7/27 Smores: Transitioning from IV to Lantus

Hey All,

We are newly diagnosed after a DKA episode. I've been getting help over at the general forum, but I think it's time to transfer to here. Here's the previous post:
viewtopic.php?f=28&t=48454

The short version: He was on dry food (Science Diet Sensitive Skin), he stopped eating completely for 24hrs and was taken to the ER (Mon morning). They diagnosed DKA and DM, put him on IV insulin (don't know which) and fluids. He was on IV insulin for ~40hrs, and then first Lantus shot this morning (1U). He has started eating Hill M/D wet and dry at the vet.

I am getting ready to take Smores home tomorrow afternoon (hopefully), and I want some advice on initial dosing recommendations and tracking. Unfortunately, I don't have the full history of BG readings yet, but what I have is in the SS. He just started on 1U BID with a 315 at +1. I will be feeding him the right wet Friskies cans (all <<10% per the list)

Based on what I've learned so far (and the protocol), I expect to stay at 1U for the PM dose, and go to 1.5 if he is still >300 tomorrow AM. I was thinking to move up on the early side of the 24-48hr window in the protocol b/c the initial dose "should" have been 1.5U according to the protocol formula, and he is clearly ketone prone right now.

I am posting b/c there is not much out there on this initial transition from an acute DKA episode, and I don't want to undershot and end up back in DKA, or overshoot due to new diet, etc and end up hypo.

Thanks.

Welcome to LL! You'll get lots of help here. I wouldn't be too fast in upping the dose. Lantus builds up a reserve (we also call it a shed or depot) in a cat's system . So a little of the dose goes to that every shot until it is balanced out. When starting lantus it takes about a week to fill the shed. Until that happens S'Mores is not getting the full effect of the dose.

Also Lantus is dosed on the nadir, the lowest number in the cycle not on the preshot test, which is usually the highest. Yeah, we do a lot of testing here. :? We test before the shot (pretest) to make sure our cats BG isn't too low to shoot safely, but also during the cycle to see when they go the lowest. It isn't always a fixed time. If the cat goes low, of course there are more tests to make sure they don't go too low. Get some data on mid cycles levels, that is what will tell us what the dose should be.

Changing from dry to wet food can also have a dramatic effect on his insulin needs too. Get him settled in the new foods before doing any changing of the dose. AND MONITOR CLOSELY during the transition! BGs can drop dramatically when a cat starts to get the right food. Speaking of which, great idea to get rid of the Hills.

I agree with Ann. I think you would want to leave on the 1U for 6 - 10 cycles, especially while you are changing food. That is just my opinion. Someone more experienced will come along soon and give you some help.

Welcome to Lantus Land!!

many of our kitties have been where s'mores is today, including my own. if you haven't already, please pick up some ketostix or ketodiastix from any pharmacy so you can test for ketones at home everyday. i was able to use a long-handled soup ladle to collect alex's urine. others employ various methods such as using aquarium gravel or saran wrap in the litterbox. follow the directions on the ketostix or ketodiastix label carefully.

will you be transitioning s'mores off of dry food? if he'll eat wet food exclusively... ditch the dry. however, if he won't eat canned food willingly, try gradually weaning him off of dry food. dr. lisa has a lot of tips for Transitioning Feline Dry Food Addicts to Canned Food on her web site.

edited to add: while feeding canned food under 10% carbs is optimal, it's imperative for kitty to eat. if s'mores won't eat canned food, dry food is better than nothing!

you're correct in thinking a dose adjust may become necessary. the best advice i can give you is to test s'mores blood glucose and urine frequently. if you post the results daily we can help guide you through dose adjustments. lantus is a "depot" insulin and therefore the effects are cumulative, meaning it does take a few days to see what a particular dose can do. dose adjustments are made according to nadir (the lowest part of the cycle)... not the preshot number. however, because kitty is just coming off an episode of DKA we may want to suggest an increase sooner than we normally do in order to keep those ketones at bay.

edited to add: there are 3 main ingredients which make the recipe for DKA:

• lack of insulin

• not eating enough

• infection or other health issues

we want to make sure s'mores is getting enough insulin, is eating well, and any infection/health issue is being treated.

take the time to read through the "stickies" (marked with star icons) at the top of the forum. it's a lot to absorb at once. refer back to them often. as time goes on, they'll make more sense to you.

last, but not least... try not to worry. we're here to help you. many of us have first hand experience dealing with ketones and diabetic ketoacidosis.
hope to see you posting often...

something else i forgot to mention...
keeping s'mores well hydrated is important. adding as much water as he'll tolerate to his food will help to flush out ketones.

I don't have the ketostix's yet, but they are on my shopping list (I also need the rest of the hypo toolbox). I'm using a CatGenie now, and it looks like I can pull the urine from the base of the unit easily (I checked after his last use before we took him in to the ER, and there was a nice small pool sitting there for me).

