6/22 Henrys back in the hospital already (3rd time)

[John & Henry]

I'm so frustrated and confused at this point...

Vet said bring him in this morning, after checking his blood their main concern was that his blood acid/base had already dropped to 7.1 (it should be between 7.351–7.463). Not as bad as before, but not good. They said since he seemed so sick and couldn't undergo anesthesia they weren't able to do any invasive studies to diagnose possible underling causes, and recommended he be hospitalized for 24 hours first. The vet said, "While I'm sure the Ketones he currently has aren't helping, I don't think that is the cause of his blood acidifying so quickly, we need to look for other conditions that can cause the blood to acidify" ... Maybe she realized giving that shot so late yesterday certainly didn't help matters at all!!! This study showed a cut-off value of 2.4 mmol/l revealed 100% sensitivity and 87% specificity to diagnose DKA. Granted the sample size wasn't huge, but it's saying that if blood ketones go over 2.4 there is an 87% chance of DKA! Last ketone check I did it was 1.9 and that was late last night/early this morning. I really wish I'd had checked it before I left, but at the rate it was increasing yesterday I'll almost guarantee it was at or over 2.4 when I left today. I'm going to look at other studies to see if this holds true, but if true, it's not unreasonable to think that ~24 hours of elevated ketones was responsible for that .25 pH decrease.

So on the DDX we got: possible liver problems, possible pancreas problems, possible GI problems, she just added possible kidney problems to the mix (explaining that bicarbonate can be released from the kidneys acidifying the blood, they're running urine tests now to see if that may be the case), possible brain tumor (acromegaly), I've probably missed a couple others because its hard to absorb all that during a conversation without writing it down... She also said that pH can leak from the intestines acidifying the blood too as a possible cause. So basically she has no idea! I really can't asses her level of prowess since I'm not a doctor or a vet. I keep trusting that her good Cornell & CSU pedigree means she knows what she's doing.

So after I got the call from her I called UC Davis and Cornell to see if I could pay to have one of their IM experts review his chart and get their opinion. Davis said they generally don't do that and IM is booked to October and they're not even accepting additional appointments right now. If I wanted him looked at by IM at davis I'd need to bring him to the ER. The ER at Cornell wasn't sure if they could do that, but asked me to leave a voicemail with scheduling and they'd call me back and let me know (it was after hours there apparently? not sure how since it was before 5pm on the eastcoast, but anyway..) The voicemail said it could be a couple days before they'd return your call anyway, so it didn't sound so promising. I looked online for places that do second opinions and most of them are ads for "Did your dog swallow chocolate? let our vet tell you if you should take him to the ER" .. I found one website that did have actual second opinions with specialists that would review records, but no mention of their education and it takes 3-5 days to get a response! perfect!

Am I wrong in thinking that she should have collogues or professors or classmates she want to school with she could talk to & get some ideas? I mean, I guess she's already got plenty of ideas, but maybe narrow them down a bit or something? idk I get it's a probably a hard job, and I can tell she's frustrated too and I'm sure animal medicine is miles away from human medicine, but @#$*!

My last thought is maybe try to go to Dove Lewis the big ER here in Portland. They have 2 IM specialists on staff which is one more than where I'm currently at. One of the IM's at dovelewis went to cornell vet school, but she looks quite young. But what if I go there and they can't give me any better answers? I figure where I'm at least they've promised a discount and still haven't even asked about me paying for the last hospitalization yet. What that discount even is, I have no idea. Would they try and charge me more if I switch to dove lewis?

So frustrated, so many decisions to make and what if I go through all this and he doesn't even end up making it? ffs. I think it's xanax:30

 

[Wendy&Neko]

Sorry to see Henry is hospitalized again. You can't seem to catch a break on the vets. I hope they really work at getting a diagnosis this time.

possible brain tumor (acromegaly),

Benign tumour of the pituitary gland, technically part of the brain. I have yet to see it cause ketones and unless you pony up for a CT scan or MRI, you wouldn't get blood work results on the test for it until probably a week Friday. However acro can cause cats to need higher doses of insulin and "not enough insulin" is one of the factors in the DKA formula. A cat go got to the 50's yesterday doesn't seem to be on too low a dose. Also in the DKA formula is inflammation or infection. That's the piece they have to figure out.

