? How to prevent DKA with kitty that had it twice

Maverick is currently back at the ER with DKA. He was there pretty exactly 1 month ago with DKA, pancreatitis, possible bowl inflammation, possible triaditis, jaundice, and elevated liver values. He has a history of liver failure in the past (not sure if he had DKA back then also).
Anyhow, he was very bad last time and we almost lost him. This time I caught it very early tanks to ketone home test strips. He's now been at the ER for about 10h and are about to get discharged. On the scale he was a +2, but all his other values were normal except for chlorine that was somewhat low, and cholesterol that was somewhat high. He's been on fluids now for about 6h and they want to discharge him because he is eating and doing clinically well (as he did already before I took him to the ER). The problem seems to be that he is not regulating on the insulin and has been consistently high lately. I asked for them to prescribe me a bag of fluids so I can give him that in case he gets dehydrated or tests positive at home for ketones again, but they refuse.
What should I think about from now on in terms of feeding, or other precautions to avoid him getting DKA again?
I'm not really sure what suggestions I'm asking for, all I know is that Maverick is a really complicated case and being $10000 deep for only this month, we really can't afford him getting sick again. The ER vet is suggesting we consult an internal specialist, but we really can not afford that right now, and I am not interested in putting him through vary invasive diagnostics.

 

Hi Matilda and Mavrick.
I am so sorry Maverick has been back in the ER withDKA. Well done catching it early.
I would ask again if they will give you a bag of fluids to give sub Q fluids. That would be very helpful if ketones reappear to help flush them out.
I know he is eating at the moment but I would make sure they give you some antinausea medications such as cerenia and ondansetron in case he stops eating. It would be good if you could have both medications as they work on different pathways and can be given together if needed. And sometimes when one won’t work, the other one will..

Once you get home it is really important that you dont miss any insulin doses. I can’t see your spreadsheet at the moment. I’m going to ask @Bandit's Mom to have a look and see if she can fix it for you.
Is he still having Lantus?
Can you ask them what insulin and dose they were giving him in the ER please?
If needed he may need some higher carb food to ensure the insulin doses can be giving so make sure you have some higher carb food at home.

The most important thing is he is eating (as well as the insulin being given) so make sure you have a good selection of food for him.
He will need to eat 1 1/2 times the number of calories he normally eats.
That will mean lots of snacks through the day and evening to ensure you get those calories into him.

You will need to post every day and we can help you with the insulin dose.

Make sure you have a good supply of Ketostix at home as well. I would test twice a day in the beginning to make sure that no ketones are appearing.

Keep asking questions. We will help you with Mavericks recovery.

 

Hi Mathilda, could you please change the link to your spreadsheet to
https://docs.google.com/spreadsheet...bUNpM1E8ZUivp91BfYLdzwn1cve8g-k#gid=361360320

Bron, you can see the SS at the above link.

 

Yes I can see that one thanks Bhooma

 

Matilda, I can see the SS that @Bandit's Mom has posted.
You don’t mention in the SS or your signature whether you are doing TR or SLGS dosing Methods.
Here are the two methods for you to have a look at.
With DKA in the picture you would be better doing the TR as we can adjust the dose more quickly.
https://www.felinediabetes.com/FDMB...-low-go-slow-slgs-tight-regulation-tr.210110/

I also notice you are giving a different dose in the morning to the night time. Lantus works best if the same dose is given consistently as giving different doses can mess up the depot..What is a depot https://www.felinediabetes.com/FDMB/threads/what-is-the-insulin-depot.150/
How many hours before you collect Maverick? If I know, I will try and be online to help you when you get home.

 

Hi Mathilda,

I'm sorry to hear that Maverick is having ketone issues again. Well done catching them quickly.

Given Maverick's history of pancreatitis, I'd suggest asking them to confirm whether they tested him for this again (it can wax and wane so retesting is wise). If positive for pancreatitis then I'd suggest asking them for some buprenorphine to give at home should he need it to help him keep eating steadily.

As you know, the three factors that contribute to the development of DKA are:

• Not enough food (calories) + not enough insulin + infection / inflammation / other systemic stressor.

Have they managed to identify any underlying condition in Maverick's case (e.g. UTI / dental issue / resurgence of pancreatitis / other)? If something is present then treating it would help reduce the risk of Maverick generating ketones.

I'd also suggest asking for an appetite stimulant to use at home should one be needed.

On fluids, would it be worth approaching your regular vet about them if the ER continue to refuse to prescribe them?

When it comes to asking for any/all supportive meds I'd suggest trying to make the case that it's the holiday period and having the appropriate treatments immediately to hand would mean that you could respond straight away to help Maverick.

Is Maverick underweight at the moment? If yes, then helping him to regain the weight may help him to become more stable ketone-wise. Feeding grub at a slightly higher carb level in order to support his getting enough insulin as Bron suggests above may also help him to regain a bit of weight. It might also be an idea to find some foods that are more calorie-dense for him to eat while he's recovering (e.g. kitten food).

Wishing Maverick a speedy and solid recovery. (((Maverick)))


Mogs
.

 

You might have a better chance getting the sub q's, cerenia, and bupe from your regular vet as opposed to the er vet.

I'm so glad you are testing both ketones and bg at home. I would say work on getting the numbers back into the greens. Give the 0.5 both shots, but in a day or so consider raising to 0.75.

