4/26-Scratchie-AMPS-445, +11-380 - Neg Ketones

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Scratchie'smom

Good morning all - crappy crappy numbers. I thought we were going to have better numbers with the +3 last night, but didn't happen. On the really good side - negative ketones!!!! Test last night and again this morning were both negative. Doesn't mean I'll quit watching - I'll still test as often as possible. Appetite is good - he lost a pound and needs to gain that back as he didn't have a pound to lose.

Now for questions.
1. Should I go straight to 3.5u?
2. The vet gave Scratchie 'R' and that seems to help the horrible bounces. Should I get a scrip for that to help him out?
3. Are the high numbers due to the Covenia (sorry if I spelled that wrong) antibiotic that they gave him? I know that this one does affect numbers so is that the problem or just the lovely bouncy dang Lantus? Or is he just trying to settle. He's been on 3u since I Tuesday night as I skipped his shot on Tuesday morning due to his lower number and I didn't know what to expect after the ER hospital and Vet time.

Any help, advice and/or comments are greatly appreciated - I do need some help here as I don't want to make any more mistakes with my boy.

Wishing great numbers, safe surfs and good health to all our kitties and beans!!

Jo
 
Re: 4/26-Scratchie-AMPS-445 Increase?

Jo,

I have never worked with R but do know a couple of folks that have if you want to go that way. Those reds really worry me, I think I would take him up in full units right now so if you have to use the Lantus ...Go to 4u and if that doesn't bring him down in about 3 days then jump to 5u. When dealing with ketones chances you want him out of those numbers as fast as possible.

Personally if he was my boy, I would print out both your 2012 and 2013 spreadsheets, take those to your vet and show them how lousy he does on Lantus and just about demand a script for Levemir. He was responding so much better on the Lev than he every has on Lantus so I honestly don't think that is what caused the ketones, just probably need to start him on a higher dose next time and force him down into those blues and greens faster. Either he is going to end up needing doses like an Acro on Lantus or he needs a change in insulin. And the way he was going on the Lev I don't think he is an Acro or IAA, I just think Lantus isn't a good insulin fit for him. So the other choices would be Prozinc or Levemir but you can't leave him another year above renal threshhold or I'm worried his organs are going to be damaged.

Mel, Maxwell, Autumn & The Fur Gang
 
Re: 4/26-Scratchie-AMPS-445 Increase?

R is a short acting insulin (2 to 4 hours only) that brings down immediate numbers and is supposed to keep the bounce from going so high. It is used in conjunction with long insulin's as kind of an early 'whammy' system so they don't rise too high for the later insulin to effect.

It is usually used in small units- .5 to start out with because it is a short acting one and is different for each cat. And I think feeding is a factor, too. It is used a lot for acromelegy and IAA.
 
Re: 4/26-Scratchie-AMPS-445 Increase?

Thanks for the advice you guys. I will take him to 4. As for getting the Lev, money is tight now with the $1400 vet bill so I need to stick with the Lantus for now. Usually at the higher doses required on Lantus a pen only lasts me 32 days. If I get this ER and Vet bill paid off quickly *groan* then I can work on getting him the Lev which is what I would prefer to do. Wish I was rich!!!
 
Re: 4/26-Scratchie-AMPS-445 Increase?

Wish I knew for sure Autumn was going to give up the juice in the near future because then I would just send you the extra I have. <sigh> To bad we don't have a crystal ball right now to know for sure if I'm going to have an extra box of 5 pens or not...silly girl needs to make up her mind what she is going to do.

Mel, Maxwell, Autumn & The Fur Gang
 
Re: 4/26-Scratchie-AMPS-445 Increase?

Hi Jo

I'm glad Scratchie is eating and ketone are negative.

I don't know if, in the long run, lev is a better choice for him or not. I agree with Mel that it wasn't the insulin change itself that caused the ketones.....it was most likely infection and the insulin dose was way too low. I also don't know that I would think he needs acro type doses ...he was responding on lantus at just over 5u.

I've been using R with Gracie and it has worked well to keep the bounces from going high and it also has brought her numbers back down. I would not increase his lantus by 1u. I'd see where his nadirs are and take the dose up by either .25u if they are below 300 and by .5u if they are above and then I'd use the R to control the high bounces.

