GA New Member— Kitty Hospitalized

[Brianne]

Hi, everyone. This is about my sweet baby, Howie. Anyone that has been in this situation (hospitalized for ketosis), I would love to hear your stories. We are very worried and emotionally a wreck.

He is currently hospitalized with ketosis (pH normal but +3 ketones), severe electrolyte imbalances, a high liver enzyme (ALT 900, bili 7.6) and inflamed abdominal organs on ultrasound.

Howie was limp when we took him in Christmas morning. He can now lift his head up but is still not eating. Waiting on today’s update..

The vets say he is very “Atypical” and are wondering what exactly caused this. They say he can have “regular diabetes with abnormal presentation” or something else that caused the diabetes (autoimmune, cancer, etc..). Liver and kidney aspirate negative for cancer cells (thankfully). Taking this all minute by minute...

In November the vet said he was “possible diabetes” so we switched him to tiki cat wet food, as it is little to no carb. His liver enzymes were also high & reticulocytes up. He didn’t tolerate vetsulin at that time, went hypoglycemic. After a penicillin antibiotic, he improved for a week and then all of a sudden he stopped eating again. Now he’s in the hospital on an insulin drip, IV Antibiotics, and fluids with added calcium, potassium, magnesium, and phosphorus.

Today the vet is placing an NG tube for feedings & said she thinks it’ll make a significant difference for his liver. He is having a “positive response” to diabetic and electrolyte treatment thus far. We’re hopeful.

 

[Critter Mom]

Hi Brianne,

I'm very sorry to hear that Howie is in hospital for DKA plus organ complications at the moment, but he's where he needs to be in order to get better. (And, please God, he will.) I'm glad to hear he's responding positively to the insulin and electrolyte therapy.

DKA is rough going and kitties can feel incredibly poorly while it's in progress but it is treatable and kitties can and do go on to make a full recovery. Here is some helpful information:

Ketones, DKA and Blood Ketone Meters

Because Howie's currently not eating properly, the NG tube will help get calories into him and that will be protective of the liver. (If a cat can't get enough food then there is a risk of hepatic lipidosis.) If further nutritional support is needed (hopefully it won't be), an e-tube is another potential avenue for treatment (the sound of them is worse than the practical reality of feeding with them).

Nausea is a big contributor to a DKA kitty not wanting to eat. Here's a very helpful resource for you to bookmark:

Nausea and Inappetence - Symptoms and Treatments

(Note: It's from a CKD site, but the symptoms and treatments are also pertinent for cats suffering from eating difficulties associated with DKA, pancreatitis, etc.)

Question:

1. Is Howie getting any anti-nausea meds?

It's important to also ensure that the kitty isn't constipated because that can affect appetite (for the obvious reasons), trigger vomiting, and contribute to lethargy. Anti-nausea meds don't tend to work for a cat that isn't pooping normally.

An appetite stimulant can also be helpful but they don't tend to work until any nausea, eating discomfort, and constipation issues are addressed (or their use can lead to development of food aversions).

Key to making a solid recovery is ensuring that:

1. any underlying condition is found and treated (infection/inflammation/other systemic stressor)
2. the kitty gets enough insulin and food to prevent ketone generation.
[ETA]
3. the kitty stays well hydrated so that any ketones which may develop are flushed out of the body quickly.

It sounds like your veterinary team are on top of item #1 (antibiotics, diagnostic tests).

Question:

2. Do you know whether they've also tested for pancreatitis (often a fellow traveller with feline diabetes).

If Howie were to test positive for pancreatitis then pain meds are also recommended and their use can help the cat to start eating better (in conjunction with other supportive treatments, especially anti-nausea meds). Here's another helpful resource:

IDEXX Feline Pancreatitis Guidelines

The vets say he is very “Atypical” and are wondering what exactly caused this. They say he can have “regular diabetes with abnormal presentation” or something else that caused the diabetes (autoimmune, cancer, etc..). Liver and kidney aspirate negative for cancer cells (thankfully).

In November the vet said he was “possible diabetes” so we switched him to tiki cat wet food, as it is little to no carb. His liver enzymes were also high & reticulocytes up. He didn’t tolerate vetsulin at that time, went hypoglycemic. After a penicillin antibiotic, he improved for a week and then all of a sudden he stopped eating again.

Further questions:

3. What blood glucose (BG) range was Howie running in at time of diagnosis?

4. What dose of Vetsulin was Howie on when he became hypoglycaemic?

5. What was the highest BG that Howie was running in when he was on Vetsulin (i.e. how high was the BG at preshot before he went hypo after the insulin injection)?

6. Was Howie receiving any insulin in the days before he stopped eating, or had you suspended insulin treatment after the hypo event?

7. Are you home testing Howie's BG? Do you know what BG range he was running in before he stopped eating and started generating ketones?

8. Has Howie been underweight since developing diabetes? Is he currently underweight?


Mogs
.

 

[Critter Mom]

(((Howie)))



.

 

[Brianne]

Mogs,

thank you so much for responding!! I will work through all the educational material you sent. In the meantime, here are the answers to your questions.


