? Snickers - DKA and BG staying very high - tried a booster shot.

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Eric Minor

Eric Minor

Member Since 2017
Snickers was taken to the ER on the evening of May 3 and seemed to be near death. We didn't realize there was any problem up till then, but in hindsight there were some signs we didn't take notice of like excessive water drinking and high urine volume going on for perhaps 6 months.

It was touch and go for several days but she made it through and has been home now 4 days. We are trying to get insulin dosing figured out and she is no where near regulated as of yet, usually in the 550 or 600 range before insulin injection and getting down to about 350 at nadir for the first curve I did on day 2. We started at 1 unit of glargine twice a day but after 2 days of mediocre results we bumped that to 2 units twice a day.

Still we wind up back at 550 before the next shot so today I tried a 1 unit booster (still Glargine) at the 6 hour mark. For the regular shot tonight at 8:30 PM we were at 460, which is better than 550 or 600 in my mind. We will see how the nadir tonight looks and what we wind up at tomorrow morning.

We need to get food figured out. She had been on dry her whole life. She came out of the ER DKA trauma skin and bones so we have been giving her Nutro wet food and she has been eating it well. We ordered a dry food called "Young Again" which hasn't arrived yet which claims to be a good diabetes dry food and claims to get a good number of cats into remission.

We are also giving her 1 ml Pet-tinic and 2.5 ml VetOne RenaPlus Potassium Gluconate twice a day per the ER vets instructions. I'm poking her ears frequently for blood samples. She tolerated it better than I would have expected to start but is getting angry with me now -- but we need data so that is that.

.....

Yes, I gave a second shot 6 hours after the first. I was aware that it would give me a 2nd nadir and (I thought) I wanted that. I was (I thought) no where near being too low and felt like I wanted to get her baseline BG to drop a bit in advance of the evening shot...just felt like I was stuck up in the mid-500's and 600's and needed something to change.

From the first several readings after that experiment I felt like it did what I wanted. Two hours later it had dropped slightly from the AM+6 reading and at the PMPS reading it was about 100 points lower than all the previous pre-shot readings (464 instead of 550's or higher). I read about the Simogyi effect and was pretty sure that wasn't in play. However, the 3 readings since the evening shot have gone poorly and entirely in the wrong direction. I can't decide if the evening shot was poorly executed (she moved on me a bit) and delivered nothing or if there is in fact something else going on. We went from 464 PMPS to 513-513-646 at 2 hour increments. I'm dreading what I'm going to find at the morning reading and if I'm going to have to haul her into another ER for IV insulin to try to get her down into an acceptable range.

I haven't tested for ketones yet but have been intending to. With these BG levels I have to believe they are probably present. I'll post this in that other forum as well.
 
Hi,
I have no input to offer but if you can add question mark as a prefix to your post title you will get more attention. I am sure someone on the board used the technical and will share the experience.
Best of luck to you and Snickers!
 
As feared, the next reading was over the 750 scale on the meter and read "HI". Still 4 hours until the morning shot.
 
Hello--

So sorry you are going through this with Snickers! DKA is very rough, and the initial period after recovery can be tricky. We have some experienced members here who can help you with it. It sounds like you are very dedicated to Snickers' treatment, and that is the most important factor!

A few quick points: first, please don't give additional "booster" shots-- it's really not a good idea except under very very very rare circumstances with very experienced caregivers who know their cat's BG patterns thoroughly. Right now, while you are still trying to get Snickers stabilized, it will be a de-stabilizing factor to have multiple shots active at the same time, especially with a "depot" insulin like Lantus.

Second point: the "recipe" for ketones is, infection/inflammation + not enough insulin + not eating. Please do test for ketones ASAP, it's critical to keep an eye on this after DKA, but it's not necessarily the case that high numbers = ketones. It takes time to get a cat regulated and into better numbers. I know it is really hard to see those high numbers after seeing how sick your kitty was with the DKA, getting the ketone tests in may help put your mind at ease (or, of course, let you know that it really is time for the ER if that's the outcome).

Last point: I don't know if this will help, but I want to emphasize what I just said, it takes time to get a cat into regulation-- weeks, even months. So, two days in high numbers isn't an indication that there's a major problem. It probably is an indication that more insulin is needed, especially in a DKA kitty, but what we'd recommend then is to increase the twice-daily dose. We usually increase in 0.25U increments, and in a systematic fashion. There are two procedures we use with Lantus (Tight Regulation and Start Low, Go Slow), detailed in the yellow "stickies" at the top of the Lantus forum. For a DKA kitty and regular testing we'd probably recommend TR because it is more aggressive on dose increases and a DKA especially needs to get to the right insulin dose. Some of the most experienced members here might even be able to guide you further on dosing in a post-DKA situation (I'm not one of those members, though).

