Yahiko's progress (& his mom's anxiety LOL)

[Rebecca M]

I know I have the other thread going but I just got back from the ICU and I'm absolutely freaking out. It's Saturday night and Yahiko has been in the ICU since Wednesday morning w/ DKA. Most vets have been (or became) EXTREMELY optimistic. One vet told me yesterday morning that there was a "good chance" his values would never stabilize enough to come home but then by evening was talking about sending him home with me. His blood sugar isn't great (200s-300s) but it's under control.

But after his potassium trended upward since yesterday morning and was looking really good, it suddenly crashed. He received 2 units of insulin this morning at 9AM after eating. His blood sugar was around the 200-250 range until 9:30PM or so when they took blood and ran it, and his blood sugar was 359 (which the vet was still happy with) and his potassium had suddenly plummeted from its highest yet of 3.4 at 1PM to its second lowest yet of 2.5. I am absolutely freaking out. Below is a record of his potassium numbers.

Dec 13 10AM: 4. Arrival at clinic.
Dec 14 9AM: 1.8. They told me it was kind of to be expected after 24 hours on an insulin drip but he was so unwell they were talking euthanasia. He perked up when he saw me and they decided to move forward with the 4-hour max drip.
Dec 14 4PM: 3.3. following conclusion of the 4-hour drip. He was feeling SO good. He was up and about, vocal, perky, bright.
Dec 14 11PM: 2.5. I went in to visit him and thought he didn't look nearly as bright, vets thought he was just tired but at my insistence they checked and he had gone down quite a bit. They were surprised because he's been on IV K supplements consistently, but I didn't think much of it. They weaned him off of the short-acting insulin to switch him to Lantus in the morning and did a second 4-hour K max drip.
Dec 15 - 9AM: 3.1. He was given 1.25 units of Lantus at this time. The vet told me she was increasing his oral supplements but leaving the IV the same.
Dec 15 - 2PM: 2.8. It went down, not as dramatic a crash but in 5 hour span it was concerning (but also understandable since it followed Lantus). Again she said we would continue with the increased oral supplements but leave the IV.
Dec 15 - 11PM: 2.8. Stayed the same. Not great because still low, but not terrible considering he had 2 units of Lantus 2 hours earlier and it was staying stable.
Dec 16 - 5AM: 2.9. Tiny increase despite Lantus so was still too low but looking promising. Vet told me she wasn't satisfied with those numbers so increasing his IV fluids (this could be when they did the other 4-hour max K drip, not sure - they said there were 2 but I only knew the first one).
Dec 16 - 1PM: 3.4. He had gotten 2 units of Lantus at 9AM. His BG was in the 200s and his potassium was almost normal. I bought a ton of stuff for my home to make it easier for him when he comes home. They were talking about releasing him to me 10 hours later because everything looked stable. Multiple vets were onboard with this plan, though I wasn't (and, it turns out, for good reason).
Dec 16 - 9:30PM: 2.5. This was about an hour and a half ago. This is his biggest drop since the IV insulin tanked him - from his highest K since arriving to his second lowest. Possibly clinical presentation but it was hard to tell if he was just getting sleepy after our visit, which usually happened. The vet had no explanation for it. She was shocked. She said she suspected underlying disease but that didn't make sense with his original number of 4 before the insulin.

EDITED TO ADD:
Dec 16 - 5AM: 3.1. They had decided to give him Spironolactone to treat any underlying disease causing him to shed potassium, and his number went up (no changes to supplements)
END EDIT

So I'm absolutely panicking because it looked like we were on an EXCELLENT path and now we're looking at a .9 drop in potassium in only 8 hours. I can't bring him home like this. Which is fine for now, he can stay there, but that other vet's words are just ringing in my ears, that maybe he won't stabilize. But why?? Why won't his potassium stabilize? Has anyone else had a DKA cat with potassium levels that just DROPPED out of nowhere like that? Did they ever stabilize? How long did it take? I'm trying to be calm but I'm having a meltdown if I'm being honest. If they could explain it, it would be one thing, but they can't, so she phrased it as "may not be responding to treatment," and that feels like the worst set of words in the world right now.

Additionally, for any who have been in the same boat and remember what treatment they went with - she's offered a few, though she's stumped: 1) her preference, leave it and watch overnight since he's still on IV and oral K supplements, 2) try the 4-hour max K drip again "but we tried it 2 times already and it didn't stick", 3) assume he's got an underlying disease and start him on Spironolactone (a mild diuretic) but that that could make him dehydrated, which worries me. He's on IV fluids at the vet, but what about when he comes home?

EDITED TO ADD:
She put him on the spironolactone and it increased his potassium from 2.5 to 3.1. She doesn't think it will dehydrate him enough to warrant sub-Q fluids at home so if he continues to respond to the medicine, the plan is to keep him on it until we can follow up with his regular vet.
END EDIT

And I committed to spending any amount of money to save him but they are already WAY beyond even their own estimate and I am getting legitimately afraid now. They told me it would cost 1-2k per day and gave me a low estimate of 6k and a high estimate of 9k, total, for his treatment. This morning at 11AM we hit 72 hours and it was 8k (~2700/day). By tomorrow morning they've told me it will hit 10k (and based on their under-estimates every other time, I bet it will be more like 10,700). I had/have 3,000 in cash and 10,000 in financing - that will buy him MAYBE another day and a half in the ICU for a total of 5.5 days. I just financed 6k more, so probably 2.5 more days. 8 days total. I don't care about the money; I can make more money and there's no price on him. But I care that I don't think we will be approved for more than that, and my WORST fear is running out of time because I've run out of money. And after $19,000, to lose him because of a lack of money would be so beyond cruel. It seems like DKA ICU treatment is so much cheaper for everyone else based on the posts I've seen - I don't know if it's just where I live or what but I'm too scared to try moving him regardless.

I'm just looking for some advice and maybe some reassurance that someone else has been through this and their cat stabilized. And if it happened to you - what made the difference? Time? A medication? Will the oral supplements eventually kick in and take over? What can I research, what can I suggest?

 

[Red & Rover (GA)]

@Wendy&Neko
@Suzanne & Darcy
@Marje and Gracie
@Sienne and Gabby (GA)

 

[Red & Rover (GA)]

This list may be a bit outdated.

• Financial Help Links

 

[Wendy&Neko]

Previous post here if someone hasn't read the background: https://felinediabetes.com/FDMB/thr...ssion-and-into-dka-looking-for-advice.284599/

I'm sorry I can't answer on the DKA and potassium issue. My only experience with lower potassium was with a cat with ileus. And getting more food into her, along with a short course of potassium supplementation is what helped. How much food has Yahiko been eating at the clinic?

For financing, I think Care Credit is a common option in the US.

 

[Marje and Gracie]

I’m so sorry that his potassium hasn’t stabilized. I will have to do some research in this tomorrow because I also don’t know why this is happening.

I don’t know where you are but if it’s a large city, are there any internal medicine specialists you can consult with? Unfortunately you won’t be able to until Monday so that doesn’t help with the immediate issues.

See how he does overnight and let’s hope he takes a big step forward and holds it and I’ll see what I can find out.



Edited to add: while he’s not dealing with low potassium due to chronic renal failure, there is a lot of good info on low potassium on this site. How are his magnesium levels? It seems low magnesium can also contribute to low potassium. Also, I wonder if he could have an underlying adrenal gland issue? Has anyone checked his thyroid for hyperthyroidism or his blood pressure for hypertension? Are his sodium levels high?

It is not uncommon for diabetic cats to have lower potassium because insulin causes the uptake of potassium from the blood into the cells which is where the potassium is needed. However, potassium levels shouldn’t be as low as his which is clearly a sign of the DKA.

One of the paragraphs I read stated that potassium values might waver a bit when IV potassium is first given but it eventually stabilizes. There is also information that not eating can contribute but I’m not sure this applies to him since he’s getting IV and oral supplementation.

I just thought I’d post that so you could read through it. It’s very late here but it would give you something to look at until I can look more tomorrow.

 

[Rebecca M]

Previous post here if someone hasn't read the background: https://felinediabetes.com/FDMB/thr...ssion-and-into-dka-looking-for-advice.284599/

I'm sorry I can't answer on the DKA and potassium issue. My only experience with lower potassium was with a cat with ileus. And getting more food into her, along with a short course of potassium supplementation is what helped. How much food has Yahiko been eating at the clinic?

For financing, I think Care Credit is a common option in the US.

