Newly diagnosed cat (1/27)

Hello,

Yes, this is another newly diagnosed cat thread.

A week ago (Friday) my soon-to-be 14 year old cat presented with some lethargy and difficulty urinating. She had been fine in the days leading up to that - eating, drinking, using the litter normally, and being her usual spunky self.

I called my vet on Saturday (they are only open half day) and they said it was probably cystitis or a UTI and to schedule an appointment and not to worry too much unless she stopped drinking and/or stopped urinating entirely. The next available appointment was in 4 days so I went with that.

That night she got a little worse - more lethargic and walking like her tummy hurt. The next day she was even more lethargic, still trouble urinating (although doing so) and acting like she was in pain. She walked very gingerly and would take a few steps before lying down. She was still drinking but stopped eating. This was in stark contrast to just 2 days before when she raced by me when I opened the door to a room that was closed that she wanted into so I got really worried.

I took her to the ER that night. They said she was dehydrated, had an extremely high WBC count, and had a positive fPLI test result. Based on that they diagnosed her with pancreatitis. They wanted to keep her overnight for two nights to give her IV therapy and then an ultrasound on Monday when the internist came in. They took x-rays which didn’t show any stones or other blockage and her bladder was pretty empty at the time so obviously she was not blocked.

I didn’t want to leave her at the vet for 2 nights just to get an ultrasound so I refused. Also, quite frankly money was an issue. Just the one visit was $1300 so figured it would be another $1-2000 for two days plus the ultrasound. My baby is worth any amount of money, but I just didn’t have it to spend at that particular moment.

The vet gave me Clavamox, gabalentin for pain, omeprazole, and Cerenia (even though my cat was not vomiting). He had me give her subcutaneous fluids, which I have done before and so I was comfortable doing that.

The next day my cat still acted pretty sick but maybe a little better given the painkillers including a Buprenex injection on her way out. On Monday I called my regular vet and told her what happened. They said take her back to ER if she got worse but gave no other instructions.

The next 2 days my kitty got A LOT better. In fact, by the end of the 2nd day she was acting close to normal. I was still giving the meds and subq fluids. I still am.

I finally met with my regular vet and they examined her and did a retest of her blood. They found her WBC better but still REALLY elevated and kept her on the antibiotics. She had no urine so they could not do a urinalysis.

Today they called and said that the urine culture the ER did showed an E. Coli infection in her bladder but to just keep the protocol going as it was obviously working since she was behaving so much better. She eats, drinks, urinates, and does everything normally at the moment - even jumps and races by me.

Then they said that she had elevated blood glucose and that she had elevated blood glucose at the ER as well. Also, she had lost 2 lbs (11 to 9) since the last time she went which was about a year ago. The kicker was that she also had sugar in her urine. The vet said that given all that plus the fPLI and the UTI that my cat was (her estimate) “99.8%” likely to be diabetic and we should start her on insulin next week or no later than the week after that. She wants us to bring her in for a glucose curve test as well. She said she would start with 1 IU of glargine.

My cat’s blood glucose was normal when she was tested last year so it was a bit of a shocker to hear she is diabetic. My wife and I are willing to treat her but to us it seems fast to put our kitty on insulin already. Does it make sense to help the cat over the UTI first and then retest? It seems like a lot to be giving her another 10-14 days of antibiotics and subq and then be starting the insulin and testing that comes with that at the same time - a lot for us and a lot for the cat.

I think if I had my preference I would make sure she is over her infection, redo the urinalysis (she had just one result so far) and blood test and go from there. Is that reasonable? My vet says that with so many factors (pancreatitis, UTI, weight loss, repeated blood glucose test, and sugar in urine) it all points to diabetes. I hear what she is saying but I also wonder how much the infection is skewing the lab work. She has a point about the weight loss but my kitty has been acting pretty normal if not spry for a cat her age - at least until a week ago. Even now, with her WBC still sky high she is acting pretty much like her normal self.

Should I pressure the vet to be more conservative? Should I get a second opinion? I read some folks said to start testing at home already prior to starting insulin which may be a good strategy. I don’t want to defy my vet (at least not yet) because she has been my kitty’s vet since I first got her as a 3 month old kitten 13.5 year ago and I want to maintain that relationship but to me this all just seems really fast.

Sorry for being so long winded.

Thanks for your advice!

