Previous: https://felinediabetes.com/FDMB/thr...125-7-133-8-145-9-155-11-187-pmps-235.265070/ Alright, after a great day yesterday, fingers crossed it stays that way today.
This is awesome John - the ketones staying at .3. Very good news. Just remember they do fluctuate around quite a bit during the day/night. I used to drive myself crazy with it, but finally settled down into checking once a day (most days unless they were really high - and then more) unless there were clinical signs. So happy about No R needed. Now we can see what this 1.75 will do on its own. Such a lovely cycle last time.
It’s looking like the Friskies 18% last cycle at +8 wasn’t really necessary. But that’s just Monday Morning Quarterbacking! Lol! But seriously you are gathering really good data on Henry and how he responds to carbs, etc. I am feeling really optimistic about Henry right now!
Yeah, that was my first thought when I saw the 272 as well. Just really hope we're not going into another bounce. We'll have a clue in a half hour at +2
What’s the WCR so far today? Regarding testing for ketones, at this stage my recommendation is to not let more than 24 hours pass without a test. BK once went from “trace” to “large “ in exactly 24 hours. Next stop was the emergency clinic…
Totally agree about testing ketones daily or more at this point. You can’t afford to skip a day at this point. When he’s safely staying in low ketones on a daily basis, you will know when you can gradually back off the ketone testing. It will happen…eventually. I’m really just sitting here waiting for the next test.
Okay, darn. A pink. Now is the time for me to say that it’s very flat with meter variance and that it’s probably that the Lantus hasn’t really onset yet, etc. We will wait for the next test. You can always reevaluate mid-cycle to see if action will be necessary. Speaking of action… Henry, give us some downward BG action.
It is really important that only Sandy give advice on R as she is the pro. Please listen to her only.
Well, not a very encouraging +2 compared to the drop at +2 last cycle. Back in the 300s Oh yes, Henry just did one of those routines on Wednesday. His urine ketones weren't even showing (although blood ketones were 1.9), but his blood pH still managed to make it to 7.1 in 24 hours. I recently read an academic paper on DKA in cats that said the urine ketone strips only detect one type of ketone, but there are multiple types and some cats may produce more of one than the other. The conclusion was DKA can't be ruled out by ketone strips alone. I think the blood meters detect the same type of ketone as the urine strips tho (don't quote me on that last part) WCR is about the same as yesterday. Still laying by the front door non-stop for no known reason. Lots of eating and begging to eat despite the fact he's getting 5 cans per day and of course that requires lots of litter box visits. Overall seems in pretty good shape aside from his new found perching location.
Of course, John is taking R advice from Sandy and Wendy at this time. Although we know that Wendy has been out of pocket this weekend- but I mean, of course, when she returns.
Ketones were holding steady at .3 2 hours ago at AMPS, so that's good. Down from 1.1 2 cycles ago. I've been putting the ketones in the + boxes with the BG #s when they're taken. Been taking AM & PM ones, especially when running high.
Of course Wendy too. I meant today as Wendy has other commitments. We all want to help but they are the best ones to help with R. The only other one I can think of is Marje and she’s not around right now. It’s a very tricky thing using R.
Good grief, if anyone can show me a post where I have told John how much R he should give Henry then I would like to see it. I never have done so!
So you now have 3 consecutive Lantus doses at 1.75 Which is great. When using R it’s a good idea to periodically skip it (assuming there are no ketones or symptoms of DKA) so that you can evaluate the action of the Lantus dose and check nadir (they can and do move around). Let’s see what he has in store for you this cycle.
Not a single person aside from Wendy has given any instructions on when or how much R to give aside from Liz who has only re-iterated to follow Wendy's dosing instructions and Wendy asked her to help me. I've been very appreciative of her assistance and keeping an eye on things.
