05/13 Maverick AMPS 367 +2 356 +8 407 +10 402 PMPS 447 something is going on

Mathilda and Maverick

Mathilda and Maverick

Member Since 2020
We are in Maryland, USA.
I'm at a loss again with Maverick. He had relatively good number for a while and managed to stay away from ketones for about 3 months but now numbers are going out the roof again and ketones coming back on a regular. I haven't been posting here for many months because it gives me so much anxiety, and as he been regulated and we had a very good specialist I've felt comfortable with our situation. Well, the specialist moved, his food in the specific taste is nowhere to be found, his BG is increasing, ketones are coming back, and I am starting to loose hope. His RBC has gone down from 45 to 36 since December, and last time he got anemic it happened very fast. New specialist wants to do a new ultrasound, have me give 100mls SubQ fluids once a week for his kidneys, and put a libre on him to closely monitor his trends in hope to figure out the causes of the ketones. She had me stop the blood thinner meds, but keep the budensonide.

Good thing is that his weight is still stabile, I have always been able to fight off the ketones with SubQ fluids.

We think that Maverick gets ketones as a response to pancreas flares. I have had a suspicion that he may be allergic to chicken- that that his IBD may have been triggered by allergens. However, for over a year he's been doing good at Castor and Pullox Organix pate Turkey flavor, which contain chicken. A few weeks back, we had to change to the chicken flavor in the very same brand, so he is currently on both flavors, but will change full-time when we run out of the turkey as we can not find it to purchase anymore. The reason we are sticking with the brand is their relatively low carbs and phosphorus (as he also has kidney issues). Now, the last few weeks he has had elevated BG and I'm worrying it's due to the food, or if he has another infection of some kind I can't pinn point as the blood panels looks pretty good.

He gets Lantus 3U BID, is it time to increase? I'd worry with increasing as his numbers are all over the map and can drop very fast. The issue we have ran into before is that he'll start to bounce. Specialist suggested the libre to be able to monitor him better so we can increase insulin, but I'm hesitant as I know wearing the libre and a onesie will stress him out more, but I also can't check on him throughout the night anymore as I don't get any sleep as is with baby and toddler.

We have the ultrasound scheduled for Monday, but I'm considering postpone it. It's a drop off at 8AM when specialist will check him and then the ultrasound technician won't be there before 12AM- Maverick will be seen then or after potential emergencies. Obviously they want him to fast, but that makes me worried as he normally eats 3 snacks throughout the night. I don't want him to go into hypo at the hospital, and I don't want him not to eat now that the BG is so high and risk DKA.

Sorry for long post, just wanted to give some background info. Any suggestions, input, brainstorming, and help are welcome, I really don't know what to do. TIA!
 
Hello again. Here is the link to your last post here for continuity: https://felinediabetes.com/FDMB/thr...stalled-126-1h-later-what-should-i-do.243427/

Sorry, lots of question/comments first. First off, you look at HCT not RBC for anaemia. How long ago was his previous ultrasound and what is it for this time? Is there any carb difference between the the old and new food? I fed home made food with the EZComplete premix and turkey (and other proteins) for my CKD kitty. How low a phosphorus number are you looking for? I see a few other options under 250 mg, more if you are OK with combining with duck.

Why was he on chlopidogrel? That's usually for clotting or heart issues, and fluids can be counter indicated if those are present. I found that out the hard way. :(

OK, onto the blood sugar. First of all, you are holding doses too long, but I can't tell how low 3.0 units is taking him, so I don't know if the dose is too little, too much or just right. The last two nights you shot blue preshots (under 200) at night, then did no more testing. Yesterday AM he was probably breaking a bounce, which is why his PMPS was so much lower than AMPS. That can mean lower numbers the cycle following, which he must have done last night because he's bouncing today. The question is how low he went and should he get a reduction? Even if following SLGS, it's really strongly recommended to get a before bed test every night. Can you do that for a couple days/nights and then post back here for help?
 