Question:

1. Is Howie getting any anti-nausea meds?

They said he is getting “gastric protective meds and anti-nausea and appetite stimulant”

2. Do you know whether they've also tested for pancreatitis (often a fellow traveller with feline diabetes)

He was negative for Pancreatitis a few weeks ago. I do not believe they tested him this visit.


Further questions:

3. What blood glucose (BG) range was Howie running in at time of diagnosis?

He was 402 at time of admission.

4. What dose of Vetsulin was Howie on when he became hypoglycaemic?

He received 3 units

5. What was the highest BG that Howie was running in when he was on Vetsulin (i.e. how high was the BG at preshot before he went hypo after the insulin injection)?

He was 350ish preshot and dropped to 60

6. Was Howie receiving any insulin in the days before he stopped eating, or had you suspended insulin treatment after the hypo event?

He never had insulin at home. Just the one trial at the vet and then none after. I switched him to tikicat wet food, 1.5 weeks later He went to internal med, his Fructosamine was normal and she said no diabetes. Two weeks later it was slightly elevated. Two weeks later he got a freestyle libre

7. Are you home testing Howie's BG? Do you know what BG range he was running in before he stopped eating and generating ketones?

He was between 300-486 (mostly 300-360) on freestyle Libre for 2 days prior to ketosis

8. Has Howie been underweight since developing diabetes? Is he currently underweight?

He lost three pounds from July to November then another 1.5lbs November to December. Unsure of his current weight, on the 22nd he was 11.5lbs. His regular vet said 13-14lbs would be appropriate for him (he’s a big cat).


.[/QUOTE]

 

[Brianne]

Here is his internal medicine report from 12/21.Howie was acting himself for the entire week before this visit. That morning his appetite decreased, but all his labs looked better. On 12/23 they Places a freestyle Libre at my request because he was urinating more and drinking more/eating less.
I also posted his admission labs on 12/26 7AM and then yesterday’s labs (12/27, 2pm)

 

[Critter Mom]

Brilliant, Brianne. It'll take me a little while to peruse the above. Will get back to you when I've done so.

Great picture of the two of you in your avatar, BTW. Howie's a real cutie!


Mogs
.

 

[Critter Mom]

Hi Brianne,

There follows some comments on things that have caught my attention (not in any particular order).

First up, 3IU was too high a starting dose for Vetsulin (aka Caninsulin, depending on which country one is in). The maximum starting dose according to the most recent manufacturer's guidelines is 2IU per cat.

If the preshot BG that day was around 350, then the maximum dose that should have been given was probably 1IU.

I think perhaps the vet should have revisited the dose, not discontinued insulin treatment completely (or, better again, revisited the dose and gone for a gentler-acting, more cat-appropriate insulin like Lantus, Levemir or Prozinc). Reasons why I think this, plus other things to consider:

1. At time of Dx Howie was running in diabetic numbers in a range warranting initiation of insulin treatment. (I am assuming here that they performed a fructosamine test as part of the diagnostic work-up prior to giving that Vetsulin dose.)

2. It was noted that Howie's breath had been fruity-smelling on and off for some time. This is one of the clinical signs that may be observed when a cat is generating ketones. Also, in one test they registered trace ketones in the urine. (Note: While trace ketones isn't an emergency in and of itself, given the other clinical signs and Howie's history, I think this test result should have carried more weight.)

3. There was some suspected underlying disease process - kidney/liver/other (hence antibiotic treatment).

4. Although his fructosamine test was normal at that time, glucose was elevated in the blood work. (Note: This is a tricky area because BG can become temporarily elevated due to vet/travel stress, but the possibility that numbers might be starting to trend upwards should have attracted some bit of weight given the other factors in play at the time).

5. Howie's appetite was variable.

6. After a cat has been shown to be hyperglycaemic for a protracted period (i.e. is diabetic) then a normal fructosamine test result after a reduction in the dietary carb load does not automatically imply the cat is not diabetic (see below).

7. Re-emergence of polyuria/polydipsia.

8. Howie had lost significant weight and was underweight at presentation. (According to this article, underweight body condition is common in cats presenting with DKA so it's not unreasonable to consider it a potential risk factor.)

9. Presence of dental disease was observed.

10. Ketones can build up to significant levels in a very short time (hours). If there's evidence a cat is ketone-prone then there's even more reason to recommend monitoring ketone status at home.

The trifecta of factors leading to development of ketosis/DKA is:

Not enough food + not enough insulin + infection/inflammation/other systemic stressor.
​

It's not clear from the information you've posted whether the vets gave you any recommendation to monitor Howie for ketones at home. IMO there were enough red flags flying for them to do so: history of hyperglycaemia, evidence of ketone generation, no insulin being given, underweight, underlying conditions, variable appetite, re-emergence of clinical signs of diabetes. (We recommend ketone monitoring here by default with newly diagnosed cats as a general safety precaution, especially when insulin support has been suspended/withdrawn for any reason.)

General note: While the majority of cats who present with ketosis/DKA are running in high BG numbers at that time, FDMB has had reports of cats in lower BG numbers who have developed ketone-related complications.