You're doing great so far, especially with all the testing you've been doing! Make sure to give Snickers a treat of some kind after every test (successful or not!)-- helps a lot with the patience of your patient :cat:. Last thing: you'll want to get a spreadsheet set up for recording your BG data-- it's a fantastic tool not only for you, but for the people helping you, to be able to see the patterns as they emerge. Instructions are here, just holler if you need help setting it up!

Finally: welcome!
 
Hopefully someone experienced in looking at spreadsheets will come by to take a look at things. Could you mark down where you tried the booster shot with a note in the cell?

One thing I will observe is that it's possible that a lot of the high numbers you've been observing over the past couple of days are due to a phenomenon called "bouncing". Basically, the cat's body reacts to "low" numbers by dumping extra glucose into the blood to prevent hypoglycemia. "Low" is in quotes because it's relative-- obviously, Snickers hasn't gone anywhere near hypoglycemia, but those yellow numbers in the 200's might look really low to her body if she's been in high diabetic numbers for a while. Cats can also bounce if they experience a steep drop in BG numbers, even if they don't get low at all at the bottom of the drop.

The really annoying thing about bounces is that they are variable in length but can last for up to three days after the triggering event! So, looking at Snicker's spreadsheet, it's hard to tell because you're missing data on some days, but it's possible that the 274 on 5/10 triggered a bounce that lasted until yesterday when finally her body let the insulin bring the numbers down... and now we're starting another bounce.

That said, there are others around here with far more expertise at analyzing spreadsheets, so let's see what they have to say. The other factor going on is that you've made some big jumps in insulin dose over a short period-- not necessarily a bad thing for a DKA kitty, now that you're here at the higher dose, but probably best to slow down right now. Dose changes that rapid make the patterns harder to interpret and keep the Lantus depot from settling down (the "depot" is the fraction of each dose that is reserved for later action).
 
I like Nan's advice. Lantus is an excellent insulin but needs to be dosed carefully. It's slower in onset and gentler than the in-and-out insulins but you always have to pay attention to the depot. The depot does its best work when it's filled (can take up to 3 days) and when doses are held constant for a minimum of 6 cycles so that it isn't being disturbed by dose changes. Once you're at a dose it can take up to three days to see the effect because of the depot needing to fill. Unfortunately, the phenomenon called bouncing that Nan referred to can confound the picture and lead you to think a dose is too low when it isn't.

Others with more experience will weigh in soon.
 
Eric Minor said:
She is acting OK comparatively (compared to almost dead a few days ago) but is drinking a ton.
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All the easier to get her to pee for a ketones test ;)!

It is a good thing that she's drinking-- not good for what it means about her BG (high, but you already knew that), but good in that it's helping to keep her from dehydration, which is a factor in developing ketones. The more fluids she gets into her right now, the better.
 
Hi there,

With DKA in the recent past you are now in a time of intensive care.

As someone mentioned earlier, the recipe for the formation of ketones is lack of insulin, lack of calories, and infection/inflammation/stress. Did the vet mention infection or inflammation was detected ?

Get some ketostix asap, today. You need to monitor several times a day and watch the formation of ketones. Any reading above 'trace" warrants a call to the vet. Ketones can quickly develop to life threatening levels.

Ditch the dry if at all possible. It's part of the problem. Mix as much water as kitty will tolerate into the wet food. Hydration is very important. Don't get hung up on wet food carb content right now. Snickers needs calories.

Lantus is given 2x per day and shot every 12 hours. It is slow acting and not suitable as a bonus insulin. You can add a fast acting insulin into the treatment if needed however guidance from someone experienced is very strongly recommend.

Please ask questions.


 
Please check for ketones ASAP. Also, no boosters with this kind of insulin, it acts so slowly that the effects are really hours later and so it makes it confusing as to which nadir is doing what unless you are 12 hours apart. There are other insulins that are better for this that can be combined with a lantus regimen, but there are risks to those as well.

Because you are dealing with DKA, however, it is very important to get the insulin level high enough so that there are no longer ketones in the urine. This may or may not correlate to lower blood sugars, so the best way to test for improvement isn't so much by measuring blood sugars (though you should still) but rather testing urine ketones. Also, because you need to ensure enough insulin is given, you do need to perform increases -more aggressively- than our TR protocol if ketones are still present. Increases by 0.5U every 4 cycles if the nadir is still high are appropriate.