 

[Bron and Sheba (GA)]

John
I’m so sorry Henry is back in the ER.
With the study you mentioned about blood ketones we say here that 2.4 is of concern and the cat should be seen by a vet because DKA is possible/ probable at that point.
But a couple of cats here have shown higher blood ketones before it was a worry. That’s why I like the urine test.

In my opinion, the reason the ketones became elevated again was because of the skip of the dose yesterday so early after his discharge. His loss of appetite could have been because of the antibiotics or just because he’s had DKA. Most post DKA cats have nausea and loss of appetite.
If you are offered a feeding tube I would accept it. Sounds scary but they are a life saver and not hard to use. And not hard in the cat.
In my opinion he needs to be discharged when ready with adequate antinausea meds ( ondansetron), subQ fluids, some a/d recovery food, and make sure his electrolytes and acidity are completely back to normal before discharge.
I don’t think it is anything else causing the setback and would wait to do further investigations. But that’s just my opinion.
Thanks for the update.

 

[John & Henry]

However acro can cause cats to need higher doses of insulin and "not enough insulin" is one of the factors in the DKA formula. A cat go got to the 50's yesterday doesn't seem to be on too low a dose. Also in the DKA formula is inflammation or infection. That's the piece they have to figure out.

Well that kinda describes whats been happening. Shooting greens one day and a week later a high dose isn't bringing the numbers down at all, then yesterday! same thing. from 50 to 500 in less than 12 hours. Seems like infection should be covered with the broad spectrum antibiotics hes on, but inflammation? idk. Dove Lewis does have a CT, so maybe they'd be able to see inflammation?

 

[John & Henry]

His loss of appetite could have been because of the antibiotics or just because he’s had DKA

I suppose, but he was eating well until last night, and even last night he was still trying to eat and seemed hungry, just wasn't pounding food like he usually does. I hate the thought of force feeding him :,( He just seemed so sick last night, comparable to his last 2 DKAs right before I took him in, but his blood pH wasn't nearly as far out of whack as it was before the DKAs, why so sick all of the sudden? He wasn't that sick after he came home (although he did seem worse after he came home the 2nd time vs the 1st) but quickly went downhill this last time.

I don't think the vet will ever admit she messed up by not telling me to give that shot sooner, but if that's what caused all this?!

edit: If this is all due to the high BG yesterday, I don't see how this can possibly be controlled at home when the numbers are all over the place without being able to quickly adjust the BG with something like a fast acting insulin.

 

[Wendy&Neko]

Shooting greens one day and a week later a high dose isn't bringing the numbers down at all, then yesterday! same thing. from 50 to 500 in less than 12 hours.

Nope, that's just regular old bouncing. A cycle of numbers they aren't used to followed by a skyrocketing numbers for up to six cycles.

I agree with Bron. A recently DKA cat needs their insulin. No skipping. We joke you can feed them anything, even a hot fudge sundae (minus the chocolate of course), as long as you get the insulin in them.

What you described yesterday sounded like nausea. Ondansetron is really helpful for nausea. If the vet doesn't have a/d food, Royal Canin Recovery also works and is easy to syringe.

CT requires anaesthesia, not sure he'd be up to that at this point. There should be other ways (ultrasound for example) to see what's going on inside.

 

[John & Henry]

I've been reading a paper on the exact mechanisms that cause DKA, and even my technically inclined, information sponge of a mind is overwhelmed with the 50+ individual mechanisms and chemical processes occurring. Such a delicate balance occurring and any of those variables can throw the whole thing outta whack. I did find this part very interesting tho:

making the diagnosis is not as straightforward as the identification of ketones in the urine. When present, the diagnosis is confirmed, but, since not all urine ketones are detected by urine reagent strips, some ketoacidotic patients may be overlooked if the results of urine strips are the only basis for assessing the patient with possible DKA.​

 

[carfurby (GA)]

Sending prayers.