 

Hi, thank you so much for your help! I'll start to answer here because I'm freaking out and I did not have the ability to go online before now.
So, Maverick came home at 1AM today. The ER doctor was completely useless- the only thing he wanted to do was transferring him over to a internal medicine specialist they work with, which I denied do to the price of just consultation. I wanted them to make sure to flush the ketones out but he said they couldn't do anything as Maverick did not show the clinical signs they normally see in cats with ketones. So he discharged him, saying most ketones "should be flushed out by now" this was after about 5-6h with fluids, and he didn't want to do continues insulin and refused to prescribe me a bag of fluids. He was never tested for UTI even though I requested it and he was not retested for ketones before discharged.

I am aware that Lantus works better with consistent dosing but my reg vet kept on telling me to do the different, the ER vet told me to keep at consistent .5 and .5.

I was just able to test Mavericks ketones again and he is way worse than yesterday before admitted to the ER. I do not know what to do as the ER is no help and I do not have fluids.

ETA. I have not followed any protocol yet, but think I should be doing TR, right? I'll review and print those instructions out today. Maverick has been very hard to regulate, but as insulin is so important now, seeing his chart, do you think .5 morning and night is enough? before when we increase, he seems to go up in values a few cycles before somewhat settling- do you think thats risky now with the ketones in his body?

 

I feel like it doesn't matter that I'm catching it early when I can't do anything and not even the ER is listening or caring

 

Thank you, I changed it! Can it bee seen now?

 

Thank you! I'm trying my hardest but the vets are really giving me a hard time so I'm feeling very helpless. Maverick has even more ketones now than before going into the ER.
I will try getting it from the regular vet, but the ER vet got everything wrong and wrote some crazy soap notes my reg vet will get and I think that kills my chances of getting her to prescribe me some. Someone gave me a website where I can buy it without prescription, but it wont arrive before 7-9 days and probably later because of the holidays.

I probably should, but think I'll need to feed him more if so as he has repeatedly dropped down to lower than safe to shoot before on those doses.

 

Thank you! They did some testings yesterday but I do not think it included pancreatitis. I asked them to check UTI but they ended up not doing it. The ver was very incompetent and suggested transferring to internal medicine specialist, I denied for several reason of which two are their horrific reliefs and their pricing. All I wanted was them to flush out the ketones but they failed that also, discharging him after only a few hours on fluids- he's now home and just tested for moderate ketones. Maverick is doing pretty good clinically, he is a tired but not lethargic, he's having big appetite, and he is steadily increasing in weight. He has been going aside to sleep much today, and he has been drinking water which he doesn't normally do this way. Even though I'm completely soaking his feed. He's not at his ideal weight yet though. We do have appetite stimulant and use as needed but haven't needed it in the past 2 weeks.

I just got the reg vet to give me a bag!! How much would you recommend giving him today?

 

UPDATE: Maverick is home as of 1AM this morning. The vet only gave him fluids, did not retest for ketones and he is still high on ketones. The vet opted for transferring him to a Internist Medicine Specialist which I denied for several reasons- he said theres nothing they can do then. He was never tested for UTI even though I thought he would be. I was able to get a hold of a fluid bag. I'm freaking out knowing he still has DKA and do not know what to do as my reg vet do not have app openings, ER vet won't do a anything, and holidays are coming up. I do have a app at the regular vet Saturday but fear it will be too late. Maverick still does not show much of clinical signs, he has good appetite, but more tired- I wouldn't call it lethargic yet, and he shows some different behaviors as he does when he's not feeling good as drinking more. He was sitting with his mouth open which I also take as a red flag. I'm worried sick, Is there anything I can do at home tonight? I'll try to get an app at the regal vet tomorrow anyways. Should I feed him more, more insulin, give him more water? How much fluids should I give him and how often? I feel like you guys are the only ones to help me right now so I can't even tell you how much I appreciate all your time and help!

 

I don't have the experience to help you, but I'm tagging @Wendy&Neko who appears to be online and may be able to help. If you think it's an emergency (and high ketones may just qualify for that) you might change the title of the thread to include the "911" tag. (See "Thread Tools" at the very top of the thread.)

 

Thank you! As of now, I am so incredible upset because it doesn't seem like it matters that I caught it early as I think the ER greatly failed in helping Maverick in the proper way. He has been very tired today, and just tested for moderate ketones with the home testing. I was finally able to get a bag of fluids so I'll have it in about 1 hour. How will I go about safely flush the ketones out at home? Is that possible in a timely manner to help my kitty? He is currently on cerenia and I have 3 more tablets, he's getting 1/4 a day but I'll definitely ask for the other ones and make sure I always have them.

He is still on Lantus. The reg vet wanted me to do .5 in the morning and .5 at night- the ER suggesting to do .5 morning and night. With the high number he had lately and the DKA, I personally think it may be good to increase to perhaps .75, but the issue is that he previously been too low to shoot several times at night on higher doses. But I'm thinking as he's eating better now I may be able to feed him more often and that may limit that problem? Otherwise, how do I handle it if he's too low to shoot- I'm thinking under 150?

He is on PPP D/M pate right now, 1.5 can/ day. Is that ok? All the vets has said to give him only 2 times/day but I've learned thats crazy and wrong, so when the numbers been lower I've fed him more times, but with high numbers I'm still worried to feed him several times/day.

Is there any way to mess up Lnatus insulin? I'm worried I'm doing something wrong that cause the effectiveness of lantus to decrease.

