Blood ketones slightly elevated, not responding to insulin as usual, BGs too high almost constantly

[Lauren and Loki]

Previous thread: https://felinediabetes.com/FDMB/thr...5-73-on-relion-5-5-113-on-relion-6-25.273285/

@Suzanne & Darcy @FrostD @Bron and Sheba (GA)

Hey everyone, am needing some help. Loki has not been responding as usual to his insulin doses, and I think he might be having a pancreatitis flare up, his blood ketones are slightly elevated. Please take a look at his SS, and please keep reading. He hasn't had a blue in quite some time, is receiving 1U, and that's concerning considering he was going into blue before, even on the 0.75U dose. Should his insulin be increased during a possible pancreatitis flare? How do you know if an insulin brand change is needed?

I have been trying to find the correct food for him. This past week I have been trying Weruva BFF Pate's. He seemed to like them at first, but then not so much. But I had also weaned him off of the Cerenia first, then the Ondansetron over a couple of days because he had been doing so well. I think that was possibly a mistake, as he started to not want to eat the food, and I thought he could be nauseous. I started giving them again, along with an appetite stimulant. I have now been feeding Beyond Grain Free Pate's and he is loving those, and still will not eat the BFF Pate's. So it's hard to know if it was nausea or the food/flavors. But I will continue the anti-nausea meds.

However, I did a blood ketone test yesterday morning, and it was 1.3. I have marked the tests in bold in the remarks on the SS. I tested again last night, and blood ketones were 1.1. This morning blood ketones were 1.5. This was just after I gave insulin, so I suppose it would be better to test the ketones a few hours after to see if it's helping bring them down. His urine ketones have remained negative, as I have read it makes a difference if showing up in both blood and urine? I will try to get another urine test today. Is he possibly having a pancreatitis flare up? And if so, could this be causing the such high BG numbers? Or is it the other way around, and his high numbers are causing a pancreatitis flare up?

I'm just glad he's eating this food, it's supposed to be low carb. I know food and insulin are key for keeping ketones at bay, I'm just not sure what I'm supposed to do. He is acting fine overall, and has been playing, chilling, and loving.

Thank you!

 

[Diane Tyler's Mom GA]

Previous post
https://felinediabetes.com/FDMB/thr...n-5-5-113-on-relion-6-25.273285/#post-3037755

 

[Sienne and Gabby (GA)]

If this were my cat, I'd be considering following the modified Prozinc method for dosing and not holding the dose for more than 3 days. With a relatively recent history of DKA, I'd vote for your being more aggressive especially given that Loki likes bouncing into really high numbers.

 

[Bron and Sheba (GA)]

Is Loki eating lots of food? Remember with a fairly recent DKA it is early important that they eat lots.
Is he well hydrated?
I’m going to tag @FrostD and @Suzanne & Darcy about the dose.
I would post daily for guidance

 

[Lauren and Loki]

Like I said, he wasn’t eating great earlier this week. He had been eating pretty well prior to that, so I stopped giving him his anti-nausea meds (slowly over a few days), to see how he would do. Then over the next couple days after, he was not liking the new food (Weruva BFF Play pates) like he did initially so I wasn’t sure if it was nausea or a distaste for the new food. I’ve been trying to find a consistent food for him since he won’t he Fancy Feast anymore. I started giving the anti-nausea meds again to see if it would help, and he still would not eat the BFF food. I also started giving the appetite stimulant. I now have been feeding him Beyond Grain Free pates, and he is loving those, thankfully.

When you say “lots of food,” how much is “lots of food?” I have no idea how much I should increase his food intake. Like six 3oz cans a day? I think I’ve been told double a normal intake but I’m still learning feeding.

How do I tell if he’s well hydrated? He does drink water, and I assume with eating all the wet food (and I also add water to his food) that he would be hydrated.

I’m really worried about his consistently high BG numbers and what to do about the dose. He is not going into lower numbers on these doses like before. So I do not know if he’s having a pancreatic flare or if this is all because of his high BG, or both if one is caused from the other. Why would he not be responding to the insulin as well all of a sudden? Does it have to do with the couple days he struggled to eat?

I need to learn about the modified ProZinc method, I do not know how to do this yet.

Also, I retested ketones @ +5.75 and they went slightly down to 1.2. I read I should test after insulin to see if the insulin is helping to reduce them.

 

[Bron and Sheba (GA)]

Keep giving the anti nausea medications for longer as post DKA cats can be nauseated for a while.
Try and get him to eat more than he normally eats if possible as food help keep ketones away. The other thing that keeps ketones away is insulin. And fluids can help flush them way as well
Test anytime for ketones. 1.2 on the blood ketones meter is OK.
You will find the MPM on the ProZinc page…I would print it off
To check for hydration…..lift the scruff..it should drop down quickly not slowly.
Feel his gums….they should he slippery, not sticky

 

[Lauren and Loki]

I will definitely keep giving the anti-nausea meds. I thought he might be okay, but I believe stopping them was a mistake. I just got new refills this morning.

I guess I will basically just keep low carb food out for him instead of at exact planned times. As far as fluids, he does drink water, and I add water to his food. Is this enough? Is there something else I can do for fluids?

As far as insulin, I suppose we are waiting to see the others opinions on dosing? Or should I read and start the MPM right away?

Ok so I don’t need to be super super worried about the 1.2? I know it’s important, but not terrible right?

I’ll check his scruff and gums as soon as I get home in just a little bit.

Thank you so much!!!!!

