Smudge is Home! How to start TR?

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allicatmeow

allicatmeow

Member Since 2023
Smudge is home and quite happy! Purring and rubbing against me almost constantly. Peed and pooped right away and is exploring his new bedroom. Ate a few nibbles of DM.

I took his BG (using my Relion) as soon as he settled a bit and it is 92 @ +8.25.
His AMPS BG (on an AlphaTrak2, NOT Relion) was 368.
I forgot to try to do a dual reading with the AlphaTrak3 and Relion because I was anxious and just wanted a reading to record.

His take home instructions state to give 4U at 7am and 7pm. Walgreens only had the vial in stock, not the pens.
I only have whole unit syringes from them, just ordered half units that will arrive next week.

How many times per day for the next few days should I be getting his BG? I want to be sure things look okay with the Relion and also if he is getting too much, he can adjust. I really want to start the TR method and they okayed it, they want to see him back on 9/8 for a checkup.

He could not have cared less that I had to poke him twice. Just laid there like nothing was happening. He is such a good boy!!


Original thread: https://felinediabetes.com/FDMB/threads/new-unique-situation-for-smudge.280874/
 
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Tried to do a BG reading @+10.5 and cannot do it. Either the lancet doesn't draw blood (ears are warmed) or the Relion is giving me Err4 every time I actually do get blood (insufficient amount or too thick). Giving up til PMPS.
 
Sorry just saw this. It should be fine to skip as the vet instructed. Let him eat whatever he wants right now, the key to keeping DKA at bay is lots of food, water, and insulin. As he is not getting insulin tonight, food and water will have to do.
 
allicatmeow said:
Tried to do a BG reading @+10.5 and cannot do it. Either the lancet doesn't draw blood (ears are warmed) or the Relion is giving me Err4 every time I actually do get blood (insufficient amount or too thick). Giving up til PMPS.
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often with Hendrick I have to prick, then gently massage the ear, "milk" it to get the drop large enough for the meter

if too small, you will get that Err4

it takes a while (or it did for me at least) until you know by just looking at it, if the droplet is big enough
 
Hendrick Cuddleclaw said:
Sorry just saw this. It should be fine to skip as the vet instructed. Let him eat whatever he wants right now, the key to keeping DKA at bay is lots of food, water, and insulin. As he is not getting insulin tonight, food and water will have to do.
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But then what happens for the morning "meal" they want him to have at 7am to then give 4U?

Sorry, I am just panicking. I did not expect his BG to be so low (normal) after all the daily numbers in hospital.
 
I think 4U is crazy. To be honest. We have had many many diabetic cats who only got to 4U after months of .25U increases, little by little with lots of monitoring and BG checking.

Let's see what some of the experts say. I tagged some members, we'll here from someone.
 
Suzanne & Darcy said:
For heaven’s sake, he needs to eat after a DKA!!
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That's why I'm so upset. My vet that I have a 20yr relationship with said it was fine to graze because he showed them in hospital that's what he wanted to do. The on-call gave the adamant "2 meals, 12 hours apart" stance. I had them leave my vet a message to call me in the morning.
 
So absolutely do not shoot 4 units with a PMPS OF 84 on the Alpha Trak. Try testing him in 2 hours from 7 pm and see how he is doing. What was the cause of the DKA? Was there an infection present? Is he on antibiotics?

ETA: I want to go back and edit this comment to explain for anyone who comes along later. I was concerned about the starting dose of 4 units for this cat when there was almost no spreadsheet data. That I what the above was meant to say -- it was the large starting dose of 4 units and no data. It is, of course, very important for a cat who is post-DKA to have adequate insulin, and food, and lots of water, and for ketones to be tested daily.
 
