? Should I give a token dose?

Discussion in 'Feline Health - (Welcome & Main Forum)' started by RachelBee & Spooky, Aug 16, 2022.

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  1. RachelBee & Spooky

    RachelBee & Spooky Member

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    Spooky has been sick the last 36 hours. He didn't want to eat yesterday so I skipped his insulin am and pm even though his blood sugar was high. I took him to the vet today and he stayed all day for observation and treatment. He had fluids, a shot of Cerenia, and an insulin shot, although I'm not sure how much they gave him. Vet kept saying "a unit" of insulin. She didn't tell me the time of the shot, but said they wanted to do one more blood glucose test before he left and that was 337 about 3 hours ago. Just now his blood sugar is at 209, of course on his regular human meter. The vet said I should give him his regular shot tonight. I don't know that I'm comfortable giving him his full shot when he's at 209, not knowing if his numbers are rising or falling. My inclination is to give him half his regular dose, which would be about 1.25. What do you all think?
     
  2. RachelBee & Spooky

    RachelBee & Spooky Member

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    I wanted to post the above quickly - but the rest of the story is that when we did the blood work in June when Spooky was diagnosed, the vet also thought he had cancer. Today we did x-rays and he definitely has a mass in his abdomen pushing on his intestines. We are waiting for blood tests, but I'm not very hopeful. He hasn't been doing very well the last few weeks. Not acting like his normal loving self. And now he's been hiding since yesterday. I feel like he's in pain, and I can't stand it. Thank you all for being here and commiserating.
     
  3. Diane Tyler's Mom

    Diane Tyler's Mom Well-Known Member

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  4. RachelBee & Spooky

    RachelBee & Spooky Member

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    No worries - I tested him every half hour until his numbers started going up, then gave him half his usual dose since he's still not eating normally.
     
  5. FrostD

    FrostD Well-Known Member

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    How is he doing?

    It's curious his numbers came down so much after the vet. Did he technically get 3 shots of insulin that day? That probably explains it.

    What is the plan for anemia? Tagging @Suzanne & Darcy as she knows more about it than I do.
     
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  6. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    Hi Rachel. Your Spooky is beautiful and I am so sad to read about his struggles. I’ve been having a similarly bad week this week with one of my babies, and my heart REALLY goes out to you. I don’t see labs posted but I see on your spreadsheet that Spooky is severely anemic. This definitely should be addressed. I don’t know what the HCT level is at the last bloodwork, but if it’s below 20 then it’s time to administer meds such as Epogen or Darbepoetin to help stimulate the bone marrow to produce more red blood cells. Did you ask the vet the cause of the anemia? If the HCT gets really low then you get into blood transfusion territory. No matter what, I know you don’t want poor Spooky to suffer from lack of oxygen. It’s just some things to ask your vet about. I am so sorry this is happening. Of course, it sounds like you are juggling multiple conditions here. I am sending you big hugs and some tears too — from one worried cat mama to another. :bighug:
     
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  7. RachelBee & Spooky

    RachelBee & Spooky Member

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    I am going to go through his medical records today and figure out what they did. The vet says they gave him 1 unit of Vetsulin at around 10-11am, SubQ fluids, a cerenia shot. I don't think they fed him. I don't know if any of that explains why he's been doing so much better the last few days. He's still nauseous each morning and I am giving him 8mg Cerenia and doing 50-100ml of fluids before breakfast and his shot. If he only got 50ml I do another 50ml later in the day.

    The vet wants to recheck him in a week to see if his numbers are coming back up. I suggested B vitamins and iron (since that's what I did when I was anemic as a teenager) and she said go ahead. So I searched the FDMB and found that people like Jarrow B Right and Liqui-tinic. The Jarrow should arrive today and the Liqui-tinic tomorrow. I also started a new bag of fluids and asked the vet to put B-vitamins in it.
     