Wendy&Neko said:
Hello again. Here is the link to your last post here for continuity: https://felinediabetes.com/FDMB/thr...stalled-126-1h-later-what-should-i-do.243427/

Sorry, lots of question/comments first. First off, you look at HCT not RBC for anaemia. How long ago was his previous ultrasound and what is it for this time? Is there any carb difference between the the old and new food? I fed home made food with the EZComplete premix and turkey (and other proteins) for my CKD kitty. How low a phosphorus number are you looking for? I see a few other options under 250 mg, more if you are OK with combining with duck.

Why was he on chlopidogrel? That's usually for clotting or heart issues, and fluids can be counter indicated if those are present. I found that out the hard way. :(

OK, onto the blood sugar. First of all, you are holding doses too long, but I can't tell how low 3.0 units is taking him, so I don't know if the dose is too little, too much or just right. The last two nights you shot blue preshots (under 200) at night, then did no more testing. Yesterday AM he was probably breaking a bounce, which is why his PMPS was so much lower than AMPS. That can mean lower numbers the cycle following, which he must have done last night because he's bouncing today. The question is how low he went and should he get a reduction? Even if following SLGS, it's really strongly recommended to get a before bed test every night. Can you do that for a couple days/nights and then post back here for help?
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Thank you for your response, Maverick is a complicated case so questions are necessary.
Yes, sorry, HTC. HTC is down about 9% since December. I'd have to look up exactly when his last ultrasound was but I'd say about a year ago. He's done 2 since diagnosed. I'ts for the same purpose this time as last time- to look for changes and trying to figure out the reason for recurrent ketones. Maverick's BG is not quite what one would expect to be for passing ketones. The explanation we can come up with at this point is that ketones is one of his reactions to pancreatitis flares. Yes, there is a slight difference in the foods- but to the better. New one is 4% carbs vs old one 5% carbs, new one is 182mg phosphorus/100kcals and old one 193. Is there any way you can link what you fed? I'm really looking at as low as I can get. Last year we had the scheduled app for putting him down but cancelled one hour before as he seemed to be doing clinically good- however his kidney values had shot out the roof just overnight- I was able to bring them back to normal with fluids and they haven't been elevated like that since. So I really worry about that to happen again.

So, as for the blood thinner, it was given to him because of suspected heart issues- he has not been to a cardiologist. However, seen on both ultrasounds and -ray is that one of his kidneys are much smaller than normal size and one is much bigger- and there are uneven surface. Shortly said, specialist, based on new studies, worried that that may be related to heart issues hence the blood thinner. I know that fluids may affect a bad heart negative, but there are no other pointers saying that Mav suffers bad heart and that part of the reason to why new specialist said it was ok to quit the meds- reason to why we haven't dare to quit it before is because he's been doing pretty good with his meds. Can you explain closer what you mean by counter indicated?

What do you mean by how long 3U are taking him? We shoot pretty late as that's whats working with our schedule so we can only test one hour or two before bed- and he's always higher then (obviously). If you look back at his numbers when I test mid cycle, his nadir is very late. He kind of increases and stay high and then drops just before PM shot. That I'm shooting so close to his nadir, may that have any impact on bouncing? What's worries me about yesterday though is that fluids normally impacts his BG, but it didn't seem to happen yesterday at all- I'll see if it does today.
 
Please test again in less than an hour from that 97. He's dropped fast today and I think this might be too high a dose. Testing mid cycle might show you that 3.0 units is taking him below 90, which means his dose is too high and needs to be reduced by 0.25 units. You next test will tell you if that's happening.

One of the things I fed was EZComplete premix - details here. It does have chicken livers in it, so might not work for you. Another product some use is Alnutrin, but I'm not sure of the ingredients so you might have to contact the website. Note that products with egg shell for calcium are less phosphorus than ones with bones.
Mathilda and Maverick said:
know that fluids may affect a bad heart negative, but there are no other pointers saying that Mav suffers bad heart and that part of the reason to why new specialist said it was ok to quit the meds- reason to why we haven't dare to quit it before is because he's been doing pretty good with his meds. Can you explain closer what you mean by counter indicated?
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My cat had CKD and it got to a late enough stage that fluids were started. She had had an echocardiogram 6 months before that by a cardiologist vet that didn't show anything. After a few weeks of fluids, she went into heart failure. She did recover from that episode but could never have fluids again. Many heart meds are hard on kidneys and treatments for kidneys can be hard on the heart.
 
