4/12 Barsa

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Vintry

Vintry

Member Since 2014
Me again. I have a couple of urgent questions. Please help with advice if you can. Thank you!

1) Levemir dose. The last increase doesn't seem to have any effect. Barsa have been on 2units for 3 days now. It is possible 3 days was just not enough time to see the effect but I don't know if that is the case here. Should I increase the dose?

2) She has vomited this morning (a little) at 4am. That's 2 hours before her morning shot, which is a sign of DKA. I know it is DKA because it was the same last time she had it. She never usually vomits. We are going to see vet on Monday because it's Sunday (of course, lucky as usual). I gave her an early shot today, 5am instead of 6am. This is supposed to act as increased dose. What should I do about it? Shoot at 5pm or 6pm tonight? The question is more about whether I want it to act as an increased dose..I know that I can slowly shift it to original shot time. But do I want to, considering 2units are not doing anything and that ketones persist?

3) When increasing the dose (whenever) would it be ok to go up by 0.5? 2.5units rather than 2.25.
 
Numbers are actually worse, which I expected. @Elizabeth and Bertie was very kind so send me her spare glucometer. Just measured BG 1 hour after food. On my Freestyle meter it's 21, on One Touch Ultra - 26
 
Oh yes, of course. It's a pink colour on the urine test strip - 1.5mmol. It was that last night and this morning it's the same. I think it probably would have gone worse had I not syringe-fed her water all night long. She's behaving surprisingly ok-ish. But I know how quickly things can change. For now, tail is up, she's eating and not lethargic. Holding on.
 
If you can continue to shoot at 5, I would for now because, as an early shot acts like an increase, a late shot acts as a decrease. If you need to get back onto 6, you can do it slowly as you mentioned.

I'd increase the dose. If you remember, Jill mentioned on 4/10 that you don't need to be worrying about following a protocol right now...you just need to get the dose up to where the ketones disappear OR use a bolus insulin like R to help bring the numbers down.

What I can't decide is whether you should take her up by 0.5u or just 0.25u. Let me mull that one over and get some other thoughts. I'm glad she's eating and you are smart to stay on top of getting fluid into her. Add water to her food as well as syringe water. If she stops eating and is still showing ketones, please get her to the vet right away.

I'll be back in a bit with more thoughts on the dose. You can take the 911 down....you have our attention. :)
 
from Jill in yesterday's post:

Also, don't concern yourself too much with "protocols" or their guidelines at this point other than to allow the depot to build up for a minimum of couple of days between dose increases if she isactively throwing ketones. We *usually* see the presence of ketones treated with a bolus and basal insulin combination, but that's not happening here. There's a difference. When a bolus is in use we give more weight to "protocol" guidelines.
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I think you could go ahead and increase with your next shot. You've got 5 cycles at this dose and it's not getting her below 200's. I'm not sure on the amount - the typical amount with those nadirs would be 0.25u. But your circumstance is different. You need to get more insulin into her since she's showing ketones again.

If you increase by 0.5u then you may need to increase her carbs, even feeding her all high carbs, in order to keep her safe. I think it would be ok to do that, as long as you keep her eating and getting plenty of water into her.

I see Marje just posted. Hang on.
 
Iryna, are today's BG tests on the new glucometer? I'm just wondering if yesterday's were on a different meter and that's why yesterday was yellow (typical of a freestyle) and if today was on the Touch Ultra.
 
I gave it 3 days because I thought maybe she'd show results not earlier than 2-3 days.

Hanging on
 
No, everything that is recorded on the spreadsheet is measured by Freestyle meter. It underestimates figures. So Freestyle's 21 is actually 26..well it's obviously going to be even higher on Alphatrak
 
We started with a Freestyle - the spreadsheet of kitties on Freestyles is typically almost all blues and yellows. They don't seem to be the best for our diabetic cats. they do measure accurately in low numbers, however, so you can assume it's accurate if he gets low.
 
Julie and I have been talking and I think we both agree you should increase by 0.5u and monitor her closely as you have been. You might need to feed a little bit higher carb food to be able to get that much more insulin safely into her.
 
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Vintry said:
Just measured BG 1 hour after food. On my Freestyle meter it's 21, on One Touch Ultra - 26
Click to expand...

