Returning Member Snow - recent DKA & pancreatitis help?

[GreySnowman]

Hi,

I am desperate for help this group has been invaluable in the past (when Snow was first diagnosed 1+ year ago). I'll try to keep this as organized as possible but I'm all over the place. I'll start with recent history, but my current concern is that her BG is too high, and I'm terrified of another DKA episode (ketostix is showing no ketones but dark brown for glucose).

On 10/11 Snow started vomiting after eating and I brushed it off (big mistake). This continued over the weekend so I stopped her insulin over the weekend afraid that without food she could have a hypo episode. Other than vomiting she was acting completely normal. By Monday (10/14) I made an emergency appt with her vet and she was seen that morning. Turns out she was in DKA and we rushed to the ER vet immediately. Her ER admission documents show ketones >8 when she arrived. She was kept for 4 days until she stabilized. Showed signs of triaditis or pancreatitis (and a mass on her lung but worrying about that later). We suspect the pancreatitis or similar caused inflammation and impacted her response to insulin (I think?). She was sent home with cerenia, mirataz and clavamox (and continuing her glargine--previously got 1u 2x/day and upped it to 1.5u 2x/day). She had diarrhea for 2 days and I discontinued the clavamox and her stool began to harden.

On 10/25 Snow had an appointment with the ER internist for a BG curve. I don't have those numbers (but believe somewhere in 300 range, will report back when the clinic responds). My wedding is in 3 weeks and the internist acted like Snow could coast until after the wedding. This was a Friday evening. That night I noticed Snow had diarrhea worse than before again. We're now down $11,000 in vet bills and I'm terrified of running out of money to treat her. I've happily spent our honeymoon fund.

On 10/27 I contemplated taking Snow back to the ER because of the diarrhea (and hyper-vigilance due to her recent DKA). The night vet said we could monitor her and showed me how to give her subQ fluids and refilled the cerenia. The goal was to keep her okay until her regular vet appointment on Wednesday (10/30) [side note: I love her current vet--she's a feline specialist but only works on Wednesdays and sometimes Thursdays, so I may need to find someone else].

On 10/30 at her vet appointment the goal was to figure out the pancreatitis. Vet checked her vitals and said everything seemed good (did not take blood or anything). We decided to do a freestyle libre since last year's BG testing at home was really hard on Snow and me. I updated Snow's google sheet with the freestyle numbers but it only worked for a little over 24 hours. Vet gave me a prescription for Budesonide for the pancreatitis.

Snow has been on 1/2 tablet Cerenia every morning since. Was getting Mirataz in alternating ears in the mornings but her regular vet advised to pause and see if it is necessary. I believe the goal is to make sure she keeps eating but I've been bribing her with boiled chicken and as a result Snow seems to have lost interest in her regular wet food. However, I have been monitoring her a motion-activated pet camera in the night and she goes for her dry food (Dr. Elsey's high protein chicken flavor) frequently in the night and also intermittently throughout the day.

The freestyle libre was placed early afternoon on 11/01 and we got readings until yesterday evening. I was hoping to have continuous monitoring so we could start the budesonide. I'm really scared for the budesonide but also think her triaditis/pancreatitis needs to get controlled alongside her diabetes again. I gave her 1mg budesonide for the first time today about 2 hours after her am insulin shot. I have her 100mL subQ fluids this afternoon.

I'm about to do her PMPS blood glucose on the reliOn and will update her chart asap (I didn't realize I was out of the test strips this morning). Based on last night's Freestyle alerts that her BG was "HIGH", I've been following her all day and got 2 ketostix readings in the last 5 hours. About 4 hours ago (3:30pm my time) the ketostix showed no ketones but 1/2 g/mL (light brown) on the glucose side. Just over 2 hours later the ketostix still showed no ketones but the darkest brown (2++ g/mL) on the glucose side.

Any guidance or thoughts you could provide would be immensely appreciated! Should we stop the budesonide until her blood sugar is regulated?

I could really use help with her feeding schedule, too. When she was diagnosed, I tried every low-carb wet food on Dr. Pierson's list, and she wouldn't eat anything, so we're still on Royal Canin adult instinctive wet food. We were at least able to switch her to Dr. Elsey's dry food. I know boiled chicken doesn't have enough nutrients for the long term, but I'm just trying to get her to keep eating. The Dr. Elsey's dry food is always out. I put down a can of wet food (and lately a bunch of boiled chicken) 2x/day right before I give her the insulin. Should this be staggered to make best use of the insulin?

I felt so confident that Snow's BG was under control and now I'm in a panic and don't trust what I thought I learned last year. I would be so grateful for any sort of help. In the meantime, I'll update her chart with readings from the ReliOn (just got 237 for PMPS and will try a +2 this evening, then we'll resume testing in the morning). Could my panic at her PU/PS be the side effect of the budesonide? It seems quick to start side effects.