I switched him to tikicat wet food, 1.5 weeks later He went to internal med, his Fructosamine was normal and she said no diabetes.

The switch to a low carb food - and possibly resolution of the suspected infection - may have been enough to drop Howie's BG back into the normal range so that the average BG for that period gave a fructosamine result in the normal range. However, one cannot automatically infer from a normal fructosamine result that a cat is no longer diabetic. For some lucky cats, the diet change alone is sufficient to send them quickly into remission, i.e. they become diet-controlled diabetics, they do not cease to be diabetic. A diet-controlled feline diabetic would have fructosamine results in the normal range.

Diabetics are more vulnerable to infection and inflammation. If they do occur they can drive BG levels upwards (and can knock cats out of remission).

He was negative for Pancreatitis a few weeks ago. I do not believe they tested him this visit.

Given that the ultrasound showed inflammation of the abdominal organs, I'd suggest asking the vet whether it would be helpful to run another test for pancreatitis, reason being that if the pancreas were inflamed then giving pain relief (buprenorphine) might help Howie with his eating. (I was advised by an internal medicine specialist at one time that effective pain management may also help speed up resolution of a pancreatitis flare.)

On the other issues, I'm going to tag @Marje and Gracie to ask her to have a look at the labs for you.

I'll try to post again tomorrow with some tips about what things to get in place to support convalescence at home. (I'm in the UK and it's after 3am here so I need to try to get some sleep.) Having the right supportive meds available plus a strategy for feeding, insulin administration and BG/ketone monitoring helps greatly with the recovery process.

Rooting for your boy. (((Howie)))


Mogs
.

 

[Bron and Sheba (GA)]

Hi Brianne and Howie and welcome to FDMB.
Im so sorry Howie is in hospital and I’m hoping he gets better very soon..but it’s the best place for him with DKA.
Having had an NG tube put in will make it much easier for you to ensure he is getting enough food once he gets home.

Cats recovering from DKA need 1 1/2 times as many calories per day as they would normally get, so having the NG tube in will make it much easier to achieve. The vets may give you some suitable food to use with the NG tube such as Hills a/d

Use this time while he is in hospital to get his spreadsheet and your signature set up so it will be up and running by the time he gets home. If you have any trouble setting up the SS @Bandit's Mom will be able to help you I’m sure.
Here is a link which has link to the SS and signature
https://www.felinediabetes.com/FDMB/threads/new-how-you-can-help-us-help-you.216696/

Also make sure you have plenty of Ketostix for his return as well as you will be needing to check the urine for ketones twice a day initially. Some people like to buy a ketones meter instead if collecting a urine specimen is difficult.

I would also get a collection of suitable canned foods for when he starts to eat again. As well as low carb, get in some medium and high carb food as well.

I would ask the vets to give you some cerenia tablets and a script for ondansetron tablets as you may need them as well for nausea and it is far easier to have them on hand than to chase the vet up later for them.

It will be really important you don’t skip any insulin shots so make sure you have plenty of testing equipment, maintain the SS by putting in all the BGs you get and posting each day so we can help you get Howie back to his old self! If the preshot BGis lower than normal, stall, don’t feed and test again 20 minutes later and post and ask for help.

I’m sure all this sounds a lot but we are here to help you each step of the way. Ask as many questions as you like as we all know it’s a steep learning curve and stressful in the beginning.
Bron

 

[JanetNJ]

I'm so sorry you're going through this. I'll say a prayer for your cat. If he survives this, consider a different vet. This one overdosed your cat. 3 units is a crazy high starting dose. You're supposed to start at 1 unit. And ask for lantus or ProZinc insulin. They aren't as hard acting. While some cats do fine on vetsulin, for some it is too harsh or they don't get long enough duration. It's really more of a dog insulin.


Also looking at the Bloodwork, your cat is anemic! I hope they are doing something to adress that. Anemia can cause fatigue and inappetence. Wow really low potassium. I'm not experienced in that, but that can cause trouble walking and stuff.

Did they give him a feeding tube?

 

[Critter Mom]

Hi Brianne,

How is Howie doing today?

(((Howie)))


Mogs
.

 

[Critter Mom]

Helpful information on anaemia (again from Tanya's Site, but it is a good primer and covers non-CKD causes of anaemia as well).

All About Anaemia


Mogs
.

 

[Brianne]

Mogs,

I agree 100% with everything you have said. This is why I’m so so upset about his current state— he did NOT have to get to this point if proper care was given.

I pushed for insulin from the vets everytime I talked to them. I’m an RN and see DKA in humans all the time, so I kept saying to my boyfriend and mom “it’s not right, he can’t walk around with high glucose, he’s going to go into DKA”. But I trusted the vets since they’re vets and I’m not. And here we are

I’m also very upset the ER sent him home on Christmas— his potassium was 2.9, which isn’t critical but is low. My poor boy couldn’t walk at him without looking like he was drunk. The ER vet said “he’s walking here”, but he always does better in the vets than at home. He’s a cat, cats try to hide their illness from strangers. I’m just so so upset. By 4AM I took him back and his potassium was 0.7 (normal Is 3.5).