 

[Roxana & Henry]

So stressful. Praying for you both. Your poor Henry needs a break. He is lucky to have you taking such good care of him!

 

[Bron and Sheba (GA)]

making the diagnosis is not as straightforward as the identification of ketones in the urine. When present, the diagnosis is confirmed, but, since not all urine ketones are detected by urine reagent strips, some ketoacidotic patients may be overlooked if the results of urine strips are the only basis for assessing the patient with possible DKA.

There are other symptoms of DKA apart from ketones in the urine. Here is a list from our information on DKA. All these are red flags. So it’s not just ketones in the urine that needs to be looked at when assessing a sick cat.
Signs of Diabetic Ketoacidosis (DKA)

• Drinking excessive amounts of water OR no water
• Excessive urination
• Diminished activity
• Not eating for over 12 hours
• Vomiting
• Lethargy and depression
• Weakness
• Breathing very fast
• Dehydration
• Ketone odor on breath (smells like nail-polish remover or fruit)

You must be exhausted and stressed. We are all thinking of you and sending our very strongest vines to Henry for a full recovery.

 

[Liz & Minnie]

Honestly, if they offer the e-tube I would take it. My fear of it was so much worse than the reality. It's not "force" feeding, more like a straight shot to esophagus. and shocking how quickly it heals back up!

 

[Suzanne & Darcy]

John
I’m so sorry Henry is back in the ER.
With the study you mentioned about blood ketones we say here that 2.4 is of concern and the cat should be seen by a vet because DKA is possible/ probable at that point.
But a couple of cats here have shown higher blood ketones before it was a worry. That’s why I like the urine test.

In my opinion, the reason the ketones became elevated again was because of the skip of the dose yesterday so early after his discharge. His loss of appetite could have been because of the antibiotics or just because he’s had DKA. Most post DKA cats have nausea and loss of appetite.
If you are offered a feeding tube I would accept it. Sounds scary but they are a life saver and not hard to use. And not hard in the cat.
In my opinion he needs to be discharged when ready with adequate antinausea meds ( ondansetron), subQ fluids, some a/d recovery food, and make sure his electrolytes and acidity are completely back to normal before discharge.
I don’t think it is anything else causing the setback and would wait to do further investigations. But that’s just my opinion.
Thanks for the update.

I totally agree with this. I think you have hit the nail on the head. I would not go searching for additional exotic causes.

 

[Suzanne & Darcy]

Honestly, if they offer the e-tube I would take it. My fear of it was so much worse than the reality. It's not "force" feeding, more like a straight shot to esophagus. and shocking how quickly it heals back up!

Yes. The e-tube saved my cat’s life. It’s like a 15 minute procedure under anesthesia. If they get him stabilized, I would do it.

 

[Nathalie & Boris]

Hugs to you. When my cat was not eating, I found that freeze dried raw nuggets he would go crazy for and that was how I got him to start eating again. Prayers for you and Henry!

 

[John & Henry]

Just off the phone with the vet and she just kinda went over everything we had talked about previously in more detail. The kidney test they were waiting on wasn't off by much (so that's good), but she was sending urine off for additional tests. Surprisingly she said they were sending off for the fPLI/fTLI/folate test from Texas A&M as suggested by someone in an earlier thread to check for pancreatitis and EPI, I haven't been able to find the comment to see who suggested it, but thank you. I brought up the idea of using a fast acting insulin as an adjunct to the Lantus and surprising she wasn't against it or have any sort of condescending tone. She said she'd think about it. She seemed much nicer tonight with a pleasant tone. They're planning on doing the liver asperation tomorrow. They've given him fluids to try and flush the ketones and bring up the blood pH and they're giving fast acting insulin to try and get his BG under control (which she said was in the 400s). One thing that made me go "Hrmm?" was she said that some cats just have a lower blood pH, and since they didn't have a baseline on him before the first DKA it was possible his just ran a bit lower than normal. I can't adjudicate that statement since I really have no clue other than what I posted before that the "normal" range for feline blood pH is 7.351–7.463 That's everything I can think of for now. Thank you everyone for the support and suggestions