  8. RachelBee & Spooky

    RachelBee & Spooky Member

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    Hi Suzanne. Thank you for the response - I'm so sorry to hear that you're having a bad week too. I will be posting labs later today and I will tag you when they're in. My understanding is that his blood volume is very low, but most of his other blood values are normal. My vet is always very vague which is one of the reasons I'm planning to find a new vet. She did say that if his numbers didn't improve in the next 5-7 days we will have to do a blood transfusion. She thinks that with his other issues Epogen side effects would be too hard on him. I haven't done my own research on that one yet. We're pretty sure he has cancer of some sort. She thinks possibly a bone marrow cancer. Hopefully by comparing his last few blood tests I can get a better picture.

    Edited to say he has also been very dehydrated despite giving him subq fluids, and that he seems to be drinking just fine, but peeing a lot.
     
    Last edited: Aug 19, 2022
  9. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    I don't know what kind of side effects she's referring to -- except that sometimes cats can develop (over time) a sort of autoimmune reaction to it (totally worth the risk if she's talking transfusion.) The (newer drug) Darbepoetin is much less likely to cause an autoimmune response. My vet's approach to this problem is, since Epogen works more quickly, to do an initial shot of Epogen (which also vets usually have on hand) and then after that switch to the Darbepoetin. This approach has worked for me and I've never had a cat yet who has developed the reaction to the Darbo. I mean, if she's talking transfusion soon then... what the heck... it could make Spooky feel a lot better. Let me find and link some reliable info for you here. I will put it in my next post. I'm currently going through similar stuff with anemia and am (for now) giving the Jarrow B-Right B-Complex and I divide it into 10 capsules -- size number 4 gelatin capsules. I also will be giving B-12 (cyanocobalamin) injections. So I am taking a stab at it. I have used this before with success... but I have found that it will work for a while when their HCT isn't terribly low and eventually you need to add the "big guns" of Epogen or Darbepoetin. Even if Spooky does have cancer, if you can stabilize and make him feel more comfortable and happy then you have done a good thing and may be able to have more happy days with Spooky. Every day is precious, as long as Spook can be made more comfortable and happy. Only God knows how long Spooky has. I have had many cats where the vets said they didn't have much time, but with supportive care they were made happy and comfortable for quite a long while. Does he have kidney disease? I guess I will be able to tell when you get the labs. It sounds like your vet is not very helpful in a lot of ways. If he is nauseated, then I would suggest adding in Ondansetron tablets, which are very effective at treating nausea. But for now, keep up the good work. I'll post the info on the ESAs.
     
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  10. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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  11. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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  12. RachelBee & Spooky

    RachelBee & Spooky Member

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  13. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    First off, it looks like Spooky has a urinary tract infection - I say this because of the high number of both red and white cells in the urine sample. I would ask my vet about this. Tell me again... were you given antibiotics for this? These can be dangerous in CKD cats because they can progress to a kidney infection (well can happen to any cat, but you don't want this to make the kidney function even worse.) I've had cats with an overall white blood cell count that still had a UTI that needed treating.
     
    Last edited: Aug 19, 2022
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  14. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    And holy cow, the hematocrit is REALLY LOW as hemoglobin and RBC as you can see. This really needs attention right away. I'm sure you agree.
     
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  15. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    And his potassium is low, so I think a supplement like Renal K powder would be good. Ask your vet about it. Above 4 and below 6 is good. Optimally mid-4 between 4 and 5.
     
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  16. RachelBee & Spooky

    RachelBee & Spooky Member

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    No, she said his kidneys looked ok. She mentioned there was blood in his urine sample but didn't seem concerned about it. I will call tomorrow and see if we can get an antibiotic - is there one you would recommend?

    We've talked about CKD before and she felt his kidney numbers weren't bad enough to treat.
     
    Last edited: Aug 19, 2022
  17. RachelBee & Spooky

    RachelBee & Spooky Member

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    It looks like this has been brewing for awhile. I'm not sure why it wasn't caught 6 months ago. Would you go straight to a blood transfusion?
    This stuff? https://www.amazon.com/gp/product/B08CZ1GZBT/ref=ewc_pr_img_1?smid=ASOGC58PFXUBG&psc=1
     
  18. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    Does he get nauseated? Didn’t you say you give Cerenia? What was that prescribed for? How does she explain the elevated BUN? Why are those uremic toxins building up so high? I have seen much worse kidney values yes. And his phos is not super high so that seems good. Creatinine is not high but it could be due to weight loss or muscle wasting as well. Anyway, there’s tons of info on the felinecrf.org site about all of this. A UTI can alter some of the blood values. What other notes from the lab are on the lab results? Didn’t you say you were giving fluids? What was that for if not kidneys?
     