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Suzanne & Darcy said:
So absolutely do not shoot 4 units with a PMPS OF 84 on the Alpha Trak. Try testing him in 2 hours from 7 pm and see how he is doing. What was the cause of the DKA? Was there an infection present? Is he on antibiotics?
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He got into a fight with a neighborhood cat and got an abscess on his face. The healing was extremely slow and he got lethargic, so we had a recheck and bloodwork/urine showed diabetes and DKA. He had a 2nd convenia shot on 8/24.
 
allicatmeow said:
That's why I'm so upset. My vet that I have a 20yr relationship with said it was fine to graze because he showed them in hospital that's what he wanted to do. The on-call gave the adamant "2 meals, 12 hours apart" stance. I had them leave my vet a message to call me in the morning.
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Do not listen to that wrong thinking about two meals twice a day! I promise you. Cats do much better on multiple small meals and snacks fed throughout the day and even the evening (especially our diabetic babies). You are doing fine and your knowledge of your cat and intuition in this instance are correct. Post DKA it is even more important than ever that your baby eat!
 
Hendrick Cuddleclaw said:
The one good thing about the AlphaTrak is how little a droplet it needs. When we switched to the human meter we had to adjust.
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I'm may to have to stick with the AT3 for some time if that's the case with the smaller droplet. I changed the batteries in the Relion in case that was an issue (reading on forums it can throw repetitive Er4 instead of E04! when it's running low).
 
allicatmeow said:
He got into a fight with a neighborhood cat and got an abscess on his face. The healing was extremely slow and he got lethargic, so we had a recheck and bloodwork/urine showed diabetes and DKA. He had a 2nd convenia shot on 8/24.
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Okay so it was the infection that pushed him into a life-threatening DKA. I understand. He will be fine now as long as you feed him adequate calories, you test for ketones and he gets enough insulin. However, with his BG being so low tonight and having virtually no data on the spreadsheet, I think it was right to skip insulin tonight. Get in a test or two tonight and we will see where he is in the morning.
 
Suzanne & Darcy said:
Okay so it was the infection that pushed him into a life-threatening DKA. I understand. He will be fine now as long as you feed him adequate calories, you test for ketones and he gets enough insulin. However, with his BG being so low tonight and having virtually no data on the spreadsheet, I think it was right to skip insulin tonight. Get in a test or two tonight and we will see where he is in the morning.
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I will test at +2 (9pm EDT) (even though he's pretty upset with me). I also was able to dunk half the ketones stick end pad into his urine before it absorbed into the litter at about 3:30pm and it showed negative.
 
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allicatmeow said:
How many times per day for the next few days should I be getting his BG?
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Just getting back to this original query -- TR says a minimum of 4X/Day: AMPS, PMPS, and then at least one other test mid-cycle, for both cycles. (cycle as in, the 12-hour cycle of the insulin)

But the truth is I often tested 6+ times a day. Because I would always test AMPS and PMPS and then another test at what we call +2 (2 hours after the insulin) to see how the insulin is kicking in and get an idea if more tests are needed. If there is a sharp drop from the pre-shot value, then more testing is needed. If things stay about the same, or flat as we call it, then usually more tests are not as critical.
 
allicatmeow said:
I will test at 9pm (even though he's pretty upset with me). I also was able to dunk half the ketones stick end pad into his urine before it absorbed into the litter at about 3:30pm and it showed negative.
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This is good (the negative ketones ). I will check back with you about 9 as I am also in Eastern time zone.
 
Since we don’t have much data on your cat, as many tests as you can get away with would be helpful. Tonight, since you skipped insulin, I would get a +2 and see how it goes. That’s only a few minutes away now. I will go feed my very hungry cats and check back in a few.
 
That is good the ketone test was negative.
How long past PMPS are you at now?...sounds like almost +2
I am a bit concerned about skipping the pm cycle but obviously can't shoot an BG 84 on the alphatrak meter.
What time is your AMPS and PMPS at the moment?

I will be around for the AMPS @Hendrick Cuddleclaw. Its only 10.45 am here.

I also echo what @Suzanne & Darcy said about eating. Your kitty needs to be eating 1 and a half times the number of calories he normally eats while he recovers from the DKA
 
allicatmeow said:
@Bron and Sheba (GA)
@Suzanne & Darcy

Used the AT3 again and he is 89 @ +2.
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Okay. Your spreadsheet says 84, but it doesn’t matter because that’s essentially the same as 89. Sp he is flat, no change. That is good. I definitely would not shoot 4 units tomorrow morning.
So let me get this straight. He was just diagnosed 4 days ago on the 25th of August. Do you know what his Fructosamine test number was? That is the test to diagnose diabetes as it will give a kind of average of his blood glucose over a period of two weeks or so.
 