 

[Suzanne & Darcy]

Hi Lauren, I think it sounds like you are doing everything right, with the feeding, hydration, anti-nausea meds. He isn't constipated is he? It sounds like Loki is behaving like a happy kitty. This could be related to pancreatitis, yes, but like I said, you are doing everything right -- especially keeping on top of those ketones. I would say that Loki is definitely due for a .25 unit increase. Far too many blacks are on that spreadsheet. He is still very bouncy -- bouncing into blacks from the yellows. I would do a .25 unit increase for now and keep up with your excellent monitoring. Then lets reevaluate (check in here) after 6 cycles and we will see again. Of course, we don't mind hearing about Loki every day, but I'm just saying that we can talk about his dose and how the BGs are doing after 6 cycles. @FrostD what do you think?

 

[Suzanne & Darcy]

And Lauren, you can take a look at my spreadsheet if you want to see a cat that produced a lot of ketones at one time. But he never went into DKA again. It was an infection that pushed him into DKA in the first place. I worried about the ketones, but getting a 1.2 is not horrible considering his numbers -- especially as you tell me he's a happy, playful kitty who is eating well and drinking water. I know it's very hard not to worry! But I think you are okay. You are in control because you are testing those ketones.

 

[Suzanne & Darcy]

So @FrostD Loki's nadirs are above 200, so technically an increase of .50 could be recommended, but I was thinking we should make a conservative recommendation of .25 and reevaluate after six cycles and not wait for a full week. Lauren does enough testing for MPM, she just needs to know the differences between MPM and SLGS. MPM would allow her to adjust Loki's doses more frequently, although I still expect him to be bouncy for a while.

 

[FrostD]

So @FrostD Loki's nadirs are above 200, so technically an increase of .50 could be recommended, but I was thinking we should make a conservative recommendation of .25 and reevaluate after six cycles and not wait for a full week. Lauren does enough testing for MPM, she just needs to know the differences between MPM and SLGS. MPM would allow her to adjust Loki's doses more frequently, although I still expect him to be bouncy for a while.

I was thinking the same thing. He could use a larger increase, but the main downside to adjusting the dose (with ProZinc anyway) during a possible flare/inappetence spell is larger than usual drops.

If he were my cat (and hypo kit/assist feeding supplies if necessary), I'd do a 0.5U increase and just monitor very closely. If that's too uncomfortable, a 0.25U increase and evaluate after 6 cycles.

The blood ketone results aren't immediately worrisome, no. But they are a very good warning system that something is brewing and to stay on top of food, fluids, insulin, and his behavior.

 

[Suzanne & Darcy]

Okay so it’s really what you feel comfortable with, Lauren. Either a .25 or a .5 increase. What do you think?

 

[Lauren and Loki]

Hi Lauren, I think it sounds like you are doing everything right, with the feeding, hydration, anti-nausea meds. He isn't constipated is he? It sounds like Loki is behaving like a happy kitty. This could be related to pancreatitis, yes, but like I said, you are doing everything right -- especially keeping on top of those ketones. I would say that Loki is definitely due for a .25 unit increase. Far too many blacks are on that spreadsheet. He is still very bouncy -- bouncing into blacks from the yellows. I would do a .25 unit increase for now and keep up with your excellent monitoring. Then lets reevaluate (check in here) after 6 cycles and we will see again. Of course, we don't mind hearing about Loki every day, but I'm just saying that we can talk about his dose and how the BGs are doing after 6 cycles. @FrostD what do you think?

Hello! So sorry I'm just responding. Thank you for the encouragement!
I can't say if he is constipated or not, what signs do I look for to see if he is? As far as hydration Bron was asking about, his scruff seems to act normal and fall quickly, and his gums are slippery, not sticky.
Yes, he seems happy and normal! His bouncing is insanely bouncy and doing the same for my anxiety!! Lol... I will keep up the monitoring!
And happy to hear a recommendation for an increase! All the blacks on the SS have been making me quite anxious and frustrated. This sounds like a good plan! Anything that comes up within the next 6 cycles, I will address here.

And Lauren, you can take a look at my spreadsheet if you want to see a cat that produced a lot of ketones at one time. But he never went into DKA again. It was an infection that pushed him into DKA in the first place. I worried about the ketones, but getting a 1.2 is not horrible considering his numbers -- especially as you tell me he's a happy, playful kitty who is eating well and drinking water. I know it's very hard not to worry! But I think you are okay. You are in control because you are testing those ketones.

This is very reassuring! I will definitely take a look at your SS.

So @FrostD Loki's nadirs are above 200, so technically an increase of .50 could be recommended, but I was thinking we should make a conservative recommendation of .25 and reevaluate after six cycles and not wait for a full week. Lauren does enough testing for MPM, she just needs to know the differences between MPM and SLGS. MPM would allow her to adjust Loki's doses more frequently, although I still expect him to be bouncy for a while.

I'd do a 0.5U increase and just monitor very closely. If that's too uncomfortable, a 0.25U increase and evaluate after 6 cycles.

Okay so it’s really what you feel comfortable with, Lauren. Either a .25 or a .5 increase. What do you think?

I am definitely comfortable with an increase, I chose to do a 0.25U increase, and started this last night. I will update his SS today! We will check back on it in 6 cycles. Is that the way MPM works? A 6 cycle dosing method instead of a week? I will read up on the MPM method in the meantime too.