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  19. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    Anyway, the part that’s scaring me the most right now is the anemia. That’s quite severe. Why wait until he needs to be on oxygen and be transfused? I’m so upset for you and your Spooky.
     
    Last edited: Aug 19, 2022
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  20. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    https://www.chewy.com/vetoquinol-renal-k-powder-kidney/dp/109759

    this stuff is the Vetoquinol Renal-K powder. Most of my cats have tolerated the chicken liver flavor very well. It just needs a little supplementation. Maybe once per day? I would ask my bet if there was any objection to it.
     
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  21. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    So hard to say about a blood transfusion. I would ask the vet again about at least trying a shot of Epogen and seeing if it works. I understand the need to try to understand the cause of the anemia- but why can’t your vet explain her objections to you and let you decide. If it works then you may not need the transfusion. Epogen can work quickly. If she thinks it won’t work then why not?
     
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  22. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    Oh and remember he has high white cells in his urine in addition to high red cells. They probably should have sent it off for a culture. If not. At least prescribe a borax spectrum antibiotic. Has he ever had Clavamox (Amoxi-Clav) before? Unless you know he’s okay with it, I would steer away from it. It is a very effective broad spectrum antibiotic, but it can cause inappetance, vomiting and diarrhea in a lot of cats. Some of my cats are okay with it and some just can’t take it. For poor Spooky, who is probably weak, it may not be worth the risk
    , unless he’s taken it before and you know it’s okay. Whatever you do, don’t let them give him a Convenia shot.
     
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  23. FrostD

    FrostD Well-Known Member

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    (Suzanne thank you!!)

    To quickly explain the diabetes portion of this - his numbers are just slightly better. But that is likely due to fluids. If his blood volume is very low, then glucose would be more concentrated. When you give fluids, that helps blood volume and makes glucose a little more dilute.

    Think of it as adding a drop of blue food dye (glucose in this analogy) to a glass of water (blood in this analogy). If the cup is half full, it will be fairly blue. But if it's completely full, it's not going to be quite as blue.

    As far as timing - when are you giving fluids in relation to shot, in terms of minutes/hours? And location? Sometimes the fluids can have the effect of diluting the insulin; this doesn't seem to be the case bas d on numbers, or you got lucky and it's diluting the insulin and avoiding a possible hypo.
     
  24. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    Yep. I never got lower BG in response to fluid that I could track anyway- bit some people do. I figured that you probably had the dosing sorted on this so I was only focusing on the other part right now. I do know that he is a whole cat and the diabetes portion is soooo important. Some people wait a little while between insulin and giving sub-q fluids (I waited an hour or so) and some give the fluids in a different location (I did not as scruff or perhaps a little lower was the best place where there was space for the fluids). I would not give fluids in the flank as there’s not enough subcutaneous space there. Now I was using a depot insulin at the time I was giving fluids (Levemir) so that probably made a difference too.
    I was happy to see that Spooky has had some blue numbers on this dose! Very happy. Now if he would only smooth out a bit with lower AMPS and PMPS. You have my respect and admiration for trying to handle all this Rachel!
     
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  25. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    Has his blood pressure been checked? What about thyroid in past tests predating these most recent ones?
     
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  26. RachelBee & Spooky

    RachelBee & Spooky Member

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    Thank you @Suzanne & Darcy and @FrostD - There is a lot to respond to here, but I will do my best!

    Let me preface this by saying - I'm trying to find a different vet.

    He refused food, and was vomiting foam for the first time on Monday 8/15. She asked if he seemed interested in food, and I said yes, so she prescribed Cerenia for the vomiting and presumed nausea.

    She didn't explain any of this. And I didn't think to ask for the labs to look at them myself. Even looking at them I don't know what I'm seeing...