I am sorry for the wall of text. I was hoping all the background might help since the pancreatitis is complicated. Thank you so much for your time!

 

[Bron and Sheba (GA)]

Hi Nicole,
Just a FYI in future…if Snow won’t eat or eat much, you can give a 1/2 dose of insulin. I would not stop it altogether. Diabetic cats need insulin otherwise other problems arise.

Did you finish the course of clavomax? Why did they put her in it, do you know?

At the moment it is really important she is eating well, so let her eat whatever she wants. Eating is more important than trying to make sure it is low carb. I would try and make sure she eats well before the doses of insulin and then try and get her to eat every couple of hours. The aim is to get her to eat 1 and a1/2 times as many calories as normal.
I would continue the cerenia and the Mirataz daily for the time being as eating well is so important after DKA. Many DKA kitties can be nauseated for a few weeks afterwards.
It is food and insulin that will help keep ketones at bay.

Test every day for ketones and if you could put the result into the remarks column of the Ss that would be helpful, thanks.

Try and get a preshot BG test done every time and then one during the cycles so we can see how low the dose is taking Snow.
Don’t forget to get a test in during the pm cycle as well.
Has Snow only been on the 2 unit dose for a couple of days?

Did the vet give Snow anything for pain with the pancreatitis?

Keep asking questions. We are here to help you.

I will tag @Wendy&Neko to get her thoughts on the budesonide

 

[Wendy&Neko]

Here is a post on pancreatitis: A Primer On Pancreatitis
You will notice that budesonide is not mentioned as a treatment for pancreatitis. Budesonide is a steroid that is locally acting on the GI system. It is used where GI conditions are present, such as IBD or small cell lymphoma - which is why Neko took it. Did the vet say anything about thickened bowels? Typically an ultrasound is done to check if the bowels are thickened or there is something else present. Kitties with SCL or IBD often get pancreatitis.

To help with the diarrhea, s. boullardi is a good option. More here:
https://www.ibdkitties.net/supplements/probiotics/

 

[GreySnowman]

Hi Nicole,
Just a FYI in future…if Snow won’t eat or eat much, you can give a 1/2 dose of insulin. I would not stop it altogether. Diabetic cats need insulin otherwise other problems arise.

Did you finish the course of clavomax? Why did they put her in it, do you know?

At the moment it is really important she is eating well, so let her eat whatever she wants. Eating is more important than trying to make sure it is low carb. I would try and make sure she eats well before the doses of insulin and then try and get her to eat every couple of hours. The aim is to get her to eat 1 and a1/2 times as many calories as normal.
I would continue the cerenia and the Mirataz daily for the time being as eating well is so important after DKA. Many DKA kitties can be nauseated for a few weeks afterwards.
It is food and insulin that will help keep ketones at bay.

Test every day for ketones and if you could put the result into the remarks column of the Ss that would be helpful, thanks.

Try and get a preshot BG test done every time and then one during the cycles so we can see how low the dose is taking Snow.
Don’t forget to get a test in during the pm cycle as well.
Has Snow only been on the 2 unit dose for a couple of days?

Did the vet give Snow anything for pain with the pancreatitis?

Keep asking questions. We are here to help you.

I will tag @Wendy&Neko to get her thoughts on the budesonide

Thank you! I've been reading all of your prior posts regarding DKA, which helped me initially realize the importance of the food despite her regular vet not necessarily focusing on that. She has not been given anything for the pain. Is there something I could suggest to her vet?

The Clavamox was given as a precaution, but it didn't have a specific purpose. As far as I know, there were no signs of a bacterial infection. We stopped the Clavamox after 2 days due to the diarrhea. I am questioning if this was the right move now. I had read Clavamox could cause diarrhea and hoped to help her without incurring another expensive vet bill (I'm trying to space them out but recognize that may not be possible to get her fully treated and stabilized). Her regular vet said she doesn't like Clavamox but didn't offer an alternative. This was last week, when we got the budesonide.

Do you have any tips for food? Or rather, since she's really only been interested in boiled chicken lately, I'm giving it to her often but worry it does not have enough nutrients to help her recover. She devoured a Royal Canin glycobalance can that the ER vet gave us to try. I wouldn't want her on that regularly but maybe I should try to get more to help keep her eating.