Just a reminder (you have more important things to deal with right now) but all meters can be off by 20%

21 is 378 for us
26 is 468 for us

378+20%= 454
468-20% = 374

21 + 20%=25.2
26 - 20% = 20.8

So actually, those 2 numbers are about the same....We have also heard some reports about the meters with "Free" in the name testing low

Hope Barsa continues eating....that's a good sign! You're doing a great job with her!
 
The thing is she eats Loads. I can get her to eat about 400g a day if I have to. But then..who knows..KDA can take the appetite away in no time
 
low carb is everything under about 10% - medium carb is about 11-17%ish and high carb is over that.

hard to say what to give him - your goal is to give him enough to make it work with the insulin. You'll have to experiment to see what you need.
 
I'd try to stick with something in the 8-10% range to start and see how she does with it and her numbers.

Good luck with the increase. I hope the ketones are gone tomorrow.
 
Since you'll be talking to your vet on Monday...
I think treating Barsa would be much easier for you as well as being more effective if you had these "tools" on hand...
and know how to use them:
  • Subcutaneous fluids (bag of fluids, a line, & needles)
  • A fast acting insulin (see these previous posts for what may be available in the UK --- 4/3 Barsa and 4/10 Barsa)
Anyone in your vet's office/clinic can teach you how to administer fluids. We can also find some links to "how-to" to videos for you. If I were in your shoes, I'd really push to have fluids and a fast-acting insulin to help you treat Barsa at home.

I have some house guests visiting for the next several days, but there are plenty of members here who can help, offer suggestions, and guide you.

Good luck with the dose increase! Please monitor carefully...
 
Hi Iryna,
Just wanted to say hi and say I am so sorry you are having all these problems with ketones. You must be so tired looking after Barsa and worrying about her.:bighug:
I hope she has stopped vomiting.
You are getting great advice though from the experts here..
Sending 'ketone destroying' vibes to Barsa:cat: and :bighug: to you
 
Bron and Sheba, thank you. Ketones are worse. Barsa is holding on for now. I'm just praying she will get through tonight so I can take her to vet tomorrow.
 
Iryna

Is there an emergency vet you can get her to? If ketones are getting worse, I would urge you to get her to emergency.

I hope they can find the source of her infection. I don't recall if she's on an antibiotic or not but I'd discuss that with my vet as well.

I also don't know if you've ever given subq fluids at home but if you haven't, perhaps the video we made on How to Give Subcutaneous Fluids at Home would help.

I agree with @Jill & Alex (GA) that you really need to get the fluids, including needles and lines, and the fast acting insulin. I've been using R over two years now just to help with bounces and we've got several other members who have or are using it as well. Even with the time difference, we can sort out a way for someone to be with you online when you give it.

I would be sure the vet checks her potassium levels again since you've been giving a supplement and some subq fluids contain potassium. You don't want her to go the other way on potassium levels as too high is as bad as too low. She might still need the kaminex but just be sure your vet is monitoring it.
 
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Praying for Barsa's ketones to lessen and be gone soon.
Make sure you have some high carb food on hand, too, just in case you need it.
I'm sure you've been asked this before, but is there an infection present that is helping to cause these ketones?

Just cross posted with Marje.
 
Eliz

Jill did some research and gave her a list of fast acting insulins. I believe the "neutral" is the same as our Humulin N (normal) so the duration would be more like a six hour insulin where the R equivalents Jill gave her are closer to four hours which is what we need for Barsa so she can give it more often if necessary.
 
No. She was given Kaminox after they flushed ketones out. Potassium levels were still low. Vet thought they'll go up with this potassium supplement as long as sugar is in good numbers.
 
Here in the US we can buy fast-acting insulins without a prescription. We purchase directly from a pharmacy just by asking the pharmacist. Have you checked into that there?
 
Yes, there's an emergency service. It charges crazy money on weekends. What they offer is put her on the drip overnight, then transfer to my vet to be put back on the drip in the morning. So vet fee, emergency fee, drips, blood tests, glucometer and bg measuring fees. Two weeks ago I paid about £600 for all that. I am facing the same situation again :(
 
And then when I bring her home I am on 24/7 watch because these ketones don;t go away if sugar is high (from experience). And I cant bring it down :( All the tips are noted, it's just that I have to wait to see my vet to ask him for subq fluids diy and fast-acting insulin. Now also another problem I will be giving her tonight an increased dose of 2.5units and I don;t know how that will work when she;s at vets for 20hours on the drip..I mean how that will work with short-acting insulin (if they want to give that). Plus last vet in the emergency clinic was not even familiar with Levemir. They all work with Caninsulin, majority.
 