 

Hi and welcome to the forum. I’m sorry your kitty has been so unwell.
Did either vet do a fructosamine test? That test will tell you what the blood glucose has been over the last few weeks and is not stress related. If it is higher than normal then a diagnosis of diabetes is confirmed.
It is possible for a cat to have a higher than normal blood glucose if they are stressed or unwell.
However with all the things going on with your kitty…..a UTI infection and very high WCC, pancreatitis, not eating, lethargic, dehydrated…I would not wait to start the insulin if the fructosamine test was above normal. With all those things going on and not giving insulin if it is needed…you run the very real risk of your kitty getting ketones and then DKA (diabetic ketoacidosis) which can be deadly.
DKA happens when there is not enough insulin, not enough food and an infection or inflammation in the body. I thought as I was reading your post, you were going to tell me she had DKA.

If this was my kitty I would be on the vets doorstep at the first available time and ask for a fructosamine test to be done that day and then depending on the result…get the insulin started asap. Glargine is a very good insulin for cats.
In the meantime, I would strongly recommend you go out and buy a bottle of ketostix from Walmart if you are in the US, or a pharmacy. Collect a urine sample from your kitty and test the urine with one of the test strips and read the result of the test exactly15 seconds later against the colours on the side of the bottle. There should be no ketones in the urine. If there are any ketones I would ring the vet straight away. Normally we say if there is more than a trace of ketones to ring the vet but I would ring the vet with any ketones because of your situation.
Make sure your kitty is eating really well in the meantime. And well hydrated.
If you get a diagnosis of diabetes…and I think you most likely will…I would recommend you start posting here and we can help you with what food to feed her, help with dosing, getting set up to home test the blood glucose and lots of other information.
Not sure if I have answered all your questions. If not let me know.
Please let us know how you get on.
Bron

 

Just wanted to add that it will be much cheaper if you do the glucose testing and not the vet.
If you are in the US you can pick up a ReliOn premier glucose meter for $9 and a box of 100 test strips for $17.88.
You will also need a box of lancets size 26 or 28 and some cotton rounds to hold behind the ear when you test.
Don’t freak out at the idea of home testing. Both you and your kitty will get used to it very quickly.
In answer to your questions:

No.she is doing the right thing wanting to start the insulin…just get the fructosamine test done first.

No, not in my opinion

that is fine if the kitty is not unwell like your kitty is. If you wait a couple of weeks to start insulin, you might end up with ketones or DKA. I don’t want to frighten you…I’m just telling you what could happen.

Not if your kitty is a diabetic. If you wait until she is over the UTI and she needs insulin…you have 2 of the three things necessary for the recipe for DKA (not enough food, not enough insulin and an infection/inflammation)
Make sure when the course of antibiotics is finished for the UTI that you get another urine test done to make sure the infection is completed cured. This is important.

 

Hi and welcome to the FDMB! Bron is one of the experts around here, she helped me and my cat a year ago so I just wanted to chime in
and say you can take that advice to the bank. DKA is not to be messed with, my boy Hendrick went into DKA and almost died, ended up at the ER vet for 2 nights ($4500!)

instead of ketostix, we used a blood ketone meter and tested for ketones when we were also testing Hendrick's blood sugar by getting a blood droplet from the edge of an ear.

This is the blood ketone meter we used. The strips are like $2 a piece though which is outrageous.

https://www.amazon.com/Nova-Max-Glucose-Monitoring-System/dp/B01G5OE0QY/ref=sr_1_5?keywords=Nova Max&qid=1674911339&sr=8-5

 

Thanks for the responses! That sounds like excellent advice.

I talked to the vet today and she said that there were “moderate” ketones present in the urine but that they did not do a fructosamine test at the ER. Is one still warranted given the presence of ketones? She said she would like to do one later once she is on the insulin to sort of establish a baseline.

She wants me to buy insulin this weekend and meet on Monday morning to administer at the vet’s office. She said she hasn’t decided whether to do a glucose curve yet. We will definitely do one, but she thought getting insulin into the cat is most important and that with the small amount and the type of the insulin it is pretty safe to get her started and to do the glucose curve later. She said she is still mulling that over, though.

Update: She said we won’t bother with a curve or with any at-home monitoring for now. She is comfortable with the amount of insulin given my cat’s high glucose levels and other symptoms. We will give the first dose at the vet’s office so they can monitor with a blood test. Also, she said she might have considered 0.5 units but that is really hard to measure and administer so that is why she is choosing 1 unit.