I can't believe how high his numbers are after he fell so fast on the dosing scale. Is this a common occurrence for them to work their way back up? Or can the pancreatitis cause the higher numbers and ketones directly? Or is it more because of pancreatic nausea so he wouldn't eat, and it's just a domino effect? Trying to understand why he is needing more insulin. I'm worried it could maybe be the bottle of ProZinc losing potency? It's towards the end of the bottle, and was wondering if I should order a new bottle to see if it makes a difference. I mean I've kept it in the fridge and done everything right to store it, I'm not sure it's even 2 months old, will need to check. I can't help but wonder if even ProZinc is not the correct insulin for him, but I'm sure that's too early to tell for sure. I'm just speculating because I can't believe this. FD kitty mom thoughts! Lol

He is definitely eating much more now, he is eating all the food I'm giving. I'm so happy about that. Which I wanted to ask, he seems a lot more hungry now, as in him seeming maybe not completely satiated after eating a good amount of food, and was wondering if the appetite stimulant (Mirtazapine) can cause this? Like making him overly hungry? Should I maybe rub less, like half the amount, on his ear instead of a full dose? It's hard to tell if he really is this hungry because of what's going on with him, or if the medicine is making him a little ravenous for food. I don't want to change anything right now too much if he is eating, I just want him to feel satiated and not be feeling hungry if the medicine is causing that.

Thank you all so much for your time and help!!

 

[Sienne and Gabby (GA)]

This is the link to the sticky note with the Prozinc Dosing Methods information. The modified version is toward the bottom.

 

[Suzanne & Darcy]

Or can the pancreatitis cause the higher numbers and ketones directly?

Pancreatitis can cause higher numbers, yes. And higher numbers in turn cause the ketones.

 

[Suzanne & Darcy]

he seems a lot more hungry now, as in him seeming maybe not completely satiated after eating a good amount of food, and was wondering if the appetite stimulant (Mirtazapine) can cause this?

They tend to eat more when their numbers are higher (my body did) and yes Mirataz is an appetite stimulant and it can work very well to increase appetite. With Mirataz, I would not give the full dose unless it's absolutely necessary. Many cats will get kind of crazy on Mirtazapine (the reason we call it Meowtazapine). It can make them aggressive, restless, excessively meow-y, etc. I always recommend starting with one half of the length of the strip that is on the box (or even a little less) and not giving it every day. A lot of the time, every other day works just fine. You can see what works for Loki. Always wear a glove when rubbing it on his ear, too.

 

[Suzanne & Darcy]

Trying to understand why he is needing more insulin. I'm worried it could maybe be the bottle of ProZinc losing potency? It's towards the end of the bottle, and was wondering if I should order a new bottle to see if it makes a difference. I mean I've kept it in the fridge and done everything right to store it, I'm not sure it's even 2 months old, will need to check.

I doubt if the insulin is losing potency after two months and having been stored correctly. Infection, inflammation (e.g. pancreatitis), stress can all raise BG. And insulin needs can and do change over time :-( In Loki's case, I hope the need for an increase is only temporary.

 

[Sienne and Gabby (GA)]

One word of caution. Some cats will still develop ketones if they are not experiencing high numbers. They may be more likely to develop ketones if numbers are high but not always. A cat who has had a recent episode of DKA may be more prone to develop ketoacidosis if not eating or not getting enough insulin. It's why we push caregivers to test for ketones especially if their kitty went through a recent episode of DKA. Cats are masters of deception and may not be "telling" you if they have an infection brewing.

 

[Lauren and Loki]

They tend to eat more when their numbers are higher (my body did) and yes Mirataz is an appetite stimulant and it can work very well to increase appetite. With Mirataz, I would not give the full dose unless it's absolutely necessary. Many cats will get kind of crazy on Mirtazapine (the reason we call it Meowtazapine). It can make them aggressive, restless, excessively meow-y, etc. I always recommend starting with one half of the length of the strip that is on the box (or even a little less) and not giving it every day. A lot of the time, every other day works just fine. You can see what works for Loki. Always wear a glove when rubbing it on his ear, too.

Meowtazapine lol That’s exactly what I wanted to know, thank you! I’ve been giving the full length for three days now. Tomorrow I will give less, like half the length, and try that amount every other day, and then maybe even less. Will see how he does and make necessary adjustments. And yes, I’ve been wearing gloves. It also says on the box to throw out after 1 month from opening, is that really necessary?

In Loki's case, I hope the need for an increase is only temporary.

I hope so too..thank you so much for answering my questions, and for being here!! <3

Lastly, how do I recognize if he is constipated?

 

[Lauren and Loki]

One word of caution. Some cats will still develop ketones if they are not experiencing high numbers. They may be more likely to develop ketones if numbers are high but not always. A cat who has had a recent episode of DKA may be more prone to develop ketoacidosis if not eating or not getting enough insulin. It's why we push caregivers to test for ketones especially if their kitty went through a recent episode of DKA. Cats are masters of deception and may not be "telling" you if they have an infection brewing.

Thank you for explaining this. How will I know if he is dealing with an infection, and not just a pancreatic flare? That would have to be determined by blood work right? I suppose the need to take him in is determined if his way of acting was not improving (not eating, seemingly in pain, or sick seeming). But because he’s seeming okay right now, and just has high numbers and slightly elevated ketones, that’s not necessary quite yet at this point.

 

[Suzanne & Darcy]

Meowtazapine lol That’s exactly what I wanted to know, thank you! I’ve been giving the full length for three days now. Tomorrow I will give less, like half the length, and try that amount every other day, and then maybe even less. Will see how he does and make necessary adjustments. And yes, I’ve been wearing gloves. It also says on the box to throw out after 1 month from opening, is that really necessary?