    IDEXX SDMA says normal value of 12, - "SDMA and creatinine are within the reference interval: impairment of GFR is unlikely. Recommend next step: evaluate complete urinalysis"
    Hemolysis Index 1+ - "Index of N, 1+, 2+ exhibits no significant effect on chemistry values"
    Lipemia Index N - "Index of N, 1+, 2+ exhibits no significant effect on chemistry values"
    The only other note is that they repeated the urine glucose test to verify that yes, he really is passing a ton of glucose.

    Spooky is extremely dehydrated. He lost a lot of weight before we figured out he was diabetic. He went from a healthy weight of 12lbs to an unhealthy weight of 7.6lbs and falling.

    Her failure to explain is part of an ongoing problem. I really should have found another vet a long time ago. That's on me. All she said is Epogen might be hard on him since he is so ill, but we would discuss it at his follow up in 5-7 days.

    I think they may have given him a Convenia shot on Tuesday when he was at the vet all day. I got all his medical records yesterday and they are woefully lacking in detail. We were never charged for Convenia, but when I spoke to the vet on Tuesday afternoon I wrote in my notes that they gave him an antibiotic shot. When I asked if he was given an antibiotic yesterday, the office said there was no record of it. So who knows? Definitely did not prescribe one.

    Thank you for the analogy! I agreed that his dehydration is part of why his numbers were looking worse and now better. We were originally giving him 50ml a few times a week, and now we are doing 50ml morning and evening for the last few days.

    Nobody instructed me on this - I've been trying to do the fluids before his AMPS and PMPS blood tests because it's easier to get a little blood when he's better hydrated. Then Cerenia, then food, then insulin. Fluids go in the scruff because it's the only place with room when he's so skinny. Insulin I've been doing in his flank, where it seems to absorb better and result in better numbers. But sometimes it doesn't work out like that. This morning he wouldn't sit still for fluids, and he's a bit more nauseated so I'm waiting for him to eat a bit more and I'll do the fluids later in the day.

    Oh my gosh me too! So happy to see some better numbers finally. And I appreciate the support and encouragement. I do also work full time but I work from home most days so that helps. But with his health this week I ended up taking a couple of sick days and have not been taking care of myself. I haven't slept a good night's sleep since Sunday night. I'm soooo tired.

    In my other current thread https://felinediabetes.com/FDMB/threads/advice-suggestions-on-how-to-find-a-new-vet.267235/ I've gotten a lot of great suggestions on how to find a new vet. My husband is going to call one that was recommended by a friend of ours when they open this morning. We'll see if they are taking new patients. If not, I have an appointment for Spooky at our current vet on Tuesday. And I'm going to call the current vet today and see about an antibiotic. Their go-to for UTIs is Baytril

    Spooky's Background: Spooky was my mother-in-law's cat. She passed away in 2018 and we adopted him. He had a history of inappropriate litter box usage, UTIs, and early CRF. He was 15 lbs when we got him. Vet said, put him on a diet so we did and he got down to 12lbs by 2021. June of 2021 we brought him in for his annual and there was a lump that the vet excised and biopsied. Biopsy showed post-injection inflammation. He also had a dental cleaning at the same time. In March 2022 he had a medication recheck (he's on 2x weekly Prozac for anxiety). In April 2022 I noticed that his runny eyes had a new brown discharge, so I took him in for antibiotic eye drops. Vet found a bad tooth so we had another dental and four extractions. June of this year was the blood work that diagnosed diabetes. At that same exam, the vet found that on palpation one of his kidneys was enlarged and bumpy. She suspected cancer, to be confirmed with blood work. Blood work inconclusive for cancer I guess, or she forgot about the enlarged kidney. It is nowhere in his medical file, but my husband and I were both at the appointment and both remember her warning us that he probably had cancer. When we brought him into the vet Tuesday they ran the most recent blood work where she saw the anemia, and is thinking it is related to cancer. They did xrays and the xrays show that there is a mass pushing his intestines out of place. The mass is in the right place to be either kidney cancer or liver cancer, but since the kidneys and liver look ok (to her) she thinks it's either bone marrow cancer or blood cancer.

