10/3 - Bandit - CKD + sudden high numbers - TID dosing?

Bandit's Mom

Bandit's Mom

Member Since 2019
Link to previous post:
https://www.felinediabetes.com/FDMB/threads/experience-with-clavamox-augmentin-side-effects.250318/

Bandit's numbers have been TERRIBLE for the last month. She has always been bouncy but she's now routinely bouncing to HI. Her CKD has also taken a turn for the worse (Stage III) and I desperately need to get her numbers under control to stop the PU/PD and the stress on her kidneys.

I am not sure what has caused this sudden deterioration in her numbers (BG and kidney values and whether the two are related). She is not uniformly high but just swinging wildly between greens/blues and blacks/HI. When she first started throwing HI's, almost a month back, I thought a dose reduction might reduce the bouncing, but nowadays she's going to HI from blues!

I am part of Tanya's CKD group but none of the Moderators or regular members have much experience with CKD+diabetes. They have no explanation for why her numbers are so bad - whether CKD could be elevating her numbers. Nothing in the labwork or urinalysis indicates an infection. Urine C&S was clear.

She is on dry food and will eat when she wants. I have tried everything to get her to transition to wet/raw and to get her to eat in the first part of the cycle. And given up. I know that her eating after the nadir is reducing duration. I have tried moving shot times around to see if I can prevent that, but she shifts her eating accordingly! :banghead:

Things are worse in the last few days, because she is even refusing to eat Young Again/Dr. Elsey's and wants only the HC kibble. For the last 2 days, I have had to mix the HC kibble with Dr. Elsey's for her to eat.

I tried using R to bring her numbers down but haven't had much success - I am able to bring her numbers down for a few hours in the first part of the cycle but she doesn't get enough duration since she keeps grazing on food through the cycle. And now she's going to be eating higher carbs after the nadir.

To cut a long story short, I was wondering whether to try TID dosing with Levemir? If that would give more duration?

Would also appreciate if anybody had ideas on what could be causing her numbers to swing to such high levels.

@tiffmaxee
@Wendy&Neko
@Sienne and Gabby (GA)
@Marje and Gracie
 
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This is beyond my ability to figure out. I hope one of the others can advise. :bighug::bighug::bighug: In your shoes I would try anything to break this trend but I have no experience with TID.
 
Has your vet checked out Bandit's heart? I see subq's are a recent addition to her and just wanted to make sure that wasn't causing any problems.

Are you using an R scale? We very strongly recommend that if you try R, you do it with the help of experienced people here. There are many thing to learn about giving R, and more importantly, learning when not to give R. Giving it wrong can mean a vicious cycle of diving and bouncing. I see a few instances of too much R, causing a steep drop and resulting mega bounce. We use U-100 syringes, not U-40 for R.

Why famotidine?

I wouldn't proactively increase a dose like you did because you are adding HC, but rather hold the dose at least six cycles before increasing once it's shown that the dose is not enough insulin. What %carb is the HC kibble.

I don't see evidence of lack of duration, which is the only reason I'd try TID.
 
Wendy&Neko said:
Has your vet checked out Bandit's heart? I see subq's are a recent addition to her and just wanted to make sure that wasn't causing any problems.
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Yes, I though about that and I am planning to get her heart and BP checked this week when I take her to the vet.

Wendy&Neko said:
Giving it wrong can mean a vicious cycle of diving and bouncing. I see a few instances of too much R, causing a steep drop and resulting mega bounce.
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Yes, I realized this, so cut back on the R. I wasn't giving more than 0.25U but reduced it to a drop. Even stopped R in between because I thought it was increasing the bouncing.
I am using R40 with U40 syringes. I am saving my U-100 syringes (which I get shipped from the US) for Levemir. We get U-40 syringes of 30 unit capacity which makes it easier to dose. The U-100 syringes available here are 100u capacity.

Wendy&Neko said:
Why famotidine?
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Bandit was throwing up bile and the vet prescribed Famotidine after seeing pics of her vomit saying it is because of acid build-up.

