Need experienced help - 2wks post DKA crisis - severe glucose swings with Lantus

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nursjuju

nursjuju

Member Since 2016
Trying to make this as brief as possible...
Sophie went into a DKA crisis 2 weeks ago and has been home for about 10 days now. I'm not exactly sure how it happened other than I had trouble the few months prior with her going very high 300s and then very low (20-30 a few times). I was measuring with a Relion Confirm. Apparently it was WAY off with the readings measuring much lower than the actual glucose. When I took her into vet suspecting somethimg was brewing her glucose readings were in mid 200's. It was 227 with mine & 450 with vets AT2! I have been since checking with AT2 and Confirm since she's been home & the readings are usually significantly different with theRelion being much lower (sometimes 100-150 points!) so that being said I will NEVER again rely on human glucometer.

Vet was having me give anywhere from .5u to 1.5u several times a day the first 2 days she was home. I was nervous about this bc I knew there would likely be a severe drop on day 3 and sure enuf there was. It appears she's rebounding and been trying to go down slow but I'm absolutely terrified of her going into DKA again. Ketones negative in urine daily. I've tried to load into spreadsheet since day 1 home. I'm not sure if this is right way to send link.

https://docs.google.com/spreadsheets/d/1F1uj7pV5HaDEt1JA28a1GODwsCWvW2x5OLY5t3DRMXY
 
Your link works, and the numbers don't look too bad, just a bouncing cat. I see that you are not shooting the same dose every 12 hours. Because Lantus is a depot insulin, it works best if given the same dose on a consistent basis if possible. Usually cats tend to go lower at night time, and they don't tend to eat as much at night, so giving more insulin at night time, could cause some bouncing, but most cats that bounce just do because they have been diabetic for a while and their livers are not used to normal BG numbers and thus they make the cats bounce.
I would make sure Sophie gets lots of food (hopefully, you are feeding wet food) and stays hydrated. Did the vet say there was an infection and if so, did she get antibiotics?
 
nursjuju said:
theRelion being much lower
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A human meter will ALWAYS read lower than a pet meter - that's in about any piece of info on testing anywhere. That's why 2 different ranges are used for what's considered 'normal' range. Human meter is 50-120 while pet meter is 80-140.

nursjuju said:
It was 227 with mine & 450 with vets AT2
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Was that on the same drop of blood at the same time?

nursjuju said:
Vet was having me give anywhere from .5u to 1.5u several times a day the first 2 days she was home
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Since you posting in the Lantus/Levemir forum, I'm assuming you're using Lantus. If so, this vet has ABSOLUTELY NO IDEA how Lantus works. Giving that varying amount and several times a day is just plain playing with Sophie's life. That's dosing for an 'in and out' type of insulin such as Vetsulin, NPH or 'R'. R is very dangerous to use at home unless someone is very experienced. It's NOT dosing for a depot insulin such as Lantus or Levemir.

DKA - did they give her antibiotics too? Recipe for DKA is not enough insulin PLUS not eating PLUS infection/inflammation.

HUGS...
 
This is how the 2 days before crisis went. On 4/26 she didn't eat as much breakfast (yes feed wet 1% carbs 2-3x day), an I felt like something was brewing so I took her to vet that afternoon, they drew labs, urine, etc. She ate dinner fine. Glucose on Relion was in 200s so I wasn't extremely concerned. Am 4/27 she wouldn't eat breakfast & unfrtunately I had to go to work, left food out. When I got home she had thrown up. Vet office was already closed and had no results from lab. By am she was lethargic & raced her to vet at 6a. The labs from 2 days prior had trace ketones in urine, blood draw glucose 281, everything else normal. She did have multiple doses of iv antibiotics. The only thing was leaukocytes in urine which she is still showing today even after all the antibiotics. Urine culture negative. She went on assumption of pancreatitis even though enzymes were normal.

I have never experienced her swinging this high until after crisis. I honestly don't know if lowering her dose is the right thing to do. The 400s really bother me. She drops so fast that even though the lows don't seem that low, the drop is significant. And also on the sheet where there are 60s, I was feeding her every hour to keep her that high.

I've always known that the human glucometers were lower but not the huge gap that there is. I have been using both to compare & it is truly a significant difference.

The spreadsheet was AT2. If I had loaded the Relion, it would look like a cat that is very hypoglycemic or regulated well which is clearly not the case. I haven't texted the vet in a couple of days because I have a feeling she will tell me to give more & then she will drop radically.