 

I was able to get the fluids! Will pick it up here shortly!

 

Again, I'm a newbie and I can't give advice, but I've read advice here saying to feed high carb food and adjust insulin to keep BG within reasonable limits. Don't withhold insulin.

from Ketones, Ketoacidosis, and Diabetic Cats: A Primer on Ketones

Treatment
If the cat is bright, alert, and well-hydrated, the cat will not require intensive care. Your cat will require insulin, food, constant access to water, and close monitoring for signs of illness such as vomiting, anorexia, and lethargy.

 

Thank you I appreciate it! I might do that. Am I doing this right to post updates in the tread, or should I make an ETA in the initial post about updates- if that is possible?

 

Thank you so much for your time and helping, I truly appreciate it! He has definitely been more quiet today, but not quite lethargic, so I do think he's fitting into this category and that why the ER vet felt they can't do anything. Maverick is not regulating on the insulin and I think thats a huge problem, but I also think I'm doing things wrong or can do things better to help him, so I'm so grateful for all expertise and help here!

 

I'd start a new thread using the 911 prefix and say something like "Ketones, Help needed!" and then copy over one or more of your posts that summarizes where he is today.

The 911 prefix generally gets prompt attention, although there don't appear to be a lot of people online right now.

 

@Larry and Kitties @Gill & George @Lisa and Witn (GA)

Can you help?

 

Another question: Before when I increase doses, he seems to spike higher in values for a few cycles, do you think it's risky to increase now when he has ketones in his body in case he'll spike?

 

I can't help with this question. It's way outside my level of expertise.

 

Ok, no worries! If I do a 911 post, is it best to make a new one or edit this headline?

 

Either/or. It's easiest to edit the title of this one, but there will be a lot of posts for them to read through.

 

That's new dose wonkiness, I wouldn't worry about it. It's having enough insulin that's important. I would definitely shoot no lower than 0.5 tonight.

It's really late here I've sent an SOS out to some experienced folk.
In the meantime
Make sure he eats, feed him regular snacks he needs more calories, keep him hydrated, you can add water to his food, and do not reduce his insulin dose.

If the insulin is clear and had no floaties/milky appearance it's most likely fine.

 

Tonight I would make sure you give him the full 0.5 units of insulin. Mogs has given you the formula for DKA and that is part of it. You also want to feed as many calories as you can into him.

 

I don't have experience with DKA or TR. I have posted on the Lantus board asking someone to help advise you.

 

He needs the insulin to get rid of the ketones. It is not the insulin making his ketones rise. Raise the dose with the next shot. Do you know how to give sub q's? Get as much food into him as he will eat. If he won't eat hand feed him or assist feed him. How is he behaving? How much does he weigh?

 

Ok, I'll do .5 tonight. I do know how to do the fluids and just got ahold of a bag. Do you thing 50 or 100 is good for today? the vet said no kore than 100/24h. Luckily he's still eating, Ive been giving him feed 3 times today, will give more in about 1h. Should I get up and feed him through the night also? He just want to lay down sleeping at a specific spot, but will come when I call its feeding time so he's still attentive. He's was 10.86lbs at the vet yesterday. When healthy he's around 12-13lbs.

 

Thank you so much!

 

Thank you! Should I get up feeding night time also?

 

Thank you!
So the spike because of NDW is not as serious as a spike from no insulin? Should I shoot even higher tomorrow morning or is that to increase to quick? I just realized I've treated the insulin pen wrong by shooting in air so I'm getting a new one tonight to be on the safe side, it is still clear though.

 

My cat had DKA, and that was when she was diagnosed with diabetes. She continued to have trace ketones in her urine for about two months after the DKA episode. She's now totally fine with no ketones in her urine. What made Ruby's episode dangerous was the fact that she basically stopped eating for two days and lost a lot of weight. So if your cat continues to eat well you might avert a serious situation. Keep feeding him, and also add water to the DM as much as you can to make sure he remains hydrated through his food as well as through the subQ. And give him insulin as consistently as possible, and don't skip doses unless his preshot number is low (this depends on the protocol you choose). I don't recall if you've been given any appetite stimulants like Cerenia or Mirtazapine. Having those on hand to give to Maverick will also help in case he stops eating. UPDATE: Sorry just saw in your sig that you have the stimulants.

 

This was Mavericks situation the first two times he had DKA also, he stopped eating. I think I did catch it early this time, but the high ketones still in his body freaks me out and I'm hoping I can prevent him from getting so bad again. I'll be giving subQ, does it matter if I do that before or after insulin? We do have both of those meds on hand. He's getting the cerenia daily now, and the other just as needed, but hasn't needed it for about 2 weeks now.

 

I might do them in different locations. I'd do 0.75 starting with the next shot.

 

Hi there
I got an sos from Gill -
I'm up the road from Davidsonville, in Baltimore. Gonna take a few minutes to read up on you details and will be back.
Hang in there!
btw, which er did you take him to?

 

Hi! Thank you! I took him to the AAVEC in Annapolis. I'm at currently debating if to increase the does to 0.75 or not tonight. I'll also give him 50 subQ tonight, and debating whether to give him that before, right after insulin or wait a few hours.
Edit: 0.75 instead of 0.5 tonight, he's been on 0.25 for the past couple weeks.