    Sorry for the wall of text - my brain isn't at full capacity. I lost a cat in 2020 to cancer and I kept him around too long because I selfishly didn't want to lose him. I don't want to keep making that same mistake.

    Edited to add the xray findings.
     
    Last edited: Aug 20, 2022
  27. RachelBee & Spooky

    RachelBee & Spooky Member

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    Sorry - forgot to respond to this question. There is nothing in his chart about blood pressure. Oops! I forgot to put his T4 in his spreadsheet. Yes, Total T4 has always been in the normal range.
     
  28. FrostD

    FrostD Well-Known Member

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    I would keep doing what you're doing with fluids then. He's not dropping too low, and there's probably enough time between administering and onset it's ok.

    I'm sure we've asked but how much does he eat? Are you limiting food in any way? The weight loss concerns me, typically even when they're unregulated and on insulin they can still maintain IF given enough food. Any recent GI panels? (Sorry if I've asked that too ha) It could be explained by possible cancer + diabetes + kidneys but it's just too much weight loss from what I'm seeing here.
     
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  29. RachelBee & Spooky

    RachelBee & Spooky Member

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    When we first got him we were free feeding dry food along with two meals of wet food. When the vet said to put him on a diet we stopped free feeding. He got two wet meals and two dry snacks. That was how he intentionally got to 12 pounds. Then the vet said - enough! So we added more wet and more dry. If there was food left at the next meal/snack I figured the food amount was fine. Now that we know he is diabetic, we eliminated the dry food but he has an unlimited amount of wet food. On our home scale he had gained about 1/4 of a pound over the last month or so, but then he weighed the same at the vet. Not sure if that was just because he was dehydrated or if he actually lost 4 ounces in just a few days. No GI panels every that I can recall - maybe before we had him. Let me go check.

    Edited: It looks like in 2017 he was having a lot of diarrhea and had a high Amylase and PrecisionPSL was positive for mild pancreatitis. He was also diagnosed with a heart murmur around the same time. My mother-in-law's records show that his weight wasn't ever stable. He ranged from 16lbs to 12lbs from year to year.

    As far as his appetite - prior to Monday I would have said his appetite was okay. He was always present for meal time, and even if he didn't eat a lot, he would be back for seconds a bit later. This is the first time I've seen him not want to eat, which is why it was so alarming to me.
     
    Last edited: Aug 20, 2022
  30. RachelBee & Spooky

    RachelBee & Spooky Member

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    Quick follow up - we weren't able to get into the vet that was recommended to us by a friend, but we have an appointment Monday at a different clinic. I was impressed by the intake over the phone and by email so my fingers are crossed!
     
  31. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    I want to think over all of this and respond. Don’t give up yet. It is by no means certain that Spooky has cancer. It’s all very vague. The vet is jumping to conclusions because Spooky isn’t doing well and sometimes this can be cancer. But there is no definitive proof. A new vet could be a game changer.
     
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  32. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    How is Spooky?
     
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  33. RachelBee & Spooky

    RachelBee & Spooky Member

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    Hi Suzanne - He seems pretty good today. I was surprised to see how low his BG was at 5am - 172. We did his fluids, Cerenia (although he didn't seem nauseated this morning), then I fed him and waited. Took another reading at 6am - 260. Gave him half his regular dose and he's hovering in the 100s. He's eating well, has some energy and is alert. Today is his 4th day on B vitamins, 2nd day of potassium and iron.

    We have the appointment with the new vet this afternoon.
     
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  34. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    Oh that’s Vetsulin for you. It can push them down too hard. But you are doing a good job of monitoring. I’m really happy to hear that he seems to be perking up with the treatments.
     
  35. Suzanne & Darcy

    Suzanne & Darcy Well-Known Member

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    But those blue numbers are very good to see on his spreadsheet!
     