With his previous history of liver issues, I can’t understand why they didn’t do NG feeds day 1-2 instead of day 3 of hospitalization. Now his bili and ALT are sky high.

I’ll ask about pancreatitis today when the MD calls me. Thank you so much for your advice. I’ll read through the rest later— I’m at work now

Hi Brianne,

There follows some comments on things that have caught my attention (not in any particular order).

First up, 3IU was too high a starting dose for Vetsulin (aka Caninsulin, depending on which country one is in). The maximum starting dose according to the most recent manufacturer's guidelines is 2IU per cat.

If the preshot BG that day was around 350, then the maximum dose that should have been given was probably 1IU.

I think perhaps the vet should have revisited the dose, not discontinued insulin treatment completely (or, better again, revisited the dose and gone for a gentler-acting, more cat-appropriate insulin like Lantus, Levemir or Prozinc). Reasons why I think this, plus other things to consider:

1. At time of Dx Howie was running in diabetic numbers in a range warranting initiation of insulin treatment. (I am assuming here that they performed a fructosamine test as part of the diagnostic work-up prior to giving that Vetsulin dose.)

2. It was noted that Howie's breath had been fruity-smelling on and off for some time. This is one of the clinical signs that may be observed when a cat is generating ketones. Also, in one test they registered trace ketones in the urine. (Note: While trace ketones isn't an emergency in and of itself, given the other clinical signs and Howie's history, I think this test result should have carried more weight.)

3. There was some suspected underlying disease process - kidney/liver/other (hence antibiotic treatment).

4. Although his fructosamine test was normal at that time, glucose was elevated in the blood work. (Note: This is a tricky area because BG can become temporarily elevated due to vet/travel stress, but the possibility that numbers might be starting to trend upwards should have attracted some bit of weight given the other factors in play at the time).

5. Howie's appetite was variable.

6. After a cat has been shown to be hyperglycaemic for a protracted period (i.e. is diabetic) then a normal fructosamine test result after a reduction in the dietary carb load does not automatically imply the cat is not diabetic (see below).

7. Re-emergence of polyuria/polydipsia.

8. Howie had lost significant weight and was underweight at presentation. (According to this article, underweight body condition is common in cats presenting with DKA so it's not unreasonable to consider it a potential risk factor.)

9. Presence of dental disease was observed.

10. Ketones can build up to significant levels in a very short time (hours). If there's evidence a cat is ketone-prone then there's even more reason to recommend monitoring ketone status at home.

The trifecta of factors leading to development of ketosis/DKA is:

Not enough food + not enough insulin + infection/inflammation/other systemic stressor.
​

It's not clear from the information you've posted whether the vets gave you any recommendation to monitor Howie for ketones at home. IMO there were enough red flags flying for them to do so: history of hyperglycaemia, evidence of ketone generation, no insulin being given, underweight, underlying conditions, variable appetite, re-emergence of clinical signs of diabetes. (We recommend ketone monitoring here by default with newly diagnosed cats as a general safety precaution, especially when insulin support has been suspended/withdrawn for any reason.)

General note: While the majority of cats who present with ketosis/DKA are running in high BG numbers at that time, FDMB has had reports of cats in lower BG numbers who have developed ketone-related complications.



The switch to a low carb food - and possibly resolution of the suspected infection - may have been enough to drop Howie's BG back into the normal range so that the average BG for that period gave a fructosamine result in the normal range. However, one cannot automatically infer from a normal fructosamine result that a cat is no longer diabetic. For some lucky cats, the diet change alone is sufficient to send them quickly into remission, i.e. they become diet-controlled diabetics, they do not cease to be diabetic. A diet-controlled feline diabetic would have fructosamine results in the normal range.

Diabetics are more vulnerable to infection and inflammation. If they do occur they can drive BG levels upwards (and can knock cats out of remission).


Given that the ultrasound showed inflammation of the abdominal organs, I'd suggest asking the vet whether it would be helpful to run another test for pancreatitis, reason being that if the pancreas were inflamed then giving pain relief (buprenorphine) might help Howie with his eating. (I was advised by an internal medicine specialist at one time that effective pain management may also help speed up resolution of a pancreatitis flare.)

On the other issues, I'm going to tag @Marje and Gracie to ask her to have a look at the labs for you.

I'll try to post again tomorrow with some tips about what things to get in place to support convalescence at home. (I'm in the UK and it's after 3am here so I need to try to get some sleep.) Having the right supportive meds available plus a strategy for feeding, insulin administration and BG/ketone monitoring helps greatly with the recovery process.

Rooting for your boy. (((Howie)))


Mogs
.

 

[Brianne]

No update on Howie yet.. the ICU Vet typically calls early afternoon. But no news is good news, they only call with bad news (aside from update). If I call to check on him I only get “he’s sitting up” or “the doctor will call you later”

 

[Critter Mom]

Covid restrictions don't help matters either. Fingers 'n' paws crossed for a good update later.

(((Howie)))


Mogs
.

 

[Tracey&Jones (GA)]

No advice but lots of support.