Is there anything else I should ask or should be doing especially with respect to preventing or dealing with ketoacidosis?

My cat’s name is Lily by the way, but we always call her Lil Bit because she was the tiniest most miserable kitten you have ever seen when we found her in our yard 14 years ago. She is a blue point Siamese mix.

 

From everything i have learned here it sounds like your vet is spot on, and has given you excellent guidance, especially not waiting to begin insulin therapy, as Bron explains above. (Bron is amazing and knowledgable..... I am fairly new, so not an expert in any way) But I can comment on doing a full blood glucose curve... As your vet says, she may hold off on doing a curve, considering the other test results. The curve gives an indication of how kitty's blood glucose fluctuates throughout the day, and is usually performed in conjuction with insulin treatment.
In a simplistic, general way....... Once a kitty has been on insulin for a certain amount of time, the curve will show how well (or not) the insulin and the dosage is working for YOUR kitty, Lily. A full curve is repeated at specific intervals throughout this process, and based on the results, the insulin can be fine-tuned for Lily.
(Lil Bit - very cute)

 

Welcome to FDMB!

Not to throw a brick at your vet but I would strongly encourage you to home test. Think of this a bit differently. Would a pediatrician tell a parent not to test their child's blood glucose (BG) levels when they are administering insulin? I seriously doubt it and if the MD did so, it would likely be considered malpractice. We encourage members to test before giving a shot so you know if it's safe to do so. Likewise, you need to get at least one test during both the AM and PM cycles so you know how low the insulin is bringing your cat's BG numbers. Not testing, leaves you with a great deal of unknowns and the potential for your cat to experience a symptomatic hypoglycemic event which could be life threatening. Vets seem to make the assumption that caregivers won't test or they have been known to tell cat parents that testing will ruin their relationship with their cat. There are a great number of people here who will tell you something very different. We have LOTS of information to share on home testing.

A human glucometer is fine to use. Many people here use the Walmart Relion brand meter as the strips are very reasonably priced. If your vet pushes for a pet meter, the cost for strips for a pet meter runs about $1.00 each. The Relion strips cost approximately $0.17 each. If costs are an issue, there is no comparison.

The value of a curve is that it tells you when insulin onset occurs (i.e., when the insulin "kicks in"), when the lowest point in the cycle is (i.e., the nadir), and how much duration your getting from the insulin you're using.

I'm very glad you're giving fluids. They will help with the ketones. Please purchase Ketostix. These are urine dipsticks that you can find at any pharmacy. As Kyle noted, there are ketone meters but if Lil Bit has been showing ketones in her tests, you do not have time to wait to get a ketone meter. We get nervous if ketones are more than trace. Hopefully, they are resolving but you can test for ketones at home providing you can stalk you kitty to the litter box.

Ketones are not really related to the results of a fructosamine test. Ketones occur because your cat's metabolism is off -- it's become more acidic. Instead of burning glucose for energy, your cat is burning fat which produces ketone bodies. Usually this is occurring because your cat isn't eating -- all food is converted to glucose and insulin helps the glucose get into the cells. If a cat has an infection or inflammation, has a loss of appetite, and not enough insulin is being produced or not enough insulin is being administered if the cat is already diabetic, your cat may try to burn stored fat for energy and ketones result. A fructosamine test is comparable to a hemoglobin A1c in humans -- it tells you the relative blood glucose level over a period of several weeks. It may be hard to know if the fructosamine test will be helpful given that Lil Bit has been symptomatic for a few weeks.

Hopefully, the vet recommended Lantus (glargine) or Prozinc. These are the two types of insulin endorsed by the American Animal Hospital Association for the treatment of feline diabetes. The generic/biosimilar of Lantus is available and is much less expensive than branded Lantus. You may need to call around to find it -- Semglee is the name of the biosimilar.

FWIW, 0.5u is not hard to measure. You need to get syringes that are calibrated in half unit doses. If you are using Lantus, you are looking for syringes that are:

• U-100 3/10cc syringes with half unit markings are the best to use for drawing Lantus, Levemir, or the Biosimilars from vials, cartridges, and pens. Do not use the needles that fit the pens. The pens will only dispense in 1.0u amounts and you have to prime the pen for it to dispense resulting in your wasting insulin. You can draw off insulin from an insulin pen using a syringe.
• BD Ultra-Fine, CarePoint Vet, Monoject, GNP, UltiCare Vet Rx, Sure Comfort, and ReliOn are just some of the brands available with half unit markings.
• Syringes come in ½ inch or 5/16 inch needle lengths. Needle gauges are 29, 30 or 31 (31 being the thinnest. Most of us use 30 or 31 gauge needles.