I definitely cannot get regular insulin without prescription. Doubt I can get any other kind.
 
I don't know how they do it in the UK but often here with a cat that might have DKA, they just give The fast acting insulin in the clinic, not the Lantus or levemir. The good thing with that is its in and out and they can give it as often as they need without having to worry about the depot from the L insulin. The bad thing is then you have to refill the L insulin depot when they get home but you continue to use R as you are doing it. But again, not sure about UK and you'll have to ask them.
 
For now I am waiting for a miracle because last time after I brought Barsa back from vets and 2 days later checked and there were ketones (above traces) I called my vet. Told him she has ketones again, asked if I can bring her for half-day to flush them out, at least subq fluids, not the IV. But he said no, that I should bring her back if she stops eating. So that's why I am not acting yet. That and price. If she doesn;t get worse tonight then tomorrow is monday, it will be cheaper. If the worst happens tonight then of course I'll get up and go asap.
 
With my cat this is how KDA progressed the first time. Very quickly. 2 hours before morning feed she threw up. I didn;t think much of it, thought maybe it was something to do with bad digestion. But the next day same thing happened at the same time. I measured for ketones in the urine and there it was - the reason, 8mmol ketones. Went to emergency clinic, they gave subq 500ml fluids to get us through the night (wrong decision, should have left on the drip) and it didn;t help at all. She threw up in the morning and refused to eat. Back to vet on the drip. 2 days, just over £600 for treatment.
 
the things you can do at home tonight to help:

make sure he's getting plenty of food. You've said he's starving - maybe he needs more food.
Add water to the food, as much as he will tolerate.
increase the insulin dose as has been suggested to 2.5u.
 
Marje and Gracie said:
Eliz

Jill did some research and gave her a list of fast acting insulins. I believe the "neutral" is the same as our Humulin N (normal) so the duration would be more like a six hour insulin where the R equivalents Jill gave her are closer to four hours which is what we need for Barsa so she can give it more often if necessary.
Click to expand...
Aha, I see...
Just found a list of UK insulins on 'Diabetes UK' site:
http://www.diabetes.co.uk/insulin/insulin-types.html

Although vets in the UK might use fast/short acting insulins in their clinics, I don't know how keen they would be to prescribe one for a caregiver to use. It's hard enough to get anything other than Caninsulin in the UK... Feline diabetes treatment in the UK is not like it is in the US, unfortunately...
 
Oh, Elizabeth, thanks for that link.

Humulin S seems to be the one I need. "Humulin S is a short acting human insulin, produced by Eli Lilly & Co, which will usually be taken 20 to 45 minutes before eating. It’s peak activity occurs after about 30 minutes and last for approximately 2 hours. It’s activity then tails over the next 3 or 4 hours."

Just worried he's going to say no to diy. We'll see
 
Hi Iryna,

Remember too that cats usually metabolize insulin much faster than humans, so the duration in cats will be shorter.

I am so sorry that you and Barsa are going through this. And I am really praying that all will be well.

Huge hugs to you,

Eliz
 
Here's what you can do to reassure the vet that you have some idea of what you will be doing. This is what your use of R will look like. Perhaps you want to print this out and show it to your vet so they understand what our process is.

You will adjust the dose based upon the blood sugar test number.

Initially you will start with 0.1u - take a look at photos on the New to the Group sticky to see what that looks like. You will then test every hour for 4-5 hours to see how much it lowers the blood sugar. During that time you'll have supplies for hypo ready in case it sends him into low numbers.

We'll evaluate what 0.1u dose does, then you'll give 0.25u for a second trial. You'll test hourly for 4-5 hours after that shot.

If that doesn't reduce his blood sugar enough, you'll try 0.5u, repeating the 4-5 hour monitoring. There are times that we have to go higher in dose - if so we increase by 0.25u increments. For most cats it doesn't take more than 0.25u-0.5u when used in combination with the basal insulin.