Wendy&Neko said:
What %carb is the HC kibble.
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18-20%

Wendy&Neko said:
I don't see evidence of lack of duration, which is the only reason I'd try TID.
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What would you suggest in terms of dosing? Any thoughts on why she is swinging so violently suddenly? I had stopped R between Sep 3rd and 13th and she was still bouncing to HI.
 
I'm trying to get a whole picture of Bandit. Including other conditions and meds used to treat them. There are many things such as infection/inflammation/secondary conditions/certain meds that can cause numbers to fluctuate wildly. I see she hasn't had a thyroid test for over a year. How are her teeth? The latest labs are odd because her potassium is high and the phosphorus lower, and I'd expect the reverse for CKD. Was she getting supplements for either of them?

Looking at Table 9 in (2016) ISFM Consensus Guidelines: Diagnosis & Management of Feline Chronic Kidney Disease
Omeprazole is preferred over famotidine in the paragraph after that table.

What is the name of the U-40 R you have there?

She looked pretty good until early September, when she did not get reductions that were well earned. Short term recommendations. First, stop R. I'd like to get a picture without it in the mix. Plus it's causing way too big a drop. You want the BG's to go down no more than 100 points over the four hours after it's given. Even "some" tonight was too much. R is used as a nudge down of the numbers, to give Lev a better number to work with. Would it be possible to get +3 tests for a few cycles? It seems to be her onset, and I'd like to see if she's dropping on her own without R.

There are times to give R and times not to. You don't want the nadirs of the Lev and R to overlap. Similarly, no R the first cycle of an increase or when breaking a bounce, cause those can be more active cycles that don't want R in the mix. I don't see hourly testing after R since you started it, so I don't have a good idea of R's onset, nadir and duration in Bandit.

There's a lot going on with Bandit right now. :bighug: I'd like to simplify things, get a baseline, then see where to go from there.
 
Hi Bhooma! I have no suggestions for you (sorry!), but just wanted to let you know im keeping my fingers crossed for you to find the magic solution.
:bighug::bighug:
 
Hugs from us too :bighug::bighug::bighug: it’s so easy for us to forget that those who help also have their own babies to worry about. I hope you find the answers for Bandit. You’ve been so wonderful to Oscar and I!:)
 
She won’t eat wet food, but will she eat those creamy treat sticks, like Gnawlers Smooth Creamy, Inaba Churu, or Sheba Melty? If you haven’t tried them, they are like crack. I’d be surprised if any kitty would say no to them.

Pricey, but you can stretch one as a topper over 3-4 meals https://www.amazon.in/Sheba-Melty-Premium-Chicken-Chicken-Whitefish/dp/B07GVN8HL4

The Gnawlers are less:

https://www.amazon.in/Gnawlers-Smooth-Creamy-Flavour-Launched/dp/B092SH2BR9

Maybe a good enticement over the YA/Dr. E?

What are the parameters for it now being Stage III?

I can’t believe I missed that! Was it something from the latest blood test results?
 
Wendy&Neko said:
There are many things such as infection/inflammation/secondary conditions/certain meds that can cause numbers to fluctuate wildly. I see she hasn't had a thyroid test for over a year. How are her teeth? The latest labs are odd because her potassium is high and the phosphorus lower, and I'd expect the reverse for CKD. Was she getting supplements for either of them?
Click to expand...
Bandit was suddenly displaying PU/PD in July. The labs did not show any worsening of her CKD but my vet thought she had an infection. She was put on Baytril (for 15 days) after a strong initial reaction to Clavamox (probably because the dose was double the cat dose!). The symptoms didn't resolve and Batyril was discontinued.

I did get her thyroid checked at the end of July and it was normal - sorry I didn't update it in her labs.

She had a dental in Oct 2020. Her vet checked her teeth/gums last month but didn't seem to think anything was off. Will have him recheck them when we see him later this week.

Yes, the latest labs look incorrect to me but the vet says such fluctuations are possible. She got 5 days of subqs (100 ml of LRS daily between labs done on Sep 18 and 24) but no supplements.

Wendy&Neko said:
Looking at Table 9 in (2016) ISFM Consensus Guidelines: Diagnosis & Management of Feline Chronic Kidney Disease
Omeprazole is preferred over famotidine in the paragraph after that table.
Click to expand...
Famotidine was what was recommended by my vet and most cats on Tanya's CKD group seem to be on it. I checked with them and they said it was fine.

