NEW MEMBER - Suki - Can't Control Ketones

[Becca & Suki]

Hello everyone! I hope this is the right place to post. My 15 year old cat Suki was diagnosed around a month ago, fructosamine at 451, main symptoms were excessive drinking and urination with lethargy and low appetite. We're based in the UK.

She's been started on ProZinc 0.5U, monitoring with a human meter (VivaChek Ino). Once diagnosed we switched her to low-carb wet food (Sheba Fine Flakes in Jelly - around 2% carbs). What I noticed from the get-go is that her appetite just wasn't there. She'd be lethargic during the day, eating and drinking very little, then perk up and night and eat a lot more. A few days into treatment we ordered a ketone blood monitor (GK Dual) and realised she was having ketones. Messaged the vets immediately who weren't concerned. From that time we were never able to get on top of the ketones (they'd be high at insulin time, lower during the day, but never gone). We added extra carbs to try to buffer her system however it only helped temporarily, and then her BG readings would be erratic the next days. We had a few no shoot numbers and at that time she stopped eating completely and went into mild DKA. She came home from the hospital a few days ago with a clean bill of health and an appetite stimulant (mirtazapine) but since then WE CAN'T CONTROL THE KETONES.

What we're doing now:
- ProZinc 1.0 (had to up to 1.25 this morning as ketones were 1.6)
- Higher carb food (anywhere from 13.5% - 19%) with appetite stimulant to try to get her eating MORE and to be able to tolerate more insulin, although I'm unsure what level would be most appropriate

I am at a loss for what I should be doing here. The vet surgeons sent her home with a "give her 1.0U and whatever food she'll eat". She's horribly lethargic, clearly uncomfortable. I desperately need help to prevent her going into DKA again. Any advice or suggestions I would be so, so grateful for.

Her SS: Suki - UKFD SS HUMAN METER Template

 

[squeem3]

@Suzanne & Darcy can help you with ProZinc.

@Bron and Sheba (GA) @Wendy&Neko @Sienne and Gabby (GA) can help with the ketones.

I know there are UK members here but not sure how active they are. @Elizabeth and Bertie might be around occasionally.

Here's some info on dealing with ketones: Ketones, Ketoacidosis, and Diabetic Cats: A Primer on Ketones I think you basically feed whatever the cat will eat for now and make sure she stays hydrated and keep a close eye on the ketones and blood glucose levels.

 

[Suzanne & Darcy]

Higher carb food (anywhere from 13.5% - 19%) with appetite stimulant to try to get her eating MORE and to be able to tolerate more insulin, although I'm unsure what level would be most appropriate

Feeding carbs is not the way to go. This is only going to increase BG and that causes ketones to rise. .

What kind of numbers are you getting on your blood ketone meter. I am very familiar with high ketones as my boy had high ketones for a long time (post DKA) and I could not usually get the vet to take them seriously!

You need to feed a lot of low carb food and keep him well hydrated by watering the food if he tolerates it and sub-q fluids at home if you can. And we may need to increase insulin. I will take a look at your spreadsheet. Doing different doses all the time usually leads to erratic BG numbers.

 

[Suzanne & Darcy]

I do understand that you need to keep him eating. Do you have appealing foods that are low carb?

 

[Suzanne & Darcy]

Those ketone readings I see on the spreadsheet are not super high, however, I am very concerned about the lethargy and lack of appetite. Was Suki checked for a urinary tract infection or other possible infection? How are her teeth? Has she had any antibiotics recently?

 

[Becca & Suki]

I do understand that you need to keep him eating. Do you have appealing foods that are low carb?

This was my fear but from what I read the initial thing to do with ketones is get carbs in. We have lots of low carb food in that she likes, and with the appetite stimulant she'll eat. Our problem has been that she only licks up the gravy but doesn't eat the chunks, so we're going to start pureeing so the food is mostly gravy now - hopefully this will get the calories in. It's infuriating that vets don't take this seriously! Suki is drinking plenty and we add extra water to her wet food every time (especially now as we're going to be pureeing). No UTI found or other infection, her teeth have been looked at by quite a few vets and no problems found. She had some antibiotics at the hospital but kept vomiting them up when we got home, so the vet said to stop them as no infection was present in the bloods.