 

[Brianne]

Wow. I didn’t know 3U was too high for him. I will be sure to ask about this.

He got an NG tube for feeds yesterday evening.

I brought up the anemia to the ICU vet yesterday, who said she will look into it more appropriately.

I am very concerned about his care, as there have been so many “why aren’t you doing this?” From me... very worried

I'm so sorry you're going through this. I'll say a prayer for your cat. If he survives this, consider a different vet. This one overdosed your cat. 3 units is a crazy high starting dose. You're supposed to start at 1 unit. And ask for lantus or ProZinc insulin. They aren't as hard acting. While some cats do fine on vetsulin, for some it is too harsh or they don't get long enough duration. It's really more of a dog insulin.


Also looking at the Bloodwork, your cat is anemic! I hope they are doing something to adress that. Anemia can cause fatigue and inappetence. Wow really low potassium. I'm not experienced in that, but that can cause trouble walking and stuff.

Did they give him a feeding tube?

 

[Brianne]

Thank you thank you thank you!

I will work on the spreadsheet on lunch and after work.

I am so grateful I joined this board.

Hi Brianne and Howie and welcome to FDMB.
Im so sorry Howie is in hospital and I’m hoping he gets better very soon..but it’s the best place for him with DKA.
Having had an NG tube put in will make it much easier for you to ensure he is getting enough food once he gets home.

Cats recovering from DKA need 1 1/2 times as many calories per day as they would normally get, so having the NG tube in will make it much easier to achieve. The vets may give you some suitable food to use with the NG tube such as Hills a/d

Use this time while he is in hospital to get his spreadsheet and your signature set up so it will be up and running by the time he gets home. If you have any trouble setting up the SS @Bandit's Mom will be able to help you I’m sure.
Here is a link which has link to the SS and signature
https://www.felinediabetes.com/FDMB/threads/new-how-you-can-help-us-help-you.216696/

Also make sure you have plenty of Ketostix for his return as well as you will be needing to check the urine for ketones twice a day initially. Some people like to buy a ketones meter instead if collecting a urine specimen is difficult.

I would also get a collection of suitable canned foods for when he starts to eat again. As well as low carb, get in some medium and high carb food as well.

I would ask the vets to give you some cerenia tablets and a script for ondansetron tablets as you may need them as well for nausea and it is far easier to have them on hand than to chase the vet up later for them.

It will be really important you don’t skip any insulin shots so make sure you have plenty of testing equipment, maintain the SS by putting in all the BGs you get and posting each day so we can help you get Howie back to his old self! If the preshot BGis lower than normal, stall, don’t feed and test again 20 minutes later and post and ask for help.

I’m sure all this sounds a lot but we are here to help you each step of the way. Ask as many questions as you like as we all know it’s a steep learning curve and stressful in the beginning.
Bron

 

[Critter Mom]

Wow. I didn’t know 3U was too high for him. I will be sure to ask about this.

You mentioned earlier in the thread that Howie's a big cat. By way of general info, in a previous iteration of MSD's Caninsulin/Vetsulin guidelines (in use in 2014, possibly later) they used to recommend basing starting dose on both weight and level of hyperglycaemia at time of Dx. That said, even in the old guidelines the maximum recommended dose was 2IU.

I brought up the anemia to the ICU vet yesterday, who said she will look into it more appropriately.

My civvie, Lúnasa, has IRIS stage III kidney insufficiency and she became anaemic earlier this year so I had to gen up on it a bit. Here are a couple of headline points I found helpful:

* Anaemia is a symptom of something else going on. If the cause can be identified and treated then blood values should improve if the anaemia's regenerative. (Not including ways of countering erithropoietin deficiency here: it's fairly CKD-specific.)

* There are different types of anaemia. The type needs to be identified and other intercurrent conditions taken into account in order to determine the appropriate treatment. In particular, if an infection is present then iron supplements are contraindicated until the infection has been cleared up. (Bacteria apparently thrive on the stuff, hence the body's ability to sequester iron in cells to counteract infections, which may sometimes give rise to anaemia.)

There's oodles of information at the Tanya's Site anaemia link I posted above.

I am very concerned about his care, as there have been so many “why aren’t you doing this?” From me... very worried

Here's a link to a WSAVA article on the management of feline DKA. There might be some helpful pointers therein on the possible range of treatments you might expect Howie to be receiving.


Mogs
.

 

[JanetNJ]

I will work on the spreadsheet on lunch and after work.

I am so grateful I joined this board.

I know it's super overwhelming. We are here for you and sincerely hope for the best outcome. Once he's on his feet (paws crossed) we can help with dosing and such. I hope he shows good improvement today.

 

[JanetNJ]

He got an NG tube for feeds yesterday evening.

I brought up the anemia to the ICU vet yesterday, who said she will look into it more appropriately.

The feeding tube will ensure he gets the calories he needs. Hopefully he will eat normally soon.

I'm glad you mentioned the anemia... I know from personal experience with my own health issues that anemia can knock you on your butt. I was dosing off at work and at red lights.

 

[Brianne]

**UPDATE**

The vet said Howie is lifting his head up and sitting today versus laying, he is also slightly more interactive.

