3/24 Minnie +11.75 163, PMPS 211, + 40min 211, +1.5 232, +2.75 241 - vet report

https://felinediabetes.com/FDMB/thr...tones-1-6-am-ketones-1-1.245126/#post-2765933

BG improving everything else the opposite!

Last night bedtime she started drinking water again though appetite improved after the ondansetron with FF trout dinner.

This morning seemed hungry but walked away from normal DM breakfast to lie down. Then ate most of the FF trout flakes again. Increased dose to 5u. At first showed no interest in ondansetron/pill pocket then ate some weruva chicken so I dropped the pill pocket in. Drinking more water.

Vet will earn her consult fee today!

 

Good luck with the vet appointment! And the dose increase

 

Good luck with the vet. Sending lots of vetty vines your way.

 

I'm waiting for a Minnie update. Poor baby doesn't feel well.

 

Vetty vines.

 

Just got home a little while ago. They kept her to do bloodwork and ultrasound, will add details.

@Wendy&Neko @tiffmaxee @Bandit's Mom
More urgent for now:
Question - do I go ahead with the 5u as scheduled?

They gave her sub-q fluids and 1u R 2 hours ago (6pm). They offered a bit of our FF but said she didn't eat it so she hasn't eaten all day. On the way home, giant BM that just looked like undigested food. I thought it was vomit til I saw it all over her backside. She's still washing. Took a bit of Weruva chicken, mostly the juice. Not interested in pill pocket/ondansetron. Seems alert.

(I think yes, new IM said - she needs the insulin to drop the ketones but typically we say hold the insulin if they're not eating, and they don't eat because of the ketones. All completely makes sense. Only new info is the BM. I left a message with them, waiting to hear back)

I will fill in all the rest after this, just concerned about the clock and shot time. I have all the stuff in the hypo kit.

thanks

 

With ketones I think she needs the insulin. Can you syringe feed her if necessary?

 

On this forum, we say that UNDER 150 you stop, do not feed, and ask for help. Above that SHOOOOOOT!

 

One quick question, why the R and why that much?! It usually lasts a couple more hours, so you'll see the BG dropping a bit until L onset.

 

No, we don't say no insulin if not eating. Even diabetics cats who cannot eat due to surgery and having anaesthesia get at least half a dose. Insulin does more than combat carbs in food. When is Minnie's onset? You have until then to get some food in her.

 

Thanks, ladies. Amazing how you freeze when things go all unexpected on you.

5u given. I will have a crash course in syringe feeding if needed, she is not interested in food. She won't touch the pill pocket and I haven't pilled her before, so no ondansetron. Should I apply Mirataz anyway? I read recently that you shouldn't when they're nauseous, though she did eat a little bit about 30min ago.

 

Maybe +2 onset, +6 nadir? been so hard to tell the last week or so.

I will check discharge notes to confirm R dose. Vet said that it was a way to combat rising ketones when she has these episodes without needing to go into hospital. She said insulin fights the ketones (I'm a bit tired and brain full of info so I may not be repeating this accurately).

 

Can you test again and see what her numbers are doing?

Can you put a bit of butter on the ondasetron and slide it in her mouth. Grab her scruff and tilt her head back a bit first. Follow up with a syringe of water. and stroke her throat.

 

Here's a copy/paste of discharge notes. I'll put the labwork onto the s/s but this is quicker for now.

Assessments:
Potential reasons for her hard to control diabetes include pancreatitis, hyperlipidemia, Cushing's, or less likely acromegaly. Kidney infections may also be playing a role. Her triglycerides are severely elevated in a manner consistent with idiopathic hyperlipidemia of cats. I am concerned if she has that, it could be the cause for her pancreatitis and diabetes. Ultra lowfat diet is recommended. If that does not reduce her triglycerides to less than 500-1000, then bezafibrate will be recommended.