 

[Becca & Suki]

I'm sorry that your boy also suffered with this! I feel like we can't get stability right now and I think that's exactly what Suki needs. My gut feeling is the lethargy is coming from the ketones as everything else was checked at the hospital - ultrasound showed nothing in the organs, bloods all clear, urine sample and culture the same.

 

[Becca & Suki]

If we're going to get her back on low-carb food, should I transition her slowly? I'm worried that suddenly changing will then cause a BG drop and the insulin will be too much and potentially hypo her.

 

[Gill & George]

with ketones is get carbs in

It's not so much carbs as calories, she needs to be having more calories, particular if she's lost weight.

The balance is
1) enough insulin
2) enough hydration
3) enough calories

Do you have a spreader set up with her blood glucose levels?

To some extent of she has no appetite, whatever food she eats is what's good for her, but if that's high in carbs the insulin dose has to go up accordingly. Ideally we want her eating well and lower carbs.

 

[Becca & Suki]

It's not so much carbs as calories, she needs to be having more calories, particular if she's lost weight.

The balance is
1) enough insulin
2) enough hydration
3) enough calories

Do you have a spreader set up with her blood glucose levels?

To some extent of she has no appetite, whatever food she eats is what's good for her, but if that's high in carbs the insulin dose has to go up accordingly. Ideally we want her eating well and lower carbs.

Yes, I think our problem has been the calories and not getting enough in. She has an appetite stimulant now which is really helping but she only like the gravy of the food so we're trying to puree it all now. I have her spreadsheet here: Suki - UKFD SS HUMAN METER Template

 

[Suzanne & Darcy]

If we're going to get her back on low-carb food, should I transition her slowly? I'm worried that suddenly changing will then cause a BG drop and the insulin will be too much and potentially hypo her.

Yes. If she is eating all medium to higher carb food, you can gradually make the change back to LC food. It shouldn’t take more than a few days 3-5 days though— depending on how she does with the switch. If you are monitoring her BG you can keep her safe.

 

[Becca & Suki]

Yes. If she is eating all medium to higher carb food, you can gradually make the change back to LC food. It shouldn’t take more than a few days 3-5 days though— depending on how she does with the switch. If you are monitoring her BG you can keep her safe.

We'll keep monitoring as closely as we can. What dose of ProZinc do you think would be reasonable to keep her on for now? Since coming back from the hospital over the last few days she's been on anything from 0.5 to 1.25 - I'd really like to stabilise the dose for her little system to settle but obviously with changing the food back to LC I desperately want to avoid a hypo situation, while keeping ketones under check of course.

 

[Suzanne & Darcy]

We'll keep monitoring as closely as we can. What dose of ProZinc do you think would be reasonable to keep her on for now? Since coming back from the hospital over the last few days she's been on anything from 0.5 to 1.25 - I'd really like to stabilise the dose for her little system to settle but obviously with changing the food back to LC I desperately want to avoid a hypo situation, while keeping ketones under check of course.

Looking at her numbers today, I think you can keep her at 1.25 units. You have plenty of room for her numbers to go down and, as long as you are monitoring and making the changes over the course of a few days, you can keep her safe. If you feel more comfortable, you could go with 1 unit and see how it goes. You have been feeding around 13.5 percent carbs, you said, so that’s considered medium carb and isn’t as bad as 20 percent or super high carb kibble (which is oftentimes 35-40 percent carbs.) Hopefully, that means the change in BG won’t be as dramatic (but we are hoping to see lower BG.)

 

[Suzanne & Darcy]

Now that your questions are being addressed, would you please remove the 911 from your title?