Thank you so much for responding - can you tell me a little more about this? What were the symptoms of the ileus and what were the potassium readings like?

Yahiko hasn't eaten much. I got almost a full can in him last night. They only let him eat every 12 hours, when he takes his insulin, because they're trying to regulate his blood sugar with his eating or something?? I was in there ready to press it when they brought the bloodwork results back and then I wanted him back on his potassium drip ASAP and he wasn't willingly eating anymore so they took him.

Re: financing, the vet hospital accepts Care Credit and Scratchpay but I've maxed out the financing I'm approved for.

 

[Rebecca M]

I’m so sorry that his potassium hasn’t stabilized. I will have to do some research in this tomorrow because I also don’t know why this is happening.

I don’t know where you are but if it’s a large city, are there any internal medicine specialists you can consult with? Unfortunately you won’t be able to until Monday so that doesn’t help with the immediate issues.

See how he does overnight and let’s hope he takes a big step forward and holds it and I’ll see what I can find out.



Edited to add: while he’s not dealing with low potassium due to chronic renal failure, there is a lot of good info on low potassium on this site. How are his magnesium levels? It seems low magnesium can also contribute to low potassium. Also, I wonder if he could have an underlying adrenal gland issue? Has anyone checked his thyroid for hyperthyroidism or his blood pressure for hypertension? Are his sodium levels high?

It is not uncommon for diabetic cats to have lower potassium because insulin causes the uptake of potassium from the blood into the cells which is where the potassium is needed. However, potassium levels shouldn’t be as low as his which is clearly a sign of the DKA.

One of the paragraphs I read stated that potassium values might waver a bit when IV potassium is first given but it eventually stabilizes. There is also information that not eating can contribute but I’m not sure this applies to him since he’s getting IV and oral supplementation.

I just thought I’d post that so you could read through it. It’s very late here but it would give you something to look at until I can look more tomorrow.

Thank you so much for taking the time to answer me. It's about 5:40AM here and I'm waiting on his 5AM potassium results to see if it dropped further or not. You mentioned chronic renal failure but he actually does have stage II kidney disease - could that be a factor? When he arrived almost 4 days ago, his creatinine was at 3.3. His original baseline was I think 1.8 or 1.9 so they always called him borderline Stage I/stage II. His creatinine has been steadily but slowly decreasing since then and at 9PM it was 2.06. Is that severe enough CKD to tank his potassium that abruptly though? And if so, why would it only be sometimes? I'm just trying to wrap my mind around it. My hope is that since he's only been on the oral potassium supplements for about 2 days, maybe they haven't really been able to impact his blood levels yet and that will increase, but I don't know if that's a realistic hope or how much of an increase I can count on.

 

[Rebecca M]

Hi all, quick update. His 5AM bloodwork showed that his potassium had gone back up to 3.1 without increasing any of his supplements, which is amazing. They started him on the spironolactone. She told me she doesn't think it will dehydrate him enough to require sub-q fluids at home. (I'm obviously still not taking him home any time soon by my choice but I was asking for the future). So she wants to see how he keeps responding and probably keep him on it, at least for 5-7 days after discharge when he can be checked by his primary care vet, though I plan to follow-up with them much sooner than 5-7 days. His blood sugar is still stable in the 200s and 300s which all of the vets seem happy with and maybe I will just have to learn to be happy with it.

I don't know if this is good news or bad news; I need to research the other disease she thinks he has that would cause the potassium to drop. I hate that he now has ANOTHER comorbidity that he doesn't seem to have arrived with, but whether he does or doesn't, fingers crossed that his potassium continues to trend upward so that he's at least stable. I'm still waiting on the ketones/urine glucose and will probably find out in an hour and a half when I go in to get him.

 

[JL and Chip]

Yahiko hasn't eaten much.

They only let him eat every 12 hours, when he takes his insulin, because they're trying to regulate his blood sugar with his eating or something??

I seriously question this approach. Food is very important when treating DKA — a common goal is 150% of normal calories so restricting food, especially in an inappetent cat, makes no sense to me. @Bron and Sheba (GA)

 

[Sienne and Gabby (GA)]

How are his sodium levels?

 

[Marje and Gracie]

Thank you so much for taking the time to answer me. It's about 5:40AM here and I'm waiting on his 5AM potassium results to see if it dropped further or not. You mentioned chronic renal failure but he actually does have stage II kidney disease - could that be a factor? When he arrived almost 4 days ago, his creatinine was at 3.3. His original baseline was I think 1.8 or 1.9 so they always called him borderline Stage I/stage II. His creatinine has been steadily but slowly decreasing since then and at 9PM it was 2.06. Is that severe enough CKD to tank his potassium that abruptly though? And if so, why would it only be sometimes? I'm just trying to wrap my mind around it. My hope is that since he's only been on the oral potassium supplements for about 2 days, maybe they haven't really been able to impact his blood levels yet and that will increase, but I don't know if that's a realistic hope or how much of an increase I can count on.

I am sorry if I misled you into thinking he has chronic kidney disease (CKD). I was just linking the discussion on potassium from that site because it’s pretty thorough. I know your vet has said he has Stage I or II CKD based on a creatinine of 1.8-1.9 but you can’t look at creatinine in a vacuum when diagnosing CKD. For example, raw fed cats (like mine) might have a higher baseline creatinine. Larger cats also tend to have higher baseline creatinine. In order to diagnose CKD, your regular vet would need to also look at an SDMA test and his urine specific gravity (USG) from the first urine of the morning to determine if he can concentrate his urine. But those are things that can wait until he’s much better because, with receiving fluids, his USG will be lower.

However, for the sake of discussion, let’s say he does have Stage I or II CKD. I never say never but we would not “typically” expect CKD to affect the potassium at those early stages. One of my cats was in Stage III for years and never had low potassium. The low potassium here is most likely associated with the DKA.

I can’t emphasize enough that he must have more calories and, if he were my cat, I would really be pressing this issue. For a vet to say she doesn’t want him to eat because his BG will go up tells me they don’t understand how to manage FD. We deal with DKA here a lot and we tell members who have the kitty at home that it doesn’t matter if they want ice cream….they need calories and you can always adjust the insulin to bring the BG down. I am extremely worried that he is at risk for fatty liver disease because it can and does happen with just a reduction in calories over several days (and less for some cats). If they know what they are doing, they can shoot a bolus insulin like R if his BG climbs but to limit his food to every 12 hours is….frankly, working at odds with resolving the DKA.

I wonder if they are also doing that because of their vet tech schedule. At any rate, I don’t know if you are off work for the holidays but if you have the ability to go down there every couple hours and feed him…even with a syringe…he will be better off. You want the highest calories food you can find that you can syringe. Something like Hill’s Prescription Diet/Urgent Care has 180 kcal in a 5.5 oz can. If you look at this food chart, it lists the calories per ounce of many, many canned foods and there are several that have more than the Hill’s and there might be something he would prefer to eat but he must have lots more calories.

Are they monitoring his liver values because that is important considering how little he is eating? And as Sienne said, it would be good to also know what his sodium level is. And magnesium.

If his potassium continues to come up today and they feel you can orally supplement him, you might need to seriously think about whether he’d be better off at home with you. Yes, his nursing care will be intensive and you’ll probably need to take time off work. I am concerned about the spironolactone dehydrating him. I’m not certain if that is typically used in DKA cases (I haven’t seen it before but that doesn’t mean it isn’t used). However, I did a search within FDMB and not one reference to it came up in conjunction with DKA. It’s typically used for congestive heart failure.

IF you felt you could take him home and IF you are able to give subq fluids (we have a video to teach you), you could ask the vet about giving him additional potassium through a port in the line you administer the fluids with.

 

[JL and Chip]

I am extremely worried that he is at risk for fatty liver disease because it can and does happen with just a reduction in calories over several days (and less for some cats)

As someone whose naturally lean diabetic cat went into HL within 48 hours of not eating enough while hospitalized (despite my excellent IM vet telling me it wouldn’t happen), I agree wholeheartedly.

 

[Rebecca M]

Thank you all SO MUCH for your responses!! So much to think about.