For her ketotic episodes, more aggressive home management when ketones are present can be tried. Today, her glucose around 445P was still quite high at 333. We gave her an extra 1U of your regular insulin at that time. Generally speaking, when ketones are present, she will need more insulin, even if she is not eating well. To address this, you can monitor her glucose and, when her glucose is over 300 and ketones are present, give her an extra 1U, or 0.5-1.5U as you become more familiar with the effect of this protocol, to help suppress ketones and help her feel better with a more normal glucose reading.

Study: Abdominal ultrasound date of exam March 24, 2021
No free fluid is seen within the peritoneal space. No enlarged lymph nodes are seen. The urinary bladder is moderately distended. No calculi are seen. The spleen is mildly enlarged and slightly hypoechoic but no focal masses are seen. The liver, gallbladder, and extrahepatic bile duct are normal. No stomach or intestinal wall thickening is seen. Intestinal layering is normal. The ileocecocolic junction is normal. Both kidneys measure within normal limits and have good corticomedullary distinction, the right kidney is 4.8 cm in length, the left kidney is 4.3 cm in length. No renal pelvis dilation is seen. The adrenals are larger end of normal, the right adrenal is 5.5 mm in width, the left adrenal is 4.4 mm in width. The pancreatic duct is mildly dilated. The pancreatic tissue is normal. No peripancreatic inflammation is seen.
Conclusion:
The appearance of the spleen may indicate inflammation, hyperplasia or extra medullary hematopoiesis. Diffuse neoplastic process such as mast cell tumor is considered unlikely but aspirates are possible. The dilation of the pancreatic duct is of unknown and questionable clinical significance. There is no sonographic evidence of pancreatitis at this time.

MEDICATIONS:
Levemir insulin - Continue with 5U SQ twice daily.
Ondansetron (she foams when Cerenia is given as a suspension) - Give once to twice daily as needed for nausea.
Lactated Ringer's solution - Give 100-150mL SQ once daily as needed for dehydration.
Regular insulin - When blood glucose is running >300 and appetite is picky such that increasing her Detemir is not
comfortable to give, ok to give 1U SQ once every 4 hours, or up to every 2 hours for more severe elevation.
DIET:
Ultra low fat diet is recommended for Minnie. Ideally this would be Purina OM, or possibly Hill's w/d. If she won't eat these, the lowest fat diet she will eat is what is recommended.
PLAN FOR RE-EVALUATION:
Since Minnie is not feeling well this week, we will try to suppress ketones and rehydrate her at home. I ideally recommend repeating the fluids tomorrow as well. is a Youtube video that demonstrates this or she may also get these on an outpatient basis at a vet clinic. Recheck fasting triglycerides are recommended in 1-2 weeks. If pancreatitis management and lower fat diet is not helping, bezafibrate will be recommended.

TRIGLYCERIDE 3145 mg/dL (range 25-160)

Test Results Unit Lowest Value Highest Value Qualifier
Total Protein 7.6 g/dL 5.2 8.8
Albumin 4.5 g/dL 2.5 3.9
Globulin 3.1 g/dL 2.3 5.3
A/G Ratio 1.5 0.35 1.5
ALT (SGPT) 50 IU/L 10 100
Alk Phosphatase 70 IU/L 6 102
BUN 53 mg/dL 14 36
Creatinine 1.1 mg/dL 0.6 2.4
BUN/CREAT RATIO 48 4 33

Sodium 148 mEq/L 145 158
Potassium 4.1 mEq/L 3.4 5.6
Chloride 110 mEq/L 104 128
Comment(s)
Lipemia 4+. Magnesium may be increased by 25%. See online reports for specific comments regarding this interference. No other significant analyte interference.