 

[Becca & Suki]

Looking at her numbers today, I think you can keep her at 1.25 units. You have plenty of room for her numbers to go down and, as long as you are monitoring and making the changes over the course of a few days, you can keep her safe. If you feel more comfortable, you could go with 1 unit and see how it goes. You have been feeding around 13.5 percent carbs, you said, so that’s considered medium carb and isn’t as bad as 20 percent or super high carb kibble (which is oftentimes 35-40 percent carbs.) Hopefully, that means the change in BG won’t be as dramatic (but we are hoping to see lower BG.)

Halfway through the day she's decided she doesn't want her 13% and will only eat her 8% food so I think to be safe I'll go for a 1U, trying to get a little more of the medium carb in here and there to help the transition. Thank you for all your help today, Suzanne!

 

[Suzanne & Darcy]

Well, 8 percent is fine. If that is what she wants I am happy she will eat it.

 

[Gill & George]

I wouldn't worry too much as long as you're doing wet food the carbs get out of the system pretty quick, kibble is much higher and dependent on the cat it can take a few days, which can be tricky to judge, with the carbs in wet you're looking at a couple of hours, they will affect the insulin cycle of course, usually shortening the duration and seeing the Nadir's higher. It's important to get enough insulin and as much food as possible.

The other thing I forgot to mention is that it's important to address any infection or inflammation as often its a combo of not enough insulin, not enough calories and infection/inflammation.

So keep an eye out for any signs of infection/inflammation, that's why Suzanne was asking about her teeth and othe common issues

 

[Becca & Suki]

I wouldn't worry too much as long as you're doing wet food the carbs get out of the system pretty quick, kibble is much higher and dependent on the cat it can take a few days, which can be tricky to judge, with the carbs in wet you're looking at a couple of hours, they will affect the insulin cycle of course, usually shortening the duration and seeing the Nadir's higher. It's important to get enough insulin and as much food as possible.

The other thing I forgot to mention is that it's important to address any infection or inflammation as often its a combo of not enough insulin, not enough calories and infection/inflammation.

So keep an eye out for any signs of infection/inflammation, that's why Suzanne was asking about her teeth and othe common issues

The hospital cleared her for any infections so I'm hoping we're all okay in that department! I didn't know though that wet food carbs clear much quicker than kibble - Suki was on 18% kibble for about a day and half when she first came out of the hospital (it's all she would eat) so I'm a little worried her numbers right now might still be being affected by that.

 

[Suzanne & Darcy]

The hospital cleared her for any infections so I'm hoping we're all okay in that department! I didn't know though that wet food carbs clear much quicker than kibble - Suki was on 18% kibble for about a day and half when she first came out of the hospital (it's all she would eat) so I'm a little worried her numbers right now might still be being affected by that.

She’s been home from the hospital for five days so the dry food influence is gone. It doesn’t last that long. High carb wet food will only raise BG for about two hours. But you have only been feeding MC, but still that will influence BG for about two hours.

Still, when making food transitions, it’s always right to be monitoring BG carefully as you are already doing.

 

[Suzanne & Darcy]

think to be safe I'll go for a 1U,

I am okay with this unless her ketones start going up substantially. We may have to make adjustments in either direction based on her numbers as you transition the food and based on ketones. Sufficient insulin is very important for preventing DKA.

 

[Wendy&Neko]

Have you changed the spreadsheet? I am to read it. You need to change the sharing so that it's is "anyone with the link". Also best to put the link to the spreadsheet in your signature, so it's there all the time.

A ketones level of 1.6 is not a red alert, though you'd like it lower.

 

[Bron and Sheba (GA)]

Hi and welcome to the forum.
I can’t read the spreadsheet either.
If Suki is not eating she may need an antinausea medication such as ondansetron. This should be given before the appetite stimulant.
How often are you offering food?

 

[Becca & Suki]

Have you changed the spreadsheet? I am to read it. You need to change the sharing so that it's is "anyone with the link". Also best to put the link to the spreadsheet in your signature, so it's there all the time.