One of my cats died because she had an undiagnosed heart condition and was receiving fluids for CKD. She should have not been receiving fluids - at least not in the amount/ frequency that she was. She died from fluid around her lungs and she couldn’t breathe. Her heart was not able to handle the sub-q fluids.
 
Do you have any labs that you can share on Maverick? A hematocrit of 9% is very concerning. That’s blood transfusion territory- so I am wondering if I am understanding you correctly? If he has kidney disease and is that severe severely anemic, it’s time to start a treatment called ESAs which is an injection to stimulate the bone marrow to produce more red cells. I have used these successfully in my own cats. I can link you to some information on them if you would like.
 
Wendy&Neko said:
Please test again in less than an hour from that 97. He's dropped fast today and I think this might be too high a dose. Testing mid cycle might show you that 3.0 units is taking him below 90, which means his dose is too high and needs to be reduced by 0.25 units. You next test will tell you if that's happening.

One of the things I fed was EZComplete premix - details here. It does have chicken livers in it, so might not work for you. Another product some use is Alnutrin, but I'm not sure of the ingredients so you might have to contact the website. Note that products with egg shell for calcium are less phosphorus than ones with bones.

My cat had CKD and it got to a late enough stage that fluids were started. She had had an echocardiogram 6 months before that by a cardiologist vet that didn't show anything. After a few weeks of fluids, she went into heart failure. She did recover from that episode but could never have fluids again. Many heart meds are hard on kidneys and treatments for kidneys can be hard on the heart.
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So the reason to the quick drop today, I believe is the fluids he got yesterday- it normally impacts his BG the day of and the net day. Today, thus far he was AMPS 209 +3 97 +5.75 89 +7.75 101 and he has eaten all his snacks. These number are as you can see in the spread sheet, very uncommon- he's normally much higher at these times, even when its not due to a clear bounce.

Thank you for the feed suggestions! I'll look into that. I wonder how egg shells would work if he now are sensitive to chicken.

How often did you do fluid treatment? We will be starting 100mls once a week, and have before done it on a as needed basis and he seems to have been handling it well. When we had the kidney scare we did 8 constructive days of fluids and then every other day for 1 week and he did not seem to have any issues with it. Do you know if blood thinner is hard on the kidneys? It's definitely a game of prioritizing when picking what to treat and how.
 
Blood thinner is fine on the kidneys, but things like Lasix are not.

If you are following SLGS, that 89 earned a 0.25 unit reduction in dose. He also went below on 4/29.
 
Suzanne & Darcy said:
Do you have any labs that you can share on Maverick? A hematocrit of 9% is very concerning. That’s blood transfusion territory- so I am wondering if I am understanding you correctly? If he has kidney disease and is that severe severely anemic, it’s time to start a treatment called ESAs which is an injection to stimulate the bone marrow to produce more red cells. I have used these successfully in my own cats. I can link you to some information on them if you would like.
Click to expand...
Oh gosh no! He was down 9% hes been at 21 before and that was scary, 9 he'd probably be gone. Sorry I wasn't clear. His HTC has been steady at 45% the past year or so- last was December 10. However, on April 25 he was at 36.6% and it concerns me as he dropped very quickly last time he was anemic. here are some of the number from the latest panel:
CBC--Hct 36.6%, WBC 7.6K, PLT 296K
CHEM 315mg/dL, creat 1.8mg/dL, phosph 3.5mg/dL, CL 103mmol/L, AG 36mmol/L, alb 3.9g/dL, CK55 U/L, Tbili 0.1mg/dL
Anyhow, Id love if you can link that info so I can read up on it just in case. Thank you!
 
Suzanne & Darcy said:
One of my cats died because she had an undiagnosed heart condition and was receiving fluids for CKD. She should have not been receiving fluids - at least not in the amount/ frequency that she was. She died from fluid around her lungs and she couldn’t breathe. Her heart was not able to handle the sub-q fluids.
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Would you mind sharing what amount and frequency she received? I'm so sorry to hear that! What a terrible situation! I'll consider getting a cardiologist to see him if I need to do fluids on the regular.
 