This is what Tanya's website says:
"So why don't I recommend starting with omeprazole rather than the histamine H2 antagonists, such as famotidine? Well, firstly, because I've seen the histamine H2 antagonists used for much longer, since 1999, and most people seem to find they are effective with few side effects. Secondly, a number of human studies have found that PPIs are associated with a higher risk of kidney problems. See Risks for more information."

Wendy&Neko said:
What is the name of the U-40 R you have there?
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The one I am using is Human Actrapid 40 IU/ml manufactured by Novo Nordisk
https://www.1mg.com/drugs/human-actrapid-40iu-ml-solution-for-injection-163017

Wendy&Neko said:
First, stop R. I'd like to get a picture without it in the mix.
Would it be possible to get +3 tests for a few cycles? It seems to be her onset, and I'd like to see if she's dropping on her own without R.
Click to expand...
Done and done!

She has been grazing on a mix of Dr. Elsey's (4%) and HC kibble (18%) through the second half of the PM cycle. Did not really want food in the first half. That's my biggest challenge with her. She will eat when she wants. She has kept us up 2 nights in a row (between 2am and 5am) wanting her Dr. Elsey's to be spiked with HC kibble.

Just recapping all the meds she is on right now:
2mg Ondansetron every 8 hours
2.5mg Famotidine once a day
1/4 tab B-Complex once a day
350mcg Methyl B-12 as a subq shot once a week (now - used to be once every 2-3 weeks)
1/8th tsp psyllium husk once a day
1 mg Cyproheptadine (as required)
80-100mls LRS every day - in the BG numbers she is in right now, she is peeing and drinking crazy amounts.
 
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smorgasbord said:
Maybe a good enticement over the YA/Dr. E?
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She will probably lick it off and leave the YA/Dr.Elsey's. I could try. Aren't they higher carb though?
Once I start her off on a topper, she expects it to be there all the time! :rolleyes:

smorgasbord said:
What are the parameters for it now being Stage III?

I can’t believe I missed that! Was it something from the latest blood test results?
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Creatinine above 2.9 is Stage 3. See this http://felinecrf.org/how_bad_is_it.htm#iris_blood_tests
Her creatinine was stable till July and suddenly deteriorated in Sept.
 
Bandit's Mom said:
Once I start her off on a topper, she expects it to be there all the time!
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I mean, you're not wrong. Sigh.
And yes, they are higher carb. Less than the HC kibble, but barely, probably fall in the MC range (None of those are available here, just based on the ones we get).

Bandit's Mom said:
Her creatinine was stable till July and suddenly deteriorated in Sept.
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Damnit. Ok.

Any chance she has sterile cystitis and that's why she has higher WBC and the C&S came back neg?
 
Bandit's Mom said:
The one I am using is Human Actrapid 40 IU/ml manufactured by Novo Nordisk
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Hmm, not sure we've had anyone here using that. If you do get back to using it, I'd do a bit more testing to find out the onset and nadir. That would mean hourly testing for 4-5 hours a couple times.

As for the kidney disease, did your vet consider a possible kidney infection? That takes a longer treatment on ABs, and can impact the kidney numbers.
Bandit's Mom said:
Done and done!
Click to expand...
Let the experiment begin!
 
Sending my love and prayers to you and Bandit. I am so sorry she is struggling with so much. You have been our life saver more times than I can count for the last year, wish I could offer help to you two. Tons of hugs and prayers Bhooma and Bandit :bighug::bighug::bighug::bighug:
 
Wendy&Neko said:
As for the kidney disease, did your vet consider a possible kidney infection? That takes a longer treatment on ABs, and can impact the kidney numbers.
Click to expand...
I'm taking her to a vet specializing in kidney issues this week. He had ordered a set of tests including Urine C&S but wasn't able to see us last week. I have a ton of questions for him.
I'm wondering whether to get her back on Baytril irrespective of what he says. Fortunately, we don't need a script for meds.