I hope so too..thank you so much for answering my questions, and for being here!! <3

Lastly, how do I recognize if he is constipated?

Oh. Sorry I forgot to answer about the constipation. It’s nothing special… just make sure you see he’s having regular BMs. Preferably every day. Do you have other cats? That makes it more difficult to track. Also his poop should not be really hard small balls. You know… just normal poop.

I have kept my Mirataz ointment for a long time and it was still potent even after the expiration date. I would definitely not discard it after only one month! What a waste.

 

[Suzanne & Darcy]

Thank you for explaining this. How will I know if he is dealing with an infection, and not just a pancreatic flare? That would have to be determined by blood work right? I suppose the need to take him in is determined if his way of acting was not improving (not eating, seemingly in pain, or sick seeming). But because he’s seeming okay right now, and just has high numbers and slightly elevated ketones, that’s not necessary quite yet at this point.

I probably would not take him to the vet unless he seems sick and lethargic and won’t eat, is vomiting a lot, etc. Since he seems okay right now, I agree that it is not time for bloodwork. Yes, bloodwork would most likely tell if he did have an infection because his white blood count would probably be high. The problem is that sometimes you don’t know what is the source of the infection. I think you’re good for now.

 

[Suzanne & Darcy]

Sienne is correct about the ketones. My personal experience is that my cat went into DKA while mostly in yellow and low pink numbers. In his case his ketones continued very high for a long time but he never went into DKA again. I was worried and I certainly watched him like a hawk and tested ketones, gave fluids, etc. It’s strange how his ketones started to come down even before his numbers really improved (proving that there’s more to ketones than numbers). I was increasing his insulin a lot at the time. But my cat had acromegaly so he needed a lot of insulin so don’t worry about that part, but I am just saying that getting enough insulin for each individual cat’s needs is important. That’s why it’s good if you can follow MPM and adjust doses more swiftly.

 

[Suzanne & Darcy]

Hi Lauren, I'm hoping you can update your spreadsheet. Looking at what's there this morning, it looks like another increase is needed. Let us know how you and Loki are doing. Ketones? I'm sure you've tested. I think you should add a column (look at my SS all the way over to the right before the remarks section. There's a column for ketones. It just makes it so much easier to find when you don't have to read through the other comments.

 

[Bron and Sheba (GA)]

I’m wondering if he might have something causing these higher BGs as he was doing better earlier on.
Do his teeth need checking?. Or could he have a UTI?
I wonder if he would do better on Lantus?

 

[Lauren and Loki]

Oh. Sorry I forgot to answer about the constipation. It’s nothing special… just make sure you see he’s having regular BMs. Preferably every day. Do you have other cats? That makes it more difficult to track. Also his poop should not be really hard small balls. You know… just normal poop.

I have kept my Mirataz ointment for a long time and it was still potent even after the expiration date. I would definitely not discard it after only one month! What a waste.

I do have another cat, so I will try to keep an eye. But she is healthy and you kind of know your cats BMs, you know? He did have a BM this morning, and it was kind of like half normal half a sticky/mushy looking poop, lighter in color, not dark. If he's having a pancreatic flare, this can cause some diarrhea correct? I have a new bottle of Jarrow S. Boulardii probiotic that I was recommended when he was on antibiotics. Would that help him with both diarrhea and constipation? Or just in general help with his BMs? I have no idea how much to give. Or do I need Miralax? Again, I don't know really know what to give for either situation or how much.

And thank heavens on the Mirataz! Seriously lol.

In his case his ketones continued very high for a long time but he never went into DKA again. I was worried and I certainly watched him like a hawk and tested ketones, gave fluids, etc.

I have 3 bags of fluids that I purchased from a member here, so I have those on hand, with IV tubes and needles. I have zero idea how to use them, or how to properly administer these. But I do have them in case.

Hi Lauren, I'm hoping you can update your spreadsheet. Looking at what's there this morning, it looks like another increase is needed. Let us know how you and Loki are doing. Ketones? I'm sure you've tested. I think you should add a column (look at my SS all the way over to the right before the remarks section. There's a column for ketones. It just makes it so much easier to find when you don't have to read through the other comments.

I'm sorry for being behind, but I just updated his SS. His ketones were 0.4 last night! I need to test again today, and will post results. I added the extra column as you suggested, and I changed my dosing method to read MPM.

Couple of things:
1) I am able to manually blood test him, he's very good at letting me. But he also has a Libre sensor that I mainly rely on. I'm afraid I will frustrate him by manually testing too many times a day, resulting in him not letting me at all, especially since we are new to this. The "HI's" on his SS could be anywhere from 400-600, and I'm not sure if it makes a difference to know where he is in this range. I blood tested last night, you can see the 480 within all those black HI's, and just wondering if I should be more consistent at this. Because seeing all the blacks is alarming, when maybe he would actually be more in the reds (not that this is great either, which is my whole point). But he was 585 the previous morning. I just don't want it to look like he's jumping from, let's say, 450 to 580 in the same cycle just because it goes from a 450 blood test to a HI Libre reading, when maybe he's actually still in the 400s. Does this make sense?

2) I'm a little frustrated because he has been eating well the past couple of days, and then all of a sudden late last night it was like he didn't want to eat as much, and didn't really finish his overnight snacks. He has eaten, just not as much, nor as swiftly as he was, and I've had to kind of coax him to eat. And it makes me wonder if he only went lower today because he hasn't eaten as much, or if this dose is actually taking some sort of effect. I worry all the time the food is making his BGs high, even though it's supposed to be low carb.