Re: feeding - I just got back from the vet. I didn't press the issue this time - I just did it. I had done it last night, too, but a little bit less and he ate less himself. This time, the vet tech brought him in and left me with him and told me he had eaten 1/4 of a can and told me I could give him "whatever" I wanted. So I did. He ate a little bit from several different cans (we have been bringing him a WHOLE buffet variety every day) but not nearly enough. I gave him 2 syringes of the FF pate blended with a tablespoon of water (I made it in advance and brought it to him) - so a little less than half of a can. And he was PISSED at me for about twenty minutes, and then... he went back and ate more on his own!! I would say he had a little over 1 can in total. Is it enough to gain weight? No, but maybe at least enough to not lose anymore. It was by far the most he's eaten, even just on his own, and the fact that he went back for it after I fed him gave me SO much faith/hope. This was also the most active he's been, maybe because he got a legitimate amount of food in his system yesterday evening for the first time. He's been very excited to see us and eat every time but usually after 10-20 minutes he gets tired and lays down. This time he did not; he was walking around the entire time, yelling at us, demanding to be pet, grazing on more food, trying to jump up onto the counter, etc. He was doing so well and you could tell by the look in his eyes and how responsive he was, his purring and nudging, etc.

Re: ketones - They gave me the 5AM urine results. His ketones are still at a 5.0, unchanged, which I absolutely hate. The urine glucose, though, has come down. It was previously 500+ and now it's 250-500 and that's more or less what she predicted as his body flushes out the excess glucose over the next few days.

Re: sodium - Levels are within normal range. I say this assumingly because I don't have copies of his tests, but I call after EVERY blood test and ask for the results of his BG/potassium and ask them if any other numbers are abnormal, and sodium has never been one of them. Anemia and low calcium are both improving (neither were critical, just low). Phosphorus has resolved. BG is stable. He is acting exactly like he acts at home. The only 2 outliers here are the fluctuating potassium and the ketones.

Re: potassium - Now that he's on the Spironolactone and went up to 3.1, and now that he's eating a decent enough amount to supply some potassium, they've taken him off of the potassium supplements and are going to retest him at 5PM to see if the spironolactone was enough to hold or increase his potassium. If it has stayed the same or increased despite no supplementation, she wants me to take him home. I'm a little bit anxious about this because 1) I would like to see one more test showing they REALLY are stable, and 2) because his ketones are unchanged, though the vet today/last night/yesterday (same as today) actually wants to send him home despite the lack of change, and I think I understand that there's nothing they can actually do to treat the ketones, they just have to disappear, and they will as long as his BG is under control which it now is. So he would just be sitting in the hospital for the sake of being tested on them. If this were a Friday night I would say absolutely not, but it's Sunday evening and I can take him to my vet at 10AM Monday to be retested or seen for any clinical symptoms if they re-develop.

And honestly, I want him home so I can FEED him. The healthier he gets the less motivated they are to let me visit and the longer the wait each time. At home I can feed him, specifically syringe feed as much as necessary, and more often if/when necessary. I feel like he's hit a wall and he can't recover anymore without food in his system and they have a completely different approach but I just think I need to go with my instinct on this one. So IF his potassium is stable and they want to send me home with him at 5PM tonight, and if he still looks good and bright and his BG is still stable, I think I'll take him. I'll bring him back if I have to but he'll be better fed. I'm honestly feeling very very anxious about all of this and really scared that I'll show back up and they'll tell me his potassium fell again because this entire situation has swung so dramatically back and forth. But I'm hopeful. I feel like I've been in a non-stop panic attack since 9PM yesterday when all this happened, but if I get a 3.1 or higher on the potassium I think I'll be able to breathe again.

Re: the CKD/potassium - I honestly need to check with my regular vet tomorrow to find out what tests they did but he was in fact diagnosed before all of this started. A vet told me stage II in I think February, then another vet in June said no, it was stage I, so it's a bit up for debate but the veterinary hospital is going with stage II. I agree, doesn't really explain the potassium, but he never seems to react to anything the way the vets are expecting so I'm just brainstorming anything it could be. Both last night's vet and today's vet seem very convinced that it's hyperaldosteronism, but I'm not convinced for 2 reasons: 1) from my very limited online research, it's usually caused by a tumor and his number was 4 a matter of days ago, so I don't feel like he grew a tumor in half a week; and 2) it's reacting specifically to the insulin. Every time he gets insulin, and especially when they've increased his insulin, the potassium plummets 5-7 hours later. It doesn't feel like a disease is stripping potassium from him, it feels like his body is just hyper-reactive to the insulin. And I think that makes sense because he's on 2 units twice a day right now; he's only ever been on 1 unit twice a day and the first time he went too low within a matter of weeks even with normal eating and the second time he went into remission after 3 months with a seizure. So this is 2x the insulin his body has ever been introduced to, and I think his body chemistry is freaking out a little. I don't know what the word for that is in scientific or medical terms but that's just what my instinct is telling me, that it will stabilize over time as his body adjusts and/or the insulin dose decreases.

He has an appointment with his new internist on January 8 and I'm on a cancellation list for a sooner one, and in the meantime I'm going to make him weekly appts (or more often if necessary) with his regular vet to test his potassium and make sure it doesn't dip too low or go too high. The internist will also be helping me develop a plan for the potential IBD, CKD, and the heart murmur that they've apparently known about for a while but which was just mentioned to me the other day and seems to be a grade 2. @JL and Chip, it looks like your kitty Charlie had a lot of really similar illnesses so if you don't mind, when I'm in a better spot, I would love to chat with you about what managing this whole array is like.

 

[Marje and Gracie]

I’m glad there is some progress and I really hope he gets to come home today.

 

[Diane Tyler's Mom GA]

Hi Rebecca, I just want to let you know I have been following your posts and have been saying prayers for Yahiko and for you ♥♥

 

[Wendy&Neko]

Paws crossed Yahiko can come home today.

What were the symptoms of the ileus and what were the potassium readings like?

She only got as low as 3.4, but normal range starts at 3.7. Three months before she had been at 3.9 and now is 4.0 or over. Symptoms of ileus were going completely off her food. Ileus means lack of motility, food wasn't moving through her. This particular cat has IBD and small cell lymphoma (in remission). We had tried tapering down her prednisolone, but apparently that made the IBD unhappy. Treatment was fluids, upping the prednisolone dose back up, and potassium supplementation for a while.

FYI, diabetic kitty Neko had CKD, heart disease and small cell lymphoma too. A heart murmur can be completely benign - figuring out the cause of the murmur will guide treatment.

 

[Rebecca M]

Paws crossed Yahiko can come home today.

She only got as low as 3.4, but normal range starts at 3.7. Three months before she had been at 3.9 and now is 4.0 or over. Symptoms of ileus were going completely off her food. Ileus means lack of motility, food wasn't moving through her. This particular cat has IBD and small cell lymphoma (in remission). We had tried tapering down her prednisolone, but apparently that made the IBD unhappy. Treatment was fluids, upping the prednisolone dose back up, and potassium supplementation for a while.

FYI, diabetic kitty Neko had CKD, heart disease and small cell lymphoma too. A heart murmur can be completely benign - figuring out the cause of the murmur will guide treatment.

Thank you!! Yahiko has suspected IBD/small cell lymphoma, though there's no thickening shown on ultrasound. He was started on budesonide in I think September and was fine on it but they took him off a few days ago when he got DKA. He had his first BM today at the vet and it was diarrhea but I've heard his tummy rumbling/digesting after food for the last several days so I'm going to ask today what it looks like if he needs to go back on the budesonide in order to gain weight (the reason he was put on it to begin with - he lost a lot of weight). Would love to hear what your experience was with the insulin/steroid combo. He was on prednisolone for 2 months in the spring but they said it could flare up his diabetes so we switched to budesonide, which took a couple months because it was back-ordered. He DID gain weight on it and was really healthy before the DKA (which I suspect was anesthesia-induced and dry-food induced; he had surgery 2 weeks before DKA presentation at BG 619, it was probably steadily building) but was also in remission that whole time so not on any insulin. With the weight he's now lost from DKA I really, really want to start putting some back on him but I'm worried feeding him won't solve the problem if he can't absorb it. Budesonide in MOST cats doesn't increase blood sugar or only does so marginally, but not knowing what actually set him off is really worrisome. I have a feeling the vet is going to say no, don't put him back on it, but it makes me really anxious because his appt with the internist isn't for another 3 weeks and 3 weeks is a long time to not be absorbing nutrition.

 

[Wendy&Neko]

My Neko was one of those diabetic kitties on budesonide that didn't see any impact on her blood sugars. She had to do budesonide, because her heart condition could not handle prednisolone. Her budesonide I got through the local compounding pharmacy, as a liquid. She was challenging to pill and she had to take a lot of meds at that point.