Wendy&Neko said:
Let the experiment begin!
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A very auspicious start! 485 @ +3! :confused:
Do you know whether it matters how high the numbers are once they are over the renal threshold? Or whether say 300 has the same affect on the kidneys as 500 or HI.
Worried about how these consistently high numbers are affecting her CKD. :(
 
I did talk to Neko's IM vet about this very topic. When she got her heart disease and small cell lymphoma diagnoses (same time :banghead: ) her numbers started going very off. Of course, she was on a bunch of new meds too. She had CKD at the time. He said that long stretches above renal threshold are worse than periodic high ones in between below renal threshold numbers. Good to hear you are getting into a kidney specialist. I'd follow what they suggest instead of just doing meds on your own.

Remember New Dose Wonkiness typically starts to show up the second cycle.
 
Bhooma, I am so sorry for the difficult time Bandit is having. I am really glad you are going to speak to a specialist soon. I don't have any expertise to offer but I do want to echo what so many others have said -- you have been such a lifesaver to me and Callie since we got Callie's diagnosis and found FDMB and I know you have been the same for countless other kitties and their scared and worried parents. You and Bandit are in my thoughts and prayers. Sending hugs to you both. :bighug::bighug::bighug:
 
Bandit's Mom said:
Link to previous post:
https://www.felinediabetes.com/FDMB/threads/experience-with-clavamox-augmentin-side-effects.250318/

Bandit's numbers have been TERRIBLE for the last month. She has always been bouncy but she's now routinely bouncing to HI. Her CKD has also taken a turn for the worse (Stage III) and I desperately need to get her numbers under control to stop the PU/PD and the stress on her kidneys.

I am not sure what has caused this sudden deterioration in her numbers (BG and kidney values and whether the two are related). She is not uniformly high but just swinging wildly between greens/blues and blacks/HI. When she first started throwing HI's, almost a month back, I thought a dose reduction might reduce the bouncing, but nowadays she's going to HI from blues!

I am part of Tanya's CKD group but none of the Moderators or regular members have much experience with CKD+diabetes. They have no explanation for why her numbers are so bad - whether CKD could be elevating her numbers. Nothing in the labwork or urinalysis indicates an infection. Urine C&S was clear.

She is on dry food and will eat when she wants. I have tried everything to get her to transition to wet/raw and to get her to eat in the first part of the cycle. And given up. I know that her eating after the nadir is reducing duration. I have tried moving shot times around to see if I can prevent that, but she shifts her eating accordingly! :banghead:

Things are worse in the last few days, because she is even refusing to eat Young Again/Dr. Elsey's and wants only the HC kibble. For the last 2 days, I have had to mix the HC kibble with Dr. Elsey's for her to eat.

I tried using R to bring her numbers down but haven't had much success - I am able to bring her numbers down for a few hours in the first part of the cycle but she doesn't get enough duration since she keeps grazing on food through the cycle. And now she's going to be eating higher carbs after the nadir.

To cut a long story short, I was wondering whether to try TID dosing with Levemir? If that would give more duration?

Would also appreciate if anybody had ideas on what could be causing her numbers to swing to such high levels.

@tiffmaxee
@Wendy&Neko
@Sienne and Gabby (GA)
@Marje and Gracie
Click to expand...
Hello Bhooma,
I know I am fairly new to the group and not as experienced, but I think the reason for the high numbers is her kidney problems.

As you know, my cat's BG has suddenly been dropping. It was explained to me that it was because his allergies are under control and the inflammation is going down.

I suspect Bandit's numbers are going higher because of the problems she is having with her kidneys.

I wishing you and Bandit the best. Get well soon Bandit !!!
 
Bhooma,
Just wanted to plant this thought for you.
Advancing kidney disease or kidney injury, requires less insulin instead of more. Of course, there could always be exceptions I guess. Infection could cause higher BGs.
 
Oh Bhooma I am sorry! I don't know anything about any of us, but good thing Wendy is on it. Hopefully Bandit feels better soon :bighug:
 
Bandit's Mom said:
I didn't know this! What is the reason for it?
Click to expand...

Sorry I put that out, and ran off! I was about to be late to give my vet another 500 dollars:blackeye: (civvie).