 

[Lauren and Loki]

I’m wondering if he might have something causing these higher BGs as he was doing better earlier on.
Do his teeth need checking?. Or could he have a UTI?
I wonder if he would do better on Lantus?

Great point, because his teeth do need checking, and I was actually wondering about it yesterday. Are diabetic cats okay under anesthesia to get their teeth cleaned?

I have also been worried about maybe ProZinc not being a good fit, and how you know when to change insulins. When he went into DKA in December, they had him on glargine, but it was dropping him too low, so we switched back to ProZinc. Could have been the dose though, which I can't remember what it was right now. I have a bottle of glargine in the fridge since December, not sure how long it lasts?

 

[Bron and Sheba (GA)]

Great point, because his teeth do need checking, and I was actually wondering about it yesterday. Are diabetic cats okay under anesthesia to get their teeth cleaned?

You need to ask your vet if Loki would be ok under anaesthetic. Lots of diabetic cats have their teeth cleaned.

have also been worried about maybe ProZinc not being a good fit, and how you know when to change insulins. When he went into DKA in December, they had him on glargine, but it was dropping him too low, so we switched back to ProZinc. Could have been the dose though, which I can't remember what it was right now. I have a bottle of glargine in the fridge since December, not sure how long it lasts?

I’ll ask @FrostD and @Suzanne & Darcy what they think about changing insulins. If the insulin isn’t working well, it is fine to change it. We don’t just like chopping and changing insulins too often but if he is in high numbers a lot it could be that the insulin doesn’t suit him. But I’d get the teeth checked out.
Lantus from December should be fine, if it was opened then. And kept in the fridge. If he dropped low on Lantus, it would have been because the dose was too high I would think, not because it was Lantus.

 

[Lauren and Loki]

@Suzanne & Darcy & @FrostD

We're coming up on the end of 6 cycles, what do we think about Loki's dosing?

Also, a few things were said that I don't think y'all saw, so be sure to read the last few comments. Thanks so much!

 

[Lauren and Loki]

@Suzanne & Darcy @FrostD @Bron and Sheba (GA)

Hey everyone, I've increased Loki's dose to 1.5U as of today's AM cycle. He is still reading HI consistently on the Libre, SS is up to date....I'm completely perplexed by this, and concerned, although he is acting just fine and eating well. I have no idea why all of a sudden it's as if the insulin is having zero effect.

My current bottle is almost empty, so I'm ordering a new bottle on Monday. I'm seriously wondering if it's lost potency for whatever reason. If a new bottle doesn't help initially, I'll be beside myself. Also worried about starting a new bottle on the increased dose (if potency is the issue) as I'll have to watch him like a hawk for hypo

But am probably gonna take him in for bloodwork next week, and also work on setting up an appointment to get his teeth looked at.

Any thoughts are appreciated. Did anyone have any thoughts about what @Bron and Sheba (GA) said about possibly needing to switch insulins? Should I try a new ProZinc bottle, have blood work done, and have teeth checked before considering this? I don't know how soon I can get teeth checked. I have a new unopened bottle of Glargine in the fridge that I got in December after his hospital stay, just FYI. If it's been unopened, it shouldn't expire soon right?

Thanks

 

[Bron and Sheba (GA)]

I have a new unopened bottle of Glargine in the fridge that I got in December after his hospital stay, just FYI. If it's been unopened, it shouldn't expire soon right?

If its been in the fridge all the time unopened the lantus will be OK til the use by date.
I would change to lantus myself.
We can't leave him in these high numbers.
Keep testing for ketones daily.
I would get the teeth checked for sure.
Ill tag @FrostD and @Suzanne & Darcy again in case the tags didn't work.
Make sure he continues to eat well

 

[Lauren and Loki]

If its been in the fridge all the time unopened the lantus will be OK til the use by date.
I would change to lantus myself.
We can't leave him in these high numbers.
Keep testing for ketones daily.
I would get the teeth checked for sure.
Ill tag @FrostD and @Suzanne & Darcy again in case the tags didn't work.
Make sure he continues to eat well

He finally has some numbers in the mid-300s just within the last hour. SS updated. Of course, not sure how long that will last, or if it’ll get better..just glad to see something under 400 at least. I can only hope for improvement.

Yes, the unopened bottle has been in the fridge this whole time. I’ll admit, I’m nervous to change insulins without telling the vet first, only because I’m afraid of her reaction about it. Like if she’ll she it as disrespectful of her guidance, and refuse to help treat him anymore if I make decisions like that without consulting. She’s already not liking that I “keep changing the dose” and that I make him wear a Libre. Going in there is already stressful enough because of these things. And she doesn’t support home testing, you know the same old story. So I’m doing everything she wouldn’t want me to do. Which, too bad, I just don’t wanna lose access to his prescriptions. It’s an internal medicine specialist, so not his regular vet, which he doesn’t even really have a regular vet because she left the practice. I’m in search of a new one.

 

[Bron and Sheba (GA)]

He finally has some numbers in the mid-300s just within the last hour. SS updated. Of course, not sure how long that will last, or if it’ll get better..just glad to see something under 400 at least. I can only hope for improvement.