A ketones level of 1.6 is not a red alert, though you'd like it lower.

Sorry for the late reply, had a lot going on this week! I've changed my spreadsheet sharing and added it to my signature - hopefully that's working now.

 

[Becca & Suki]

Hi and welcome to the forum.
I can’t read the spreadsheet either.
If Suki is not eating she may need an antinausea medication such as ondansetron. This should be given before the appetite stimulant.
How often are you offering food?

We've tried antinausea medications but unfortunately they didn't seem to work. The appetite stimulant (Mirataz) is helping a lot but obviously we don't want her on that forever, I believe it's the ketones that are making her so low appetite - Suki seems to be horribly affected by them. We offer food multiple times throughout the day and she's a grazer anyway. She usually ends up eating every 2-3 hours, with a fast before her AM and PM glucose tests. Total calories throughout the day are usually around 400 or more and she's put on a bit of weight that she'd lost.

 

[Becca & Suki]

I am okay with this unless her ketones start going up substantially. We may have to make adjustments in either direction based on her numbers as you transition the food and based on ketones. Sufficient insulin is very important for preventing DKA.

Hi Suzanne, I wonder if I might be able to pick your brain again about this. We've been holding Suki for the past week at 1U and getting BG drops, albeit not quite low enough. I've noticed something strange though and I can't make top or tail of it. We transitioned Suki to her 2% carb food, plenty of it, with the 1U insulin. Paradoxically her BG numbers and ketones seemed to go up! When chatting with the UK Facebook group they suggested adding some extra carbs as a buffer - I switched her back to her 8% food and added a few spoons of 13% AM and PM and this then dropped her BG numbers and seemed to be helping the ketones. But then we get a random day where she has no response to her insulin at all! When she next got her dose it hit her very hard and fast (near 10mmol drop by +2) and now the next morning ketones are 1.5. I'm at a total loss of what to do. Are the carbs temporarily helping and then end up hindering, and was I wrong to introduce them again? Maybe switching back to her 2% and then upping the insulin might be better? My SS is in my signature, I'd be incredibly grateful if you could have a look. I'm really struggling, and unfortunately so is Suki as she's horribly affected by any ketones.

 

[Suzanne & Darcy]

Hello! I’m happy to see the blue numbers on Suki’s spreadsheet. I would strongly discourage you from derailing a nice cycle by giving high carb food when she gets into the blue (or hopefully green eventually) numbers. I completely understand your anxiety at night though —and also since it’s pretty new to be seeing her in those blue numbers. It looks like she has a higher and flatter cycle after she gets lower numbers. It’s a kind of short-lived bounce. I see that frequently in our cats here. It’s fortunate that Suki’s bounces don’t last long like they do in some cats. Her body is reacting to the lower numbers and releasing adrenaline, cortisol, glucagons and growth hormone— which raise BG and make her insulin resistant for a little while. She’s not used to those lower BGs since becoming diabetic.

If you are testing for ketones when she is in the 300s (pink) then they will be higher than if you check them when she’s in yellow or blue BG numbers. Ketones fluctuate throughout the day and night. I am not saying not to worry about them; my cat was prone to producing ketones (and also went into DKA at one point) and it always scared me after that. He never had a second DKA though even when his ketones were high. The ketones came down after his BG numbers improved.

As for the food. It’s fine to feed 8 percent carbs as that is still considered low carb food — any food under 10 percent is fine. Some cats don’t need the lowest of the low carb food and will actually give you better numbers with a few more carbs. I would not use medium carb food (the 13 percent) for her unless I were trying to raise her BG. We use food for smoothing the cycles and preventing steep drops. That is why giving the +2 snack and another on at around +4 is helpful. If the BG drops more than 100 in a single hour (5.5 in your numbers?) then that is too fast for most cats, and it can set them up for a bounce. We “feed the curve” and some people find that their kitty does best when given a few more carbs (still under 10%) for the AMPS/PMPS meals and the +2 snack and then reducing the carbs after that when getting close to nadir. Some cats are more sensitive to carbs than others and you have to find out what works for her. An 8 percent is a reasonable choice if it works for Suki.