If you are using Prozinc, you will need U40 syringes. They may only be available through your vet or online. U100 syringes are used with human insulin and are more widely available as well as available (usually cheaper) online.

 

With moderate amount of ketones in the urine/blood, I am amazed the vet does not want to start insulin straight away.
As Sienne explained (and I gave you the recipe for DKA) Lily is using fat for energy instead of glucose and the byproduct of burning fat is ketones. Ketones are dangerous for cats.
If Lily were my cat, I would be starting insulin today and not waiting until Monday. Waiting until Monday runs the risk of the moderate ketones increasing and DKA developing. This is avoidable by starting insulin now.
Definitely commence home testing….otherwise you will be guessing all the time if the dose is correct and won’t know if the blood glucose (BG) is dropping too low. Just getting it tested every so often at the vet is no guarantee Lily will stay safe.
I will ask @Bandit's Mom to help you set up a spreadsheet if you like so you can put in the BG data. Getting the correct amount of insulin is critical in managing ketones.
In the meantime please make sure Lily eats as much food as you can get her to eat. This is very important.
I’m very glad you are doing subQ fluids.
Try and get the Ketostix strips to test Lily today and see how many ketones are still in the urine.
How is Lily’s appetite?

As mentioned get Lily to eat as much as possible. Give snacks every few hours during the day and evening.
Continue sub Q fluids
Get the insulin started as soon as possible….don’t wait until Monday. commence home testing now.
Ask for all the lab work Lily has had done. From the ER as well.

 

For some reason, many many vets will say you don't need to do home testing. My vet said the same. Also told me to only feed once every 12 hours. Unfortunately this is outdated thinking and today we know better. Testing at home lets you know what the insulin is doing and if it is safe to shoot.

 

Hi.

Thanks again for all your advice.

I picked up the insulin tonight (5 pens of Lantus which was the only quantity any pharmacy stocked) but there is no way I am just going to start administering it to Lily on my own with no way to test and no protocols for testing or administration. It will have to wait until Monday morning for better or worse. My vet is not open on Sundays and is half-day on Saturday. She said to go to ER if Lily becomes lethargic like she was, but so far she is really active and eating well.

I did buy some keto testing sticks, injectors (31 gauge 15/64” 1/2 ml), and a glucose meter. I will try to get a keto reading if I can. I went ahead and ordered the Alphatrak 2 since Amazon could have it delivered tomorrow and I wanted to head off any “concerns” my vet may have about a “human” meter. I can always switch to a cheaper meter later. I might “practice” on Lily with it tomorrow if I am feeling brave about the procedure for drawing blood. She hates having her ears touched. It has always been an issue to give her ear drops or even just cleaning them so drawing blood from her ears might be problematic.

Otherwise, that is where we are in this process.

Looks like I am taking Monday off work.

Thanks again for making me realize a lot of other kitties are going through this with good outcomes.

Edited to add: My vet didn’t say not to do home testing. She just said not to worry about it for right now and that given Lily’s levels, the small amount of insulin, and the type of insulin (glargine) a hypoglycemic crash is very unlikely. She also said that even though the injectors can measure out 0.5 IU it is really hard to know if you have given your cat such a small amount and she would rather start at 1 IU than risk not having Lily get any insulin because I am new to the injecting process.

 

I am very glad you picked up the Lantus and are ready to go. There is no reason why Lily can’t lead a normal life once you get this sorted out. The vast majority of diabetic cats eventually die with something unrelated to diabetes.

If you have the correct syringes it is actually not hard to measure out smaller doses than 1 unit. We can tell you more about that at a later date.
I’m a bit concerned about the syringes you have …

Can you take a photo of the packet of syringes please and copy and paste it into the thread?
Don’t open the packet in case they are the wrong ones.
The ones you need are U100 3/10ml 30 or 31 gauge, 6 or 8 mm with 1/2 unit markings
It sounds as if you have the 0.5ml syringes instead of the 0.3ml ones. The 3/10ml (0.3ml) syringes are much easier to measure smaller amounts which is what you are going to need as you are giving it to a cat not a human.