Yeah, not thrilled with +3 @ 337. He's back to hitting the water hard. I can almost estimate his BG just from his drinking habits alone. I'll almost guarantee ketones will be up by +6. I think the R at +6 4 cycles ago was the only thing that saved him from going into the 400s. Hopefully they won't get too bad this time. He's such an enthusiastic eater by the time he stops wanting to eat he's already in full blown DKA. The 2nd DKA he ate right up til about 6 hours before I took him to the ER. This has gotta be a bounce from getting into the greens this morning, huh?
His Lantus onset usually happens by now so yes I'd say bounce. The good thing is he's still relatively flat from PS. The bounce likely due to a combination of the lower numbers that he isn't quite used to, and also the time spent in those lower numbers.
This is very normal, and just to set expectations will likely happen for quite awhile (as in month(s)) - a stretch in good numbers, followed by a few cycles of bouncing, back to good numbers, rinse and repeat. Over time he should bounce less often, less harshly, and clear them more quickly. Not all cats do, but those cats tend to have underlying issues making regulation a little more complicated. I know this is much easier said than done, but please do not stress too much about the BGs themselves. Ketones are more complicated than just the BG. You are doing everything you can, his body has to do the rest...I know it sucks to have things out of your control. Speaking of which, I would ask your vet about budesonide for that inflammation. I don't like that that wasn't addressed at all. I have two babies/toddlers, expecting another here in a few months, a temporarily disabled husband, plus a complicated cat - I perhaps know better than anyone the cumulative consequences of all the broken sleep and stress. It is not good for anyone if one day you crash and burn!
I appreciate all that. Life is no doubt tough sometimes. I will ask about the budesonide and for her to expand on those findings. Bouncing can happen for months? Ugh.. Finally got some good (albeit interrupted) sleep last night. Having insomnia problems, I'm usually not able to just lay down and take a nap, but in the last day or so I'm actually able to lay down and fall asleep within a few minutes, so has feline diabetes cured my insomnia? lol. We don't have any human children, but I'm starting to really get a good idea of what parents go through (sleep wise) with a new born. My K9 ketone meter just went off for the first time since day before last. I've been paying particular attention to my Dog sniffing my cats head and she didn't do it at all yesterday when things were going well, but she had been doing it multiple times per day when we were in the red numbers. We'll see if she's properly calibrated in an hour and a half at +6 when i check ketones.
You said she's GSD right? Or maybe it was another type of shepherd. I almost wonder if it's the sugar not necessarily ketones. Very curious. I have a rat terrier/beagle mix and oh my goodness the things she can smell!
More like years in some cases. Some cats keep bouncing, but if you are lucky, they don't bounce as high as they used to over time. After a year, Neko mostly stopped seeing reds. Thought about timing for giving fluids today? Just catching up (exhausting but amazing volunteer job). I will not be staying up late today, but thought I'd pop in. Can someone remind me what type of inflammation Henry has and what the vet said about treatment? We are not vets, I think we need to keep that in mind.
Yep, GSD. Interesting. Yeah, it could be the sugar! Never thought about that. I gotta show her off (not sure if dog pictures are allowed, I can remove if not):
Wendy! So glad to see you. The vet has been looking for inflammation but hasn't found much. This is about the most she has said about possible causes (just got this friday):
@Wendy&Neko Just to give you some quick background so you don't have to read through everything (its long, i know). Henry came back from the ER from second DKA and in less than 48 hours later had to go back after less than 24 hours in the 400s. Ketones were clear when I had came home after 2nd DKA, but after those 24 hours (well, less actually because I didn't test ketones about 8 hours before he went back) he was at 1.9 ketones. They said his blood pH was >7.35 (normal) when he left after his last 2nd DKA, but when he went back less than 48 hours later it was 7.1 ... She didn't mention what the ketone level was (I'm guessing it was well over 2.5). Her opinion was he is creating ketones very easily and instructed me to give .5uR 6 hours after the L shot if he's >300 BG. I've been following your instructions to only give .25uR if >350 @ PS & +6 or .1uR if over >300
I see no harm in simply asking about a steroid? Vet had mentioned possible triaditis but wasn't sure if the inflammation was more widespread or just incidental in the liver aspirate. At this point I cannot remember if an ultrasound was done in the last two hospitalizations/why she might be thinking triaditis. She had just said she didn't want to try steroid or immunosuppressant in a diabetic cat (I see John quoted it as I'm typing this). Budesonide is primarily targeted for IBD I know.