SCL kitty #1 and #3 (sigh!) have been on prednisolone. Neko was #2. First kitty I tested his blood sugars due to being worried about diabetes, and although it increased his blood glucose values, it was still under 100. Current kitty has been on pred for 5.5 years, still tests normal blood glucose.

If there are any plans to biopsy or endoscopy to figure out what he has, he has to be off of steroid for a period of time first. Could be why vet is reluctant to put him back on. However, with DKA, he needs to get calories in him and on him. Steroid tapering can be done when DKA is well in the rear view mirror.

Has he had a GI blood work panel done? Specifically testing for B12 levels? Many IBD/SCL kitties have low B12 which will hinder food absorption. Supplementation in that case can help.

 

[Marje and Gracie]

Thank you!! Yahiko has suspected IBD/small cell lymphoma, though there's no thickening shown on ultrasound. He was started on budesonide in I think September and was fine on it but they took him off a few days ago when he got DKA. He had his first BM today at the vet and it was diarrhea but I've heard his tummy rumbling/digesting after food for the last several days so I'm going to ask today what it looks like if he needs to go back on the budesonide in order to gain weight (the reason he was put on it to begin with - he lost a lot of weight). Would love to hear what your experience was with the insulin/steroid combo. He was on prednisolone for 2 months in the spring but they said it could flare up his diabetes so we switched to budesonide, which took a couple months because it was back-ordered. He DID gain weight on it and was really healthy before the DKA (which I suspect was anesthesia-induced and dry-food induced; he had surgery 2 weeks before DKA presentation at BG 619, it was probably steadily building) but was also in remission that whole time so not on any insulin. With the weight he's now lost from DKA I really, really want to start putting some back on him but I'm worried feeding him won't solve the problem if he can't absorb it. Budesonide in MOST cats doesn't increase blood sugar or only does so marginally, but not knowing what actually set him off is really worrisome. I have a feeling the vet is going to say no, don't put him back on it, but it makes me really anxious because his appt with the internist isn't for another 3 weeks and 3 weeks is a long time to not be absorbing nutrition.

Is he home?

 

[Rebecca M]

Is he home?

He's home and it's such a mess but they don't want him back. They told me at 6PM to take him home but to reduce from 2u to 1u at dinner because his insulin dropped from 300s in the morning to 196 at 1PM and they thought that was too steep. I didn't like the idea of bringing him home on a brand new dose (50% the previous) because that seemed experimenting and experimenting seems like a recipe for disaster and I was right. When I got home, he was super thirsty so I tested him (Freestyle Libre) and it was 141. I checked his log out of habit and saw it had gone down to 97 at 4PM and no one had noticed because they didn't check the log, they just went on his numbers that they had specifically scanned. I immediately called the vet since they were the ones telling me to half his dose because it was 196. A vet who has never worked with him before was the one to answer and she told me to skip his insulin for tonight since those numbers are in "normal" range. I listened to her and wish I hadn't. I watched starting an hour after dinner as his BG numbers skyrocketed. I called them twice and they thought it was fine, told me to ride out until morning. When it hit 521 at 12:15 I FULL panicked that he was going to go back into DKA and called again. This time the vet (one who worked with him the last 2 nights) told me that if I was worried about it, I could give him 0.5u. So I did that about an hour ago but I know it won't even begin working until 1.5 to 2 hours. I have no idea if .5 was enough, or if it was too much since it was 4 hours after he last ate, or what that will mean for his morning numbers or morning insulin dose. I'm absolutely devastated right now and so angry with the vet who told me to skip it. It feels like I'm starting from 0 again - here he is with 500+ glucose at night after 100s during the day, absolutely wild fluctuations and I'm freaking out about how I'm supposed to find a middle ground.

He's wandering around acting reasonably? normal right now. Coming over for affection. Jumping onto and off of the bed. He was sleeping earlier. The Freestyle Libre is just giving HI and he gets really stressed every time I jab him for the ReliOn so even though I desperately want to know what his BG is going to peak at before the Lantus kicks in, I don't want to risk increasing it further. This is I think the highest it's been since his first night on the Lantus 3 days ago. I feel like such a failure.

 

[Basic's Mom]

@Wendy&Neko @Marje and Gracie @Sienne and Gabby (GA)
@Suzanne & Darcy

 

[Wendy&Neko]

Dealing with DKA is a lot, you don't need to feel like a failure. Don't bother poking him with for the Relion unless his numbers are a lot closer to 100. At this point, he is just "too high" and the exact number doesn't matter.

Is he eating at home?

With DKA, we never suggest skipping a dose. There are other options like feeding higher carb food, delaying until his numbers come higher, giving reduced dose, but not skipping. Post here and we can help you. You say you gave 0.5 units at 12:30 but that's doesn't mean anything to me as I'm not in your time zone. How many hours after your normal shot time is it?

We need to get your spreadsheet looking more like ours. The colors in the spreadsheet version we use mean something to us and we are used to seeing patterns in those colours. Either @Marje and Gracie or @Bandit's Mom can help with that.

 

[Wendy&Neko]

I'm signing off for tonight, but just a couple more points. 196 is a perfectly fine number, even 97 is safe in the middle of the cycle. Too steep a drop doesn't matter. It's important that he gets the insulin he needs. A little background reading for you when you have the time: Ketones, Diabetic Ketoacidosis (DKA), and Blood Ketone Meters

Please post for help with dosing in the morning.

 

[Rebecca M]

Dealing with DKA is a lot, you don't need to feel like a failure. Don't bother poking him with for the Relion unless his numbers are a lot closer to 100. At this point, he is just "too high" and the exact number doesn't matter.

Is he eating at home?

With DKA, we never suggest skipping a dose. There are other options like feeding higher carb food, delaying until his numbers come higher, giving reduced dose, but not skipping. Post here and we can help you. You say you gave 0.5 units at 12:30 but that's doesn't mean anything to me as I'm not in your time zone. How many hours after your normal shot time is it?

We need to get your spreadsheet looking more like ours. The colors in the spreadsheet version we use mean something to us and we are used to seeing patterns in those colours. Either @Marje and Gracie or @Bandit's Mom can help with that.

Thank you so much. He is eating at home, not a ton so I'm syringe feeding.

I agree, will never skip a dose again. Really kicking myself because my instincts were SCREAMING at me not to do it and the other vet clearly disagreed with it too but I listened and did it. UGH. Right now it's 3:30AM in my time zone (EST), so about 3 hours since I gave 0.5u. His number is now hovering around 400 according to the Freestyle Libre and the ReliOn. I'm a little worried that it's coming down too fast. 521 definitely was not as high as it got, it's just when I hit my personal comfort threshold and the vet told me I could give him .5. So even if it only went up to 550, that's a 150 drop in 3 hours, and that feels like a lot? Or not? I'm so lost. I cannot sleep for obvious reasons so I'm just reading all the threads on here and the linked Q&A pages and how-tos but I don't know if any of it is relevant to a cat still in DKA recovery. I also don't know how I'd be able to tell if he re-entered DKA with numbers like these. I feel like I can smell ketones on his breath but they knowingly sent him home with 5.0 ketones in his urine so maybe I'm supposed to? Or maybe I'm paranoid?

I would love any/everyone's help with morning dosage. I'm going to call the vet (the one he worked with before, not the other one) in the morning too to see what she thinks. She said over the phone earlier that I should keep up his routine, so still do 8AM, but I feel like it's going to be a little tricky figuring out the dosage since he will still have 4 or so hours "left" from the .5u at midnight. She said we'll base it off of his pre-shot numbers... but will those also be skewed by the late night Lantus? Otherwise it would have continued to rise, right?

Re: the spreadsheet, absolutely! It used to be same colors as all of yours, actually - I only changed it for my own benefit (very visual/pattern-based learner so it's easier for me to follow a color gradient) but will change it back now. Thanks for the tip.

 

[Marje and Gracie]

Thank you so much. He is eating at home, not a ton so I'm syringe feeding.