Some things to consider - Is your cat eating well? If not then there are medications (anti-nausea) and interventions that need to be done (assist feeding). Has your cat received subQ fluids? Ask your vet if these are appropriate for you and if they can show you how to do at home. The extra fluids can help get rid of ketones, and knock the numbers down if kitty is dehydrated. Has the vet drawn labs? If so can you get a copy and post them?
 
Sandy and Black Kitty said:
Hi there,

With DKA in the recent past you are now in a time of intensive care.

As someone mentioned earlier, the recipe for the formation of ketones is lack of insulin, lack of calories, and infection/inflammation/stress. Did the vet mention infection or inflammation was detected ?

Get some ketostix asap, today. You need to monitor several times a day and watch the formation of ketones. Any reading above 'trace" warrants a call to the vet. Ketones can quickly develop to life threatening levels.

Ditch the dry if at all possible. It's part of the problem. Mix as much water as kitty will tolerate into the wet food. Hydration is very important. Don't get hung up on wet food carb content right now. Snickers needs calories.

Lantus is given 2x per day and shot every 12 hours. It is slow acting and not suitable as a bonus insulin. You can add a fast acting insulin into the treatment if needed however guidance from someone experienced is very strongly recommend.

Please ask questions.

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No need to mix water into wet food -- she is drinking constantly -- and that is itself indicative of a problem. Yes, the presumption at the ER was UTI that perhaps moved up into kidneys. She was on IV antibiotics for the 6 days she was there.
 
Nan & Amber said:
How's it going? Have you managed to get a ketone test?
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Yes, just got one about 45 minutes ago at 3:45 PM...negative. Was only able to take one BG reading today at AM+6 and it was 486. Given that she was off the charts HI about 10 hours earlier I'll take that. Was able to caucus with the vet today and we were both surprised that antibiotics were not part of the protocol sent home from the ER, so we will add that in tonight and plan for a 6 week course. It seems possible lingering UT/kidney infection that was being treated at ER was contributor.
 
Red & Rover (GA) & "Cat" said:
The first three ingredients in Pet-tinic are: Corn syrup, water, sucrose

This would effect the BG numbers.
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Good catch, Red! I would ditch this stuff if I were you, Eric. I can't imagine why a vet would recommend it for a diabetic cat. ETA: someone mentioned to me that perhaps it was because Snickers had lost so much weight? Did the vet explain the reasoning behind it?

Welcome to Lantus & Levemir Land, the nicest place you never wanted to be.

If you haven't already done so, please take some time to read the stickies at the top of the Lantus & Levemir page. There is a great deal of info there - more than you can possibly absorb at once. Knowledge is power, and you'll need to really gear up to be ready to fight FD.

Regarding Snickers' ears: get some Neosporin ointment with pain relief and rub it into the ears every night after the last test. Wipe off the excess in the morning before the first test. It will help the ear to heal and relieve the discomfort. It also helps the blood bead on the ear, making it easier to get a sample. Some ideas to help with testing can be found in this post.

Great job with home testing. As has been mentioned, you don't need to run a curve every day, but pre-shot tests and at least one or two mid-cycle tests are strongly recommended. If you keep feeding dry (which we discourage), you would need to follow the SLGS guidelines, as TR precludes feeding dry. If you want to understand why we are so adamant about getting rid of the dry food, please check out Dr. Lisa Pierson's site, Catinfo.org.

We put together a post for new members, to help you use this site - kind of an FAQ: http://www.felinediabetes.com/FDMB/threads/updated-tips-for-new-members.173572/

I know how scary DKA is. My Cinco had it shortly after he was diagnosed. He pulled through, thanks to the help I found her on this site. You've come to the right place! Ask lots of questions. We love to help!
 
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Regarding explanation from the Vet -- no -- there was none. It was a 24 hour emergency clinic that (by necessity) had 4 or 5 or 6 doctors looking after Snick. Some seemed better than others. The day of checkout was bizarre and I can't help but think there was some miscommunication somewhere.

As of Monday night the plan was to release her Tuesday night. On Tuesday the doc that day I had never spoken to yet, said, "hey, that blood glucose level seems too low...maybe this is a kitty we only need to give one shot of insulin a day. I think we should keep her overnight to work on those numbers some more." Or something like that.

To which I said, OK, I do have an appointment set up with my regular vet tomorrow morning to check her out and get up to speed. The doc said something like, "yeah, we can treat it as a transfer then or something".