Does anyone think I'm dosing too low? Should I just try to be more patient with these swings?
 
Dyana said:
She's using Lantus. It's in the Subject Line.
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Oops. I just looked at the signature and the previous post.

Comparing meters will drive you nuts. I went through that with my backup meter. Pick one is the best advice I can give you. The protocols were written using a human meter. Many use human ones due to the cost of strips.
 
Please unconfuse me. Your title and post above says 'DKA' but your post #6 above says Pancreatitis. Was she DKA or did she have Pancreatitis? They're 2 very different things.
 
She was definitely in DKA. The vet went on the assumption that part of the reasons for going into DKA could have been from pancreatitis because I couldn't figure how she could have DKA so fast.

Btw I'm an RN, an this is far worse than managing humans!
 
Max had chronic pancreatitis for several years before becoming diabetic. I think it's why he never went OTJ. He never was DKA though. it's hard to manage as well. Was it an acute attack or is it a chronic condition?

Max was a very bouncy cat his first year.
 
Yes, kitties can go from throwing ketones to full blown DKA very quickly. My Alex went into DKA the day after she was diagnosed with diabetes and was immediately hospitalized for a week. It's why I tried to test for ketones twice a day whenever she seemed the slightest bit off.

Not sure how you'd like to proceed. With as much as you test her and given my own experiences with Alex and many other post-DKA kitties on the board, for now, I would stick with dosing 1u every 12 hours if I were you. If her BG number is less than 150 immediately prior to shot time, post for guidance. I also recommend the Tight Regulation Protocol. It's a little more aggressive than some other methods, but definitely a better choice for a kitty coming off of DKA. The data you'll accumulate will help you know if a dose adjustment is required.

I'd also make sure she consumes her normal amount of calories everyday. Add as much water to her canned food as she'll tolerate and continue testing for ketones. If she throws as little as trace amounts let you vet know right away. Please let us know, too. We're likely to suggest some other tried and true methods to help get rid of those ketones right away.

Since cats metabolize insulin faster than humans, you'll have to adjust your mindset a bit. When you attempt to analyze data from her spreadsheet, think in terms of "waves of action" rather than putting too much thought into individual cycles (unless she drops below 50 mg/dL on a human meter). Initially, these waves of action last around 6 cycles (3 days). Eventually, the waves become smaller... hopefully non-existent.

For example...
Bouncing: Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles).

We don't put a lot of stock in the high numbers seen in a "bounce" because they're only a reaction to the lower number that set off the bounce. It's the low that we pay the most attention to. Lantus dosing is based on how low the dose can take kitty with only some consideration given to preshot numbers.

I'd like to encourage you to read the "stickys" (posted marked with a yellow tag) at the top of this forum beginning with "The Basics: New to the Group? Start here!". There's a lot of info there... too much to be digested at once, but most everything you'll need to know can be found in the forum "stickys" so you can refer back to them whenever you want. I also encourage you to ask as many questions as you have.

I'm having internet connection issues tonight, but there are many here who are able to answer questions.
Hope to see you posting often!
 
Couple questions - How old is your cat? Does she have any other illnesses that you know of? Approximate weight? What was her diet prior to DKA (food amount and type of food)? Is your cat currently eating, and if so, how much?

RN here too! For whatever reason, DKA prone cats are more akin to type I diabetics. If insufficient insulin is given, especially if energy demands are increased (infection, exercise, stress, etc) they can go into DKA quite easily. Treatment for DKA in humans is regular insulin/dextrose via IV, same for inpatient kitties --> in cats at home you can support insulin intake with higher carb foods. That way you are able to give -MORE- insulin and help her store fat instead of burn it.

It is possible for people (and cats) to go into DKA when they have close to normal blood sugars for some or all of the day. It's known as euglycemic DKA, and one of the major reasons it happens is because the sugars are artificially low due to low body weight or starvation. Once the food intake increases to normal levels, the blood sugars are hyperglycemic and it is clear that more insulin is necessary. Also, underweight cats can be extremely sensitive to insulin and small amounts can lead to rapid and large drops in BS. This is known as brittle diabetes. To treat, you actually have to increase the carb intake to allow the insulin to have a substrate to work on. Brittle diabetics are usually pretty difficult to regulate until they gain a little weight. Certain illnesses that increase metabolism can also cause brittle diabetes.