There are other symptoms of DKA apart from ketones in the urine. Here is a list from our information on DKA. All these are red flags. So it’s not just ketones in the urine that needs to be looked at when assessing a sick cat.
Signs of Diabetic Ketoacidosis (DKA)

• Drinking excessive amounts of water OR no water
• Excessive urination
• Diminished activity
• Not eating for over 12 hours
• Vomiting
• Lethargy and depression
• Weakness
• Breathing very fast
• Dehydration
• Ketone odor on breath (smells like nail-polish remover or fruit)

You must be exhausted and stressed. We are all thinking of you and sending our very strongest vines to Henry for a full recovery.

The last DKA (2nd one) He was drinking so much water (and urinating so much) days before he went to the ER that it should have alerted me something was wrong. diminished activity, vomiting, lethargy, weakness weren't apparent until he was in full blown crisis. Wish I could train my very smart and trainable shepherd (from a working dog line) to alert to ketones on his breath. I've noticed these these last two incidents she will repeatedly sniff and lick his face, which isn't a common thing for her to do at all. She was doing it a ton last night. She also has totally quit trying to play with him since well before his first DKA. It's amazing what animals know.

I've been getting very little sleep taking these last few days. Getting up ever couple hours for readings, then I never easily fall asleep anyway, so yeah, it's been tough. Thank you for the well wishes and support

Honestly, if they offer the e-tube I would take it. My fear of it was so much worse than the reality. It's not "force" feeding, more like a straight shot to esophagus.

I think the etube would be less bothersome to me then trying to use a syringe and make him eat. Not sure why the thought of it bothers me so much, but it does.

So stressful. Praying for you both. Your poor Henry needs a break. He is lucky to have you taking such good care of him!

Thank you Roxana. I hope your Henry is holding up well too.

Sending prayers.

Thank you

In my opinion he needs to be discharged when ready with adequate antinausea meds ( ondansetron), subQ fluids, some a/d recovery food, and make sure his electrolytes and acidity are completely back to normal before discharge.

Yes, I'll still ask about all those things. She said his potassium is slightly low, but still within normal range. She said his sodium was a little high and this can somehow contribute to something (I forget what)

 

[John & Henry]

Hugs to you. When my cat was not eating, I found that freeze dried raw nuggets he would go crazy for and that was how I got him to start eating again. Prayers for you and Henry!

Yes, I got some of these on the suggestions of @Roxana & Henry and he's kinda luke warm on him. He likes them and eats them, but I wouldn't describe it as crazy unfortunately. Thank you for the prayers

 

[Nathalie & Boris]

Hugs to you. When my cat was not eating, I found that freeze dried raw nuggets he would go crazy for and that was how I got him to start eating again. Prayers for you and Henry!

By the way at the time Boris had high ketones and was in the 600's. The vet would have hospitalized him if he had not started eating. I had tried several different foods. The dehydrated raw was the trick for him.

 

[Bron and Sheba (GA)]

Thank you John for the update. We always like to see them!
Sounds as if they are trying to get on top of things which is good. I’m glad they are doing a fPL.
And it’s good they are checking the urine again.
Has Henry ever had a blood test before, maybe the PH was taken and you can look back and see what it was.
Sending many more vines to Henry for a full recovery.

 

[Nathalie & Boris]

By the way at the time Boris had high ketones and was in the 600's. The vet would have hospitalized him if he had not started eating. I had tried several different foods. The dehydrated raw was the trick for him.