I mention that because it was bizarre. We had been there everyday for 6 days visiting her back there in the ICU, talking in detail to the lead vet that day about what is going on each time. And on that checkout day, some tech just comes out to the waiting room with Snick in her pet carrier with two bags of "stuff" which included IV bags of who knows what that they had been using with her and she still had IV ports in both her front legs. Our understanding the day before was that she was simply ready to go home...we were expecting her in a "go home" state, not with IV ports still in place. There was no verbal instruction from anyone about what was supposed to happen.

Confusion ensued when we got to our regular vet 30 minutes later about exactly what was supposed to happen. The regular vet was able to get the attending vet from the other clinic on the phone and the upshot was that we just pulled out the IVs and threw away the several bags of IVs solutions and continued forward following what instructions there were -- namely the instructions on the several bottles of stuff -- glargine, pet-tinic, and potassium gluconate. Particularly, 1 ml of the pet-tinic twice a day.

Uggggg!
 
I was just in touch with the ER clinic. They said the purpose for the pet-tinic was primarily to provide iron for anemia. They said to go ahead and discontinue it. I'll leave it at that for now.
 
In DKA, the decrease in phosphorous can lead to what's known as hemolytic anemia which can be serious. Also low potassium can occur in DKA and also when you first initiate insulin. You should get these values rechecked in a few days at your home vet to make sure the number still aren't low.
 
Yes, during the crisis there were a number of needs that competed with each other. Low potassium was one of them and insulin drives potassium lower, but she obviously needed insulin. She was getting potassium supplements by IV and as mentioned, there was a third element to the "meds" that came home with her from the ER. The insulin, pet-tinic, and VetOne RenaPlus Potassium Gluconate (2.5 ml twice daily).

I discontinued the pet-tinic at the 8:30 pm medication party 20 minutes ago. I wondered if the RenaPlus also had ingredients that would work counter to BG stabilization. Unfortunately, the big tube of it doesn't seem to list any ingredients on the tube. I decided to go ahead and administer the 2.5 ml of it along with the insulin, wet cat food, and now clavamox antibiotic added to the mix. My vet also sent home a probiotic to be administered once per day to apparently counter diarrhea that might come with the antibiotic. I didn't do that one yet but plan to tomorrow morning (hopefully nothing in there that is counter productive to BG).

The good news is, I apparently have a handy counter-measure to a hypoglycemic event handy in liquid form along with a syringe to jam it down her throat quickly if need be.
 
Probiotic is: Proviable-DC "Digestive Health Supplement". 80 capsules, says to mix in with food once per day while on antibiotics.

Nan: Antibiotic is Clavamox, 1 ml twice daily.
 
The ER vet's instruction on the Lantus was to roll it gently. One of the sticky posts here said to *not* do that. Later on in that same post, it says that Lantus is not as fragile as previously thought and don't sweat it. What is the right answer?

I had also over-drawn the Lantus into the syringe a bit a few times and pushed it back into the bottle, which I see the sticky post says don't do. I mentioned this to my vet and asked if this was a real issue to worry about...she didn't seem to think it was. Thoughts on this?
 
Eric Minor said:
The ER vet's instruction on the Lantus was to roll it gently. One of the sticky posts here said to *not* do that. Later on in that same post, it says that Lantus is not as fragile as previously thought and don't sweat it. What is the right answer?
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Yes, the advice has changed over the past few years - my vet told me the same thing. Actually, human diabetics will carry an insulin pen with them in case they need some while they are out and about and it does just fine. They don't even refrigerate it! But then, they use much larger doses so they don't need it to last as long. The more gently it's handled, the longer it should last.

We rolled it between our hands to warm it a bit, because injecting something straight out of the refrigerator can be a bit painful.

Eric Minor said:
I had also over-drawn the Lantus into the syringe a bit a few times and pushed it back into the bottle, which I see the sticky post says don't do. I mentioned this to my vet and asked if this was a real issue to worry about...she didn't seem to think it was. Thoughts on this?
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I wouldn't do it again. You can contaminate the insulin. Just expel the extra into the sink. That said, we did it in the early days, too, before we knew better. Never caused an issue. In general, if the insulin is clear, not cloudy, and has no "floaties" in it, it's probably fine. Usually we tell people that they will be able to judge if the insulin is okay by how the cat responds, but you're early in the game with not enough data, so that probably won't work for you. As long as it looks okay, let's assume for now that it is.
 
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