 

I understand now its important with lots of calories with the DKA, however it just hit me that he has history of pancreatitis and it is not ruled out that he doesn't have it this time (I wish they tested for this yesterday but they didn't). Can increased food and calories be dangerous if he now has pancreasitis?

 

So that you understand the mechanics of the way DKA works is that when there is not enough energy from food making it into the cells, the body will breakdown it's own stored fat and protein to try and fulfill the need for more metabolic energy. The excessive breakdown of these stored reserves creates a toxic by-product - ketones. As ketones build up in the blood stream, the resulting pH and electrolyte imbalances can very quickly develop to life threatening levels , a state of DKA. So you must find that balance where he gets enough insulin to convert the calories he eats into energy and deliver that energy to the cells of his body.

Pancreatitis is something I have no personal experience with so I don't know the answer to that. I will put out an sos to find out. I do know that Pancreatitis is definitely inflammatory and painful and a stress to the system. Combined with not enough calories and not enough insulin it opens the door to ketone formation.

Since lantus is a slow acting insulin in this case adding an additional shot of a fast acting insulin can be a great help. A few questions-
What is your availability to monitor his BG?
Are you using a meter calibrated for humans ?
What does he eat?
approx how many calories each 24 hours??
When does he eat?
Can you count on him to eat?

 

Ok, thanks!

I have a ReliOn for humans and a Freestyle Libre 14 days sensor. And I can monitor his BG most times of the day and night.
He eats 1.5 can of PPP D/M pate watered down. Its 176 kcal/can so 264kcal/ 24h, I'm not sure how many calories that is.
Ive been feeding him morning, night, and t times during the day the past day. Earlier morning/night per vet recommendation, but been adding snacks in the day when BG hasn't been in 300s.
He has been vary good at eating, but tonight he was a little harder to fee, he left some, it may be because I added lots of water and he got fed more frequently. But he does seem less energetic tonight so I think I'll give him the appetite stimulant tomorrow

 

No he needs to eat regardless.

 

With pancreatitis a cat needs nausea medication, pain medication, sometimes fluids and an appetite stimulant. You want to feed small amounts often. You want to get him to eat plenty of calories, just not all at once because that can make him feel yucky.

 

are the numbers for today from the relion or the libre?

why the ppp dm?
264 calories is pretty good - 300 would be better.
When did you last test his urine and what was the result? Please document all tests on the ss. Take a look at my Black Kiitys ss, around the middle of June 2008 and you can see one way to document the ketone test results. I placed them in the cell corresponding to the +hour since the previous shot. that way they are clearly visible.

 

Sometimes giving subq fluids can drop the BG. Every cat is different (ECID). I would definitely not give it as the same time as his shot and would try to do it after he has onset so you can see how much he drops by then....usually +2. The subq fluids can still drop his BG later in the cycle after you give it so pick a time when he’s fairly flat with some room to drop.

Subq fluids never dropped my kitty’s BG but I have seen several others where it consistently did.

 

Numbers from today are only from the region, nearly every numbers from the past week in the sheet is from the meter. I realize they measure different often so I'm mostly just using the freestyle now to see what things are trending so I don't have to prick him all the time.
The vet fed him this when first at the ER and I didn't want to change before he is somewhat regulated. I'll offer him more tomorrow and see if he'll eat.
Last time I tested was today noon, and it was moderate, perhaps a little more. Thank you, I'll take a look at your SS. The vet claims that ketones in the urine will be elevated as they flush out so he expect it to look worse before it gets better- is that true? If so, how long can I expect testing to be positive?

 

Thank you! Thats great to know! I ended up giving him .5U tonight, and he got tons of water in his feed all day, he doesn't seem dehydrated- should I wait until the morning to give him the subQ so I can monitor closely how his bg is reacting to it? It may not be a good idea to both increase the insulin and give fluids overnight the first time, or what do you think?

 

Thank you! Is 4 meals a day a good strategy or is it better with more smaller feedings?

 

I would feed before the dose of insulin and give small meals throughout the cycles ...just a teaspoon or two each time, maybe each two hours.....but not feeding for the two hours before the shot is due so the BGis not food influenced.. I would also try and give some food during the pm cycles as well. What ever he will eat at the moment.

 

100 mls of LRS is 20 tsp of water just so you know. It’s really important that fluids be given to flush the ketones. I would follow my vet’s advice, and if he said to give fluids today, I’d see where he is at +2 and if he’s gone up a bit or is flat, you should be able to give some fluids. Just be sure and monitor his BG and put it in your remarks so we all know.

If the vet said to start tomorrow, I’d follow his instructions.

 

Ok! Is it very important to keep a consistent schedule with the small feedings in between insulin? Just seeing what would work with our daily life so I do not feed him small meals at different times if that would mess up his BGs

 

Could be. I have never heard that though.

More questions -
How did you discover that he was diabetic?
What was he eating prior to diagnosis?
What times do you shoot?

 

At the moment the most important things for Maverick is to get enough food and enough insulin to prevent the ketones, and fluids of course....so don’t worry about the food messing up his BG. If the BG is high, then the insulin dose can be adjusted.
Do you have other low carb foods that he likes and will eat?
I think I mentioned earlier having some higher carb food in the house as well in case it was needed if the BG needs raising to give more insulin. Did you manage to get any of that?