He went down hill so fast last time (just suddenly stopped eating mid morning on Sunday), that I am worried that by the time I notice on a ketostix, it will be too late to stave off another ER trip. Obviously, I don't have any experience here yet, so I don't know how much warning I can expect. Apparently he did have a bladder infection, which combined with the underlying DM kicked him into DKA, but I don't know how I would have noticed the infection before he stopped eating. Now that I have insulin, at least I have something to do other than rush to the doctor.

As for the food. He has really liked wet food in the past when we've given it, if anything he eats it too fast, but he's never been on an exclusively wet diet. We'll see how he takes to it. I plan to just start all wet and see if there are any issues.

He has always drunk a lot of water (yeah, yeah, warning sign, but hindsight is 20-20). The vet says that he has cleared out the ketones remarkably quickly, but he is on an IV.

When I get the chart from the vet, I'll update the SS with all of the readings they have taken and post for comment. I'll try to get them to do a full curve tomorrow.

I've read all the stickies a couple times. (and one other, that's not a stickey, but I think should be: viewtopic.php?f=9&t=46003) I'm just not sure how to modify the guidelines so soon after a DKA episode, and I have no idea how hard it is to induce another one while I'm trying to "start low go slow".

we don't "start low, go slow" in this forum... at least most of us don't when following a tight regulation protocol. click here to read through the Start Low, Go Slow method (SLGS, for short). the differences between the Tight Regulation protocol and the SLGS method are obvious. we don't hang onto doses for a week or two before increasing.

most of us don't put a whole lot of stock in data collected at the vet's office because it's likely numbers taken at the vet's office reflect vet stress. stress can elevate the numbers. the data you collect in the comfort of s'mores home will be more significant.

testing blood sugars and urine at home is your best defense against ketones. guidelines to the Tight Regulation Protocol are simply guidelines... not hard and fast rules. trust us, we're all too aware of the ramifications of ketones developing. this is why i'm encouraging you to test and post often. we need to know if ketones are present and how low the dose is taking kitty. fast tracking s'mores up the dosing scale is what we would recommend if the current dose is not enough.

is he being treated for the bladder infection?

personally, the only reason i'd like to see numbers on 1u bid for a couple of days is because you'll be cutting out the dry food. feeding a high protein - low carb wet diet exclusively can result in a significant drop in numbers... requiring less insulin.

My mistake. I had seen the phrase SLGS somewhere in here, and just assumed it was a short hand for the TR protocol. I'm planning to follow TR (with advice).

It does seem that one of the key principles for dosing of Lantus is to not overshoot the target dose by increasing too fast. That's why the advice here is going to be so important. Smores will be walking a tightrope b/w 2 cliffs until he gets regulated.

Do ketones rise slow enough that testing once a day enough to catch it, or do I really need to try to test AM and PM?

He is getting antibiotics for the bladder

ketones *can* develop in a matter of hours. i suppose testing as often as you can would never be a bad idea, but i have to say most are lucky to collect urine samples once a day. the urine must be fresh so you have to really keep an eye on when he heads to the litterbox.

again, you're correct. you don't want to overshoot the dose by increasing too fast because too high of a dose can result in high numbers... just as not enough insulin does. however, if a kitty starts developing ketones (as indicated in your ketone testing), conventional wisdom goes out the window. we need to get more insulin into the cat... in extreme circumstances that can include having to feed a higher carb food to prevent kitty from bottoming out on a higher dose in order to increase the dose safely, but at this point this thinking is putting the cart before the horse.

what antibiotic is he on? you might want to pick up some Fortiflora (a probiotic) from your vet in case the ab causes an upset tummy and/or diarrhea. you can sprinkle half a packet on his food twice a day. an alternative is to get a probiotic from a health food store. i use this one: Ultimate Flora Critical Care. i get it in the refrigerated section at Whole Foods.

Looks like you are getting super advice from Jill so just want to welcome you to LL from Do Lou and I :mrgreen:

Hello and welcome!

We went through DKA twice with BK. I just want to chime in on testing for ketones as often as possible. Like Jill said ketones *can* develop in a matter of hours.
I was lucky it was not difficult to get urine samples with BK. Sometimes he doesn't place his butt all the way down in the box, and he's not bothered by my stalking him with ketostix. If he did have his butt down low, I was at the ready, the second he moved away. There often was a puddle for just long enough to get a dip. I also was encouraged by the folks here to notate ketone tests/results on our ss. I think that's a good practice when you are on guard for DKA. We also added water to BKs food and still do to this day, even though he has not needed insulin since 10/2009.

You came to the right place.

Gabby is another DKA survivor. Fortunately, she has been ketone free since her initial ICU stay.

If you are worried about ketone testing, there is a glucometer that will also test for ketones -- the Precision Xtra meter. The downside is that the strips are expensive.

Just waving hi from a nearby town. Star was diagnosed just two months ago, so we're still new, but let me know if I can help with anything.