BG at home with AlphaTrak now, previously with the Freestyle Libre CGM in 2020 (Lantus) under vet's supervision. Minnie became allergic to the adhesive, so Libre is no longer an option. Vet proposed the Alphatrak and I used this group's excellent spreadsheet template. I re-typed the first few days of Levemir data from the Libre into the spreadsheet. The historic Lantus data is in the Libre reports I downloaded, link is in my signature but not in a spreadsheet.

Should I copy/paste into a duplicate thread in the Lantus/Levemir forum?

Thank you!

 

Hi Liz and Minnie,
I’m glad you have found us and I am sure we will be able to help you.
I am sorry you have gone through 2 lots of DKA. Managing ketones is key to stopping that happening again.
I would test daily for ketones in the urine if I were you at the moment with her being unregulated. If you see any decrease in appetite or suspect an infection or see any lethargy, test immediately for ketones.

I don’t agree with the vet about waiting until the insulin is sorted out. As long as you are testing, I would switch over slowly to a completely low carb diet. Then you will be able to see how much insulin is needed. It won’t work out the other way round!

Have you seen the list of low carb foods available 10% or under.
Press this link
https://catinfo.org/docs/CatFoodProteinFatCarbPhosphorusChart.pdf

I would also switch to tight regulation once you get all the dry food out of her diet. You can increase every 6 cycles if needed.
If you have a human meter it will be much cheaper if you use that. Is there any reason why you are using the pet meter?

 

Meant to ask how is Minnies appetite?
Do you give snacks throughout the day and evening as well as a the before shot meals?
I suspect the DM selects are higher carb....but I could be wrong.

I think part of your problem is that when you swapped over to the Levemir you went back to 0.5 units instead of swapping over to an equivalent amount.........we usually say, for safety sake to give 70% of the Lantus dose when swapping over.
Going back to 0.5 units runs the risk of ketones forming again and glucose toxicity. ....in fact I can see Minnie did develop ketones again....that would have been because of the drop in insulin.
Ketones start to form when there is not enough insulin and not enough food and the body starts to use fat instead of carbs (glucose) for its energy and the byproduct of this is ketones and is why it is really important that Minnie eats well and gets enough insulin.

 

Thanks for the tips, Bron!

I have started testing daily for ketones in urine. The Purina DM we're on is at 10% but I'll start the transition to lower carb. She's picky and doesn't like pate...

I am using the Alphatrak because 1) that's what vet suggested so I already had it ordered and 2) it needs less blood - after a week of collecting data I am struggling to get good readings from the Relion. I am trying all the tips but still not getting enough blood for the Relion. Lowest stress option for now is to continue with the AlphaTrak. I will switch to Relion later as I get better with the blood, or I'll transition to a human monitor that only needs 3microliter instead of 5.

cheers

 

She is a greedy girl now! I wasn't giving snacks before but started in the last few days if she wants something. Have ordered lots of the recommendations from here but haven't found one she likes, so she gets extra wet food. DM selects are a bit higher than the pate but she wouldn't eat the pate!

Her decreased appetite was my first clue of a problem last week. She didn't finish her food so I started testing her urine immediately and sniffing her breath! I am very frustrated because the insulin transition was per the vet's instructions (the same vet I paid to look after her for the subsequent 4 days in the hospital). I feel this last hospitalization was completely avoidable.

Now I'm experienced with the DK I am very anxious to avoid another. I have ondansetron (she's getting that now) and mirataz which I will apply if/as soon as I notice any decrease in appetite.

 

I agree that the last hospitalisation and the ketones were avoidable.
I would give three snacks during each cycle at the moment to get enough food into her. Food is like a medicine when it comes to ketones and DKA.
So that is 6 extra snacks a day as well as the preshot meals. Is that manageable? Don’t feed for the 2 hours before the preshot BG as you don’t want it to be food influenced. Keeping the snacks for during about the first 6-7 hours of the cycles is best if you can do that.

There are other low carb options apart from pate foods.....Sheba wasn’t fond of pates either.
Have you looked at the Weruva brand? It is well liked by a lot of cats and has many low carb options.

Quite understand why you want to stay with the alphatrak meter at the moment.

 

THANK YOU THANK YOU THANK YOU. I did not realize should feed extra between meals. I can easily give her extra snacks during the day, 3 during the night may be difficult but I'm barely sleeping for stress the last couple of nights, so it's possible. I can definitely get 2 in, shift their dinner a little earlier.