Suzanne & Darcy said:
Okay. Your spreadsheet says 84, but it doesn’t matter because that’s essentially the same as 89. Sp he is flat, no change. That is good. I definitely would not shoot 4 units tomorrow morning.
So let me get this straight. He was just diagnosed 4 days ago on the 25th of August. Do you know what his Fructosamine test number was? That is the test to diagnose diabetes as it will give a kind of average of his blood glucose over a period of two weeks or so.
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Sorry, I updated it to 89 but didn't hit enter. Fixed now. They did not do a fructosamine test.
 
I just want to point out that when starting Lantus, it takes several days for the “depot” to fill, meaning that you won’t see the true effect of a given dose after only one or two shots. The effects are cumulative over time.

How many 4u shots has Smudge been given? I’m concerned that the vet might have administered one or two 4u doses, saw what seemed to be a nice nadir, and determined based on that limited data that 4u was an appropriate starting dose (that’s an unusually high starting dose, even with DKA in the picture). I think it’s very possible that 4u is too much. Not to sound critical, but I’m questioning the vet’s diabetes-related expertise a bit given both the starting dose and the insistence on only two meals a day (especially given DKA). Hmmm.

With a depot-type insulin, such as Lantus, you can see the effects of a shot even after the end of the 12-hour cycle, so I’m glad you’re keeping an eye on BG.

You jumped straight into the deep end of the pool with Smudge and DKA — it’s definitely not an easy way to start out—but you’re doing a great job. I’ll leave dosing advice to Bron and the others who have been through the DKA journey.
 
allicatmeow said:
Sorry, I updated it to 89 but didn't hit enter. Fixed now. They did not do a fructosamine test.
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That’s not really good that they didn’t do a fructosamine test. As I said, fructosamine would have given a sort of average BG over the course of a couple of weeks. So we really don’t know what his BG was doing before the infection and the DKA. This is more missing information that makes me even more cautious about the starting dose.
 
Anyway, I will be around at 7 a.m. I am in your same time zone. I woke up at 3 a.m. this morning and just decided to stay up. I guess I’m waiting for the hurricane to hit. In my location we are only expecting heavy rain and winds, but I need to know when it will start so I can feed the community cats before that.

Question: do you have a blood ketone meter? I used the Nova Max Plus. Or are you using urine test strips. The threads are really long and I may have missed the answer to that question.
 
JL and Chip said:
How many 4u shots has Smudge been given? I’m concerned that the vet might have administered one or two 4u doses, saw what seemed to be a nice nadir, and determined based on that limited data that 4u was an appropriate starting dose (that’s an unusually high starting dose, even with DKA in the picture). I think it’s very possible that 4u is too much. Not to sound critical, but I’m questioning the vet’s diabetes-related expertise a bit given both the starting dose and the insistence on only two meals a day (especially given DKA). Hmmm.

With a depot-type insulin, such as Lantus, you can see the effects of a shot even after the end of the 12-hour cycle, so I’m glad you’re keeping an eye on BG.

You jumped straight into the deep end of the pool with Smudge and DKA — it’s definitely not an easy way to start out—but you’re doing a great job. I’ll leave dosing advice to Bron and the others who have been through the DKA journey.
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I'm waiting for his medical transcription of the entire hospital stay to come over, but in total, he would have been given eight total shots at 4U every 12hrs over the course of 4.5 days, plus 2 of the fast acting insulin the first day when he arrived there (the name escapes me and I'm laying in bed waking up after a terrible night's sleep).

Suzanne & Darcy said:
That’s not really good that they didn’t do a fructosamine test. As I said, fructosamine would have given a sort of average BG over the course of a couple of weeks. So we really don’t know what his BG was doing before the infection and the DKA. This is more missing information that makes me even more cautious about the starting dose.
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Unfortunately he's had this abscess/wound/infection for 7 weeks now, so I am not sure a fructosamine would help all that much. He originally got the abscess flushed, a cerenia shot, as well as ointment to heal it. Then the extremely slow heal, weight loss of 2.2lbs over 6 weeks, which then turned into increased thirst, lethargy, and plantigrade stance/walk last week all triggered the visit and the findings.