Concerning the glucometers - the human meters calculate the range based on studies of human lab values. The alpha trak meter adjust these numbers to compensate for cats having slightly different protein structure in their blood that affects readings. The alpha trak meter is actually just a human meter (freestyle) with an extra bit of software code that adjusts the number. Here on this board, all of our ranges and values take into account this issue already so everything is based on human meter reading. Per FDA guidelines, meters can have a 10-15% + or - error rate as well. Because of this, it's best to stick with one meter and not try to compare numbers brand to brand or especially across different reference ranges (cat vs human). The only numbers that really need to be accurate are hypos and normal numbers. Anything above normal really doesn't matter as high is high, and more insulin is the answer.
 
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Jill thank you so much for the info. I have read a lot of the stickys and try to go back and re-read as well.

Meya, great explanations. I've gotten more info from this site than an vet. So ironically enough, I think I have been so consumed with this crisis and what did I miss or do wrong to cause it that I actually have had a hard time seeing the Forrest thru the trees and my brain has become mush from the lack of sleep.

Sophie is 10 years old, no other health issues, no hypothyroidism, no renal issues, and it she has never shown signs of pancreatitis. She is 8lbs 2 oz (She went way down to 7lbs 11 oz during DKA). Her ideal weight is around 8.5 lbs give or take a few ounces. I've been feeding her Purina ProPlan True Nature Classic Chicken/Turkey or Chicken/Liver. Carbs are very low at approx 1-1.5%. Each can is 200 cal. She gets consistently 200-250 cal/day.

She was diagnosed 12/31/15 and honestly I thought she would go into remission because she was so well under control. I didn't however see this forum and all the great info til last November.

So in this past couple months there have been changes in house. My 16 yr old cat Lucky passed end of Jan (he had pancreatitis, hyperthyroid, megacolon) and a new stray kitty approx 1-2 yrs found his way in to my home about 2 mos later. I do think that has stressed out Sophie for sure.

So when you say high carb just how high are you talking? Because that does make sense. I've been feeding her a lot of extra low carb calories since she's been home.

Also as far the meters, if I go by the Relion then all the numbers on the spreadsheet that are in 60s were 30s with that one. This is where the dosing confuses me bc TR says to immediately decrease dose. So it feels like I will need to bump up & down every 3 days. Do u understand what I'm saying?
 
Cats with DKA or within a month of recovering from DKA should be treated a little differently on dosing due to the nature of the illness. Often, if TR is followed after DKA, because blood sugars can be very unstable, it can lead to not enough insulin being given (when you take the dose reductions with the low numbers). DKA can reoccur in this situation. That said, you do need to maintain safety from hypos.

200-250 calories sounds within the right range for most cats (200-300cals is typical). But the carbs matter too, as carbs don't have as complex of path for the utilization of those calories. I think that it's appropriate to jump to an about 10% food and see how that does. If she's still taking nose dives from the insulin, you can feed the 10% food for meal times, and maybe add a handful of even higher carb at the insulin nadir or times you see the numbers start to drop. Post DKA, you do want the numbers to be a little higher than "normal" range for safety from the hypos, but still under the renal threshold, preferable 150-200 on human meter. Don't decrease insulin to maintain in this range, rather, feed more - and add carbs as needed. With this strategy, the goal is to see the numbers even out and you will probably have to increase the insulin dose - that's ok. The BS curve should gradually come down and remain more flat with more food/carbs + more insulin and she'll be better regulated.

Once she is regulated better, you can use weekly weights to gauge her food intake. If gaining too much, reduce food/carb a little then reduce insulin accordingly. If losing weight, add food add insulin and test often for ketones. Once she is less "brittle" and well out of DKA, TR is a good method for dose guidance.
 
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Oh thank you so much. Makes total sense. (The light bulb came on lol)
It's the same concept as adding dextrose to IV fluids. She didn't eat her full bfast this am which of course makes me nervous but I am gonna go grab some high carb food this am & see if that doesn't entice her. Her AMPS was 360 AT2 274 RC. Negative ketones. Thankfully I'm off work today & all next week so I can really keep an eye on her.
 
She's doing well. Last glucose at 10 was 288 & I got her to eat more. I'm feeling much better with all the support and knowledge!! I really like my vet & she's experienced but I'm not sure she's as experienced with Lantus as it was a former vet that diagnosed Soph & put her on it before she moved. She knows I'm an RN & an "investigator" (Type AA :)) So I read vet articles, have vet manuals etc. but I don't wanna disrespect her, however it's just like any dr, sometimes we have to inform them.
 
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