His electrolytes are trending towards normal and the vet is very happy with their improvement.

Blood pressure is stable and he’s maintaining on his own, no pressers given.

His Bilirubin and Phosphorus will be Rechecked this evening. He is tolerating his NG feeds well, no concern for re-feeding syndrome at the moment.

They plan to take him off his insulin drip today and switch to short acting insulin, Vetsulin 1unit. I asked about Lantus and she said with his sensitivity to insulin, she would prefer short acting So it’s easier to correct hypoglycemia.

A CBC will be redrawn tomorrow, along with liver enzymes. She feels he needs a full 24-36 hours with feedings to show improvement in anemia. She feels the anemia could have been caused by his low phosphorus levels, and as they are correcting, so will the anemia.

His liver has been a concern for two months, along with a regenerative response in his RBC, multiple vets saying it’s suggestive of an autoimmune disorder. The current ICU vet feels it is best to start a low dose steroid in hospital where they can monitor him closely (as it can effect glucose levels). A disease called triaditis is her concern, as patients will show a positive response to antibiotics and then go back downhill (exactly like Howie did). We gave the “ok” to do the Low dose steroids while in hospital.


Thoughts?? Concerns?

 

[Javier and Leo]

Hi Brianne,

Our cat Leo recovered from Diabetic Ketoacidosis after an intense week of treatment at the pet hospital.

Stay strong, your cat will pull through!

Leo is at home now being taken care of for diabetes and fatty liver, but he's back to being himself for the most part.

 

[Javier and Leo]

Forgot to add this happened to Leo about two weeks ago, so it's very recent.

 

[Brianne]

Howie ate boiled chicken for his Daddy today!!! I didn’t get to visit him, as I’m working all day. But Josh went today and he said that all the vet techs were crying and cheering “HOWIE’S EATING! HE ONLY EATS FOR HIS DADDY!!!”. It’s very promising. And he is looking brighter today than he has been. My heart is so happy, I hope this continues

 

[Critter Mom]

Howie ate boiled chicken for his Daddy today!!!

WOOOOOOOOOT!!!!!!!!!!!!!!!!!!

Go Howie!!!!

More of this, please!


Mogs
.

 

[Nan & Amber (GA)]

Hooray for Howie!!!!!!!!!

 

[Critter Mom]

Hi Brianne,

I'm so glad you got such an encouraging update from the vet today, and absolutely delighted to hear that Howie wanted to eat something! (Feline feeding wars veteran speaking here.)

A disease called triaditis is her concern,

In which case this should surely automatically prompt her to run another Spec fPL to assess level of any pancreatic inflammation, and hence determine whether Howie needs pain relief - unless they're already giving bupe?

Triaditis Overview (pancreatitis, inflammatory bowel disease and cholangitis)

For info on inflammatory bowel disease, ibdkitties.net is a reputable site. The whole site's worth reading. Here's their page on steroids:

Introduction to Steroids (for IBD)

I'd suggest asking the vets about whether budesonide might be a suitable treatment option for Howie because it may have less of an impact on BG levels.

They plan to take him off his insulin drip today and switch to shirt acting insulin, Vetsulin 1unit. I asked about Lantus and she said with his sensitivity to insulin, she would prefer short acting So it’s easier to correct hypoglycemia.

Reasonable enough to want to use an in-out rather than a depot insulin at the moment. Aside from the daftness of poor Howie having his BG dropped like a rock by the too-high 3IU initial dose of Vetsulin, it's not a bad plan to use Vetsulin - at a sensible dose! - in the current context because, although it doesn't typically have the duration seen in depot insulins, it tends to be better at pulling down higher numbers than glargine or detemir.

The other plus going for using an in-out insulin in this context is that sometimes it can be tricky to administer insulin to underweight kitties because sometimes their BG levels can end up swinging quite wildly between too low and too high - even on a tiny, tiny dose - so if the dose were to need downward adjustment there's a little more agility of response when using an in-out cf. having to deal with a too-full depot.

If there were to be an issue of BG dropping into the hypoglycaemic range even on a tiny dose of insulin, feeding a higher carb food during the recovery period can help mitigate that (and it's what may be needed at home during post-DKA convalescence in order to support consistent dosing of sufficient insulin to keep ketones at bay, as Bron mentioned last night).


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[Diane Tyler's Mom GA]

Sending prayers your way that Howie continues to improve.
So happy to hear he ate for your husband.

What a previous looking boy Howie is.
Please keep us updated

 

[Bron and Sheba (GA)]

**UPDATE**
They plan to take him off his insulin drip today and switch to shirt acting insulin, Vetsulin 1unit. I asked about Lantus and she said with his sensitivity to insulin, she would prefer short acting So it’s easier to correct hypoglycemia.
Thoughts?? Concerns?