 

My vet wasn't there today, so I didn't really get any instructions, more than not to give more than 100mls per 24h. The ER vet refused to prescribe any fluids, he flat out thought it was a bad idea to give any at home. I called my regular vet in desperation as I won't have a appointment there before Saturday. Does drinking more water also help flushing out ketones? I've been watering down the food very much throughout the day so he got lots of water in him, Ive only seen him go pee once though but he's very sneaky with that. Can I overdue it with fluids if I give him 50mls subQ tonight without consulting a vet?

 

Ok! I have some friskis pate that he'll eat but I'm worried feeding him that as he was on that feed exclusively for probably 1.5 year after getting sick in 2018, but he seemed to develop allergy to that and I fed it to him a couple of weeks ago and he ended vomit it all up.
Yes, I do have a couple of the FF gravy. So, if the bg is low before insulin when should I feed the higher calorie feed? Should I stall, feed him and wait until its up and then shoot?

 

If you think the friskies will make him sick...don’t give it to him! Can someone go out and buy a few other low carb options for you before Christmas?

If the BG is low at preshot, STALL, DONT FEED, and test again in 20 minutes. In the meantime, post and ask for help. Change your subject line to say something like “HELP, stalling BG xx? “ and that will alert us that you need help now.
If you can get a few more FF gravy lovers, that would be good as well.

 

Drinking water is good. You can add water to his food.

 

Mavericks medical history goes back to 2018 and he had a few days of diabetic symptoms back then also. Are you able to read the details on my profile? I'm not sure I did that right, but if I did you should be able to read the more detailed story there.
Before he got sick this time he was on Blue Buffalo Freedom Pate for indoor cats for about 7-8 months and frisks prior to that. Before getting sick last time he was on Science Diet dry food for indoor, and then when sick in 2018 he got Purina C/N during recovery before switching to Friskies. the reason for the switch to BB was that he had what looked like a allergic reaction to the Friskies (all tastes).
Shooting time has kept on changing, its been very hard to keep it consistent as I sometimes had to stall because of low numbers. And I know this hasn't been ideal. But its been mostly between 7- 9:30.

 

I'll definitely do that, do you have any other suggestions but the FF pate for low carb? I'm not quite sure how to determine whats low and not.
So, I'll just change the subject on this thread, right? I've had to stall several times, but he rarely picks up after 20 min so I'll definitely call for help here. What would you consider low? under 200 or under 150?

 

Has he ever had any heart issues? What fluids do you have there? Some fluids are better than others. For example, if you only have NaCl, I would be careful as that can contribute to acidosis. LRS is a better choice.

why did the ER vet not want you to give fluids?

 

Have a look on the link here. Look for carbs 10% or less
https://catinfo.org/docs/CatFoodProteinFatCarbPhosphorusChart.pdf

On the main forum we usually say under 200 until you have some data but you have some data so I think 150 but post anyway and we can help you with when you need to test again and when to feed and what to feed.
Also I think you should start posting over on the Lantus page as soon as you are a bit more sorted as you will get more help from experienced Lantus users over there.
Here is the Iink for that
https://www.felinediabetes.com/FDMB/forums/lantus-basaglar-glargine-and-levemir-detemir.9/

 

No heart issues that I'm aware of. We got the Lactated Ringer's injection, USP. And the vet said 50-100 every 24h as needed for dehydration. I'm not sure what kind of fluids that is.
The vet just didn't listen to what I said, he got lots of things that I said wrong and he was determined that he wasn't comfortable with me "giving him fluids at home often, as it would stress out the cat" even though I explained over and over that that was not the case. His soap notes was a disaster to read today, he got so much information wrong its sad.

 

Thank you so much! I do have the Blue Buffalo Freedom indoor chicken which looks like it should be 7%, but would that one contain too little calories at 85 per 3oz for the DKA?
Ok, I'll change the title in this thread and post if I need to shoot around 150. Thank you!

 

Please start posting on the Lantus forum as Bron recommended. Start tomorrow.

Please use one thread per day for all your comments and questions you have since the forum is so busy. This will keep all pertaining to your cat together everyday.

• Start your thread with the date, kitty's name, and AMPS
• Your thread will be bumped to the top of the list when you or anyone else posts on your thread.
• The 911 prefix in the subject line should only be used for emergencies such as symptomatic hypos, very low numbers (below 30 on a human meter), and/or very sick cats potentially needing ER care. Please remove the 911 as soon as someone has responded and you have received help.

What time did you shoot tonight?

 

LRS is good. I’d try 50 mls tonight if you have everything. Here’s a video to help you.

 

Thank you, will do! He got his insulin tonight at 9:10 and I plan on trying to back it up from now 15 min per cycle to get it back to 7:30 eventually.

 

If the numbers permit, you also have the option of shooting 30 minutes early once per 24 hours. For example tomorrow 8:40am and 8:40pm; Friday 8:10am and 8:10pm and then on Saturday 7:40am and 7:40pm.

Can you get some overnight data tonight? I strongly recommend you get a +10.5 or +11. Knowing where he is coming from makes a big difference when you are faced with, and looking for help with, a lower than you have seen before PS number.

 

Ok! I do have some more overnight data on the freestyle I can add if helpful, but I'll def try to get some more data with the meter also going forward

 

Matilda you are doing a great job helping your boy!

 

Thank you so much, I appreciate it! Y'all are such great help!

 

Please raise the insulin dose next shot. We want to see the mid cycle numbers closer to 80-100.