Suzanne & Darcy said:
Question: do you have a blood ketone meter? I used the Nova Max Plus. Or are you using urine test strips. The threads are really long and I may have missed the answer to that question.
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I used a urine test strip yesterday when he got home. I have the blood ketone meter on the way, it's due in tomorrow. I don't know how I will use it though, when I'm barely getting the BG meter blood for readings right now and traumatizing him when trying.
 
Can you input the data from the vet on your spreadsheet? At least put on there when he received the 4 units of insulin? And any numbers that you get?
 
Suzanne & Darcy said:
Can you input the data from the vet on your spreadsheet? At least put on there when he received the 4 units of insulin? And any numbers that you get?
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I'm waiting for the transcription to get all the data, but I will do my best based on my calls and notes in just a few minutes.

He is up and alert and happy this morning. Ate all his food (1 can of DM) and is asking for more. Going to wait til 7am to get a BG and give him more DM so he eats more of a "meal" if he needs the 4U. I will also not be blindly giving 4U without calling *my* vet who said yes to grazing, etc and giving him the full picture of the 80s BGs last night.
 
allicatmeow said:
but in total, he would have been given eight total shots at 4U every 12hrs over the course of 4.5 days, plus 2 of the fast acting insulin the first day when he arrived there
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Hmmm, ok. I was under the impression that he was on fast-acting insulin while hospitalized for DKA and only received the 4u Lantus yesterday morning (the day he was being sent home). I’m not very familiar with using a long-acting insulin like Lantus while treating DKA. I assume any electrolyte imbalances were corrected?

Smudge did test negative for both FeLeuk and FIV, correct?
 
allicatmeow said:
I don't know how I will use it though, when I'm barely getting the BG meter blood for readings right now and traumatizing him when trying.
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It’s unfortunate that they didn’t put a Libre sensor on him then while you and he get used to the testing. I thought he was a very relaxed cat who didn’t mind the testing. I’m sorry you have been having trouble. Be sure to give a treat or two with every test. You may even want to just touch his ears like you were going to do a test and just give a treat. It also helps to have a single “testing spot” where Smudge can expect to receive treats. I did that in the beginning with my cat, but he was a gem and pretty soon I could test anywhere (even in bed with him) but we started on top of a barstool. I fed him snacks there too.
 
JL and Chip said:
Hmmm, ok. I was under the impression that he was on fast-acting insulin while hospitalized for DKA and only received the 4u Lantus yesterday morning (the day he was being sent home). I’m not very familiar with using a long-acting insulin like Lantus while treating DKA. I assume any electrolyte imbalances were corrected?

Smudge did test negative for both FeLeuk and FIV, correct?
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The first day they had said he reacted extremely well to the first dose of fast acting and they wanted to start the Lantus to get him going on it. He only needed 2 of the fast acting and then when he was constantly up over 360 at 7a/7p, he would drop into nice "low 100s" numbers after the Lantus shot for the majority of the 12hr stretch. Also, yes, he was on a fluid drip the entire hospitalization (Normosol-R).

Yes FIV/FeLV negative. We figured he had one of those or diabetes, so we tested, and here we are.

I wish I had all the number data but I don't just yet and my phone call notes are spread all over my house. Hoping I get it today.
 
allicatmeow said:
I'm waiting for the transcription to get all the data, but I will do my best based on my calls and notes in just a few minutes.

He is up and alert and happy this morning. Ate all his food (1 can of DM) and is asking for more. Going to wait til 7am to get a BG and give him more DM so he eats more of a "meal" if he needs the 4U. I will also not be blindly giving 4U without calling *my* vet who said yes to grazing, etc and giving him the full picture of the 80s BGs last night.
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Okay so you aren’t supposed to feed him for two hours prior to your preshot tests. Now, any test that you get will be elevated by food. That kind of confuses the issue - unless you did get a test?
 