I'll go back and look at Weruva, they used to get that (her brother Sam is fortunately not diabetic but it's too hard to give them different food!). I did get a couple of FF options to try which she liked, but it had some nasty effects at the other end. Started to get worried about changing too many things all at the same time. Thanks again.

 

You could start a thread on this forum and ask for other low carb options apart from FF if that doesn’t suit the cats.
I feed a raw diet so I am not up with all the latest canned foods. But there are plenty of Low carb to choose from.
BTW Minnie is beautiful!

 

Thank you! I've found various lists of food with the nutritional calcs on this site, just a question of picking a couple to add in. you've already been a great help.

Minnie has been such a good girl, tolerating loads more needles after a few weeks in clothes which she hated.

 

I believe that the Tiki Cat food is also shreds, vs pate style and is low carb.

One thought... When we transition a cat from Lantus to Lev, we do not drastically reduce the dose. The rule of thumb is to give 70% of the Lantus dose since some cats have a marked response to an insulin change. It's going to take a while to get the dose back up.

I know I would find it helpful to see Minnie's Lantus spreadsheet. Would it be possible for you to open it to sharing?

My hunch is that you weren't giving enough insulin. The best dose of insulin for a cat is the dose the cat responds to. Some cats just need more insulin.

 

Thank you for the info. Understood about the transition, I'm surprised the vet wasn't aware of this but here we are. We had been at 4u Lantus in August til the DKA, then started over and worked up to 3.5u in December. I don't have a spreadsheet for Lantus, it was all tracked using the Freestyle Libre. I downloaded all the reports from the Libreview website and posted them here. I think I've set it to share the entire folder but let me know if it's not accessible and I'll figure it out. Thanks!

https://drive.google.com/drive/folders/1R6rqMvHvkXT0q1Wk_T2dASK-MjD61iRd?usp=sharing

 

Hi Liz,

With regard to the DKA and Minnie's history ( ), I'd like to suggest getting a blood beta ketone (BBK) meter, main reasons being:

1. BBK meters detect levels of 3-beta-hydroxybutyrate (3-β-OHB), the ketone body with greatest clinical significance in DKA.

2. Testing can be done on demand in the same way as testing for glucose levels with a blood droplet from the ear, no reliance on acquiring a urine sample.

3. Ketone levels may be building up in the blood for a period before detection is possible in the urine. Therefore the BBK meter would be able to detect ketones sooner.

4. Points 2 and 3 combined create the opportunity for a faster response if ketone levels start building (hopefully enough to seek treatment sooner and reduce the chance of a cat tipping into full DKA).

I've attached below a journal article discussing blood vs. urine ketone monitoring. From the article:

Urine ketones (acetoacetate) are only a surrogate measurement of the clinically relevant capillary ketones (3-β-OHB). In diabetic ketoacidosis (DKA) the 3-β-OHB:acetoacetate ratio increases from 1:1 to 5:1.1 With treatment of DKA, 3-β-OHB is oxidised back to acetoacetate. As a result, 3-β-OHB will decrease, but acetoacetate will increase. Measuring acetoacetate with urine sticks may therefore initially underestimate the severity of DKA and then continue to yield positive readings after the resolution of DKA.​

Again from the attached article, here's a helpful table comparing urine vs. blood ketone testing:





As noted above, BBK meter strips aren't cheap, but you'd only need to test once a day (unless results were to indicate additional testing is needed) - possibly just during times when Minnie seems a bit 'off', if her appetite is sluggish and/or her BG levels are on the low side and you are considering giving a reduced dose of insulin. If the BBK meter may help to detect ketosis faster and provide a chance to 'nip it in the bud' then I think that's worthwhile - better for the kitty and ultimately for the wallet - plus it would provide a signal to investigate and treat any underlying condition contributing to the ketosis.


Mogs
.

 

Thank you, Mogs! Just ordered the NovaMax meter and strips (bonus, it also does glucose which only needs 0.3microliter so this may serve as my replacement for the Alphatrak as well!). With hindsight, I'm still kicking myself I didn't take her in when the urine test was at trace and then small, but the vet said it was ok (and didn't give me any suggestions on what to do practically so I was just crossing my fingers)

 

I knew you would find great help on here! But please...no kicking yourself! You can’t go backwards. We just take all these experiences and learn from them and move on. There is so much stress in trying to learn and keep up on everything. You owe yourself grace. Minnie understands!