It could be cat specific, but even after feeding wet food, high quality at that for months, tonight when I pulled out the dehydrated raw out again, he left his wet food and wanted me to give him those freeze dried cubes instead. I made him wait til +2 and +3 but the did pull at the automatic feeder hoping he could make things happen on his time frame. lol
Praying Henry starts eating and healing! It's hard not only being a parent to a diabetic cat, but also being their advocate. You have this!

 

[FrostD]

Everyone already covered what I'd have said, aside from no, a broad spectrum antibiotic would not necessarily resolve an infection.

Just adding hugs to the pile, I know how stressful it is. Things tend to be better with a little more sleep, just do your best to take care of yourself.

 

[Liz & Minnie]

Not sure why the thought of it bothers me so much, but it does.

It bothered me a lot, too. I think maybe because for people, a feeding tube is such a significant thing - not just the procedure itself, but what it represents. But, having been through it for Minnie, I can 100% tell you it's worth doing if suggested. Don't let your preconceptions about it being 'extreme' put you off.

Also - when Minnie had her DKAs, I could smell the ketones around her head. It was a bit like nail polish remover for her. I've read that not everyone can smell it, but also that not every cat makes the smell.

No need to add stress by trying to reply to this! Just know that you have a big virtual team behind you on this. And I echo @FrostD - get as much sleep as you can while he's in the hospital, it really will help you. Thinking of you.

 

[Lando demando]

Sending well wishes you ( and Henry’s) way

 

[John & Henry]

Has Henry ever had a blood test before, maybe the PH was taken and you can look back and see what it was.

I never thought of that. I'm sure he has, his medical record is quite extensive. The vets usually tell me... that's just too much to read through. I'm 99% sure they have his full record from his vet in California, but I'll enquire next time I speak to her.

Praying Henry starts eating and healing! It's hard not only being a parent to a diabetic cat, but also being their advocate. You have this!

Thank you!

Just adding hugs to the pile, I know how stressful it is. Things tend to be better with a little more sleep, just do your best to take care of yourself.

Aww, thank you

It bothered me a lot, too. I think maybe because for people, a feeding tube is such a significant thing - not just the procedure itself, but what it represents.

It's not so much the feeding tube that bothers me, I'd be ok with that. It's the forced feeding with the syringe. Maybe I'm picturing something that it isn't, but the thought of trying to force feed my little buddy that doesn't want to eat and is trying to escape ... it just sounds really traumatic for him.

Also - when Minnie had her DKAs, I could smell the ketones around her head. It was a bit like nail polish remover for her. I've read that not everyone can smell it, but also that not every cat makes the smell.

Interesting. It should actually be exactly like nail polish remover. One of the chemicals produced in ketosis is acetone -- literally nail polish remover. Thank you for the well wishes

 

[Diane Tyler's Mom GA]

Oh John I'm so sorry to hear Henry is back in the hospital.
I'm praying hard for the vet to find out why this keeps happening.
I could cry for Henry right now and for you. You are an amazing fur dad.
Try and get some sleep, we are all rooting for dear Henry! ♥

 

[Liz & Minnie]

It's the forced feeding with the syringe. Maybe I'm picturing something that it isn't, but the thought of trying to force feed my little buddy that doesn't want to eat and is trying to escape ... it just sounds really traumatic for him.

Honestly, in my experience it wasn't anything like that at all. It's not like syringe feeding where they're turning their head away, they don't even realize it's happening. Minnie wasn't trying to escape, she just rested there comfortably. Didn't even realize what was going on. Definitely not traumatic for her at ALL. I promise! They gave her a little collar which held the tube in place. But hopefully it won't come to that for you.

Now...try and get some sleep while you can!

 

[Bron and Sheba (GA)]

not so much the feeding tube that bothers me, I'd be ok with that. It's the forced feeding with the syringe. Maybe I'm picturing something that it isn't, but the thought of trying to force feed my little buddy that doesn't want to eat and is trying to escape ... it just sounds really traumatic for him.