With R, you want to give it just as the bounce starts. You start with a very, very low dose like .1u. I use calipers to measure it and I can barely tell there is any insulin in the syringe. You do not want it to coincide with the lantus nadir so you need to have an idea of Scratchies onset, nadir, and duration and we can also help with that. Once you give it, you have to test every hour for four hours. The goal is to stop the bounce from going higher but you might also see it bring the BG down by 50-100.

Sienne has also asked for Jill, Libby, Dyana to also check in as they have more experience using R and they might want to have you use it in a different manner than at the beginning of bounces.

eta: you don't need a script for R and please hold off on raising to 4u until one of the other ladies has checked in. That's a huge increase at one time. We can fast track him on smaller increases.....for instance 4 cycles at a dose and then increase.
 
Re: 4/26-Scratchie-AMPS-445 Increase?

Hi Jo,

I have experience using R. My guess is that you could use it on the weekends, but you really need to be able to test the cat when you give R.

When I was using R for a cat who tested positive for Acro, we did increase the Lantus (all I had at the time) in full units. It is doable and safe, and may be warranted for Scratchie due to the possibility of ketones.

Levemir is a better insulin for higher dose cats. For one thing it stings less. It has a later onset and nadir and is a more stable insulin than Lantus. Hopefully, your vet will review your spreadsheets and agree to a switch to Levemir.

All the best to you and Scratchie,

Claudia
 
Re: 4/26-Scratchie-AMPS-445 Increase?

Arghhh.... I had written out a long post and must not have seen that it disappeared.

I'm glad you've gotten the ketones under control and Scratchie is doing better.

I did send a note to several other people who are more experienced in the use of R than I am. I understand it's use in theory but haven't used it myself. When starting out with R, you do need to be around to do a curve -- testing every hour, usually for the first 4 hours. You want to do this with the starting dose, which is typically 0.1u, and any other time you may need to raise the dose of R. Given it's potency, it is definitely a start low kind of insulin. It's my understanding that one of the other reasons for getting a curve with R is to make sure the nadir for R and your Lantus nadir do not coincide.

It's my understanding that increases of 1.0u are not typical unless a cat is on a much larger dose of insulin (e.g., over 10.0u) than what Scratchie is currently getting. It's not uncommon that a dose increase of 1.0u is encouraged once a cat reaches the 10.0u threshold. I'm concerned that a 33% increase in dose is a very big change. With a nadirs that are in the above 300 range, you can safely increase the dose by 0.5u. Perhaps a compromise is to raise the dose every 4 cycles. This method of increasing is consistent with the Tight Regulation protocol and should be safe.
 
Re: 4/26-Scratchie-AMPS-445 Increase?

I agree with Sienne's thoughts on dosing which is also what I proposed earlier.....increasing every four cycles if necessary and basing the amount on where his numbers (nadir) is. Even if it is high yellow, I would think the .5u would be ok. But not 1u....it's too much for a cat that was showing green at 5.25u.
 
Re: 4/26-Scratchie-AMPS-445 Increase?

Okay maybe I'm just being dense but if Scratchie's last good dose was 5.5u then why would going from 3u to 4u be too much of a jump in dose? If it takes the shed 3-5 days to adjust to any increase, how does it matter if he gets to 4u in 4 days (increasing .5u every 4 cycles/2days) or jumps there and is held there for 5 days to allow the shed a chance to adjust to the new dose?

Afterall as I understand TR protocol if a dose reduction doesn't hold you go back immediately to the last good dose, which in this case for Scratchie would be 5.5u. Granted he was reduced further than what would normally happen if he had earned a reduction by falling below 40 but that doesn't negate the fact that his last good dose on Lantus was 5.5u and he is now on 3u. What am I missing here?

Mel, Maxwell, Autumn & The Fur Gang
 
Re: 4/26-Scratchie-AMPS-445 Increase?

hi jo. i was asked to to weigh in and share my thoughts as i have a ketone prone kitty and have used R as a bolus to keep ketones at bay...