Here is the first ultrasound report did when the first DKA occured. They're done 2 more since but I don't have the reports, but I don't think much has changed:
I am not sure if you can tell but the image upload didn't work. I mentioned the budesonide because if it is GI inflammation, budesonide usually does not affect BG (this might have gotten lost in all the back and forth last night/day before). The other steroids affect BG and make it more difficult to regulate, thus adding another variable to an already delicate situation.
Hmmm, no they're showing fine on my end. Even in your reply. Maybe I should do them one page at a time? & yep I got the budesonide on my list to ask about
I'm holding off on the .25uR I've been planning to give at +6 (15 minutes ago) until @Wendy&Neko weighs in
Can see it now, thanks! I see the GI stuff noted (along with pancreas and liver). My cat has similar "working diagnosis", but I can't anesthetize him for the biopsy to confirm what it is (IBD vs lymphoma). This vet has made a few mistakes so far, so needless to say don't jump to any decisions on treatment, meds, etc right away. Let us know what she says and we can share our various knowledge then...don't want to unnecessarily overwhelm you.
Indeed. Same here IBD or lymphoma. They don't want to anesthetize him until he's "stable" after the DKA. Will definitely be checking here before making any decision. My K9 meter just went off again...
Well, it's been an hour now since her last post, so I guess she's gone for the night. I'm going to go ahead with the .25uR as planned.
Get your R+1,2,3,4. I’m thinking about the next cycle, which will be cycle 4 of 1.75u Lantus. The R you just shot may set up a lovely AMPS. If he Lantus depot is satisfied and the dose starts showing some action you may be busy. Time will tell
It's so hard to tell sometimes. 2 days ago when I gave the R at +6 it brought BG down like 100 points. Next cycle I did the same thing and it hardly moved BG at all. But yes, I'm hoping for a beautiful PMPS. I can handle busy.
I defer to Sandy on R dosing, Black Kitty's use of R created the body of knowledge for R use here. That's unfortunate, don't want to cause an other bounce caused by big drops. Last sentence of page 1 of the ultrasound report is cut off and does not flow into the top sentence of page 2. I was expecting more details on measurements of bowel thickness and mention of particular parts of the bowel. More progress needed on diagnosis of IBD vs internal lymphoma before jumping to conclusions on treatment. ie. way too early to bring up the topic of budesonide.
I'm not sure why its cut off, but yeah, I'm seeing the same thing on my original copy too. I believe his comment about budesonide was in regards to the results from the recent liver asperate. When I'm in the 300 or almost 400s and need to get out of there due to ketone production, is a 100 or 150 point drop really too much? I think we had a 100 point drop last time this happened mid cycle. Vet said to stay out of the 300s, I'm not sure how that can be accomplished without 100 point drops when we're almost in the 400s
You want to avoid fast drops. 100 points over 4 hours is fine, just not all in 1 hour. Fast drops cause bounces, meaning you just trigger another bounce and high numbers.
Also, if the bounces are caused by the cats body "getting used to", a certain BG (ie. 300s & 400s), wouldn't it make sense to use the R to stop them from getting very far into that range in the first place? Like when I see the BG go from 150 (like today) to 300, wouldn't it make sense to intervene and prevent getting into the 300s in the first place? I get why you say to only give R PS or +6 so you can calculate nadir and see trends which may be fine for most cats that aren't producing enough ketones to go DKA in 24 hours and better for long-term remission overall. It just seems giving small doses as needed to keep out of 300s would better regulate the bounces by not allowing his body to "get used to" that range in the first place. I really don't know I'm just trying to keep him alive and following your suggestions. To me it makes sense to "head off" getting into the higher ranges in the first place and I get doing that doesn't follow the protocol, but I don't get how else to achieve not being in that range. (I haven't been trying to do that BTW, i'm just thinking out loud here) Maybe Henry's ketone production tendencies are just too much to overcome. IDK, just trying real hard to follow the suggestions and getting frustrated it just doesn't seem to be working.