If you have a feeding tube put it, you do not force feed. It just flows in and is not uncomfortable for Henry.
No mess, no stress and he gets the food he needs until he wants to eat on his own.

 

[Suzanne & Darcy]

Same here on the feeding tube. Kitty just sits there and you slowly administer the food through the tube. They don’t even realize that they’re “eating” so there’s no fighting it like sometimes can occur with syringe feeding through the mouth. Perhaps if you watch a YouTube video about it or something. Although I really hope to have a good report on Henry today and that he will be well enough to go home. FYI, here’s a link to Dr. Lisa Pierson’s article on feeding tubes for cats. It’s quite helpful.
https://catinfo.org/?s=E tube

 

[Suzanne & Darcy]

Any word on Henry?

 

[John & Henry]

Any word on Henry?

Talked to the vet this morning. They said he ate a little bit, but only offered him a little bit. Said they would try to feed him more later. Said its been a battle keeping his BG down. They hadn't checked ketones yet today. They were doing the liver asperation today. Said kidney numbers looked good today. Where yesterday she was leaning toward kidneys/GI causing the blood to become acidic, today she said it was probably due to the high BG. (Maybe I shouldn't have waited so long to give that shot the other day???) She said his case is very complex/frustrating (can't remember her exact word here.. challenging maybe?) I mentioned again about the possibility of using the R to keep BG from getting too high, and that I would be able to monitor closely. She doesn't seem against the idea, I just think she's never had a patient use it before, so I'm not sure she knows how to proceed. From my view and him producing enough ketones to acidify his blood in such a short time R seems like an absolute necessity. From many cats SS I've seen on here, they're in the 400s for days at a time with no problems, but that it can literally kill Henry within a few days maybe less. It seem very important his BG is almost always under 300.

From my reading on R it seems the hardest part is dosing such a small quantity. I've read about microvolume dosing although what seems most promising to me as far as accuracy and ease of administration is using a 10 or 50 microliter syringe. Unfortunately these syringes seem tough to get shipped quickly. Granger is like 30 days out. The manufacture sells them on their website, but no mention of ship time, I'd probably need to call them and request expedited shipping. I understand they need to be sterilized using an autoclave (which I obviously don't have), but I spoke with a friend that worked in the lab industry and did sterilization as part of her job. She said they can be sterilized using a pressure cooker at 271 degrees F & 14 PSI for 4 minutes. They're made out of borosilicate glass with a Luer tip which can accept disposable needle tips. From @ocat's post above it seems the hardest part is priming the 10 microliter, but it doesn't sound as hard with the 50 microliter. Either syringe makes it easy to gauge .1 unit injections. I'm learning towards the 50. I know keeping filled syringes isn't recommended, but my understanding of why that is the case is because the plastic from a normal syringe denatures the insulin. This shouldn't be the case with borosilicate, which I'm pretty sure is the same type of glass most insulins vials come in anyway. So it should be possible to fill the 50 microliter (50 microliter = 5 units) and keep it in the fridge to use as needed & replace the needle every other shot. If I'm missing anything here I'm happy to be corrected.

It seems Henry isn't a typical case, and where hypo is the spot bad things happen in most cats, hyper can be deadly for Henry. Obviously we don't want him to go hypo either, but it seems that should be easy to prevent with very small .1U doses, very close monitoring and high carb food if things start getting low.

@Suzanne & Darcy - I was looking at your SS and am I reading it correctly you were giving your cat 40 units at one point? I see it was a different brand than Lantus, but holy cow! I also see she was having issues with ketones in the beginning. Did she only go DKA the one time you have listed in your sig?

edit: Just an FYI, I have extensive background in the sciences even tho it isn't my day job, none of this stuff scares me and I understand it quite well, but I'm open to anyone pointing out any flaws in my reasoning.

edit2: The vet said she was thinking about sending subQ fluids home with Henry (before I even mentioned it) so that's good.

edit3: vet reported electrolytes are good

 

[Bron and Sheba (GA)]

Thanks for the update John.
I would really listen to @Wendy&Neko when it comes to giving R insulin. It isn’t to be used lightly.
I have found vets and doctors say someone or a cat is a complicated case when they can’t figure it out.
It may simply be that he should not have skipped that dose as it let ketones back in the door.
Anyway please listen to Wendy.