I think in the short term when Howie is recovering from DKA at home, vetsulin is a better choice than Lantus. This is because it takes from 5 to 7 days initially to fill the depot (Lantus is a depot insulin) and the full effects of the insulin are not felt until the depot is full. Once you are up and running with Lantus, each time you increase the dose it takes up to 3 day for the depot to fill.
Depot explanation..https://www.felinediabetes.com/FDMB/threads/what-is-the-insulin-depot.150/

When recovering from DKA the insulin dose is really important and as it will take a few days for the Lantus dose to reach its full effect, staying with vetsulin is a good idea as it is an in and out insulin and does not have a depot. Once Howie has recovered from the DKA and ketones are way in the rear vision mirror, I think it would be a good idea to swap to Lantus. But that is a conversation for a later date.

I am SO pleased he ate for his daddy! Progress!
And it does sound as if he is heading in the right direction!
Please keep us updated.

 

[Tracey&Jones (GA)]

Great update! Eating on his own is great news. I hope Howie continues to improve. Scritches for him.

These are for you.

 

[Brianne]

The vet just called and Howie took a turn for the worst. His liver enzyme ALT worsened and bilirubin is up: Blood pressure unstable and electrolytes not maintaining again.

Any advice is appreciated. They started the low dose steroid last night.

His glucose off insulin drip is 200s to low 300s. I asked to restart the drip, his glucose was 280s- low 300s when he went into ketosis.

PCV 20. So anemia worsening.

I’m so scared and worried..

 

[Critter Mom]

(((Brianne and Howie)))



I'm sorry Howie's taken a bit of a dip. Fingers and paws crossed he'll pick up again quickly.

I'm tagging @Sienne and Gabby (GA) to ask whether she can give you some more specific pointers based on her experience. (Gabby was hospitalised at time of her Dx with DKA, pancreatitis and liver problems.)

Can you tell us which steroid Howie's being treated with?

Sending prayers and positive vibes for both of you.

(((Howie)))

C'mon, little fella.


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[Brianne]

Thank you. The vets (all 7 of them) day this is so atypical and they do not have any answers for why this is happening.

They’re trying one last treatment for toxoplasmosis and getting him back on insulin drip. They say 12-24 hours is reasonable to hope for a turnaround. Otherwise they feel it’s not worth continuing treatment and making him suffer..

(((Brianne and Howie)))



I'm sorry Howie's taken a bit of a dip. Fingers and paws crossed he'll pick up again quickly.

I'm tagging @Sienne and Gabby (GA) to ask whether she can give you some more specific pointers based on her experience. (Gabby was hospitalised at time of her Dx with DKA, pancreatitis and liver problems.)

Can you tell us which steroid Howie's being treated with?

Sending prayers and positive vibes for both of you.

(((Howie)))

C'mon, little fella.


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[Nan & Amber (GA)]

I wish I could help, I hope Sienne and/or others will be able to look at those readings and have some suggestions. All I know is that kitties in DKA are often very, very, very sick.

The fact that he ate yesterday does make it sound like the key problem is not DKA (where they often feel too yucky to eat for a looooong time) but is something else (perhaps related to the anemia?) that was the trigger for the DKA and isn't yet being addressed. But I'm at a loss to even guess what it might be . I guess treating potential toxoplasmosis is a start? I don't know much about that.

All fingers and paws crossed for you and Howie...

 

[Brianne]

I’m unsure the steroid, I will ask when we go see him again this evening. They’re letting us break the rules and visit twice today.. when we saw him around 1, he was purring the whole time

(((Brianne and Howie)))



I'm sorry Howie's taken a bit of a dip. Fingers and paws crossed he'll pick up again quickly.

I'm tagging @Sienne and Gabby (GA) to ask whether she can give you some more specific pointers based on her experience. (Gabby was hospitalised at time of her Dx with DKA, pancreatitis and liver problems.)

Can you tell us which steroid Howie's being treated with?

Sending prayers and positive vibes for both of you.

(((Howie)))

C'mon, little fella.


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[Critter Mom]

I'm glad they're allowing you to visit him, Brianne. Maybe give him a few scritches from us too if you can.

(((Howie)))




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[Nan & Amber (GA)]

Will they let you leave something that smells familar (an old t-shirt, favorite towel for a bed)? Sometimes that helps them feel more relaxed when in the hospital. Every little bit helps...

 

[Sienne and Gabby (GA)]

I'm so sorry you're going through this. Your medical instincts are completely on target. Please push back with these vets!

What are they basing a dx of toxoplasmosis on?

Have Howie's electrolytes stabilizes or at lease trending to normal? Everything you know about DKA in humans pretty much applies to cats. Fluids, insulin, and calories are important. If there's an infection, antibiotics are needed. I didn't catch what the steroids are for. The obvious issue is that a steroid will drive up the BG numbers.

 

[JanetNJ]

The big drop in hct is concerning and makes me wonder if there's an internal bleed.

 

[Brianne]

They’re shootings in the dark for toxoplasmosis. His liver responded to Penicillin two weeks back. So the thought is it could be bacterial.

electrolytes yesterday stabilized but trending away again... not terribly though. BP stable now again after fluids.

the bilirubin is most concerning

I'm so sorry you're going through this. Your medical instincts are completely on target. Please push back with these vets!

What are they basing a dx of toxoplasmosis on?