Wendy, I know you and I see this differently as it has come up in the past. I don't want to clog up this thread as right now managing the BG is more important, so I will add this short bit and head to bed - I disagree it is too early to bring up the topic of budesonide. We do not know the underlying cause of the DKA, he cannot be anesthetized yet to make a diagnosis, but we do know there is GI inflammation (among other things). Budesonide has minimal potential side effects, the downside is it is metabolized heavily in the liver and you do have to wean off it should treatment change course. So yes, with current liver inflammation it may not be a good idea...hence a conversation. Edit: IBD can of course first be attempted to treat with novel protein diet The best any of us can do is weigh our options, risks, and make the best-informed decisions we can for ourselves and our cats. I personally would prefer to have a conversation with the vet, get referrals if needed - then potentially take a shot in the dark with something I consider to be minimal risk, vs do nothing for quite some time until he's stable. That is not the same decision others would make and that's ok. Again, we can table this for later as that was a big drop I see coming through. John - good luck tonight, and try to get some sleep!
I'm sorry you are feeling like that. Anything in particular you are concerned about? It looks as if the BG has stopped dropping and is steady....so that is good. And 4 cans already today is pretty good. And ketones 0.6 is good. Have you done a urine test lately?
Hang in there, John. Back to back DKA and hospital stays really take it out of you, I know from first hand experience. This is not easy but you're doing a great job on not much sleep. I hope Henry and his numbers cooperate at PMPS so you can get some more sleep, it definitely helps your perspective.
He's just hasn't been acting "right" the last couple days. The sitting by the door, and the way he looks at me. Not really lethargic or acting drunk like before. Appetite has just diminished in the last 3 to 5 hours or so. Only ate about 2/3 of his last can (he usually eats it all plus the crumbs) and maybe a 1/4 of the one I just gave him although he keeps going back and picking at it. Maybe he's just full or feeling sick. Just gave subQ fluids. Went much better than last night despite shooting through his skin twice. Warming the fluids and using the 19g butterfly needles the vet also gave really helped I think. He didn't flinch, protest or try to escape at all, so that was good. Hopefully they help him feel better.
I'm glad the fluids went well. I always found them easier than one would think. And getting those extra fluids into Henry is great. Do you let him snack while you do it? I think lack of sleep makes things so much harder. And you have had a real rollercoaster of a few weeks. I hope you can get some sleep this cycle. I'll be around for the next several hours and then Bhooma will be around.
Most snacks I have for him, he's pretty much take it or leave it. I've never had snacks he goes crazy for. I got a bunch of different flavors of the chewy cubes, and same thing. He may or may not eat them. He has been going crazy for that FF, so idk. This last subQ went really well tho, he was perfect.
So we held steady in the yellows for the last half of AMPS. PMPS was 252 and ketones were .4, so better than 6 hours ago. I'm guessing the subQ fluids are the R helped. Opened another can of FF for him and apparently he really likes beef more than chicken. Looks like he ate about 2/3rds of it. I'm going to bed for now and I'll be back to do a +2
Good start to the cycle! See you +2 hope you get a good sleep……no looking at the iPad or a book….off to sleep,!
I’m sure it will. Are you going to go back and sleep for another 2 hours? John ….do you think you would be able to change the subject line to PMPS 252, +2 303.?
Pink actually, which is better than red. Hopefully a different color in two hours (a lower yellow would be nice.). Don’t feel defeated, John. You are going to win this marathon.