 

[Becca & Suki]

Hello! I’m happy to see the blue numbers on Suki’s spreadsheet. I would strongly discourage you from derailing a nice cycle by giving high carb food when she gets into the blue (or hopefully green eventually) numbers. I completely understand your anxiety at night though —and also since it’s pretty new to be seeing her in those blue numbers. It looks like she has a higher and flatter cycle after she gets lower numbers. It’s a kind of short-lived bounce. I see that frequently in our cats here. It’s fortunate that Suki’s bounces don’t last long like they do in some cats. Her body is reacting to the lower numbers and releasing adrenaline, cortisol, glucagons and growth hormone— which raise BG and make her insulin resistant for a little while. She’s not used to those lower BGs since becoming diabetic.

If you are testing for ketones when she is in the 300s (pink) then they will be higher than if you check them when she’s in yellow or blue BG numbers. Ketones fluctuate throughout the day and night. I am not saying not to worry about them; my cat was prone to producing ketones (and also went into DKA at one point) and it always scared me after that. He never had a second DKA though even when his ketones were high. The ketones came down after his BG numbers improved.

As for the food. It’s fine to feed 8 percent carbs as that is still considered low carb food — any food under 10 percent is fine. Some cats don’t need the lowest of the low carb food and will actually give you better numbers with a few more carbs. I would not use medium carb food (the 13 percent) for her unless I were trying to raise her BG. We use food for smoothing the cycles and preventing steep drops. That is why giving the +2 snack and another on at around +4 is helpful. If the BG drops more than 100 in a single hour (5.5 in your numbers?) then that is too fast for most cats, and it can set them up for a bounce. We “feed the curve” and some people find that their kitty does best when given a few more carbs (still under 10%) for the AMPS/PMPS meals and the +2 snack and then reducing the carbs after that when getting close to nadir. Some cats are more sensitive to carbs than others and you have to find out what works for her. An 8 percent is a reasonable choice if it works for Suki.

Thank you so much for your reply and insight! The nighttime drop definitely scared me, I must admit I panicked. It seemed like such a harsh drop so early in the cycle. Suki generally eats most of her big meal with her insulin, finishes it off an hour later and then gets more food at +2 so the big drops are confusing me, I'm not sure how to smooth that out a bit more so that we can prevent the small bounces afterwards. That drop last night was even with 13% food at shot and +1! Either way, I'll remove the medium carb food and stick to her 8% for now, I think she fares better on it than fully on the super low 2%. I might trial a 2% pack midday at nadir to see if we can get lower numbers, as you've suggested. A combo might be key here.

The ketones really worry me as anytime they're over 0.6 she's very lethargic and uncomfortable, appetite down and just not herself. She seems to be incredibly sensitive to them. We're relying on Mirataz right now which thankfully works very well but I also worry about her developing a tolerance to it. She's getting about 400+ calories in per day now and has gained a bit of weight back that she'd lost which is a big positive!

Going forward, as we are starting to get blue numbers now, would you suggest holding the 1U dose?

 

[Suzanne & Darcy]

Going forward, as we are starting to get blue numbers now, would you suggest holding the 1U dose?

I think that you could hold the 1 unit dose for a couple more days and stabilize the food by just doing her 8 percent food and possibly the 2 percent if you want to try it around nadir time (although you may find she does well with the 8 percent all the time?)

I also think she can handle an increase to 1.25 units since the blue numbers are mostly mid to higher range blues. We will have a better chance of reducing those ketones if we can get her numbers down, so I wouldn’t wait much more than two days to see how it goes with the 8 percent and decide after that if it’s a good idea to move to 1.25 units.

Last night, it looks like she was breaking her little bounce into pink from that day. When that happens they can really drop quickly. She went right from pink to blue! I think you just showed yourself the importance of testing at night. We always recommend at least getting the “before bed test.”