Have Howie's electrolytes stabilizes or at lease trending to normal? Everything you know about DKA in humans pretty much applies to cats. Fluids, insulin, and calories are important. If there's an infection, antibiotics are needed. I didn't catch what the steroids are for. The obvious issue is that a steroid will drive up the BG numbers.

 

[Critter Mom]

I didn't catch what the steroids are for.

Suspicion of triaditis - so presumably for IBD?.


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[Bron and Sheba (GA)]

Brianne I am so sorry you and Howie are going through this at the moment.
I can’t help I’m sorry not I’m praying Howie will be OK.
DKA is can be a rough ride so hang in there.

 

[Critter Mom]

the bilirubin is most concerning

Have they said any more to you about the anaemia side of things, Brianne?


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[Diane Tyler's Mom GA]

I'm praying for your Howie ♥

 

[Brianne]

Have they said any more to you about the anaemia side of things, Brianne?


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Unfortunately not... just that it was happening. I’m out of questions to ask and things to think of. I feel like I hit my medical knowledge limit.. I’m trying but keep coming up with nothing

 

[Brianne]

Will they let you leave something that smells familar (an old t-shirt, favorite towel for a bed)? Sometimes that helps them feel more relaxed when in the hospital. Every little bit helps...

We have brought something everyday for him.. along with visiting. I wish we could be here 24/7

 

[Brianne]

Suspicion of triaditis - so presumably for IBD?.


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Yes, for possible autoimmune triaditis

 

[Critter Mom]

DISCLAIMER: The following is real shot-in-the-dark, brainstorming stuff from me. I don't have any experience upon which to base any concrete suggestions, and I don't know whether or not it would have any value for Howie.

At one point, Saoirse was referred to a feline IM specialist for liver abnormalities seen in an ultrasound carried out by our own vet. They offered the referral with a view to the specialist performing a fine needle aspiration to determine what might be the issue.

During the consult with the specialist they advised me that there was a risk of the aspiration procedure causing a bleed. Given that Saoirse's liver markers were fairly OK and her clinical signs didn't merit any significant concern about her liver function they considered that the risk was not worth taking and I followed the specialist's recommendation not to go ahead with the procedure (hence my inability to suggest anything to you).

It's not clear from your opening post, Brianne, when Howie had the fine needle aspirations of liver and kidneys done. I'm just chucking this information out there in case it might be in any way helpful to you.


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[Marje and Gracie]

She feels the anemia could have been caused by his low phosphorus levels, and as they are correcting, so will the anemia.

Do you know what his serum phosphorus level is because I did not see it on the labs or saw that the vets remarked on hypophosphatemia (<1.5 mg/dL). Are they treating that condition? Regenerative anemia is associated with hypophosphatemia in diabetic cats. Has he been anemic for a long time since you said several vets think it’s an autoimmune disease or do you mean several vets during this episode?

There are blood tests for toxoplasmosis so I’m not sure why they haven’t run them; the usual treatment for this condition is clindamycin. It just seems to me like this is such a shot in the dark like they threw up their hands and pulled something out of the air. My neighbor’s cat has toxoplasmosis and her symptoms are very, very different.

One thing that really worries me is his anemia and also their use of steroids. Has he had any stools or any “stool” that looks like tar? If he potentially has a GI bleed, he would have tarry “stool” even if he hadn’t eaten. I would question them at length about any potentially arbitrary use of steroids. I see many vets use them when they don’t know what’s wrong but steroids can have serious side effects including impacts to the heart rhythm and can also contribute to spontaneous intestinal perforations (this, in fact, is why I lost my kitty). My Gracie (dx with IBD/lymphoma) had very similar symptoms....elevated liver enzymes due to the IBD; her bilirubin was high...I knew this because her urine was very gold. She was treated with steroids while we were waiting to see the oncologist. She developed anemia due to internal bleeding and when I took her to the ER I told them she had a tarry stool and I was concerned about a GI bleed. They assured me they would monitor her, do an ultrasound, etc, but in less than 12 hours, she had a very serious intestinal perforation.

I’d ask:
What are his most recent liver values? Is he jaundiced? Be sure you get a copy of all labs immediately.
What is his P level and his HCT now? Are they treating the hypophosphatemia and is the HCT rising?
What autoimmune disease do they think the regenerative anemia is a result of (one vet said the hypophosphatemia is causing anemia, the others say it’s autoimmune).
Have they tested him for toxoplasmosis? Why are they giving him clavamox instead of clindamycin (Cornell states clindamycin and steroids if there is eye or CNS involvement).
Have they
When they say “inflamed internal organs on u/s, what did they see? How did his bile duct look...any chance of obstruction there
Did they actually diagnose DKA or just Ketosis?

Do you have any option to move him to a better clinic? I’m not sure where you are and if that is possible. Or if he can safely be moved.

I’m sending you many prayers for your sweet boy.

 

[Critter Mom]

From PubMed:

Hypophosphataemia and Haemolytic Anaemia associated with Diabetes Mellitus and Hepatic Lipidosis in Cats


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[Brianne]

Howie passed. We were with him. He’s no longer suffering. Thank you all for all your advice and kind words. It’s helped me through