The ketone strips show brown for glucose but no ketones. Is this likely because her blood sugar isn't regulated yet? [PM edit: around noon today (AM+4) the glucose part of the strip showed a lighter brown and no ketones; I checked again around 8pm (just after her PM shot) and the glucose part is darker brown again. The ketones portion isn't clearly pink enough for the "trace" reading but seemed to darken slightly overall. Should I be concerned? We successfully did the full curve for today and her numbers seem okay overall.] We'll continue tracking, and I'll add to her spreadsheet.

I have a slow work day, so I was planning on doing a full curve for the daytime [EDIT: results = AMPS 338; +2 233; +4 194; +6 232; +8 214; +10 267; PMPS 305]. Would +2 at night be helpful, or does it need to be later following her PM insulin?

I upped her insulin from 1.5u to 2u Friday evening due to the continuously high readings on her Freestyle Libre. This might have been too hasty.

 

[GreySnowman]

Here is a post on pancreatitis: A Primer On Pancreatitis
You will notice that budesonide is not mentioned as a treatment for pancreatitis. Budesonide is a steroid that is locally acting on the GI system. It is used where GI conditions are present, such as IBD or small cell lymphoma - which is why Neko took it. Did the vet say anything about thickened bowels? Typically an ultrasound is done to check if the bowels are thickened or there is something else present. Kitties with SCL or IBD often get pancreatitis.

To help with the diarrhea, s. boullardi is a good option. More here:
https://www.ibdkitties.net/supplements/probiotics/

This is interesting and I appreciate your insight! I was also scouring through your posts about your kitty regarding IBD. My understanding from her regular vet was that the treatment for inflammation regardless of the source would be budesonide. I might have over-simplified it as pancreatitis; I think more accurately she has inflammation throughout her GI tract. The vet explained it to be as a "chicken or the egg" issue and regardless of the source of the inflammation, due to cat anatomy it spread so we'd do budesonide. I'll read up on pancreatitis specifically to see if there is something else I should suggest.

The ER notes from when she was discharged (10/17) say: "Snow had a thorough diagnostic work up that revealed evidence of triaditis. Triaditis is a condition where there is concurrent inflammation of the pancreas, liver/biliary system, and gastrointestinal tract. These organs are in very close proximity to each other and connected by the common bile duct in the cat. As such, inflammation in one of these organs often results in inflammation in all three of the organs. In order to address this disease process, we often start out with strategies to manage chronic inflammation within the gastrointestinal tract (most commonly caused by inflammatory bowel disease or gastrointestinal lymphoma). We may ultimately recommend that Snow be started on an elimination diet to decrease inflammation in the GI tract; however, for now it is more important that Snow continue to eat well."

Her mid-October TFAST/AFAST readings were:
10/16:
- "TFAST: no pleural or pericardial effusion noted; LA:Ao ~1.27"
- "AFAST: no abdominal effusion noted; moderate hepatomegaly with gallbladder sediment. No hydronephrosis noted, mild pyelectasia (patient did not tolerae measurement of renal pelvices). Bladder measures large."

10/17:
- "TFAST: no pleural or pericardial effusion noted; LA:Ao ~1.41; pulmonary nodule in right cranial thorax measures 0.7x0.66cm"
- "AFAST: no abdominal effusion noted; moderate hepatomegaly with gallbladder sediment. No hydronephrosis noted, mild prelection (patient did not tolerate measurement of renal pelvices). Hypoechoic pancreas."

It seems between vets, some are more focused on the diabetes (predominantly) versus the inflammation but from some of your prior posts, I understand they could be exacerbating each other so I wanted to try to start some treatment for the inflammation, hence the budesonide. Could that have been premature? I'm so torn in wanting to help her with all of the things but also not wanting to throw in so much that we can't measure what's having a beneficial impact.

I have visbiome arriving by the end of this week. Is s. boullardi a better probiotic? She wouldn't touch the wet food sprinkled with fortiflora (which I now see is not optimal anyway) so I'll have to try to get her to eat it. Is it crazy to put it in an oral syringe with water to get her to consume it?

 

[Wendy&Neko]

It does sound like you are dealing with GI inflammation, in which case budesonide can help reduce the inflammation. Most cats (but not all) don't have a blood sugar impact with budesonide. It didn't impact Neko, but I have seen some where it does.

The main down side to starting budesonide is if you want to test to see if you are dealing with IBD or small cell lymphoma. Don't let that name worry you - many cats go into remission from it on the proper mild chemo protocol. Doing a novel protein diet can help you determine if there is IBD present. But that won't exclude SCL. I have a kitty with both - been 6.5 years since her SCL diagnosis and no longer on chemo. I am still dealing with IBD. Taking a steroid can both reduce inflammation but also mean a biopsy won't have enough information to tell you which condition you are dealing with. The treatments are different between the two conditions.

