4/23 RK-AMPS 574 ket 5.2 +1.5 454 +4 339 +5 413 PMPS 461 ket 0.6 +4.5 187 +6.5 93 +7 72 +8 106

Yesterday

Still holding the 0.75u Lantus dose for now.

@Bron and Sheba (GA) Per last night’s discussion re the timing of R… thoughts?

 

Oh I was hoping the AMPS and ketones would be lower. I see @Sienne and Gabby (GA) is online. I wonder if she could give some input.

 

Looks like she might have gone offline.
I think I would give a drop of R with the AMPS so high and ketones still up. How do you feel about that?

 

Agree. I just gave her two drops of R to try to take the edge off. It ended up being about half an hour after the Lantus, but that should hopefully be close enough to the Lantus shot to avoid the dreaded concurrent nadir (I wouldn’t have wanted to wait much longer). Thanks for your help, Bron.

For future reference, @Wendy&Neko what would you have done?

 

I just saw your tag. I had an errand to run.

The only thing to be attentive to is timing R so the Lantus nadir and the R nadir don't overlap. If you have a curve on both it will help so you can see where the difference is. I've not used R so I don't consider myself an expert -- I've just seen it used a fair amount. I think you were fine to use it.

 

Good morning.
Looks like the 2 drops of R dropped RK a lot more than 100 points. It might be better to go back to 1 drop next time and see how that goes. We don’t want to cause bounces if we can help it.
Apart from that how is she going?

 

Last night and today could have been the dread NDW cycles. Hopefully now over and she'll work the 0.75 units.

The half hour late R was probably OK, she seems to onset her L a bit later. Though we don't have a lot of data on regular cycles with just Lantus. Ideally when using R, you know what the L cycle looks like, so you can add R to that and figure out R's onset and nadir.

I also agree that two drops R seems to be too much at this point. Both last night and today it dropped her too much too fast.

One other thing to consider, typically kitties on dry food will start at least at 1.0 units of Lantus. If she doesn't come down below 300 by the end of the night, I'd increase tomorrow AM.

 

Will definitely go back to 1 drop of R rather than 2.

I went with Lantus alone for the PM shot and will see how the cycle goes. I can add R around +6 if needed. Do you think that was a good idea or should I have given R at PM shot time as well? She hadn’t spiked too high at PMPS from where she was at midcycle so I sort of wanted to see where this was going to go without the R variable, particularly if NDW was at play.

She’s back on Clavamox as of today. And I’m continuing the subQ fluids, ondansetron, mirtaz, syringe feedings, etc.

Last night and early this AM was rough. I could tell by her demeanor that she felt lousy. By tonight her ketones were back down to 0.6 and she actually wanted food. It didn’t last long so I supplemented with syringe feeding, but at least she ate something on her own.

I find it interesting but also perplexing how much the ketones yo-yo around, as well as how up and down her attitude and general well-being are. One minute it seems we might have turned a corner, then hours later she seems worse than ever. It’s definitely not a linear recovery.

We know the teeth are atrocious (what’s left of them anyway) but we can’t yet rule out other compounding problems. I wonder about pancreatitis (although no obvious signs of that), hyperT (vet said T4 results would be unreliable right now so not worth testing), cancer of course, and so on. Is this the typical trajectory of DKA recovery? None of the vets I’ve asked have given me a clear answer—and I’m guessing that they probably don’t have the depth of experience with it that we have around here.

Wendy, you mentioned cats who eat dry food typically start out at 1u BID … is that the case as well for featherweight post-DKA kitties who aren’t eating anything at all? Just trying to learn something here to file away for future reference. At 4.4 lbs and a recommended starting dose of 0.25 mg/kg actual weight (calc’ing based on actual weight since she’s under her ideal weight), I get 0.5u BID, so just want to know if there was a better starting dose.

Finally, what do you think the parameters should be for shooting R in her situation? I’d like to compare notes/thiughts if you don’t mind. Thanks!!

@Bron and Sheba (GA) @Wendy&Neko

 

Great to see the ketones back down to 0.6 You are doing a really good job caring for her. It can’t be easy.
Why was she put back on clavomax?
Is she still having the Baytril.?
Some cats with DKA come home and don’t have ketones during the recovery. Some throw a few traces and sometimes they can yo-yo. So I guess every cat is different. But doing what RK is doing is not the usual recovery. But it does happen.
I would still be thinking about the feeding tube. If we could get more food into her, the ketones might settle a bit…just a thought.
Cats who can eat well usually have a smoother recovery.
It’s a bit of a vicious circle in the beginning…they can’t eat because of nausea but if they could get over that hump and eat, they would probably start to feel better. Feeling nauseated is horrible.