With all of these trials, one of us will evaluate if it's safe to give it at that time, depending on where it is in the cycle and what the current blood sugar is. For example, we'll notice when Barsa begins to see effects from his Lev shot and we'll suggest you give the R shot at a time when the low point in the Lev cycle will not coincide with the low point of the R cycle. We'll begin with a high blood sugar, probably over 300.

One of us with experience using R will stay with you throughout each trial until we have confidence in how Barsa can be expected to respond to that particular R dose.

There are several of us that are experienced using R in combination with Lantus and Levemir, and we will tag-team to make sure you are helped when you need it. We've helped many cats with ketones and used R on them. It's better to do this than to keep increasing the Lev dose. R allows you to respond quickly with insulin when Barsa is throwing ketones. R is in and out in 4-5 hours for most cats. There might be times when you use it more than once in a cycle to move the blood sugar down farther.

Lev is slower to respond and lasts longer - it just isn't as ideal for responding to ketones, although it's great for providing the basal insulin need.
 
Perhaps the emergency vet can perscribe subQ fluids instead of admitting her with a big vet bill? Having the fluids available is really helpful when there are ketones, but the vet needs to be on board to test electrolytes if you give them for more than a couple days.

Are you currently giving her a potassium suppliment? Also in DKA nausea is a big thing, and usually why they stop eating or throw up. It's good to have a anti-nausea on hand as well. IMO everyone should have some anti-nausea medication in their toolbox for emergencies.

For others regarding the addition of R: Although lower blood sugars help improve dehydration, the speed at which the blood sugar is reduced can be a problem in dka or hyperosmolar syndrome. If blood sugar goes down too fast it can cause a fluid shift as sugar is reduced quicker in the blood stream than the brain. The result is a higher concentration of sugar in the brain which draws water from the body. This can cause nausea and altered mentation, therefore when using R target sugars should be higher when using for DKA.
 
therefore when using R target sugars should be higher when using for DKA.
Click to expand...

@Meya14 you lost me in this part of the sentence. Should be higher than what?

When we have members use R, the goal is to just tap down the numbers. We don't want to give so much that the BG dives quickly.
 
Vintry said:
Humulin S seems to be the one I need. "Humulin S is a short acting human insulin, produced by Eli Lilly & Co, which will usually be taken 20 to 45 minutes before eating. It’s peak activity occurs after about 30 minutes and last for approximately 2 hours. It’s activity then tails over the next 3 or 4 hours."
Click to expand...
I'm not-so-sure about Humulin S... only because ideally we're looking for a fast-acting insulin that has a duration of 4 - 5 hours. Your vet will be able to suggest an insulin which would be good to use.

I found these, but you'd have to talk to your vet...

Humalog: Humalog is an Eli Lilly product, with the active ingredient insulin lispro. It is extremely rapid-acting, and will typically begin to work within 15 minutes. Effects of the insulin last for between 2 and 5 hours.

Novorapid: The active ingredient in Novorapid is insulin aspart. When novorapid is injected, it is extremely fast-acting, and works rapidly to normalise blood sugar levels. It typically begins working after 10-20 minutes, and will last for between 3 and 5 hours.


Meya14 said:
For others regarding the addition of R: Although lower blood sugars help improve dehydration, the speed at which the blood sugar is reduced can be a problem. If blood sugar goes down too fast it can cause a fluid shift as sugar is reduced quicker in the blood stream than the brain. The result is a higher concentration of sugar in the brain which draws water from the body. This can cause nausea and altered mentation, therefore when using R target sugars should be higher.
Click to expand...
Meya14:
When we use R in a situation like this we don't try to reduce the blood sugar rapidly. It's why we suggest a tiny starting dose of 0.1u of R. Our goal is to gently pull the numbers down by a maximum of 100 points only... just enough for the the basal insulin to "grab onto" a lower number. Doing so helps to avoid the problems you've mentioned.
 
It's usually a drop of no more than 200mg/dl/hr. Anything greater can cause CNS issues. Her blood sugars aren't that high, but it's something to remember when using rapid or R in DKA/hyperosmolor. Usually there is a buildup of sugar concentration in the brain with these states.
 
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