The reason Suzanne’s kitty had a high dose of insulin is because she was an acro cat.
I’m glad they are thinking of sending subQ fluids home.

Is Henry still in antibiotics?

 

[John & Henry]

It may simply be that he should not have skipped that dose as it let ketones back in the door.

I agree with you and I think the vet is thinking that now too, but if he can be half way to full blown DKA in 24 hours of being in the 400s, how will it be possible to avoid DKA when he starts to bounce or his numbers get so high without being able to lower his BG incrementally on-demand?

 

[John & Henry]

Vet just called again, and she wants him to wear a libre and use the R if needed. I'm going to pick him up right now.

 

[Bron and Sheba (GA)]

Vet just called again, and she wants him to wear a libre and use the R if needed. I'm going to pick him up right now.

How is he eating? Didn’t you say he was only eating a little bit?
I think they should have addressed that before discharge and put in a feeding tube if necessary. I think that would be more beneficial than R.

To avoid ketones we need to make sure he is getting enough insulin, enough food and any infection or inflammation being treated.

 

[John & Henry]

In line at the pharmacy right now. She said he's eating very well and downed a whole can.

More soon

 

[Bron and Sheba (GA)]

Do you have a script for ondansetron John? I wouldn’t leave without one as you may need it if Henry gets nauseated again.

 

[Wendy&Neko]

Please forget about special syringes, instead use your regular U-100 syringes. R is a U-100 insulin. Practice with an old used syringe and coloured water (or juice/tea etc). Practice drawing 0.1 units - as that's the first dose you'd start with. Once you have 0.1 units, rotate the plunger until a drop comes out. Practice getting even sized drops. Count the number of drops in your 0.1 units. Then practice 0.1 unit a few times until you are getting fairly consistent numbers of drops in your dose. For what's it's worth, we have have literally hundreds of caregivers here learn to dose 0.1 units on their way to remission. I had no problem getting a consistent 0.1 units for dosing R. I think you're making too big a case about the difficulty getting small doses. If you haven't got them already, you could invest in a set of lighted magnifiers. You can get craft ones that fit on your head. I just used a regular magnifying glass.

It could be that Henry needs more than 0.1 units of R eventually. It really does depend on that cat. But R is so powerful, aka potentially dangerous, that we get people to start on the smallest dose. Actually the smallest dose is a drop, but I think you could start at 0.1 units.

It seems Henry isn't a typical case

Seen a few like Henry in my time here. So have several other people here. Everyone else using R has used U-100 syringes. That's where the body of knowledge is.

 

[John & Henry]

Do you have a script for ondansetron John?

So the vet actually didn't come out and talk to me when I picked him up so I wasn't able to ask (probably because she had just discussed everything with me on the phone right before hand). It sounds like she wants me to update her daily on his status, so I can always ask her to call it in if the need arises. He's ravenously hungry. He inhaled a whole can of fancy feast like he hadn't eaten in a week as soon as we got home. He took a 5 minute break and now he's back picking at the crumbs left on the plate. I'm sure he'd eat another can right now if I offered it, but I'm afraid he'll make himself sick eating so much so quickly.

@Wendy&Neko Thank you so much for that information. The dosing instructions she gave me said to give .5 units if BG goes over 300, but that certainly seems like too much to start from what I've gathered around here. She had told me before that a .25 unit dose "isn't a thing", so she probably figures .5 is the smallest dosage unit she can even prescribe. I'll start practicing on measuring out the .1U I'm certainly not married to the idea of using those special syringes, it was just the only way I could think to do it. I'm assuming you use the calipers to measure out the .1U? I'm going to re-read that thread on dosing with the calipers and get a lighted magnifier which I don't really have around here. I'll hit up harbor freight tomorrow, they probably sell them. Luckily my up close vision is pretty good.