 

With high carb/dry food, SLGS is what people are supposed to follow. 1U BID is what SLGS calls for, regardless of cat weight, if not on low carb wet/raw. We are breaking rules due to DKA and high ketones. She's a special case (note to lurkers - do NOT follow). With DKA you want to maximize insulin as much as safely possible. TR allows some fast tracking an increasing after 4 cycles if all above 300.

Over time with R you build an R scale, which really varies by cat. Meaning you shoot a certain amount of R based on the BG at the time, and possibly when in the cycle. With Neko, her max R dose was 0.5 units and as her L dose went down, so did the amount of R I shot. She maxed at 8.75 units but that was before I started using R. I've also see a 30+ unit acro kitty that maxed out at 0.5 units R.

As for when to shoot R, you are trying to avoid situations where you get that fast drop - causing a bounce and higher numbers and your trigger finger itching to use R again. It's the dreaded bounce/drop repeat cycle. So, when might cats think about dropping on their own with L and without R? Those are the situations to skip R. First cycles after an increase some cats show a little potential. Bounce breaking cycles are a no-no. Do fluids play into it for her? I might note fluids times in the Remarks or somewhere to see if you can catch a pattern.

Good times to use R include when a bounce is starting, or those darn fur shots.

I'm fine with delaying the R tonight. The more data on L by itself, the better. Most cats (not named Neko) have R onset around +2 and nadir around +4. Neko had a late onset with R. First time I shot it, I tested every hour to try to get a handle on onset/nadir and gave up after 3 hours cause nothing was happening. Went to bed on flat red and woke up to green. Which she hadn't seen for 15 days. Cats!

 

Welp, my instinct was to hold the R tonight and I’m really glad I did. PM + 4.5 is 187, so guess we’ll have to see where this goes (and hope for minimal bounce).

 

Yup, no increase in the AM! 7th cycle after last blue, bounce breaker for sure.

 

Wow…look at that +6.5 green 93
I hope she doesn’t bounce from that beautiful number.
I’ll be very interested to see what the next ketone result is.
Is she eating any better?

 

The +7 iwas 72. I’m about to get a +7.5. I want to catch where this bottoms out.

She’s been very interested in food tonight but dives in and then stops eating after a few minutes. She’s due for more ondansetron soon.

 

I see nadir was 72. Great reccy mission accomplished tonight! You must be so tired. I hope you can get some well earned sleep.

 

So we’re back up to 106 at +8. That’s no real surprise given that we should be past nadir and she also ate FF grilled at +7. I’m generally not concerned when I see a 72 on a human meter, especially at that point in the cycle, but with her recent history, I don’t mind at all that the higher carb food might have nudged her BG up a bit given that I can’t count on her to eat if she goes too low.

Questions:
1) technically on SLGS, the 72 earned a reduction however in her particular case I’m planning to stick with the 0.75u for now. The 0.75 depot should have stabilized, we’ve cleared the bounce, and I guess I’d like to see exactly what 0.75u will do. Any disagreement?

2) if she bounces and is sky high in the AM, thoughts on giving R? I’m leaning toward doing 1 drop with AM shot if the BG has skyrocketed, mostly to try to take the edge off and avoid another 3-day clutter muck (yep, it was ugly enough I considered putting on my figurative muck boots, lol). Alternatively I could wait until mid cycle and reevaluate, or just let her ride high with no R. Or maybe she’ll be nice and not bounce. We’ve just seen significant movement higher in the latter part of the cycle so figured I’d be prepared.

Ketones are 0.1.

And yes, Bron, I'm finally going to get a bit of sleep!

@Bron and Sheba (GA)
@Wendy&Neko
@Bandit's Mom

 

I agree, I would stay with the 0.75 U. (this is only dosing for RK, who has had DKA … do not follow)
Fantastic to see the 0.1 ketones. I’m jumping up and done here!
See what Wendy says but if she’s sky high, I would lean towards 1 drop R. There is no doubt that getting those BGs down helps the ketones.
Message for RK… stay off the trampoline!
Im glad you are getting some sleep.

 

Good to see the lower numbers and glad you are getting some sleep!

I too agree on holding the dose. I've read here that the cycle after the one you use R in can also be an active. I've tried using R with Bandit but never very successfully - probably because I've never measured it as accurately as I did Levemir and even a little can make a lot of difference. Sometimes I gave it at PS (if she was sky high) and sometimes after the nadir (when she was starting to bounce to reduce the amplitude of the bounce). Results were never consistent. At times I was lucky and it worked beautifully, but more often than not, it would either do nothing (she'd stay flat and high) - or she would decide to clear a bounce in the cycle I gave R in at PS and drop like a rock (and that would in turn trigger more bouncing).

 

That’s the best AMPS RK has had and look at those ketones at 0.1
Looks like she took notice and didn’t do too much jumping on the trampoline. Stay off it today RK please!