I agree, will never skip a dose again. Really kicking myself because my instincts were SCREAMING at me not to do it and the other vet clearly disagreed with it too but I listened and did it. UGH. Right now it's 3:30AM in my time zone (EST), so about 3 hours since I gave 0.5u. His number is now hovering around 400 according to the Freestyle Libre and the ReliOn. I'm a little worried that it's coming down too fast. 521 definitely was not as high as it got, it's just when I hit my personal comfort threshold and the vet told me I could give him .5. So even if it only went up to 550, that's a 150 drop in 3 hours, and that feels like a lot? Or not? I'm so lost. I cannot sleep for obvious reasons so I'm just reading all the threads on here and the linked Q&A pages and how-tos but I don't know if any of it is relevant to a cat still in DKA recovery. I also don't know how I'd be able to tell if he re-entered DKA with numbers like these. I feel like I can smell ketones on his breath but they knowingly sent him home with 5.0 ketones in his urine so maybe I'm supposed to? Or maybe I'm paranoid?

I would love any/everyone's help with morning dosage. I'm going to call the vet (the one he worked with before, not the other one) in the morning too to see what she thinks. She said over the phone earlier that I should keep up his routine, so still do 8AM, but I feel like it's going to be a little tricky figuring out the dosage since he will still have 4 or so hours "left" from the .5u at midnight. She said we'll base it off of his pre-shot numbers... but will those also be skewed by the late night Lantus? Otherwise it would have continued to rise, right?

Re: the spreadsheet, absolutely! It used to be same colors as all of yours, actually - I only changed it for my own benefit (very visual/pattern-based learner so it's easier for me to follow a color gradient) but will change it back now. Thanks for the tip.

I’m glad he’s home and eating.

Your job now that he’s home is:
--stay calm; we all have made and make mistakes with FD. You are tired and doing your best so go easy on yourself and staying calm will help him. Sleep when he’s high! It’s important you stay as rested as you can.
--get as many calories in him as you can; that means getting the highest calorie food you can find and try and get at least 150% of his normal calories in him a day. If we need to adjust insulin to account for carbs, no worries (seriously....we’ve done this alot and the calories are hugely important).
--get as much fluid in him as you can without making him so full that he doesn’t eat; I suggest contacting your regular vet and see about getting a bag of lactated Ringers solution and giving him 50 mls subq/day for a bit. That’s only 10 tsp of fluid so unless he has hypertrophic cardiomyopathy or congestive heart failure, that shouldn’t be an issue. We have a video to teach you how to do it so tag us if you get the fluids and need it.
--check his ketones a couple times a cycle at least. If the blood ketone meter is not there yet, grab some urine ketone sticks at the pharmacy or Walmart and use those; to keep the costs down, once you get the blood ketone meter, you can use it once a day and the urine ketone strips the other times. The easiest way to catch urine is just to stick a large spoon under his bottom as he squats to pee. You don’t need much.
--post here for dosing advice; if you don’t know what dose to give, change the subject title to something that gets our attention like “Post DKA; shot time need dosing help”. You can change the title by clicking on “thread tools” at the right in the first post; if you need help/have question, click on the “?” prefix to the left of the subject. When your question is answered and dosing advice given, please remove the “?” and change the title back to “Post DKA”.
--we don’t want to skip shots and, as Wendy said, we have ways to avoid that so if you get to shot time and you feel the BG is too low, don’t feed him yet, and post for help. We don’t want to let him go long without feeding. I’m not a big fan of reduced doses but sometimes it’s necessary. Often the best course of action is to stall his shot and food a bit, testing every 30 minutes and then give the full dose as soon as you see a rise, and then feed immediately. Get a +1 or +2 at latest.
--keep the SS current.
--ask us as many questions as you need to; we’ve dealt alot with DKA kitties here and we have some members who are very good at it.

We appreciate you fixing the colors on the SS but I’d like to ask you to do some SS maintenance to make it easier for us to see what you did last night. In the PMPS column, please stack the numbers like this:
127 @ 12; 174 @ 14; 289 @ 15; 521 @ 16 and then put 0.5u in the Units column. Then you can move 401 to +3 and 392 to +4.

While 127 was a perfectly shootable number with the full dose, just to give you an example of how a stall would have worked, you wouldn’t have given him food at +12 but would have checked at +12.5. I bet you absolutely the BG was on the way up and you could have given the full dose and fed.

So...when to shoot next and dose. I don’t know when your regular shot time is and what time you shot last night; normally we don’t talk in the actual “time” because we are all on separate time zones but if you can let me know, I can give you a time to shoot and then we can go from there speaking in “hours since the shot”. But, as an example, if your regular shot time is 6/6 so you actually shot at 10 last night, if he’s high this morning, you can shoot at 8 am and then 8 pm tonight with 2u. Then we will help you move the shot time back to whatever works best for you normally. Does that make sense?

 

[Rebecca M]

I’m glad he’s home and eating.

Your job now that he’s home is:
--stay calm; we all have made and make mistakes with FD. You are tired and doing your best so go easy on yourself and staying calm will help him. Sleep when he’s high! It’s important you stay as rested as you can.
--get as many calories in him as you can; that means getting the highest calorie food you can find and try and get at least 150% of his normal calories in him a day. If we need to adjust insulin to account for carbs, no worries (seriously....we’ve done this alot and the calories are hugely important).
--get as much fluid in him as you can without making him so full that he doesn’t eat; I suggest contacting your regular vet and see about getting a bag of lactated Ringers solution and giving him 50 mls subq/day for a bit. That’s only 10 tsp of fluid so unless he has hypertrophic cardiomyopathy or congestive heart failure, that shouldn’t be an issue. We have a video to teach you how to do it so tag us if you get the fluids and need it.
--check his ketones a couple times a cycle at least. If the blood ketone meter is not there yet, grab some urine ketone sticks at the pharmacy or Walmart and use those; to keep the costs down, once you get the blood ketone meter, you can use it once a day and the urine ketone strips the other times. The easiest way to catch urine is just to stick a large spoon under his bottom as he squats to pee. You don’t need much.
--post here for dosing advice; if you don’t know what dose to give, change the subject title to something that gets our attention like “Post DKA; shot time need dosing help”. You can change the title by clicking on “thread tools” at the right in the first post; if you need help/have question, click on the “?” prefix to the left of the subject. When your question is answered and dosing advice given, please remove the “?” and change the title back to “Post DKA”.
--we don’t want to skip shots and, as Wendy said, we have ways to avoid that so if you get to shot time and you feel the BG is too low, don’t feed him yet, and post for help. We don’t want to let him go long without feeding. I’m not a big fan of reduced doses but sometimes it’s necessary. Often the best course of action is to stall his shot and food a bit, testing every 30 minutes and then give the full dose as soon as you see a rise, and then feed immediately. Get a +1 or +2 at latest.
--keep the SS current.
--ask us as many questions as you need to; we’ve dealt alot with DKA kitties here and we have some members who are very good at it.

We appreciate you fixing the colors on the SS but I’d like to ask you to do some SS maintenance to make it easier for us to see what you did last night. In the PMPS column, please stack the numbers like this:
127 @ 12; 174 @ 14; 289 @ 15; 521 @ 16 and then put 0.5u in the Units column. Then you can move 401 to +3 and 392 to +4.

While 127 was a perfectly shootable number with the full dose, just to give you an example of how a stall would have worked, you wouldn’t have given him food at +12 but would have checked at +12.5. I bet you absolutely the BG was on the way up and you could have given the full dose and fed.

So...when to shoot next and dose. I don’t know when your regular shot time is and what time you shot last night; normally we don’t talk in the actual “time” because we are all on separate time zones but if you can let me know, I can give you a time to shoot and then we can go from there speaking in “hours since the shot”. But, as an example, if your regular shot time is 6/6 so you actually shot at 10 last night, if he’s high this morning, you can shoot at 8 am and then 8 pm tonight with 2u. Then we will help you move the shot time back to whatever works best for you normally. Does that make sense?

Thank you for this! I'm in EST so when you posted this I had already given him his insulin. I called the vet wanting to give him 1.5u since he was at 401 right before he ate but she instructed me to only give him 1 so that's what I did. That was at 8AM EST and it's now 10:30EST and he's at 504, which I think is probably trending downward. These high numbers really scare me because I'm afraid of him slipping back into DKA.

This morning he ate a full FF can and part of another, and I syringe-fed him 1/3 of a pate. So he probably got around 115 calories. That's definitely not 1.5x his usual but it's the most he's had so far. He definitely would eat more if I gave him more right now but with a number like 504 and him only home from the hospital for 14 hours and the smell of ketones still on his breath I'm genuinely just so scared. Would love to hear from others whose kitties recovered from DKA and how they handled it.

As for the spreadsheet - I think I understood what you meant and I just updated it, could you just let me know if I did it correctly?