His body is already used to 300's. It's the normal numbers he's not used to - hence the bouncing. That +2 tonight might be the result of that fast drop mid AM cycle. R is not a hammer to be used at will, but something to gently steer numbers.
healing has its own timetable it was 6 months, 9u Lantus every 12 hours and anywhere from 3-5u R every 6 hours around the clock before we saw green. It lasted 3 hours. It was another 6 weeks and several dose increases before we saw green again. It was about a year before he had his first taste of HC. I felt like we were drowning in a relentless sea of pink. . . By the time a kitty gets diagnosed with FD they’re likely to have been living with high BG long enough for it to be perceived as normal. R can be used to limit the upper reaches on a bounce but that’s tricky to time and you never really know how things may have gone without R. Adding R to the picture is adding another moving part - something to be avoided unless absolutely necessary.
I'd like to respond, But I'm half asleep right now.. We're 320 @ +6. as per the protocol I've been following, I'm going to give .1uR. I'll be back for +8
Opps. Sleepy John error on the play. I managed to accidentally stick myself too. It's so hard for me to try and get such a tiny amount, I wouldn't be surprised if nothing came out at all. Especially after looking at what is the actual +6 -- 309. So maybe a very very little bit. Hard to say. Anyway, be back in 2 hours for the actual +8
John, I keep studying Henry's numbers, trying to see patterns, etc. Please give him love from me, along with love for your alert German Shephard. My Springer Spaniel has let me know about ear infections and more, in my cats. You are doing great. There still isn't a lot of R data for Henry, but you are seeing what an effective tool it can be. As a T1 diabetic for example, the first step is knowing the basal rate or correct dose of Lantus it takes for BG stability. (Fasting for hours is involved and we cannot ask our cats to do that!) Then one learns how much fast acting it takes to cover carbs and to correct highs. One unit of fast acting lowers my BG by 50 pts. With your Henry, you hadn't even found a stable dose of Lantus, before adding R. Just saying this is rough with not knowing how well one is working, much less two together. However, progress IS being made and better, easier to see patterns will emerge. Then we hope you can eventually phase out the R and that Lantus will stabilize. Tons of healing wishes on beautiful little Henry. One last thought on ketones, and I may have missed it. With higher ketones, a human will take extra fast acting based on ketone level alone. I just wonder if this is also being considered. Say if Henry had a BG of 280 but with a ketone level of 1 at AMPS or PMPS, would R be considered, even though not usually given if under 300?
Thank you for the thoughtful reply Tina, I'll need to think a bit harder on them and respond a little later when I'm fully alert again. I'm going to finished off my sleep cycle now and be back for the day at either +10 or +11 since things are looking pretty stable and we're under 300.
Alright, we're back in the 300s @ +11. Henry woke me this morning and the ravenous appetite is back. He ate a whole can of FF in a couple minutes (including all the crumbs -- plate licked clean!) and started begging for more, so I obliged and gave another can, and again he licked the plate clean and continued to beg. The 3 partial cans I had left out for him when I went to bed were also finished during the night. One thing that keeps worrying me is it seems he is continuing to loose weight (which I didn't really think was possible since he's already so skinny). I can feel every little bony feature of his skull and hips. The only spots he has any muscle left at all are his front legs and hind legs. I don't understand why he doesn't seem to be gaining back an ounce. Could this be the result of the potential IBD or lymphoma? I feel like his weight issues are yet another reason it's so important to keep him out of ketosis -- he has no more tissue to spare. If you look at the picture I posted above of him and my dog, he looks so much bigger than he is now! It's striking for me to see if difference. I can't help but wonder if some of this ketone production is because he's just not absorbing or processing nutrients effectively so his body just continues to break down tissue for fuel. edit: I think I remember reading how people with severe anexoria do irreparable damage to their heart and other body organs from such extreme weight loss. I do hope this isn't happening to him, but I just don't know he has the fuel stores to provide for the ketosis to occur anymore, and his body is literally eating itself. I think the reason I got the +4 confused with the +6 (in addition to being half asleep) was because +4 was at 6pm my time, so my brain must have just saw the 6 and said, "OK, it's +6", I think I made a similar error last night on the SS that I corrected after being fully awake. I think the subQ fluids really helped, he seemed brighter during the night and even came got in bed with us (although that is his normal sleeping spot, he's been sleeping in front of the front door the last 3 nights). Will be responding to other comments shortly. Thank you everyone for your support