Scratchie'smom said:
Good morning all - crappy crappy numbers. I thought we were going to have better numbers with the +3 last night, but didn't happen. On the really good side - negative ketones!!!! Test last night and again this morning were both negative. Doesn't mean I'll quit watching - I'll still test as often as possible. Appetite is good - he lost a pound and needs to gain that back as he didn't have a pound to lose.
Click to expand...
woo-hoo for negative ketones and a good appetite!!! so happy to hear it because as you know, the recipe for ketones = an insufficient supply of insulin + a poor appetite + infection or certain systemic stresses.

Scratchie'smom said:
Now for questions.
1. Should I go straight to 3.5u?
Click to expand...
if scratchie were mine, i would immediately take the lantus dose up to 4u bid while monitoring closely. my reasoning for increasing the dose to 4u bid is because of the circumstances which are currently unique to scratchie: when he was switched to levemir, the starting dose was set too low. imho, this along with the possibility of infection combined with loss of appetite resulted in high ketones and hospitalization. his last "good" lantus dose was 4.5u bid (good meaning he wasn't throwing ketones). i think it's reasonable to bring the dose back up as quickly as possible, but hesitate to suggest taking the dose back up by more than 1unit at this time.

it's important to note: increasing the dose by a full unit is NOT recommended under normal circumstances and imho, should not be presented as such.
however, there are circumstances such as when a kitty has reached a high dose of the basal insulin (closer to 10u bid) and/or has a confirmed High Dose condition (acromegaly or IAA) where increasing in full units is and has been acceptable on the FDMB... not applicable to scratchie at this time.

Scratchie'smom said:
2. The vet gave Scratchie 'R' and that seems to help the horrible bounces. Should I get a scrip for that to help him out?
Click to expand...
you should be able to pick up a vial of humulin R (regular) or novalin R (regular) at any pharmacy without a prescription. i encourage you to call around for the best price. i recently paid $95 for a vial of R, but others have purchased it for less. i understand tight finances, but if there's any way you can swing purchasing R i'd do it. R is a great tool to have especially when battling ketones while working your way up to a good basal dose. you'll find the cost of purchasing a vial of R much less than another hospitalization... not to mention the stress from ketones on scratchie's body.

we highly recommend starting with a tiny dose of R as a bolus. the suggested starting dose is 0.1u R. the reason for starting so low is you don't want the R to yank down the numbers. yanking down the numbers will only serve to set kitty up for a bounce. when you're fighting high numbers, it doesn't make sense to purposely send kitty into the high numbers you're trying to avoid. kwim?

the goal for the R is to pull kitty's numbers down about 50 - 100 points only. anything more than that will likely cause kitty to bounce. all you want the R to do is pull kitty's numbers down some... enough for the lantus to "grab onto". a dose of 0.1u of R is enough to pull many kitties (including my own) numbers down 100 or more points in a cycle.

01unit-1.jpg


0.1u of R may not be enough. the dose may have to be increased, but we won't know that until we see how scratchie responds to R. as has been mentioned, when administering R, you'd want to test every hour for the first 4 - 5 hours... until you know and feel comfortable with scratchie's response to using R as a bolus. it's important to learn when onset occurs, when nadir occurs, and the duration scratchie gets with R. you never want the nadirs of lantus and R occur at the same time. at this very moment, scratchie's numbers are high enough that it probably won't matter when in the cycle R is administered, but this will change.

if you elect to use R as a bolus, i agree with the suggestion to administer it when you're home and available to monitor, but please ask for guidance if/when you go this route.

Scratchie'smom said:
3. Are the high numbers due to the Covenia (sorry if I spelled that wrong) antibiotic that they gave him? I know that this one does affect numbers so is that the problem or just the lovely bouncy dang Lantus? Or is he just trying to settle. He's been on 3u since I Tuesday night as I skipped his shot on Tuesday morning due to his lower number and I didn't know what to expect after the ER hospital and Vet time.
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imho, scratchie's numbers are largely due to an insufficient supply of insulin. infections are also known to cause high numbers. hopefully the covenia shot will take care of any possible infection.




fwiw, there is a group of members in the Lantus TR ISG who have been very, very successful helping caregivers work through ketone issues after hospitalization. i strongly encourage you to take advantage of their experience and give some consideration to posting in that forum for the help you and scratchie need right now.

just my thoughts... let us know how we can help.
 