Remember that numbers like 270 would be like a 320-350 on a pet meter. You don't want him staying in these yellows.

 

I know where I want him, the issue with raising doses has been that he'll never pick up from the lower numbers even with food so I'd had to skip a dose and I my understanding is that that is worse. I have him at 0.5 morning and night now, should I still increase him to .75 even though I might won't be able to shoot tonight if numbers are in 100-130? In those cases I've stalled before, but he hasn't picked up before several hours later.

ETA. And unfortunately he isn't eating as good this morning

 

Bearing in mind that you can now also give sub-q fluids, I think it might be an idea to balance that with how much water you add to Maverick's food, reasoning being that he also needs plenty of calories to help reduce/prevent ketone generation, and if too much water were to be added to his grub it might fill him up and he might end up not eating as much.


Mogs
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Yes! I was thinking the same, so I'll not be adding that much water too his feed now. He is not interested in eating now, but still pretty alert- should I be worried? BG has been lower 200s tonight and its now 197 and I'm really somewhat past shooting time due to duties. I don't feel completely comfortable raising his dose due to BG and not eating that well- what do you think? Should I stay at .5 today to see if he'll eat better by himself today?

 

Based on my experience of managing pancreatitis- and CKD-associated eating issues, when a cat's off its food in general it's something you need to be really proactive about because it's much easier to keep a cat eating than trying to reboot the appetite from a standing start, especially as no cat can go very long without eating without running into trouble because of the way their metabolisms work. Also, if the cat doesn't eat frequently its tummy might get upset (too much tummy acid, possible vomiting) and that may make it even less inclined to eat - a major negative feedback loop.

For a cat with ketones, based on the experience of other members here since I joined FDMB, I think it's necessary to be aggressive in approach to keeping the cat eating, not wait and see. The kitty needs the calories, and it needs them now. Also, reliable eating supports reliable administration and adequate dosing of the insulin that is also critical for reducing/preventing ketone generation.

Is your regular vet still open? If yes, bearing in mind Maverick's history of pancreatitis, I'd recommend calling to ask the vet if they would be willing to treat him on an 'as if' basis for a pancreatitis flare and issue an Rx for buprenorphine (and perhaps also some famotidine to counter any stomach acid build-up - sometimes needed in addition to anti-nausea meds if a cat hasn't eaten for many hours) to cover you for the next few days till they're open again (plus any other supportive meds you're low on). If they offer a SNAP fPL test today I'd go along with that if possible, but I'd also ask them to take a sample and order a Spec fPL test as well.

This is what I'd do for Saoirse when she had a pancreatitis flare:

* Monitor for any signs of nausea.

* Check/monitor for constipation (can cause inappetence and vomiting).

* If pain meds were available I would give them first, wait for an hour or so and then give the anti-nausea med.

* Give anti-nausea meds regardless of any clear clinical signs and try coaxing her to eat.

* If anti-nausea meds alone don't work after 2 hours max I'd then give an appetite stimulant.

* I'd also give famotidine on an ad hoc basis (once per day dosing) if she had not been able to eat for more than 8-12 hours.

Maybe give your vet a call and ask about similar? (Note: I've never given sub-q fluids but that's another tool you have to work with.)

I'd try various tips and tricks to help her eat (links below). Two of the simplest are raising food and water bowls a couple of inches (no bending down to eat/drink - helps nausea), and to sit close to your kitty and giving comfort and reassurance when offering food.

Persuading your cat to eat

Tips for stimulating appetite

Get a handle on the eating and the insulin administration becomes much more straightforward.


Mogs
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Thank you so much for sharing your experience!

 

I have no idea why my response came out so weird in the post

 

It's because you typed your text before the "/QUOTE" BBcode. Fret not, we've all done it at one time or another.

For members following this thread, I'm going to repost Mathilda's earlier reply below.

------------------------------------

Mathilda wrote:

I think you were right in that the water may have made him feel full before. I the past two times he's been offered feed, he's been eating better and better! Since he is eating better now I think I'll stick with not adding water but doing the subQ and increase his dosage to .75 tomorrow so I can keep an eagle eye on him all day. The numbers has been much better today, but if he keeps on eating I think he may do better on higher dose.

Our vet closed at noon today but I have an appointment Saturday morning so I'll definitely ask about the SNAP fPL then. We have stocked up on the meds such as appetite stimulant and cerenida, and he's also on Famotidin twice daily, He has not been on any pain medicine since the ER- there he only got it a couple of days- but I'll ask the vet for this also in case he needs it, he doesn't seem to be in pain now though. I think I'll also have the vet doing a urinalysis just to be on the safe side in case he does have a UTI but not showing the clinical symptoms.

I haven't been able to catch his pee today to test for ketones, but he went pooping twice already so luckily he doesn't seem constipated.

Those are really good tips and tricks- Thank you, I really appreciate it!

Does the appetite stimulant normally work pretty quickly? I gave him this morning and I'm just wondering if that's why he is more willing to eat.​

--------------------------------------------

I'm glad to hear Maverick is starting to eat a bit better now (and good that he's pooping!). Adding a teaspoon or two of water to each small feed is OK to help with fluid intake. Small, more frequent feeds can help, just make sure he has a decent amount of grub before giving insulin.

Forgot to post the following link earlier:

Nausea and appetite problems - symptoms and treatments (it's on a CKD site but all the info is applicable for nausea generally).