I'm going to make a new thread with the latest deets.

 

[Suzanne & Darcy]

They said he ate a little bit, but only offered him a little bit.

This kind of bothers me. They only offered Darcy a little food and when he didn't eat it they didn't syringe feed him (which I thought they should). He ended up with hepatic lipidosis on top of the DKA because they let him go too many days without food.

Yes. Darcy was up to over 40 units of Lantus, and it got to be so expensive that I had to supplement with R insulin as well. But this is because he had Acromegaly which made him extremely insulin resistant. I used regular U-100 syringes, but the smallest amount of R that I ever dosed with those was a .25 units. If I were doing smaller doses, I would get high magnification device (jewelers loup or similar) or digital calipers to help accurately measure a small .10 units. Still, a lot of people on this Board do .1 u doses without all that jazz. Wendy's suggestions are excellent for drawing a consistent dose. If you look at the fall of 2020, that is when my Darcy went into DKA. He never went DKA after that, despite the high ketones. He continued to have high ketones for a long time, but never went into DKA a second time (although I took him to the vet very regularly for IV fluids and antibiotics if his white count was high or ketones went ridiculously high). Finally, as he got to a better dose of insulin, his ketones started to come down even before it was reflected in lower BG numbers. Ketones came down first, then better BG numbers followed.

 

[Suzanne & Darcy]

He's ravenously hungry.

So good to hear he's hungry!
I would not start with .5 units of R. You have to move very slowly and test each hour for the first four hours to see what the response is to the R. The use of R insulin is very much and EVERY CAT IS DIFFERENT thing!

 

[Wendy&Neko]

I mostly eyeballed the 0.1 units, even though I had calipers and would sometimes use them too. 0.1 is partway between the 0.25 and the zero line. Note 0.1 is the starting dose, he may or may not need more.

Huge difference between Darcy and Henry with the L doses, so looking at Darcy's R doses isn't relevant for what might work Henry. I've also seen a cat on 30 units of Lantus that didn't any more than 0.5 units of R even with very high preshots. Every cat is completely different.

With R we really start low and then slowly increment based on what works. We don't want to drop the cat any more than 100 points over the approximately 4 hours, or you'll set off another bounce making things even worse. Start with a dose of 0.1 units and test every hour after that for 4-5 hours. You need to find the onset/nadir/duration of R. Depending on how it goes with 0.1 R, give it a few cycles, we decide if the R dose needs to increase. We do not give R on the first cycle of a L ( basal insulin ) dose increase, nor on the cycle when a bounce is breaking. Using too much R or at the wrong time means bounces, and higher numbers than if you had not used R at all. That's why we suggest an experienced person be online with your threads when you try R, until you learn the guidelines. The goal is to learn the R action to be able to safely use it on top of the Lantus action. Since Henry is new to Lantus, we are still learning his Lantus action too.

Your vet is right that we determine what dose of R to give based on the preshot. Over time you build an R scale that tells you how much R to give based on that. Usually you don't give any R at all at lower preshots.

 

[Bron and Sheba (GA)]

John, I would definitely not start with 0.5 unit R. That really shows that the vet has no experience using R with another insulin.
And please don’t start using R unless @Wendy&Neko or someone she advises, tell you to. And then they will stay with you for the duration of the R. Henry may not need it, we will need to see the data.
The problem or issue with using R with Lantus or another insulin, which you may not have realised, is that you are dealing with 2 nadirs in the one cycle. So you need someone with a lot of experience to be with you, otherwise you could get into a lot of trouble.

I’m glad He ry is eating well.
Did you get some ondansetron?
And did you get some subQ fluids?