Re: 4/26-Scratchie-AMPS-445 Increase?

I appreciate Jill's response. I was being more conservative trying to keep in mind that your work schedule and monitoring can sometimes be at odds.

Mel said:
Afterall as I understand TR protocol if a dose reduction doesn't hold you go back immediately to the last good dose, which in this case for Scratchie would be 5.5u. Granted he was reduced further than what would normally happen if he had earned a reduction by falling below 40 but that doesn't negate the fact that his last good dose on Lantus was 5.5u and he is now on 3u. What am I missing here?
Click to expand...

Mel -- what you stated is correct. I think the difference here is that when we're talking about a reduction not holding, it's typically a matter of a reduction that's been either 0.25 or 0.5u. I don't think you're suggesting that to follow the dosing strategy exactly, that would then need to Jo raise Scratchie's dose to 5.5u. There's always a risk that by increasing a dose too aggressively, you miss what could be a good dose. I'm not saying this would the case with Scratchie. I think this happens to be an ECID situation vs. a generalization. In some cases, when we've "fast tracked" a dose back up, we've used either 0.25 or 0.5u increments, depending on the nadir, and increased every 4 - 6 cycles. I would want Jill's input but with a 1.0u increase, I don't know if increasing in less than 6 cycles would be prudent unless it's possible to be monitoring carefully.
 
Re: 4/26-Scratchie-AMPS-445 Increase?

Thanks Sienne,

No that was why I didn't initially suggest that Jo go all the way back up to that 5.5u dose but said to jump him a full 1u from 3u to 4u. So was just asking for clarification on what the thinking was with only going up by .5u when his last best dose was higher than where I was suggesting on taking him next. So that I will personally have a better understanding of the process should the need arise again. Sorry I have a horribly curious mind and like to always know the whys behind things so I can store it for future reference.

Especially since my DH and I have already decided after having our two wonderful adopted diabetics Maxwell and Autumn that as our present herd thins out we would like to replace their spots in our heart and home with other sugarcats that are looking to be rehomed and as I have learned with the two I have presently not only ECID, that in adopting them as already diabetic I seldom have much background on them and thus a host of unique situations to deal with when trying to regulate them. So anytime there is a case that I can learn a new trick from I like to have the rational behind it.

Mel, Maxwell, Autumn & The Fur Gang
 
Re: 4/26-Scratchie-AMPS-445 Increase?

for learning purposes, i'd like to clarify something...

the highest dose i can see on scratchie's spreadsheet is 5.25 units from waaaaaaaaaaaaaaaaaaaay back in january. i never did find a 5.5u dose, but it's certainly possible i missed it.

anything more than 2 - 3 weeks back can be considered, but for all practical purposes... it's useless for making dosing decisions that are relevant today.

i don't know why nor do i understand virtually "starting over" the third week in january, but i'm sure jo had her reasons. she may have even been encouraged to start over. i dunno. it's immaterial now other than to illustrate how insulin resistance can build up in a matter days, weeks, and months.


fast forward to today...
for all practical purposes, the last "good dose" was 4.5 units lantus. again i have to qualify that by saying 4.5u was good because of the absence of known ketones and the dose being recent... not because the dose was bringing scratchie down into normal numbers.

something we've learned through observation of many, many lantus/lev kitties... when you lose momentum by reducing the dose too soon or by "starting over" if the kitty has been brought up the dosing scale honestly, chances are you'll end up surpassing the highest dose you were at weeks or even months ago... resulting in a loss of time, money, energy spent, and glucose toxicity taking hold, as well as opening the door to the possibility of ketones.

unfortunately, we see this happening over and over again... in more than one ISG. :sad:



some food for thought...
 
Re: 4/26-Scratchie-AMPS-445 Increase?

Jill & Alex said:
i don't know why nor do i understand virtually "starting over" the third week in january, but i'm sure jo had her reasons. she may have even been encouraged to start over. i dunno. it's immaterial now other than to illustrate how insulin resistance can build up in a matter days, weeks, and months.
...
Click to expand...