Thank you for all that wonderful information Tina. I do wonder how much of an effect the FF has on his BG with its very low (<3%) carbs. One of the problems I find I'm having with the R is getting a consistent dose with such tiny amount. It may be due to my inexperience, but I find dosing .1U and .25U consistently (even when I'm just practice shooting it onto a piece of paper) almost impossible. I have a lab quality analytical balance that can precisely measure down to .1mg (+/- .3mg error variance) so I'm thinking I'm going to try and see if that may be of assistance in measuring a precise quantity. I'm just stating all this because you had mentioned needing to know "how much R" to counteract BG, and the "how much" part seems to be a problem here. At first I was writing it off to air bubbles and not having 1/2 unit markings on my syrigine but even using calipers it just seems I can't find that "sweet spot" The part about the ketones makes a lot of sense, and I honestly think 290 is even too high. I have been keeping my eye on the ketones like a hawk, and it's so strange their still showing up even when he has good BG days like 2 days ago
Insulin isn’t like saying “my car is a quart low on oil so I’ll just add a quart.” If only, right?? Cats are complex biological entities with multiple reactions/influences/inputs, as you’ve been reading. Anyway, as for the R, the difference you're describing could happen if one was a bounce cycle and one was not. In a bounce cycle, the R might only “keep a lid” on the BG whereas in a more normal cycle it would likely drop the numbers. Sometimes the best we can do is try to keep a lid on things; dosing R heavier to try to force down the numbers too aggressively often results in a whiplash effect (think a steep roller coaster). That just makes things worse. Not to mention that R can be downright dangerous to use. Interpreting the data too quickly or extrapolating dosing based on a few data points is how people get in trouble. I’m glad you continue to be very respectful of R and are being patient. Absolutely. Any type of malabsorption, whether related to EPI or lymphoma or IBD or whatever, can cause severe weight loss. Charlie was a walking skeleton. Any word on the TAMU GI panel results yet? That might help rule some things in or out. I’d also ask the vet clinic to re-send the report you posted that was missing some lines dealing with the intestines. That portion seemed relevant. Poop can offer a clue as well. You mentioned it was off color and a bit funky. Details? I’ve been wondering about too, although many starving “simple” diabetics don’t go into DKA. It’s possible you have compound problems. The good news is that you have testing in process; just need to hang in there until you get the results and the vet can hopefully make sense of them. Sometimes it’s like peeling an onion. I’m a HUGE believer in subQ fluids. I’ve done subQ on more sick cats than I can count and it does often give them a boost in a way that simply drinking water does not. I’m heading back into lurker mode now. (What say Penny today?? Let’s hope she is smelling sugar or some other odor change rather than ketones, but either way it’s cool that she’s giving you an assist) Also (and I don’t really want to wade into the budesonide discussion prematurely) … even though budesonide has the reputation of having more “localized” impact to the GI tract and not raising BGs, it *is* an ECID different thing. Charlie’s BG spiked every bit as much on budesonide as it did on prednisolone (he had confirmed IBD). However, we do what we have to do and pick our battles. Often a different disease has priority over diabetes, so if steroids are needed, so be it, we work the insulin dose accordingly.
Thank you for that informative reply Chip. I was going to say no readings from the Penny meter yet today, but literally as I'm typing this she went into action doing the first through sniff over of the day. No results yet other than possible inflammation in the liver that could be systemic to the GI tract (I posted the exact email I received above). His IM attending will be back in tomorrow. Hopefully we'll have more answers then. It's depressing that steroids will cause an increase in BG that I've been trying so hard to control. I know absolutely nothing about budesonide other than what I've read on here.
So for several months prior to him going into the first DKA I had noticed it was a light color -- a shade of pink. I've mentioned it to the vet multiple times but she hasn't said anything about it. Always firm and large. Since he's been home the last few days, it actually looks normal again FWIW.