Visbiome is a great probiotic and supplements the good bacteria in the GI. S. boullardi has a different role, it mops up the bad bacteria. You can give both. S. boullardi is readily available and can help quickly. Visbiome is tasteless, shouldn't be a problem giving it with food. Having said that, I have given it occasionally in a little puddle of Churu - provided chicken is not an allergy.

 

[GreySnowman]

It does sound like you are dealing with GI inflammation, in which case budesonide can help reduce the inflammation. Most cats (but not all) don't have a blood sugar impact with budesonide. It didn't impact Neko, but I have seen some where it does.

The main down side to starting budesonide is if you want to test to see if you are dealing with IBD or small cell lymphoma. Don't let that name worry you - many cats go into remission from it on the proper mild chemo protocol. Doing a novel protein diet can help you determine if there is IBD present. But that won't exclude SCL. I have a kitty with both - been 6.5 years since her SCL diagnosis and no longer on chemo. I am still dealing with IBD. Taking a steroid can both reduce inflammation but also mean a biopsy won't have enough information to tell you which condition you are dealing with. The treatments are different between the two conditions.

Visbiome is a great probiotic and supplements the good bacteria in the GI. S. boullardi has a different role, it mops up the bad bacteria. You can give both. S. boullardi is readily available and can help quickly. Visbiome is tasteless, shouldn't be a problem giving it with food. Having said that, I have given it occasionally in a little puddle of Churu - provided chicken is not an allergy.

Based on your prior posts I had asked my vet about concerns about SCL and she seemed to indicate treatment would be the same whether IBD or SCL so I'm glad this came up! I'm so glad to hear about your kitty's remission!

In terms of a biopsy for possible SCL, is this invasive? I was under the impression Snow would not do well with anesthesia with her diabetes (but maybe this is only currently while we're getting her back to stabilized?). Pet insurance for her and her brother kicked in last month. This would likely not be covered but I can dream! Either way, I'll want to look into it.

A big issue for us is my wedding on Nov. 23. We'll be out of town (only an hour away) from Friday afternoon to Monday morning. I'm lining up a vet tech to house-sit to ensure Snow gets her meds and to keep an eye on her and ensure she receives her medications, etc. I canceled my bachelorette party, and we've pushed off a honeymoon, but unfortunately, the wedding date is set. I mention all of this because the goal was to get her to a place where she would be safe with a sitter over that weekend, and then I could launch into more trial and error as soon as the wedding was over. Do you think having her on the budesonide until after the wedding will cause harm? I'm wondering if post-wedding, we can wean her off of the budesonide under close supervision. If she has either IBD or SCL, it doesn't sound like reducing the inflammation via budesonide would be a cure, so presumably, the inflammation would come back, and we could go the biopsy route at that point. Does that sound accurate / like a reasonable approach?

Would you recommend a novel protein diet after (or even alongside/while waiting for the results of) the biopsy? I want to ask a bunch more questions but will read up a little more to make sure I understand better before taking too much of your time. It might be premature to launch into too many details now if I'm going to revisit more thoroughly in 3 weeks.

Also, do you always give them the probiotics or just during bouts of diarrhea until the diarrhea passes? My other kitty developed diarrhea when Snow returned from her BG curve at the internist vet. I hope it's sympathy diarrhea, but I assume otherwise. We have an appointment for him to see the vet on Wednesday (during which I may bring Snow, or at least ask some follow-up questions to ensure we have a plan in place).

 

[Wendy&Neko]

In terms of a biopsy for possible SCL, is this invasive? I was under the impression Snow would not do well with anesthesia with her diabetes (but maybe this is only currently while we're getting her back to stabilized?)

There are special anaesthesia protocols for diabetics. Neko had 6 anaesthesia for treatment of her acromegaly and 3 for dentals while she was diabetic. For the majority of those, she was not regulated. Then she got heart conditions which meant she could no longer have anaesthesia.

The biopsy is either done by endoscopy or a surgical biopsy, depending on where in the GI system the inflammation is. The difference in treatments is that steroid may be short term for SCL, but may be long term for IBD. There are diet concerns for IBD, but diet makes no difference for SCL. There is a mild chemo given for SCL but not usually for IBD, unless it is really severe.

For IBD, probiotics is ongoing, it's not a bad thing to give long term. A fibre like psyllium husk fiber could also be added. S. boullardi has two ways of dosing, one for emergency stop procedures, some give more regularly. I just gave the emergency procedure, but my 3 GI issue kitties were vomiters, so diarrhea not common.

A couple websites that might help the diet questions: https://www.ibdkitties.net/ and https://www.rawfeedingforibdcats.org/

You can leave her on budesonide if it's helping. Then if later you decide you want to do a biopsy, you'd stop it until symptoms return before the biopsy.