 

[Marje and Gracie]

Thank you for this! I'm in EST so when you posted this I had already given him his insulin. I called the vet wanting to give him 1.5u since he was at 401 right before he ate but she instructed me to only give him 1 so that's what I did. That was at 8AM EST and it's now 10:30EST and he's at 504, which I think is probably trending downward. These high numbers really scare me because I'm afraid of him slipping back into DKA.

This morning he ate a full FF can and part of another, and I syringe-fed him 1/3 of a pate. So he probably got around 115 calories. That's definitely not 1.5x his usual but it's the most he's had so far. He definitely would eat more if I gave him more right now but with a number like 504 and him only home from the hospital for 14 hours and the smell of ketones still on his breath I'm genuinely just so scared. Would love to hear from others whose kitties recovered from DKA and how they handled it.

As for the spreadsheet - I think I understood what you meant and I just updated it, could you just let me know if I did it correctly?

I hope you will start to rely on us for dosing advice. There is usually someone on this site 24/7 and we have experienced members all over the world. You have to be really, really careful with how often you give the lantus shots and shooting four hours early is not something we typically do here. An early shot acts like a dose increase. Because so much less insulin was given last night, I’m hoping shooting so early today won’t cause any issues but, honestly, your vets do not know what they are doing with the dosing. He is not going to improve with his BG as long as they are bouncing the dose around so much so, please, let us be the ones that help you determine his dosing. We are much, much, much better at it.

I’m glad he’s eating. I hope he keeps it up. Ketone test??

On the SS, you would put all of the BGs I listed in the same cell on the same line; you don’t put them on additional lines. You will then have to manually color the cell. If you need any help with this, please send me a private message and I can do it for you. Just click on “marje and gracie” to the left and “start a conversation”.

 

[manxcat419]

I wanted to add just a couple of things for information purposes.

We had a cat who was not diabetic, but had CKD. Her CKD never progressed beyond Stage 2, but she was very prone to potassium crashes. During the almost 4 years she had CKD (she was diagnosed at 16), she was hospitalized 3 times to stabilize her potassium after it dropped extremely low despite being on 3x a day supplementation. So yes, some cats in Stage 2 can have low potassium incidents. And giving IV insulin would definitely make that worse (I think Marje explained the insulin/potassium link earlier in the thread).

Our current diabetic, Roxi, is on budesonide for IBD - she generally has no IBD symptoms, but does show intestinal thickening. Her IM wanted her on a low dose of steroids despite the lack of symptoms because in her experience, cats have a better outcome when steroids are started early. Roxi is not a tightly managed diabetic because she also has other issues, but I never saw any significant change in her glucose levels as a result of starting the budesonide. If they'd asked you to start pred, I would expect you to see rises in BG, but budesonide has a lower systemic effect and mostly just acts on the gut.

With CKD staging, technically Stage I is kind of pre-renal, so the creatinine is under 1.6 but the cat is known to be high-risk for CKD or has other issues such as dilute urine. Once the creatinine rises above 1.6, you're technically in Stage II. As an example, Roxi consistently has a 1.5 creatinine. It's been that way for 4 years now. But, because she had a couple of incidents where her creatinine was higher as a result of her Addison's, she's classed as Stage I. Even though her creatinine has been completely stable below 1.6 and her SDMA is consistently in the higher end of normal at 12.

 

[Rebecca M]

I hope you will start to rely on us for dosing advice. There is usually someone on this site 24/7 and we have experienced members all over the world. You have to be really, really careful with how often you give the lantus shots and shooting four hours early is not something we typically do here. An early shot acts like a dose increase. Because so much less insulin was given last night, I’m hoping shooting so early today won’t cause any issues but, honestly, your vets do not know what they are doing with the dosing. He is not going to improve with his BG as long as they are bouncing the dose around so much so, please, let us be the ones that help you determine his dosing. We are much, much, much better at it.

I’m glad he’s eating. I hope he keeps it up. Ketone test??

On the SS, you would put all of the BGs I listed in the same cell on the same line; you don’t put them on additional lines. You will then have to manually color the cell. If you need any help with this, please send me a private message and I can do it for you. Just click on “marje and gracie” to the left and “start a conversation”.

Absolutely grateful for this community! At the time, no one had responded to my post re: dosing yet and I wasn't sure if I should make a new topic or wait for a reply here. Will make a new post next time

I did the ketone test strip just now. It only showed trace in his urine. I have the meter too but haven't used it yet, I just poked him for a blood test, then gave him Spironolactone, then syringed him 9ml water since I'm waiting to hear back from my regular vet re: the subQ fluids (thank you for that tip). He's sick of me and I don't want stress to cause another spike so if you think it's okay, I'll wait an hour or two before doing the blood meter. I'm not sure if the urine ketone test strip was accurate, but if it was, his ketone was only "trace" which is amazing and much much better.

I did as told w/ the SS but not sure which color to use for the cell since it's different ones in the same cell - do I go with the highest?

 

[Rebecca M]

I wanted to add just a couple of things for information purposes.

We had a cat who was not diabetic, but had CKD. Her CKD never progressed beyond Stage 2, but she was very prone to potassium crashes. During the almost 4 years she had CKD (she was diagnosed at 16), she was hospitalized 3 times to stabilize her potassium after it dropped extremely low despite being on 3x a day supplementation. So yes, some cats in Stage 2 can have low potassium incidents. And giving IV insulin would definitely make that worse (I think Marje explained the insulin/potassium link earlier in the thread).

Our current diabetic, Roxi, is on budesonide for IBD - she generally has no IBD symptoms, but does show intestinal thickening. Her IM wanted her on a low dose of steroids despite the lack of symptoms because in her experience, cats have a better outcome when steroids are started early. Roxi is not a tightly managed diabetic because she also has other issues, but I never saw any significant change in her glucose levels as a result of starting the budesonide. If they'd asked you to start pred, I would expect you to see rises in BG, but budesonide has a lower systemic effect and mostly just acts on the gut.

With CKD staging, technically Stage I is kind of pre-renal, so the creatinine is under 1.6 but the cat is known to be high-risk for CKD or has other issues such as dilute urine. Once the creatinine rises above 1.6, you're technically in Stage II. As an example, Roxi consistently has a 1.5 creatinine. It's been that way for 4 years now. But, because she had a couple of incidents where her creatinine was higher as a result of her Addison's, she's classed as Stage I. Even though her creatinine has been completely stable below 1.6 and her SDMA is consistently in the higher end of normal at 12.

Thank you for this. He's never had a history of low potassium and was at a 4 when he went in; I think/hope it was just the insulin. Right now worried about dehydration in particular since Spironolactone is a diuretic and he's not on IV hydration anymore. The last time they told me his creatinine it was a 2.06 (3.3 at admission). I think his old baseline was a 1.8 and they said the creatinine was still improving but I understand DKA can permanently increase creatinine too.

 

[Diane Tyler's Mom GA]

I did as told w/ the SS but not sure which color to use for the cell since it's different ones in the same cell - do I go with the highest?

Marje and Gracie said in her post above

On the SS, you would put all of the BGs I listed in the same cell on the same line; you don’t put them on additional lines. You will then have to manually color the cell. If you need any help with this, please send me a private message and I can do it for you. Just click on “marje and gracie” to the left and “start a conversation”.

So I would private message her .
I hope the ketone test strip was accurate , that's wonderful news
If you vet does suggest sub fluids it's very easy to give but I understand you don't want to stress him out .

 

[Marje and Gracie]

Absolutely grateful for this community! At the time, no one had responded to my post re: dosing yet and I wasn't sure if I should make a new topic or wait for a reply here. Will make a new post next time

I did the ketone test strip just now. It only showed trace in his urine. I have the meter too but haven't used it yet, I just poked him for a blood test, then gave him Spironolactone, then syringed him 9ml water since I'm waiting to hear back from my regular vet re: the subQ fluids (thank you for that tip). He's sick of me and I don't want stress to cause another spike so if you think it's okay, I'll wait an hour or two before doing the blood meter. I'm not sure if the urine ketone test strip was accurate, but if it was, his ketone was only "trace" which is amazing and much much better.

I did as told w/ the SS but not sure which color to use for the cell since it's different ones in the same cell - do I go with the highest?

The major thing with the urine ketone strip is to be sure it’s dipped in urine and not the pee clump in the box. Also, you must read it exactly at the prescribed time (usually 15 sec) as even a second or two early/late makes a difference.