You can start getting Lily ready for testing by taking her to a spot you have chosen to do the testing and giving the shots….like a table or on the ground somewhere. You need to chose somewhere and stick with that spot. Lily will come to realise that means a treat spot.
Once you have chosen the spot, rub her ears gently and then give her a small treat. Do this many times during the day. This will get her ready for testing. Read about home testing below and then try it tomorrow. Document any tests you do and well put them into the spreadsheet.
Expect to fail a few times before you have success. Follow the hints. If you need to distract Lily when you test, you can give her a small low carb treat as you test. Don’t be discouraged if you are not successful straight away. Both you and Lily need to get used to the more routine. Make it s pleasant as possible. Even if you are unsuccessful, always give her a treat.
Here is link to HOMETESTING HINTS AND LINKS

It is not true that cats can’t drop low on 1 unit of insulin…some cats respond really quickly and others take there time. Everyone here tests their cats and we see the results of small amounts of insulin every day.
Continue to make sure she is eating lots of food. Food helps keep ketones away.
Sounds as if you are getting well organised which is great.

 

Sorry for the diagnosis. I hope she starts to feel better soon. I have a link in my signature showing how I tested my cat CC at home.

 

@DimitriG
Where do you live?
If you live in the US these are the U-100 syringes with half unit markings

You can get the syringes with half unit markings at a Walmart. Their ReliOn Brand syringes of 0.3 cc (30 unit) capacity come with half unit markings. Cost $12.58 for a box of 100
This is what the packaging looks like: either box
They won't say it half unit on the box but the are . open then and look before you leave the store, can't be ordered on line , need to go into the store
:


Or these
https://www.adwdiabetes.com/product/1316/surecomfort-u100-syringes-half-unit-31g-3-10cc-5-16in-100ct

10% off your next order!

You will need a script , tell them what you want and they will contact your vet to fax a script over, give your vet a heads up, ask for refills
We use the half unit markings because we adjust doses by 0.25 units

 

Measuring 0.5 units isn't hard at all with the half unit marking, plus we adjust doses by 0.25 units at a time ,so you would just eyeball if you ever had to give , let's say for an example 1.25 units . Not hard to do

 

I got a copy of the urinalysis from last week at the ER and at that time the ketones were 50 mg/dL which from what I have read is a value that should have caused some concern although not surprising for a cat with a UTI and pancreatitis as well as diabetes. I don’t know if my vet checked ketones as part of the blood work she did or if she said “moderate” based on that test from the ER.

I managed to collect some urine this morning and measured with Ketostix and the reading is either negative or possibly trace. It is certainly not more than that, which is a huge relief to me and a sign that things might be moving in the right direction.

What I don’t understand is why Lilly’s blood glucose is now so high given it was normal less than 12 months ago. Her last blood test was in March 2022 and the value was 137. Do cats really develop diabetes so quickly or is this a result of the infection?

As for the needles, I guess I have the wrong ones because they are 0.5ml and not 0.3ml. I ordered some 0.3ml and they should arrive Monday. 0.5ml was what the vet wrote on the prescription so that is what the pharmacy gave me but here in California we don’t need a prescription for syringes anyway as far as I know.

Interestingly, I just checked and the vet gave me 10 syringes to start with and they are the right ones so maybe the pharmacy made a mistake. It means I have some on hand even if shipping is delayed.

 

@Sienne and Gabby (GA)

@Bron and Sheba (GA)

 

That is very good news.

We don’t know exactly when she developed diabetes. It probably happened over a period of time. I have seen here a cat has had normal BGin a test and then a month later they had diabetes. Diabetic cats are more prone to UTIs than other cats so I would say the diabetes came first.

I am glad you have ordered the correct syringes. The pharmacy may take the wrong ones back

 

I checked the prescription and the pharmacy in fact made a mistake. Given that, they had better take them back!

Another pharmacist told me that here in California one can only buy 10 syringes at a time without a prescription. If one needs more than that it requires a prescription. I was still able to buy a box of 100 online so I don’t know how true that is.

So tomorrow Lily will be starting her insulin. The vet said to feed her in the morning as normal and then bring her into the office about an hour after that for them to check her blood glucose. Assuming it is high then she would get her first insulin injection. Does that timeline sound right?

When would one check her blood glucose again after that? 4-6 hours later? And then again before her next dose? I am trying to figure out a schedule.

Does she now need to be fed on a strict schedule? She is used to grazing throughout the day.