Wendy&Neko said:
Blood thinner is fine on the kidneys, but things like Lasix are not.

If you are following SLGS, that 89 earned a 0.25 unit reduction in dose. He also went below on 4/29.
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Ok, yes he did- but also then we had just given fluids and he had present ketones. This brings me to another question- how do I handle reduction when ketones are present. At the green number the 29th he had small ketones present, which normally flushes out with the fluids he get previous that day. Due to his PMPS I had to reduce the dose and next day he came down with large ketones. And just a couple of days before he was in the 500s. I just feel very hesitant to reduce the dose when he the past month or so, been overall higher in BG than before- it really scares me with everything thats going on with him.
 
My Neko, who was about 14.5 lbs went into heart failure at 50ml every other day.

Ideally you wouldn't reduce if ketones are above trace. The way to do that safely is to test more often to make sure he's not actually going into hypo range in those cycles when you aren't testing. Is it possible to get "before bed" test each night? Did you get any more tests in today?
 
Wendy&Neko said:
My Neko, who was about 14.5 lbs went into heart failure at 50ml every other day.

Ideally you wouldn't reduce if ketones are above trace. The way to do that safely is to test more often to make sure he's not actually going into hypo range in those cycles when you aren't testing. Is it possible to get "before bed" test each night? Did you get any more tests in today?
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Today this far: AMPS 209, +3 97, +5.75 89, +7.75 101, +9.25 123. But like I said, these numbers are out of the ordinary low and impacted by the fluids and thats why I am concerned about reducing his daily dose. Especially since he's been passing ketones so often lately. We are giving him feed and insulin pretty close to bedtime so thats the reason for reducing the dose at night when he's not at a safe number to not be constantly monitored throughout the night as it's not working with our family/work life. Also, I've noticed that not reducing the dose at the low pre shot number brings him, no doubt into bouncing- it does not take very low numbers for Maverick to bounce. So this is one of the reasons the specialist is suggesting a libre, but based on the experience we have with the libre, I worry that'll put more stress on him than helping out.
 
Mathilda and Maverick said:
But like I said, these numbers are out of the ordinary low and impacted by the fluids
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I don't see enough data to make that claim. The data is not dissimilar from March when you weren't giving fluids. Any chance of moving shot time up a couple hours so you can at least get a +2 before bed?
 
Wendy&Neko said:
I don't see enough data to make that claim. The data is not dissimilar from March when you weren't giving fluids. Any chance of moving shot time up a couple hours so you can at least get a +2 before bed?
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Unfortunately, I can’t move his shot time but I am able to do +2 as I have been. So tonight PMPS he’s 119 and I’m planning on 2U as he gone up quite quick the past hour and I don’t want to give too much to risk bouncing. And then based on how the night goes I may decrease to 2.75u. What do you think about that?
 
Mathilda and Maverick said:
So tonight PMPS he’s 119 and I’m planning on 2U as he gone up quite quick the past hour and I don’t want to give too much to risk bouncing.
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That's not what causes bouncing. Bouncing is caused by going lower than he's used to, or quick drops. If he's not used to the greens you saw today, I expect he'll bounce tonight.
 
Wendy&Neko said:
That's not what causes bouncing. Bouncing is caused by going lower than he's used to, or quick drops. If he's not used to the greens you saw today, I expect he'll bounce tonight.
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I’m aware of that. Sorry I expressed myself clumsy. Let me put it this way. If he’s not already on to a bounce, he’ll most definitely do if I give too much insulin while he is lower than normal (because than he may go even lower and the body will kick in the reaction- yes I’ve seen that), however if I give too little while he is lower/have been lower than normal and he’ll bounce, he’ll risk passing ketones (yes, I know ketones normally do not happen over short time with high BG, and def not with just a couple of hours with medium- high numbers- but it does for my cat, and that’s part of what specialist can’t explain other than being related to a pancreatitis flare). What are your suggestion to do on a night like yesterday after a day of low numbers like it was to prevent both bouncing and ketones- except from reducing insulin ahead and monitor close overnight. My question is what dose to give at that point. It’s a pickle. If you don’t know that’s fine too, just trying to find ways to cause the least damage once he is already in the bouncing spiral.
 
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