If you need dosing help, you have to change the title so people realize you need help. A lot of times with a DKA cat, most members are hesitant to post because they don’t know how to handle it. Our guidance here in this forum is to use the same thread until it reaches 50 posts (the number of posts is in the right bottom corner). That helps with consistency. You can change the title to get attention. After 50 posts, start a new thread and link this one.

Yes you did the SS revision correctly. Just manually color it with the blue we use as we need to see the lowest number.

 

[Rebecca M]

The major thing with the urine ketone strip is to be sure it’s dipped in urine and not the pee clump in the box. Also, you must read it exactly at the prescribed time (usually 15 sec) as even a second or two early/late makes a difference.

If you need dosing help, you have to change the title so people realize you need help. A lot of times with a DKA cat, most members are hesitant to post because they don’t know how to handle it. Our guidance here in this forum is to use the same thread until it reaches 50 posts (the number of posts is in the right bottom corner). That helps with consistency. You can change the title to get attention. After 50 posts, start a new thread and link this one.

Yes you did the SS revision correctly. Just manually color it with the blue we use as we need to see the lowest number.

It's a "pet-specific" ketone strip which maybe was a bad idea? It has both urine glucose and ketone test strips on it. I collected urine from under him when he peed, and I used a stop watch to ensure I measured at the right time (30 seconds for glucose and 40 for ketones). But maybe I should order normal ones for humans? Honestly, I forgot I had ordered pet-specific ones until I opened them after your post.

 

[JL and Chip]

He was started on budesonide in I think September and was fine on it but they took him off a few days ago when he got DKA

They stopped the budesonide cold turkey?

That somewhat surprises me. I’ve always been told that the dose must be weaned down. (Charlie was one of the unfortunate ones for whom budesonide did impact BG).

 

[Rebecca M]

They stopped the budesonide cold turkey?

That somewhat surprises me. I’ve always been told that the dose must be weaned down. (Charlie was one of the unfortunate ones for whom budesonide did impact BG).

Yes, and told me to keep him off it. I'm really struggling right now with what they are telling me to do, if I'm being honest.

 

[Marje and Gracie]

It's a "pet-specific" ketone strip which maybe was a bad idea? It has both urine glucose and ketone test strips on it. I collected urine from under him when he peed, and I used a stop watch to ensure I measured at the right time (30 seconds for glucose and 40 for ketones). But maybe I should order normal ones for humans? Honestly, I forgot I had ordered pet-specific ones until I opened them after your post.

I don’t know if I’ve ever seen pet urine ketone strips but as long as you follow the instructions, it should be ok. The human urine strips which just test ketones and not glucose, are probably cheaper.

 

[Rebecca M]

I don’t know if I’ve ever seen pet urine ketone strips but as long as you follow the instructions, it should be ok. The human urine strips which just test ketones and not glucose, are probably cheaper.

Thank you, will take a look for those too!

Wanted to give a quick update - Yahiko's regular vet called me from her vacation after the office ladies were SO sweet to let her know I had questions. They told me they had no appointments available until January originally but while talking to her on the phone she told me she was gong to call the office and get him in with a tech for subQ fluids, and she did. He's a big guy and was pretty dehydrated so they gave him 100ml and sent me home with more to give him starting tomorrow. She said she's not worried about the heart murmur because he did fine on the IV for the last 5 days and that's usually harder on the heart than subQ? had the exact opposite experience with the vet hospital so at this point I'm just kind of writing that off. Grateful to you for suggesting it and grateful to them for making it happen - hopefully he starts feeling better quick. They also ran a full renal panel so they'll check his urine for ketones and glucose (just in case my strip was wrong) and give me an update on where his potassium is at. I'll have those results in the morning.

Yahiko is still walking around and in generally good shape aside from the dehydration. I was getting a little bit worried because he was a little wobbly and I was afraid his BG was just overwhelming him, and maybe that was a part of it but I REALLY think the dehydration was a huge part. I'm sure the stress didn't help the glucose but I'm trying to just treat what I can treat and control what I can control. And I'm so glad I called in because from the skin tent right before I went in to the vet had gotten pretty severe and judging by how quick the drip was, he really needed it.

 

[Marje and Gracie]

Thank you, will take a look for those too!

Wanted to give a quick update - Yahiko's regular vet called me from her vacation after the office ladies were SO sweet to let her know I had questions. They told me they had no appointments available until January originally but while talking to her on the phone she told me she was gong to call the office and get him in with a tech for subQ fluids, and she did. He's a big guy and was pretty dehydrated so they gave him 100ml and sent me home with more to give him starting tomorrow. She said she's not worried about the heart murmur because he did fine on the IV for the last 5 days and that's usually harder on the heart than subQ? had the exact opposite experience with the vet hospital so at this point I'm just kind of writing that off. Grateful to you for suggesting it and grateful to them for making it happen - hopefully he starts feeling better quick. They also ran a full renal panel so they'll check his urine for ketones and glucose (just in case my strip was wrong) and give me an update on where his potassium is at. I'll have those results in the morning.

Yahiko is still walking around and in generally good shape aside from the dehydration. I was getting a little bit worried because he was a little wobbly and I was afraid his BG was just overwhelming him, and maybe that was a part of it but I REALLY think the dehydration was a huge part. I'm sure the stress didn't help the glucose but I'm trying to just treat what I can treat and control what I can control. And I'm so glad I called in because from the skin tent right before I went in to the vet had gotten pretty severe and judging by how quick the drip was, he really needed it.

That is fantastic!!

I’ve been doing subqs fluids for 30 years and have helped many with them and I always find the vet demo is great to give you an idea but seeing it and doing it become two different things once you get home. So we used one of our wonderful (but sadly at the Bridge) kitties to make a video for FDMb members but people worldwide have used it.

Two things:

1. Did they give you Lactated Ringers or Normosol? I prefer LRS as it has a little potassium and Normosol stings.
2. Did they give you 18g needles as this is what vets usually use and they are harpoons! If that’s what they gave you, call and see if they have any 20g. It will take longer but it will hurt less. I actually use 21g but my kitties have always been fine with laying still for however long I needed. If you can’t get the 20g from them, it’s ok to use the 18g as he probably won’t need these more than a few days but you might want to think about it for the future so you can have 20g on hand. I always keep IV sets and 21g needles here because you never know when a kitty is going to need a little extra support with hydration.

 

[Rebecca M]

That is fantastic!!

I’ve been doing subqs fluids for 30 years and have helped many with them and I always find the vet demo is great to give you an idea but seeing it and doing it become two different things once you get home. So we used one of our wonderful (but sadly at the Bridge) kitties to make a video for FDMb members but people worldwide have used it.

Two things:

1. Did they give you Lactated Ringers or Normosol? I prefer LRS as it has a little potassium and Normosol stings.
2. Did they give you 18g needles as this is what vets usually use and they are harpoons! If that’s what they gave you, call and see if they have any 20g. It will take longer but it will hurt less. I actually use 21g but my kitties have always been fine with laying still for however long I needed. If you can’t get the 20g from them, it’s ok to use the 18g as he probably won’t need these more than a few days but you might want to think about it for the future so you can have 20g on hand. I always keep IV sets and 21g needles here because you never know when a kitty is going to need a little extra support with hydration.

Thank you for this video!! The vet did a brief demo but I was just sitting here thinking about how I wasn't sure that was enough - it's like you read my mind.

1. It's Lactated Ringers but with no potassium, just B vitamins. They're skipping the potassium because he's on 2x daily potassium supplements plus Spironolactone to stop it from being excreted in his urine and want to see where that level is at first.
2. Harpoons!! LOL. I didn't even look until you said that (which is weird because I have spent 20+ minutes debating which gauge lancet to buy that will hurt my kitty less but get enough blood, multiple times!!). Yes, they're 18 gauge! I'll try to overnight some 20g and if I can't I'll go in and ask for a few.

 

[Marje and Gracie]

Thank you for this video!! The vet did a brief demo but I was just sitting here thinking about how I wasn't sure that was enough - it's like you read my mind.

1. It's Lactated Ringers but with no potassium, just B vitamins. They're skipping the potassium because he's on 2x daily potassium supplements plus Spironolactone to stop it from being excreted in his urine and want to see where that level is at first.
2. Harpoons!! LOL. I didn't even look until you said that (which is weird because I have spent 20+ minutes debating which gauge lancet to buy that will hurt my kitty less but get enough blood, multiple times!!). Yes, they're 18 gauge! I'll try to overnight some 20g and if I can't I'll go in and ask for a few.