Should I expect her to act any differently (for better or worse) after her insulin? Will she act tired or eat more or less? I am not sure what to expect or how long it will take for her body to get used to the insulin.

Also, if for whatever reason Lily does have a hypoglycemic reaction what are the obvious signs and what does one do? I read to spread honey on her gums and take her to ER. Is that the protocol there?

Thanks for all your help!

 

@Bron and Sheba (GA)

 

Feeding several low carb meals throughout the day is best for most cats, just no food at least 2 hours prior to the preshot test so the number is not food influenced. A low carb food like fancy feast classic or Friskies pate is good.


You'll want to test just before the shot and then some point mid cycle. Yes 4-6 hours is good.

When I was working id take a reading in the morning, then 2 hours later before work. Then again before the evening shot, and then a test 4-5 hours later before bed. On weekends and days off I tested more. We have a great template for tracking the numbers. Once you start you can get that and put a link in your signature so we can help you when you need it.

 

Here is the info on hypoglycemia

https://www.felinediabetes.com/FDMB/threads/how-to-treat-hypos-they-can-kill-print-this-out.15887/

 

The timeline for testing is test/feed/then give the dose of insulin.
If you are set up to test, I would get a reading before you feed. Then if the vet wants to take another one, that's OK.
Then you can get a couple of tests during the cycle around the +4 to +6 or +7 mark.
I have asked @Bandit's Mom if she can help you set up the spreadsheet so you can start adding data straight away.
If you could also set up your signature, that would be helpful.
The link to that is in this link HELP US HELP YOU

If you are hometesting you will be able to see the BG dropping and should be able to intervene with food before it drops too far. However it is a very good idea to acquaint yourself with the signs and symptoms of a hypo.
Please let us know how you get on at the vet

 

Hi @DimitriG, welcome to FDMB!

I can help set up your spreadsheet and signature. Will send you a PM with the details I need. Look for it in the Inbox at the top right corner of this page.

 

I will take a look at the spreadsheet. I am not sure how much testing I want to do.

The first tests resulted in a lot of blood and a wary and unhappy cat. I don’t want her to be fearful of me. The injections and the subq are more than enough for her stress levels. I don’t know how some of you guys manage to test 4 times per day on top of the injections.

That said, her glucose was 353 before the vet visit and it is 173 now almost exactly 6 hours later. I have no idea if that is in the realm of expectations. Vet was not particularly helpful other than to recommend I test again before the next injection. Does that seem right?

If it is lower tonight (say 130) then do I skip? I imagine if it is 300 again I do it for sure. What if it is still 170? I didn’t get good guidance on that from the vet.

Also, no ketones again today.

 

I’m glad there are no ketones.
It would be really helpful if you could set up your signature please and all information about Lily. At the moment I have to keep looking back through the thread if I want to know something which is very time consuming. Please also put into the signature that he had ketones at diagnosis. It can change the advice we give you. You can find the info for that in the link HELP US HELP YOU which is above in post 22.Thanks.

Lily will not be fearful of you if you test the BGs. In fact the opposite happens and we find we have very close relationships with our FD kitties. If you follow the hints about how to test you will find it much easier. Give a treat every time your test, even when not successful. The hints and link are in post 11.
Dropping from 353 to 173 at +6 is good. Once you get the SS set up it will be much easier for us to help you. We need to see BG data to help.
You ask If it is lower tonight (say 130) then do I skip? I imagine if it is 300 again I do it for sure. What if it is still 170? I didn’t get good guidance on that from the vet…
This is exactly why we suggest home testing. To see it is safe to give the dose. If it is lower than you expect stall, don’t feed and test again in 20 minutes to see if the BG is rising. And post and ask for help. In the beginning we say not to shoot if the BG is under 200 until you get more data on how Lily reacts to the insulin. However with ketones in the very recent past I would be reluctant to skip completely. If this happens please post so we can suggest a token dose.
The vet is correct in telling you to test before the next dose.

 

Thank you so much! I will find time to setup the signature.

What I am reading is that generally (your mileage may vary) if the glucose levels are over 200 then it is safe to give a dose of insulin but if it is under 200 then skip?

Is that a pretty good rule of thumb to use?

 

That is the general rule while gathering data. But because of the history of ketones in your case, we don't want you to skip doses.
Once we see more data, we can lower the BG where you need to think about whether you skip or not

 

I'm guessing you must have accidentally hit the vein. You want to aim for the section between the vein and the edge. It hurts less and will bleed less.