Yes, the unopened bottle has been in the fridge this whole time. I’ll admit, I’m nervous to change insulins without telling the vet first, only because I’m afraid of her reaction about it. Like if she’ll she it as disrespectful of her guidance, and refuse to help treat him anymore if I make decisions like that without consulting. She’s already not liking that I “keep changing the dose” and that I make him wear a Libre. Going in there is already stressful enough because of these things. And she doesn’t support home testing, you know the same old story. So I’m doing everything she wouldn’t want me to do. Which, too bad, I just don’t wanna lose access to his prescriptions. It’s an internal medicine specialist, so not his regular vet, which he doesn’t even really have a regular vet because she left the practice. I’m in search of a new one.

The internal specialist doesn't sound very proactive. And she is certainly not keeping up with the latest recommendations for FD. Not supporting hometesting when the CG want to do it is crazy!
Was she the one who changed the insulin because of the low numbers on Lantus?
When Sheba was really sick with pancreatic cancer I saw an internal medical specialist who was lovely, but she knew very little about feline diabetes and was asking me all sorts of questions about levemir (which she had heard of but never used), asked my opinion about different things and I realised I knew a lot more about FD than she did.....and she was quite open about it.
I would not let the specialist stop you doing what you know is best for Loki.
I would be looking for a new vet. You need a vet who will work with you and respect your point of view. Loki is your cat and you are paying her for advice, If you dont want to take it, she should not be making you feel bad!
You are Loki's advocate as he can't speak.
You don't need a specialist for FD or post DKA. You can get prescriptions for insulin and antinausea meds from a normal vet.

 

[Lauren and Loki]

The internal specialist doesn't sound very proactive. And she is certainly not keeping up with the latest recommendations for FD. Not supporting hometesting when the CG want to do it is crazy!
Was she the one who changed the insulin because of the low numbers on Lantus?
When Sheba was really sick with pancreatic cancer I saw an internal medical specialist who was lovely, but she knew very little about feline diabetes and was asking me all sorts of questions about levemir (which she had heard of but never used), asked my opinion about different things and I realised I knew a lot more about FD than she did.....and she was quite open about it.
I would not let the specialist stop you doing what you know is best for Loki.
I would be looking for a new vet. You need a vet who will work with you and respect your point of view. Loki is your cat and you are paying her for advice, If you dont want to take it, she should not be making you feel bad!
You are Loki's advocate as he can't speak.
You don't need a specialist for FD or post DKA. You can get prescriptions for insulin and antinausea meds from a normal vet.

I completely agree with everything you said. She’s the same one I mentioned before who said it was hard to interpret his Libre data because I kept changing the dose lol..and yes, it was under her care of the changing of insulins. I had expressed concern about it to her in the beginning, wondering if the insulin was too powerful for him (way before I knew any of what I know now, cause you know, I’m not the doctor ) and she said we could go back to ProZinc, instead of just suggesting we lower the dose! What is with them wanting to overdose with insulin? As if anything under 2U is blasphemy.. Which I went back and checked his medical records from his DKA hospital stay, and I believe he was getting 3 units of Lantus towards the end (that’s the instructions on the prescription box too!) and then I think they lowered to 2, and then possibly 1. It was hard to read their notes to be honest.

I have a new vet in mind and have to fill out new patient paperwork. I’ll be doing that this week. It’s a vet who’s a cat specialist, and only sees cats, so we will see. Again, I agree with everything you said. Thank you for the reminders and encouragement

Just need to see what the others think of switching insulins. I don’t know anything about how Lantus works, so not sure who here can help me with that if the switch is made.

 

[Bron and Sheba (GA)]

I can help you with the switch and so can many others. There are a lot more people here who use lantus than prozinc.
When you go to the new vet you will need to say that you are hometesting and adjusting the dose your self and make it clear from the beginning what you are doing and want to continue doing.

 

[Lauren and Loki]

I can help you with the switch and so can many others. There are a lot more people here who use lantus than prozinc.
When you go to the new vet you will need to say that you are hometesting and adjusting the dose your self and make it clear from the beginning what you are doing and want to continue doing.

I appreciate you all so much..thank you isn’t enough

A switch to Lantus would be justified by the fact that at one point he was doing better on lower doses of ProZinc, right? Instead of just continuing to increase his ProZinc dose? The fact that he’s continually high after several increases just shows something is not right instead of it just being too low of dose, correct? I hope that makes sense. Because I can hear a vet saying “you should’ve increased it more” An insulin can really just stop working for a cat all of a sudden? Geez..as if this all wasn’t scary enough

 

[Suzanne & Darcy]

The internal specialist doesn't sound very proactive. And she is certainly not keeping up with the latest recommendations for FD. Not supporting hometesting when the CG want to do it is crazy!
Was she the one who changed the insulin because of the low numbers on Lantus?
When Sheba was really sick with pancreatic cancer I saw an internal medical specialist who was lovely, but she knew very little about feline diabetes and was asking me all sorts of questions about levemir (which she had heard of but never used), asked my opinion about different things and I realised I knew a lot more about FD than she did.....and she was quite open about it.
I would not let the specialist stop you doing what you know is best for Loki.
I would be looking for a new vet. You need a vet who will work with you and respect your point of view. Loki is your cat and you are paying her for advice, If you dont want to take it, she should not be making you feel bad!
You are Loki's advocate as he can't speak.
You don't need a specialist for FD or post DKA. You can get prescriptions for insulin and antinausea meds from a normal vet.

Amen! Well said!