I learned about it when in the hospital with severe sepsis (never found infection source), that included AKI (acute kidney injury). My Lantus insulin went from 18 to 13 units before the kidneys got better. I still have lowered kidney function, but I'm back steadily at early stage 3 (similar to both our cats, Bandit and Tina).

Quote from does renal affect insulin:
Impairment of the renal clearance of insulin prolongs the half-life of circulating insulin by a number of mechanisms and often results in a decrease in the insulin requirements in diabetic patients.

There is a lot of information about CKD and diabetes together, but it is NOT clear as mud! Insulin resistance can also be a factor (maybe with Bandit), which seems to be the opposite of needing less insulin. I will read more today, and see if I can get it to click in my brain enough to write about it.

Thank you for being YOU.
 
How is your civvie?

Tina has been CKD Stage III for nearly 3 years now! I see she gets 100ml RLS daily. Does she not need anti-nausea, antacids or appetite stimulants?

Tina Marie and Jan said:
Quote from does renal affect insulin:
Impairment of the renal clearance of insulin prolongs the half-life of circulating insulin by a number of mechanisms and often results in a decrease in the insulin requirements in diabetic patients.
Click to expand...
I wonder if cats react the same way as humans?

Thanks for this! :bighug:
 
Bandit's Mom said:
How is your civvie?

Tina has been CKD Stage III for nearly 3 years now! I see she gets 100ml RLS daily. Does she not need anti-nausea, antacids or appetite stimulants?


I wonder if cats react the same way as humans?

Thanks for this! :bighug:
Click to expand...

The human and cat - quite different and similarities too yep! I must clarify, yes!
I am now just doing Tina’s fluid every other day again. Advice I receive from vet is to keep doing what I am doing! She does not need any other help - no app stimulant or anti nausea drugs. Her big thing is needing to keep the bowels moving.
I will update SS.
Tina’s last ProBNP (?) blood test was 78 and should be under 100. That test predicts or guesses heart disease probability.
If I knew her heart was fine, I’d likely go back to daily fluid.
My civvie is in the hands of a great doctor. She has IBD or lymphoma, high ALT, and now a UTI. We are on top of treatment, thank you!
 
Bhooma, just thinking of you and Bandit and praying for solutions. Hope Budge is behaving while you try and figure the best course of action. All in my heart and prayers, Dolly sends her love :bighug::bighug::bighug::bighug:
 
Bandit's Mom said:
Just recapping all the meds she is on right now:
2mg Ondansetron every 8 hours
2.5mg Famotidine once a day
1/4 tab B-Complex once a day
350mcg Methyl B-12 as a subq shot once a week (now - used to be once every 2-3 weeks)
1/8th tsp psyllium husk once a day
1 mg Cyproheptadine (as required)
80-100mls LRS every day - in the BG numbers she is in right now, she is peeing and drinking crazy amounts.
Click to expand...

I noticed Fish Oil is missing:facepalm: :smuggrin: I give Tina Nordic Naturals Omega 3 pet, .75 ml daily

-------------------

Kibble specifically, and HC . . . I was reading that HC could stay in/affect the cat's system for up to 24 hours. Oh, I need to slow down (real rest), stay on the same device, and post my links.

I hope you are sleeping by now:bighug:
 
I use Nordic Naturals too but my cats would not take it by itself so I put it in wet food. Not sure how to do it with dry. It does have one that is flavorless now though.
 
Tina Marie and Jan said:
The human and cat - quite different and similarities too yep! I must clarify, yes!
I am now just doing Tina’s fluid every other day again. Advice I receive from vet is to keep doing what I am doing! She does not need any other help - no app stimulant or anti nausea drugs. Her big thing is needing to keep the bowels moving.
I will update SS.
Tina’s last ProBNP (?) blood test was 78 and should be under 100. That test predicts or guesses heart disease probability.
If I knew her heart was fine, I’d likely go back to daily fluid.
My civvie is in the hands of a great doctor. She has IBD or lymphoma, high ALT, and now a UTI. We are on top of treatment, thank you!
Click to expand...
I had no idea your Tina Marie was struggling. I'm sorry. How do you keep the bowels moving, Jan? I'm starting to think that Susie might be dealing with this too. Sorry to hi-jack your thread, Bhooma.
 
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