  36. RachelBee & Spooky

    RachelBee & Spooky Member

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    Waiting on more blood work but it looks like the new vet agrees with the old vet about the diagnosis of cancer. She palpated a large mass near the liver/kidney. Based on the last blood tests she suspects hemangiosarcoma. It's rare in cats, but virtually untreatable. Radiation and/or chemotherapy could give him another six months tops. Without treatment he will probably only live a few more weeks. We did get a prescription for ondansetron and buprenorphine for pain, and we will try to keep him as comfortable as possible until it's his time.
     
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  37. Virginie & Chewie (GA)

    Virginie & Chewie (GA) Well-Known Member

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    Oh, that's such sad news Rachel, I am so sorry. I hope you can spoil the heck out of Spooky for as long as possible, until he lets you know he is ready. As a mom of 4 seniors, my heart really goes out to you.
     
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  38. FrostD

    FrostD Well-Known Member

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    I am so sorry for that news. I am hoping the blood work points to something less aggressive, but I know how these things tend to go :/ Will a pathologist look at the blood?

    If it is the final diagnosis, and I do not intend this to be depressing, just thinking quality of life - if it were me, I'd scale way back on testing. I would just get a +3.5-ish to make sure he won't go too low (that gives you time to intervene with food). The rest don't really matter, let him relax with minimal poking.

    And forgive this next part, as it's delicate but need to make sure you know - BG can do some very odd things towards the end, especially on Vetsulin. Very high highs, and low lows; the only.pattwrn is lack/disappearance of a pattern . This is the main reason I'm still recommending that midcycle test vs not testing at all. I'm sorry because it really is a rock and a hard place; some caregivers choose to skip insulin entirely but that's additional wear and tear and DKA risk, some choose to reduce testing but then you also risk hypo.

    :bighug:
     
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  39. RachelBee & Spooky

    RachelBee & Spooky Member

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    I'm glad you brought that up - I'm planning to reduce his insulin and test less. He doesn't seem to be eating at night. Yesterday and today his morning number was under 200. I don't want to keep poking him, so I was thinking to test before shots and maybe one midcycle if I can get it. And if the mid-cycle is too low I will reduce, and if the before shot number is below 200 I will give a token dose (I'm thinking 1 unit.) What do you think?
     
  40. FrostD

    FrostD Well-Known Member

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    Right now I'd say that's good. But it may shift on you.
     
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  41. RachelBee & Spooky

    RachelBee & Spooky Member

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    I got his new blood work last night. Kidneys look worse, anemia seems to be improved (but still anemic) but the strange one is his Potassium went from too low to too high. The amount of potassium supplementation I was giving him (4mg Potassium Citrate 2 times a day) would not explain that. I'm not sure how it could change that much in one week.

    The tumor is in a location where it is impacting his intestines, liver, and kidneys, and it is growing fast. He also has a heart murmur since forever.

    I got him an automatic feeder for overnight and that seems to have worked - he ate last night.
     
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  42. FrostD

    FrostD Well-Known Member

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    Hmm. My only thought would be the fluids? If it's lactated ringers vs just saline, LR has potassium.

    Does the bupe seem to be working for him?
     
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  43. RachelBee & Spooky

    RachelBee & Spooky Member

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    He is on lactated ringers. Would it be better to switch him back to normal saline?

    So far he hasn't been showing much/any pain so we haven't tried the bupe. His head is up, ears are alert, no tension in his jaw. He's eating and drinking. The only indication I have that he's uncomfortable is that he retreats to his bed under my husband's desk after meals, and he only comes looking for me for food, not love :(
     
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  44. FrostD

    FrostD Well-Known Member

    Joined:
    May 27, 2020
    Unfortunately I can't answer that, his case is more complicated beyond my ability to make recommendations. Because it has other electrolytes, etc I'm not sure how that would affect things....lactated ringers is technically contraindicated in cats with advanced kidney disease so I'm not quite sure why vet is giving you that. Perhaps they don't consider it advanced, or it's a "lesser of multiple evils" sort of thing.

    I'd call, mention the lab results and see what to do about the citrate and lactated ringers vs saline.

    I'm glad he doesn't seem to be in pain. I hate when they're not feeling well and distant :/
     
    RachelBee & Spooky likes this.
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