 

[Suzanne & Darcy]

I appreciate you all so much..thank you isn’t enough

A switch to Lantus would be justified by the fact that at one point he was doing better on lower doses of ProZinc, right? Instead of just continuing to increase his ProZinc dose? The fact that he’s continually high after several increases just shows something is not right instead of it just being too low of dose, correct? I hope that makes sense. Because I can hear a vet saying “you should’ve increased it more” An insulin can really just stop working for a cat all of a sudden? Geez..as if this all wasn’t scary enough

I do not think the ProZinc has necessarily stopped working. I think there could be another factor here that is raising his BG. The tooth? But I think that changing to Lantus is not necessarily a bad idea. We can help you with that as well. I am happy to hear that you saw better numbers on him today. That is encouraging.

 

[Lauren and Loki]

I do not think the ProZinc has necessarily stopped working. I think there could be another factor here that is raising his BG. The tooth? But I think that changing to Lantus is not necessarily a bad idea. We can help you with that as well. I am happy to hear that you saw better numbers on him today. That is encouraging.

There’s nothing obviously wrong with his teeth, just that if there is, teeth play a big role in regulating diabetes. So he just needs to get it checked out to be safe, and possibly a cleaning, just to rule it out. It’s been awhile since he’s had them looked at. The problem is I do not have a regular vet at the moment, she left the practice and I have to schedule at a new one, who hopefully respects my stance. And I can’t start that process till tomorrow (Monday) because they are closed. So I’m just sick from worry about his high numbers and how long is it gonna take before I can get his teeth looked at.

He only stayed in the 300s for about 2 hours last night, before going HI again. And he’s been reading HI all day today. I have to update the SS, but he’s just been HI.

My questions are, should I take him to the specialist to have bloodwork done tomorrow or the next day, to rule some stuff out, and work on the whole tooth situation, before switching? And keep increasing his dose as needed? (Is it every 6 cycles with MPM?) It just seems crazy since he was doing better on lower doses of ProZinc before, like something is up obviously, we just can’t be sure of what. If I stick with the ProZinc I have to order a new bottle tomorrow, as I’m almost out. Or should I just switch? @Bron and Sheba (GA) basically said they would just switch I think. I just need a game plan we all agree on because I’m feeling like a nervous train wreck lol. Thanks all <3

 

[Lauren and Loki]

Also, I was wondering about something - there has been two instances in the past couple of weeks, where Loki was trending down (before this high number madness), and then he suddenly shot up from stress/excitement, and never came back down again.

The first instance was I turned on a handheld vacuum and he was pretty close to it. I didn’t mean to scare him, but it did and he ran off. It spiked his BG, and he stayed higher.
The second instance was my mom came to visit and he was happy and excited to see her. The same pattern happened with his BG.
Shouldn’t the insulin be working to stop this from happening, or even if there’s a quick spike reaction, shouldn’t he be able to trend back down? I just felt like the insulin wasn’t doing it’s job of stopping this. Maybe I’m way off, but it seemed strange to me. Also could be because he’s not regulated yet? Just wanted to point this out because I thought it might be important and has been bugging me.

 

[Suzanne & Darcy]

But you did also suspect a pancreatitis flare, right? You could take him for bloodwork and the fpL test for pancreatitis to see if there are any indications of infection? Or do you want to wait and get this done by a new vet?

 

[Suzanne & Darcy]

We will help and support you whichever way you wish to go. Lantus or ProZinc, etc. We want Loki out of the blacks. Lantus may make it easier to get him into lower numbers, although if there’s an underlying medical problem then it could still be challenging until that is addressed.

 

[Lauren and Loki]

But you did also suspect a pancreatitis flare, right? You could take him for bloodwork and the fpL test for pancreatitis to see if there are any indications of infection? Or do you want to wait and get this done by a new vet?

Yes, I did expect a pancreatitis flare. He seems much better now. I don’t mind taking him to the specialist for the bloodwork. I will call them first thing tomorrow morning, I think it may be best to just check blood first. I will ask for an fpL test as well. What does that test show exactly?

I updated his SS, his ketones were 0.4, so that’s great! Also did a BG test simultaneously, and he was 446. I think I need to blood test manually more, maybe he’s not in the blacks as often as it seems (Libre limitations), but he’s still high obviously in the reds, and I know he can go that high into blacks. So idk, I just hope I can find a solution soon. Hang in there with me y’all! I’ll take him in for bloodwork, and get on it with the new vet tomorrow morning.

With MPM, do I increase the dose every 6 cycles if needed? I will obviously consult here first, but in case I don’t get a response, just checking. I also will read the MPM protocol. Just trying to get a quick answer about it.

Thank y’all so much!

 

[Suzanne & Darcy]

Yes, I did expect a pancreatitis flare. He seems much better now. I don’t mind taking him to the specialist for the bloodwork. I will call them first thing tomorrow morning, I think it may be best to just check blood first. I will ask for an fpL test as well. What does that test show exactly?

I updated his SS, his ketones were 0.4, so that’s great! Also did a BG test simultaneously, and he was 446. I think I need to blood test manually more, maybe he’s not in the blacks as often as it seems (Libre limitations), but he’s still high obviously in the reds, and I know he can go that high into blacks. So idk, I just hope I can find a solution soon. Hang in there with me y’all! I’ll take him in for bloodwork, and get on it with the new vet tomorrow morning.

With MPM, do I increase the dose every 6 cycles if needed? I will obviously consult here first, but in case I don’t get a response, just checking. I also will read the MPM protocol. Just trying to get a quick answer about it.

Thank y’all so much!