Keep an eye out for meatloafing or other signs of discomfort after he eats as it might give you a better idea of whether he needs pain relief. For cats with pancreatitis the nausea meds and appy stimulants work better when the pain is managed.

For cats who have a marked propensity to throw ketones, a blood beta ketone meter is a very, very good investment because it frees one from the reliance on catching urine samples. Testing is done in the same way as for blood glucose. The strips are pricey but the ability to test on demand makes the running cost well worth it (and you don't use as many of them as for BG monitoring). The BBK meter will tell you what ketone levels are at in real time - and may give you an indication of rising levels a few hours before a pee sample would.

Re nausea meds, with Saoirse I found that Cerenia would kick in a few hours after she received the injection (not available in tablet form for cats over here). With ondansetron it would be about 90-120 minutes. Also with ondansetron I found it would take about 24 to 48 hours for the dose to show its full effectiveness. Depending on the degree of nausea, ondansetron at a suitable dose size can be administered every 8-12 hours so I found it gave me more control when managing her symptoms. If nausea is present then anti-nausea meds need to be administered a little while before any appetite stimulant because either the appy stimulant is less likely to work if the anti-nausea med is not on board or if the cat feels compelled to eat while still nauseated it can lead to serious food aversions (and that's a road that should not be travelled if at all possible).

On appetite stimulants, I only gave Saoirse mirtazapine the once (she had a really bad reaction to it) and it kicked in about an hour or so after administration. Instead of the mirtz I used cyproheptadine for appetite. It would kick in about 60-90 minutes after administration. The cypro has a gentler action and doesn't last as long but it can be given every 8 hours (1/2mg for 10lb cat) so it is much more controllable than the mirtz.


Mogs
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Hi! Im a newbie here so not much advice i can give but as a dka cat owner also i can say after he was released from the ER vet ketones came back a week later at small. The vet gave him subq fluids and that night they were the darkest color on the strip at large and i freaked out. My vet said the same thing and by morning they were back to negative. A week later ketones came back again at trace. Brought him in for more fluids and they went up to moderate and were negative again the next day. He's now *fingers crossed* 22 days ketone free. I hope tour kitty gets them knocked out if their system and they stay negative too!

 

Oh, thats why! I'll try not to do that again

Thank you for all the information- I'm learning so much!

I was able to test ketones a couple of hours ago and its getting better! It's now trace- small, and I just gave some more fluids so hoping it keeps on flushing out, he has also gotten small amounts of feed throughout the day and have came running the past two times when calling so it looks like its going the correct direction. He also hasn't been so high today, low 200s- high 100s. But its now 1h until insulin and he's the lowest he's been all day at 188ish. Im starting to worry it'll keep on going down so I can't shoot. How should I handle that if stalling doesn't help?

I didn't know meat loafing was a thing, but he has definitely done that, not today though (all other days are kind of floating all together in my head), but I'll definitely pay more attention to that now and if it happens again I'll ask for the pain meds.

Is the ketone meter also for humans? I'll check them out tonight and see if I can get one.

I will keep in mind to give the cerenida before and not in conjunction with the app stimulant from now on! And I will also ask about cyproheptadine on Saturday- I do think he was on that one two years ago but have to double check

 

Thank you for sharing your experience and confirming! I did the ketone test again this PM and Maverick is now somewhere between trace and small. I hope your kitty stays ketone free from now on! Have you been doing anything different or changed his routine since he was last positive?

 

UPDATE: I got the SubQ Fluids and gave him 50mls both yesterday. Maverick was moderate on ketones yesterday PM, but it decreased to somewhere between trace and small today. I've been feeding him small amount throughout the day. He did not want to eat in the morning, but as the day progressed he has came running and asking for more the past few feedings. Maverick has been sleeping most of the day, but still seems alert when interacted with. I have now been doing .5U morning and night. Last night he was in the lower, mid-ish 200s, and he has been in the high 100s-low 200s today. the lowest I measured today this far was 2h prior to insulin at 188, it's now insulin time and he's at 236. I am planning on bringing his dose up to .75 tomorrow morning. Do y'all think that would be the right thing to do?

 

Yay! Glad he's going down! And thank you! I've done a couple things. First off he has a bad tooth and needs a dental but im having issues finding a vet to do it while he's so unregulated. Part of the perfect storm for ketones is infection so he's now going on his third week of antibiotics. So if his tooth is infected thats hopefully keeping the infection at bay and keeping the ketones negative. The only other thing i've been doing is giving him this liquid for renal failure im cats. He doesnt have any kidney issues but he's drinking and peeing so much i thought maybe dehydration was a factor. Its called rebound recuperation. I give him a dose every day mixed with boiled chicken and he loves it. It has electrolytes in it to help keep him hydrated. So im not sure if either or even both combined have been helping but im sticking with it

 

Sometimes when cats have ketones and need their insulin, but the BG is not high enough, we suggest giving some higher carb food for that cycle to raise the BG so the insulin can be given. We have had some cats that have needed higher carb food for several days so that enough insulin can be given to combat the ketones. Do you have medium and high carb canned food you can give if needed?

I think before you raise the dose tomorrow you need to see what the AMPS is first. And try and get a urine ketone test in as well if you can so we can see what the ketones are doing. The BGs have been lower today than they have been for 9 days so you will need to be cautious in raising the dose if the AMPS is not above 200 and you don’t have any higher carb food to give if needed. Also how well Maverick is eating is a factor..
Keep offering food after as it is still really important Maverick eats as much as possible.