If you can find Terumo needles, they are the best. But don’t buy them from Amazon…they say Terumo but they are knock offs.

 

[Rebecca M]

I'm a little confused/concerned. Just updated Yahiko's SS. It looks like his glucose is still trending downward 10 hours after receiving his last insulin. Previously it always peaked and then started rising again so I'm struggling to wrap my head around it and experiencing a lot of anxiety over tonight's dose; how do I accurately gauge where he's at if the insulin is still working on his blood and still reducing it at PMPS? If I dose him as usual, does that mean he could go too low if the new insulin piggybacks off the old insulin? This seems so bizarre to me - not a curve but a slide??

 

[Wendy&Neko]

Cat's don't always have the same peak or nadir at the same time. Some cats nadir later in the cycle, like my girl did.

With Lantus, the lower number you shoot, the flatter the cycle will tend to be. You won't get the same drop in numbers for a 200's preshot as you will with a much higher number.

 

[Rebecca M]

Cat's don't always have the same peak or nadir at the same time. Some cats nadir later in the cycle, like my girl did.

With Lantus, the lower number you shoot, the flatter the cycle will tend to be. You won't get the same drop in numbers for a 200's preshot as you will with a much higher number.

That's what is so strange with him, though - if you look at the previous days, he peaked mid-day, not like now. But thank you re: the flatter cycle, that makes me feel better. It's still going down and the way he reacts SO dramatically/intensely to insulin gives me nonstop anxiety. Seeing him go from a high of 544 to a low of now 270 in a matter of 6 hours is so scary.

 

[Marje and Gracie]

I'm a little confused/concerned. Just updated Yahiko's SS. It looks like his glucose is still trending downward 10 hours after receiving his last insulin. Previously it always peaked and then started rising again so I'm struggling to wrap my head around it and experiencing a lot of anxiety over tonight's dose; how do I accurately gauge where he's at if the insulin is still working on his blood and still reducing it at PMPS? If I dose him as usual, does that mean he could go too low if the new insulin piggybacks off the old insulin? This seems so bizarre to me - not a curve but a slide??

What you are seeing is him clearing a bounce from those low numbers yesterday. Anytime the BG drops quickly or drops into lower numbers than the body is used to (the numbers don’t have to be that low), the liver releases counterregulatory hormones and glucagon to bring the BG back up to the number it has recently identified as “normal’ which is high. It takes time for the liver to not panic whenever there are lower numbers but it’s always going to do that if there is a fast drop in BG. What you are seeing is a very normal pattern. It usually starts high at the beginning of a cycle and slowly decreases all cycle so the nadir is quite often at the next shot time. Again, we see this all the time.

Because Lantus is a depot insulin, one dose can affect up to six subsequent cycles. It’s possible that’s why you didn’t see such a horrific response to shooting the reduced dose (and why I don’t like them.....they can be misleading). It is possible the 2u was enough to overcome the reduced dose last night but not the bounce; he got a really early shot today so that also acts like an increase. And now the bounce clears.

When you get his PMPS, please post. I’ll be looking for you. Maybe take it about 15 minutes early (you will be shooting 12 hours from when you shot this morning, ok?) and post it. Don’t feed him. Let’s see where he is but I’m thinking you will need to shoot 2u. Sound like a plan?

 

[Rebecca M]

What you are seeing is him clearing a bounce from those low numbers yesterday. Anytime the BG drops quickly or drops into lower numbers than the body is used to (the numbers don’t have to be that low), the liver releases counterregulatory hormones and glucagon to bring the BG back up to the number it has recently identified as “normal’ which is high. It takes time for the liver to not panic whenever there are lower numbers but it’s always going to do that if there is a fast drop in BG. What you are seeing is a very normal pattern. It usually starts high at the beginning of a cycle and slowly decreases all cycle so the nadir is quite often at the next shot time. Again, we see this all the time.

Because Lantus is a depot insulin, one dose can affect up to six subsequent cycles. It’s possible that’s why you didn’t see such a horrific response to shooting the reduced dose (and why I don’t like them.....they can be misleading). It is possible the 2u was enough to overcome the reduced dose last night but not the bounce; he got a really early shot today so that also acts like an increase. And now the bounce clears.

When you get his PMPS, please post. I’ll be looking for you. Maybe take it about 15 minutes early (you will be shooting 12 hours from when you shot this morning, ok?) and post it. Don’t feed him. Let’s see where he is but I’m thinking you will need to shoot 2u. Sound like a plan?

Yes, will do! I also spoke to his vet today about his BG levels, the rise/fall etc. This vet is the one who oversaw his (very successful) treatment last time so I trust her more than the ER vets. She was leaning more towards 1u tonight to get a good idea of his curve as she's back in-office tomorrow. What are your thoughts?

Also, not sure if it's relevant or if that's why the ER vets went with that number (prior to having me skip the dose), but 1u 2x a day was what Yahiko successfully received both previous times he was diabetic; it maintained him well and then he went into remission each time. I was honestly not as involved with it as I really should have been so I rarely tested him at home and didn't understand the results even when I did, so obviously this time around is different. But I wonder if cats are at all consistent in that what works the other time(s) would be good for him again? Would be so grateful to hear your opinions - not sure if I'm full of it or if maybe TR would be good for him after all.

 

[Marje and Gracie]

Yes, will do! I also spoke to his vet today about his BG levels, the rise/fall etc. This vet is the one who oversaw his (very successful) treatment last time so I trust her more than the ER vets. She was leaning more towards 1u tonight to get a good idea of his curve as she's back in-office tomorrow. What are your thoughts?

Also, not sure if it's relevant or if that's why the ER vets went with that number (prior to having me skip the dose), but 1u 2x a day was what Yahiko successfully received both previous times he was diabetic; it maintained him well and then he went into remission each time. I was honestly not as involved with it as I really should have been so I rarely tested him at home and didn't understand the results even when I did, so obviously this time around is different. But I wonder if cats are at all consistent in that what works the other time(s) would be good for him again? Would be so grateful to hear your opinions - not sure if I'm full of it or if maybe TR would be good for him after all.

Unfortunately, how he was before on insulin and the dose he was on doesn’t really factor into now. We have to look at what we are dealing with today and we also have a new issue to consider: the DKA.

While you hold the syringe, the data on the SS tells me 2u is more appropriate for him. That’s the dose where he’s seen the best BGs. Might his BG come down tonight? Certainly. But if you are testing and you have food and supplies and you aren’t too tired to stay up for a bit, it’s my opinion that dose will be best for him. However, you can always take the in between and shoot 1.5u if that gives you more comfort.
No judgement here.

As long as he’s not eating dry food, TR would be best for him right now due to the DKA. It allows you to make dose adjustments every 4-6 cycles, if necessary instead of waiting a week. After he’s much better, if you want to switch to SLGS, you can.

 

[Marje and Gracie]

I see he is still rather flat and you shot 1u. If you can get a +2 test, if he can tolerate it, that might let you know whether you can get to bed early. If it’s higher than PMPS, he’s probably not going to come down tonight. If it’s similar to or less than PMPS, I suggest at least a +4 or before bed if you are headed to bed before then.

I am on mountain time so I won’t be up by your shot time tomorrow but post a little early and see if anyone is on that can help you with dosing.

 

[Rebecca M]

Thank you!!

 

[Wendy&Neko]

If you can, please try to get another ketones test in again tonight. And just cause we'll keep asking, put the test results on the spreadsheet, the Remarks column is fine.

I agree with Marje that he needs more than 1 unit, but am hoping he doesn't go too high. As Marje said, that +2 test will tell you if you can get some sleep tonight to make up for last night. You do need to take care of you to take care of Yahiko.

 

[Rebecca M]

Just did his +1 and it actually went down which I don't fully understand either - I'm sorry if I'm a bit ignorant about this stuff, I've been reading but I just don't understand yet.

His tummy is rumbling like he's going to have diarrhea (he hasn't had a BM since I took him home yesterday around 7, so 26 hours ago, but he had diarrhea earlier in the day yesterday before I went to get him) and I worry that malabsorption will also send him too low. Honestly, he's ACTING like he has low blood sugar but I hope it's just because it's been high for so long and he swung so hard today??

I wish I'd seen this message but I clicked on it right after he had finished peeing so going to be difficult to get another test in but hopefully in the early morning when he pees again.