With MPM you can increase every 6 cycles if needed.

 

[Suzanne & Darcy]

The pancreatitis test that you want is the Spec fPL test for pancreatic lipase. During an episode of pancreatitis, pancreatic lipase is released into the bloodstream and can be used as a diagnostic marker for the disease. Other types of lipase are released from other organs, but the Spec fPL (feline pancreatic lipase) measures lipase that is specifically released by the pancreas and not the other organs so it makes the test very sensitive to the diagnosis of pancreatitis. Don’t let them do the Snap fPL test. That’s the quick in-house test for pancreatitis that is not as accurate.

I hope this is making sense.

 

[Lauren and Loki]

The pancreatitis test that you want is the Spec fPL test for pancreatic lipase. During an episode of pancreatitis, pancreatic lipase is released into the bloodstream and can be used as a diagnostic marker for the disease. Other types of lipase are released from other organs, but the Spec fPL (feline pancreatic lipase) measures lipase that is specifically released by the pancreas and not the other organs so it makes the test very sensitive to the diagnosis of pancreatitis. Don’t let them do the Snap fPL test. That’s the quick in-house test for pancreatitis that is not as accurate.

I hope this is making sense.

Makes perfect sense. Thank you for telling me which one to ask for.

 

[FrostD]

Yeah these numbers are telling me something else is going on here.

So the "downside" to Lantus is how gentle it is. Meaning, if you switch he'll tend to stay a little higher until you can get to a good dose. The depot also takes a week to fill. You'd really really have to stay on top of increases with the TR protocol.

In my opinion, right now you need ProZinc's "harsher" action to help cut through these higher numbers as protection against ketones (if he were bouncing it would be a different story, but we know he's not bouncing right now).

We know he's not bouncing right now, so my preference would be stick with ProZinc and the increases until you either (a) hit a breakthrough dose again or (b) resolve whatever is causing these higher numbers. Once he's seeing mid blue or lower again is when I'd switch. You can certainly get the script, insulin, and syringes now to have on hand. The expiration dates are usually pretty far out.

 

[Lauren and Loki]

Yeah these numbers are telling me something else is going on here.

So the "downside" to Lantus is how gentle it is. Meaning, if you switch he'll tend to stay a little higher until you can get to a good dose. The depot also takes a week to fill. You'd really really have to stay on top of increases with the TR protocol.

In my opinion, right now you need ProZinc's "harsher" action to help cut through these higher numbers as protection against ketones (if he were bouncing it would be a different story, but we know he's not bouncing right now).

We know he's not bouncing right now, so my preference would be stick with ProZinc and the increases until you either (a) hit a breakthrough dose again or (b) resolve whatever is causing these higher numbers. Once he's seeing mid blue or lower again is when I'd switch. You can certainly get the script, insulin, and syringes now to have on hand. The expiration dates are usually pretty far out.

Thank you for your input. I’m not familiar with using Lantus, I would definitely need guidance in the future.

ProZinc’s “harsher” method is the MPM method we are trying now, correct?

Ok, so you think I actually do NEED to switch to Lantus eventually though? Even if we hit a breakthrough dose, or if some infection is going on that's causing this? For example, what if there’s some issue with his teeth, and we resolve that, and then he’s doing better on ProZinc? Do I still switch? I’m not trying to put the cart before the horse, just wondering if that’s what you mean, and if I should be expecting to be switch him regardless.

I already have an unopened bottle of Lantus (in it’s generic form glargine) in my fridge, it’s been there since mid-December, as well as the syringes for it (U-100s) I would just need the vet to write a script for refills eventually. But I at least already have the supplies on hand.

Thank you.

 

[FrostD]

It's a little hard to see the forest from the trees since it's been muddied by him not feeling well a few times.

When he was well, he did well on ProZinc and no, I wouldn't have been jumping to switch.

If he continues to get bouts of inappetence, Lantus may be a better option as it would likely allow you to give full doses with less hypo risk (as opposed to having to do token doses with ProZinc).

Sorry it's not a more straightforward answer. If it were me, I'd see how the rest of the vial goes (assuming ketones stay manageable) and then make a decision.

 

[Lauren and Loki]

It's a little hard to see the forest from the trees since it's been muddied by him not feeling well a few times.

When he was well, he did well on ProZinc and no, I wouldn't have been jumping to switch.

If he continues to get bouts of inappetence, Lantus may be a better option as it would likely allow you to give full doses with less hypo risk (as opposed to having to do token doses with ProZinc).

Sorry it's not a more straightforward answer. If it were me, I'd see how the rest of the vial goes (assuming ketones stay manageable) and then make a decision.

It’s all a little too hard to tell right now. I’m taking him in for bloodwork tomorrow morning. And I’ve set up an appointment with a new cat-only vet for this Friday to get his teeth examined and see if he needs any treatment for them, which I expect he’ll at least need a cleaning.

He’s been eating and seeming fine the last couple days. As far as the rest of my ProZinc bottle, it’s literally almost empty, so I had to place a new order this morning. I’ll get that tomorrow, and will be starting a new vial. So that’ll just be a matter of if things keep going the same way. Tonight’s dose will be his 6th cycle on 1.5U, so technically I’m supposed to increase it tomorrow morning if he doesn’t improve. I’m hoping the vial isn’t the issue, because I’m nervous about dosing him with 2U from a brand new vial if that was the issue. Although that would be the simplest way to resolve all this lol, I sure hope he doesn’t go into hypo..will be monitoring closely.