Test Results Unit Lowest Value Highest Value Qualifier
WBC 10.6 10^3/μL 3.5 16.0
RBC 10.0 10^6/μL 5.92 9.93
HGB 13.6 g/dL 9.3 15.9
HCT 43 % 29 48
MCV 43 fL 37 61
MCH 13.5 pg 11 21
MCHC 32 g/dL 30 38
Platelet Count 179 10^3/μL 200 500
Platelet count reflects the minimum number due to platelet clumping.
Platelet Estimate Adequate
Neutrophils 72 % 35 75
Bands 0 % 0 3
Lymphocytes 17 % 20 45
Monocytes 2 % 1 4
Eosinophils 9 % 2 12
Basophils 0 % 0 1
Absolute Neutrophils 7632 /μL 2500 8500
Absolute Lymphocytes 1802 /μL 1200 8000
Absolute Monocytes 212 /μL 0 600
Absolute Eosinophils 954 /μL 0 1000
Absolute Basophils 0 /μL 0 150

 

will do. back shortly

 

211 still, unchanged since PMPS (the 163 was before I posted the message, tested again pre-shot and it was 211...same 40min later).

Never thought I'd see the day I'd find the blood test relatively easy, wish me luck on the pilling!

 

A few random thoughts on the discharge notes. Acromegaly much more likely than Cushings. Any indication why they thought Cushings? Any other signs? We can help with R - do NOT do the dosing they suggest. Wait for someone experienced to help you with R. Fortunately you are in my time zone.

Ondansetron dosing is low - 2-3 types orally a day a better choice. You can also get it in a form you inject, which you might want to explore with the vet. Much easier to give if cat is nauseous.

The ultrasound results look pretty good. Tagging @Marje and Gracie to see if she's around to comment on lab results. FYI - putting the results on the Labs tab of the SS is really helpful.
How to Give Subcutaneous Fluids (Video)

She's flat and over 200, good to see.

 

(I keep getting diverted then realize I have written but not posted)

Well Ondansetron didn't go too well, it was soft because I'd tried sneaking it into food, then I couldn't get the butter into her mouth and it sort of melted around her lips. Bit of drooling and even nose and eye watering. Apparently she doesn't like butter either! I will definitely ask about the injectable one.

At +1.5 she ate a little Beech Nut baby food Turkey with Turkey broth but scarcely measurable. Numbers going up a bit.

My guess they thought of Cushing's is because of the skin tear when she ripped off the last Freestyle Libre monitor (though I explained that situation to them). I don't remember why she didn't think it was Acro. It might come back to me.

 

Cushing kitties often lose hair around the belly, as another common symptom. Interesting reading on hyperlipidemia, looks like Cushings can cause it. I've seen one other kitty here with hyperlipidemia, which tested negative for Cushings and acro. He was taking steroids though, which contributed to his higher dose needs. Never was tested for IAA.

You might want to invest in a pill shooter. I found they really helped me up my pilling game with Neko.

As for foods, there are lower fat options than w/d (which is very high in carbs) or OM (also HC). Some of the Weruva fit that bill.

 

Wow. Liz. I hope Minnie will feel better soon! At least your ultrasound did not seem bad at all. All good news there, I think. I'm optimistic about you supplementing with some R to help Minnie and hopefully get those ketones down. Wendy will be a great guide to you with the R!

I'm wondering if the way she is metabolizing fat is contributing to the hyperlipidemia... or the hyperlipidemia is contributing to the ketones, etc.

I usually get the Ondansetron "mini-melts" which are really tiny. All you have to do is get them in the cat's mouth and they just dissolve. I don't know if this is what you were given. I would definitely get a piller for Minnie, since she just doesn't take pills well, it seems. What were they talking about Minnie "foaming" when given Cerenia suspension? Did they really try to give it to her straight into her mouth? Liquid? I'm surprised they didn't give her an injection. Cerenia is very bitter. I always put it into a small gel-cap (ordered from Amazon) and give with a piller. Many cats will foam at the mouth if given Cerenia directly into their mouth, although I do have cats that will not if I put it in the back of their throat with the piller.

Poor Minnie had a long day yesterday. I sure hope she will eat for you today. I bet the sub-q fluids will help with that. Hugs!