Suzanne & Darcy said:
It’s unfortunate that they didn’t put a Libre sensor on him then while you and he get used to the testing. I thought he was a very relaxed cat who didn’t mind the testing. I’m sorry you have been having trouble. Be sure to give a treat or two with every test. You may even want to just touch his ears like you were going to do a test and just give a treat. It also helps to have a single “testing spot” where Smudge can expect to receive treats. I did that in the beginning with my cat, but he was a gem and pretty soon I could test anywhere (even in bed with him) but we started on top of a barstool. I fed him snacks there too.
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I am honestly considering a libre right now. He often has a cone on to keep him from kicking his wound while it itches. He is still very relaxed in general, don't get me wrong. He lets me do everything I need to, he just gets annoyed by the end because I have to keep him still so long with my failures, and that makes it even harder to do - snowball effect. He never ever gets actually mad or anything, just annoyed at me and wants to be alone after. Still wants love if I reach out and still purrs. I will grab a cat bed Penny doesn't use and designate that for now.

Suzanne & Darcy said:
Okay so you aren’t supposed to feed him for two hours prior to your preshot tests. Now, any test that you get will be elevated by food. That kind of confuses the issue - unless you did get a test?
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Oh thank you, I completely forgot the two hour rule, because of the okay to graze. Sigh. I can wait til 8am and get a hold of my vet in between. Or I can do 7am and 8am. I took the food away at 6am, but unsure when he actually had his last bites.
 
allicatmeow said:
I am honestly considering a libre right now. He often has a cone on to keep him from kicking his wound while it itches. He is still very relaxed in general, don't get me wrong. He lets me do everything I need to, he just gets annoyed by the end because I have to keep him still so long with my failures, and that makes it even harder to do - snowball effect. He never ever gets actually mad or anything, just annoyed at me and wants to be alone after. Still wants love if I reach out and still purrs. I will grab a cat bed Penny doesn't use and designate that for now.


Oh thank you, I completely forgot the two hour rule, because of the okay to graze. Sigh. I can wait til 8am and get a hold of my vet in between. Or I can do 7am and 8am. I took the food away at 6am, but unsure when he actually had his last bites.
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Yes. If you took the food away at 6 then if you can wait until 8 a.m. to do a fasting BG test then that would be good.
 
Or yes. You could test at 7 a.m. if you can and see where he is. Then you could check again at 8. Are you calling the vet to verify that he/she wants you to shoot 4 units?
 
Are you warming the ear before you test? That can help a lot.

I’m curious what you get for BG values this morning after skipping last night’s shot. Inquiring minds and all… :)
 
Suzanne & Darcy said:
Did you reach your vet?
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He is in the middle of an emergency procedure and is going to call me back. I feel like I need to feed him and give the 4U as instructed for now. His discharge instructions are that if he doesn't eat a "full meal" to do half dose (2U) and offer more food later. Seeing how much he will eat now...

Edit: He just called back. Because Smudge is at 413, he wants me to do the 4U now and test throughout the day. If he is low again tonight, we will either skip based on the number or I have the okay to drop back to 2U or 3U depending. Will need guidance!

He basically said the grazing "complicates the idea of 12hr dosing" but it's not uncommon and we can do whatever Smudge needs.
 
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allicatmeow said:
He is in the middle of an emergency procedure and is going to call me back. I feel like I need to feed him and give the 4U as instructed for now. His discharge instructions are that if he doesn't eat a "full meal" to do half dose (2U) and offer more food later. Seeing how much he will eat now...

Edit: He just called back. Because Smudge is at 413, he wants me to do the 4U now and test throughout the day. If he is low again tonight, we will either skip based on the number or I have the okay to drop back to 2U or 3U depending. Will need guidance!

He basically said the grazing "complicates the idea of 12hr dosing" but it's not uncommon and we can do whatever Smudge needs.
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Feeding small snacks (teaspoon or two throughout the early portion of the cycle- before nadir at about +6 for a lot of cats) will help stabilize BG and help prevent too steep of a drop which can trigger a bounce. It’s okay.
 
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