Have you tested again after getting 136 @+4.5 ( a drop of 100 points)?

 

Thank you for advising!
I do have the FF gravy lover high carb food at home. What % would be considered medium high carbs? I will need to get some of that. Would I feed only that if so?

Maverick has since started been all over the map so it's really hard to predict any turns. His PMPS was 236, +4.5 was 136 (he got fed some here), +5.5 was 170 (Ketones was measured at this hour to be negative to perhaps some trace, an improvement from earlier today). Just now, at +8 Mavericks BG was 300 so it really spiked. Is this normal with such drops and spiked just within a few hours?

Yesterday morning Maverick wasn't that interested in food, but he picked up and his appetite has been very good since yesterday after lunch. Tonight he ate a medium meal at +4.5 (perhaps I should have fed him less?), and a small meal at +8 where he asked for more (request got denied as I need him to eat well in a few hours). So, BG is much higher now than I'd like, but I've seen it drop again before insulin time so I'll see if it does that today. However, if he stays in the high 200s-300s, do you think it's safe to increase, or should I wait?
ETA. Is it perhaps a bounce we're seeing?
ETA2: I do have some D/M dry food at home, would that work as medium high?

 

Glad to read that Maverick's ketones reduced. How are things going today, Mathilda?


Mogs
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Cross-posted!

FF Gravy Lovers Beef variety is 20% (HC), the others are 15% (MC).


Mogs
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He's been sleeping most day but comes running for food and wants more, eating well. He's been in the 200s today, a few minutes ago he was 219 with about 5h left until shot. He tested negative for ketones around 3 am this morning but just tested again and its small to moderate I think I'll increase dose to .75 tonight but am worried he'll drop and I'll miss it as he's so unpredictable.

Is it the other flavors of FF Gravy lovers you refer to as MC?

ETA. I'll do another 50mls SubQ tonight hoping it will help with ketones.

 

Yep. If you look at Dr Lisa's food list (see sticky at top of Feline Health for the link) it'll give the names of the flavours and the carb %s.

You're doing a grand job of looking after Maverick, Mathilda. Keeping fingers and paws crossed that the ketones will drop back to negative (and stay that way). Given he's eating, getting fluids and getting insulin, I think the next step is back to the vet to find out what else might be going on (infection, inflammation, other systemic stressor).




Mogs
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Is it the other flavors of FF Gravy lovers you refer to as MC?[/QUOTE]

Great! I'd need to add some beef ones to my stash then- thank you!

Thank you, I appreciate it! Do you think its a good idea to increase the insulin tonight, or should I wait until the morning?
We do have a vet appointment tomorrow so I'll definitely have them do an urinalysis, check teeth, and check pancreas with either the test you were mentioning, or a lab test.. I'm fearing we will have to involve a internist specialist though, so I'll start check around for that also. Do you have any other suggestions of testing that may be helpful?

 

I'd suggest posting early on the Lantus board for advice about tonight's insulin dose, Mathilda.

Complete blood count and whatever chemistry panel your vet recommends. NB, the other tests mentioned above need to be specially ordered because they're not included in the regular blood panels. Other members might be able to make additional suggestions.


Mogs
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See what the PMPS is but seeing you have increased to just under 0.75, I would go with the 0.75 as the new dose. It may mean you will have to monitor more overnight but that is preferable to having more ketones.
Unless it is the 2 hours before the shot, I would not refuse him food, especially if he is asking for it. He needs to eat as much as he can to combat the ketones. Remember it is the insulin and the food that work together to stop ketones forming, and of course making sure there is no infection or inflammation present, and if there is, it is being treated.
I would offer small meals/ snacks often during both cycles.
And it’s really good you are able to give the subQ fluids

 

@Mathilda and Maverick dont forget to start your new thread over on the Lantus forum. This thread is getting too long, and you will get more eyes on your thread over on the Lantus forum

 

I know right now is a very difficult time for you, but did you say that you had the e-mail address where you could buy a bag of fluids without a script. If so would you mind sharing. I hope that Maverick continues to improve and never gets this again. I am no help, thank goodness I have no experience with this terrible sickness.

 

Thank you! Please do not quote me on this, I never purchased anything from here, but someone on FB told me about mountainside-medical.com where you supposedly can get Lactated Ringer's IV bag without prescription, this person had ordered from the site before, but not this specific product.

 

UPDATE: Maverick is doing ok, he just tested negative for ketones again, so I'm very happy with that. We sent in some blood to lab and will gat the results tomorrow hopefully, mainly to rule out pancreatitis. We also sent out for urinalysis to rule out a UTI. I'll be back with an update on the results. He was also put on Metronidazole as he unfortunately has diarrhea. It's also concerning that he lost weight again. I'm feeding him as often he'll eat and I'm hoping the meds and the increased calories will help him put on some more again. I also hope we can find the source of infection soon (if there is one). I increased to .75U morning and night, but his BG's are still mostly in the mid high 200s, so I'm hoping he can regulate soon. I have not given him any SubQ for a couple of days as he seems well hydrated and ketones are flushed out for now. I will spend some time getting more familiar with the board and start posting over in the Lantus forum. I want to thank everyone that has been so sweet and helping educating and supporting me in this thread- it really means the world to me and has made this hard time seem a little more manageable <3