3/30 Minnie PMPS 276, +2 249, +3 235, +4 247, +5 226 - R dosing experiment

https://felinediabetes.com/FDMB/threads/3-29-minnie-pmps-277-2-280-0-5ur-4-75-260.245418/

That girl....woke me with some clear liquid vomit but otherwise seemed fine, purring away but it's SO hard not to panic about how strongly she smells of ketones. I didn't get enough blood for a ketone test and decided it wasn't worth upsetting her with an extra poke.

Her bloodwork (electrolytes) came back ok yesterday. Back to the vet at noon for potassium subq and recheck bloodwork so I will mention the ketones again. Pretty sure the IM will again tell me we are treating the same at home as they would in hospital.

She is being super fussy about food. Likes something different with every meal. I have 7 different open cans on the counter.

 

Sending prayers.

 

poor Minnie. I sure hope those ketones come down soon and she can stop using fat for energy. I wonder how this all could be connected to the high blood fats? I have no idea. That’s above my pay grade.

 

Sorry Minnie's appy is still not good. I used to get the variety packs of Weruva foods just so that I could have a smorgasbord to offer. Anything with fish seemed to work with Ruby. Hope all goes well at the hospital. Holding you both in my thoughts.

 

Long day. More bloodwork & increased SQ fluids to 150mL (4.5mEq) subq potassium as her potassium levels have dropped. Also recommend re-visit the 1U dose of regular insulin to suppress ketones as long as she is eating. ETA - she also said she thought there was probably some low-level pancreatitis going on even though it didn't show up on the u/s.

Dropped the ondansetron prescription off and on the way home she was acting weird and meowing like she did the day she was discharged when she had the 50 reading. I panicked and detoured off the road to Mud Bay and picked up some treats to try in the car. Took a few minutes of me wiping Nulo beef & sardine treat around her mouth then she perked up and started licking it off my finger, really perked up and tried to get out of the carrier. Went back in for more and stopped again on the way home to give her a second tube. Only then did I think about testing her in the car, it was 276. Unfortunately I have no idea of BG when she was acting weird, panicked too much. [Side note - anybody else use empty strip jars as travel sharps containers for lancets?]

Help needed
- Anyone know the carb % of the Nulo treats? I have sent messages to chewy and Nulo otherwise. Wow, she loved that beef and sardine. They are going in the hypo box.

- I really need help with the R dosing. I need to put some structure around it. Is there a sticky as well? From speaking to the internist, this is the key to getting her ketones down right now.

Vet instructions are "when BG is running >300 (that's on their meter so I am translating that to upper 200s on the freestlye), ok to give 1U R insulin every 4 hours or up to every 2 hours for more severe elevation.

We are 2 hours away from PM shot. Part of me wants to give her the R now then I thought better of it looking at others' s/s. Thank you!

 

There is no R sticky - for two reasons. One, R is a powerful but potentially dangerous tool, and we don't want people doing this alone but rather under the wing of an experienced person. Two - ECID when it comes to R, dosing is based on gathering data and seeing what works for your cat. You want to learn when to give R, and more importantly, when not to give R.

We usually start with giving R at preshot time and once we have data characterizing what R does, we can move to doing it midcycle. You want to avoid situations where the combined action of L + R insulins cause either fast drops, or drops so low that it sets off a bounce, which defeats the purpose of giving R. You want the action over the 4ish hours that R works to be a nice drop of around 100 points. Over time we build an R scale, where a certain amount of R is given at a certain range of blood sugar values. Neko's was dead simple, 0.5 R over 350 (I think, been a while), 0.25 U from 200 to 350. That changed when her dose became smaller. But with R, very much each cat is different. I've seen a 30 unit Lantus cat need no more than 0.5 units of R, where Neko was around 7 ish units at the scale I mentioned.

So the process is to start slow and increase based on data. That data means testing initially for every hour for 4 hours. You want to find the R onset and nadir. So far we don't have any +4 test data on Minnie, so hard to say what 0.5 units is doing for her.

Want to start an experiment tonight? What time is preshot for you? Are your trying to move it up or was it just earlier this AM. I am in your time zone and can pop in tonight. I'd start with 0.5 units of R, depending of course what her preshot is. And whether it looks like she's trying to break a bounce - cause that's NOT the time to give R. One of the "not to give R" rules.

 

Yes please! My target preshot is 745. Confession time though, she is eating now. With the ketones I was not being strict on the 2h fasting pre-shot and she has not eaten much today at all but I guess it will interfere with experiment data. Do I need to move shot to 8:20?

There are a couple of +4 tests on 1u. 3/25 afternoon she went from 284 to 212 and 3/27 night she went from 502 to 169 in hospital (yikes). That's what triggered the vet to go down to 0.5u. You'd think just by chance I would have done a +4 by now on the 0.5u!

 

No need to worry about her eating before PMPS. The 2 hour cutoff is for newbie's, until people have enough data to know what sort of food bump their cat gets. It's only really an issue if PMPS is green and you wonder if she's be safe without that food bump anyway.

Neither of the +4's you mentioned were at home in "normal" conditions.

 

No kidding. I don't know which of the emojis is most appropriate, I've been through all of them this last week

And thanks. Again.

 

Let the experiment commence. 276. About to shoot 5u L and 0.5u R. OK to feed whenever she likes?

 

Yes on the food. I'd start with a +2.

 

And hurrah, I've got her eating. Applied Mirataz when we got home. New trick that's working today, swipe some of the Tiki or Nulo paste treat around her mouth and she quickly gets up to eat.

 

Sometimes "priming the pump" works to get them eating. I found if I syringed one or two amount, often Neko would eat the rest on her own. Keep on eating Minnie!

 

Exactly! I have no idea why, but syringe feeding a.k.a. priming the pump as Wendy called it got my cats eating many a time. I hope Minnie will be a little piggie tonight!

 

249 @+2. Managed to persuade her to eat again.

 

235 @+3. She's sleeping, will see if I can get her to eat some more.

 

She ate a bit. A LOT of work priming that pump but she got maybe a couple of ounces down - she walked away 3 or 4 times and I followed her with the Nulo treat. Not really a piggie except she is covered in the bits of food from my priming attempts.

247 @+4 so a drop of only 30. I don't have any patience pants. The ketone smell is making me way too anxious. 0.75u R with AMPS?

 

Typically we'll do a couple cycles with the same R dose, cause you are looking at the action of L + R, and more data is needed to tease out what you are seeing with R. Maybe try a bit of a scale.

250-300 0.5 R
301+ 0.75 R

I also want to see where she goes when she clears this bounce, but at some point an L increase is in order. Generally we don't give R on the same cycle as an increase, cause sometimes that's a little more active with L by itself.

 

Well, you did get some drop from the R last night (not 100, but you're still working on tweaking it). I hope she's going to do even better today. Back to vet today at noon?

 

Yes. This is heartbreaking, I'm watching her waste away before my eyes.