I can't speak for Jo, of course, but looking at her spreadsheet - it appears that the startover was related to a food change to zero carb dry (so I assume Scratchie was eating regular dry before)

1/18/13 reads in part "Shot much lower dose as moving to zero carb food. Glad I did. 1u PM"

Without getting into the dry/wet controversy - isn't the protocol to drop the dose substantially when changing to a lowcarb food?

Em
 
Re: 4/26-Scratchie-AMPS-445 Increase?

continuing this discussion for learning purposes only...

ETA:
morrieb1 said:
it appears that the startover was related to a food change to zero carb dry (so I assume Scratchie was eating regular dry before)
Click to expand...
from scratchie's profile:

Was on dry Science Diet until July 2012. now on Friskies Special Diet pate’s.
Trying Nature’s Variety frozen food worked in with Friskies.
Currently on Wellness canned - 4%

morrieb1 said:
Without getting into the dry/wet controversy - isn't the protocol to drop the dose substantially when changing to a lowcarb food?
Click to expand...
yes, to a certain extent because of the possibility of numbers dropping when kitty's diet is switched to something with an overall lower percentage of carbs. however, a reduction from 5u to 1u could be considered a pretty drastic reduction. :smile:

it was apparent early on the reduction proved to be too much. that's when kitty should be taken right back up to the last good dose.

truth be told, not all kitties show a response to switching to a low carb food, but since we don't which ones will react and which ones won't... it's safer to suggest a dose reduction.
 
Re: 4/26-Scratchie-AMPS-445 Increase?

Thanks Jill.

See I learn something new everyday. :-D And actually I may have miss stated the last good dose when I meant last dose he was on which going back over the spreadsheet looks like it was 5.25 while I was thinking it was 5.5u but then again I'm also running on very little sleep the last couple of days.

I always appreciate when I get the reasoning behind the thinking so I have a chance to learn more about this complicated dance. Plus my only experience with ketones in a cat came from dealing with them with Autumn when she first arrived as she had moderate ketones back in the beginning but never had to be hospitalized I dealt with them simply by getting sub-q fluids in her and finally getting her started on insulin and getting her numbers down quickly. Musette also went into DKA but that didn't happen until she was already hospitalized for inappetance and basically the ER vet sent her into that condition because he didn't force feed her for 3 days nor put her on an insulin drip.

Mel, Maxwell, Autumn & The Fur Gang
 
Re: 4/26-Scratchie-AMPS-445 Increase?

Wow, just typed a response to everyone - hit submit and not there!

Ok, I would thank all of you individually but don't want to leave anyone out so here's a huge 'GROUP THANK YOU!'.

Let me summarize an answer to some of the questions.
1. He was diagnosed in February of 2012. Took me until June to find this site, then get him on to wet food. Another month before testing was officially going on.
2. Highest dose was 5.25u.
3. I changed to YA food in January because of the high dose and my work schedule hoping it would help.
4. Switched to Wellness, now back on Friskies. Threw up when I tried fancy feast.
5. Switched to Lev - totally my fault on the dose! Have heard that from several people as well as the vet, hence the Ketones.
6. Back to Lantus - not my choice but that's another story.
7. I work a minimum of 10 hour days. High doses scare the daylights out of me as I can't always get home to test him. DH doesn't test or help with shots. He feeds him.
8. DH is of the opinion that my boy should be put down, hence we have some challenges here.

All that said - I have made some mistakes and I realize that. my purpose is to do what is best and move forward. OTJ is still my goal. He doesn't settle into doses within the 3 day time frame for TR - hence I like the SLGS better. I can only do dose changes on the weekends.

I will increase to 4u tonight. Vet wants me to go higher. Says R is a thought but wants me to wait a week.

Thank you all for your time and input -I truly appreciate it!

Jo
 
Re: 4/26-Scratchie-AMPS-445 Increase?

you're welcome, mel.
i'm with you... i learn something new about this disease everyday. so much has changed and many improvements have been seen just in the years i've been here. when i joined the fdmb back in 2006, lantus and levemir were relatively new to the world of feline diabetic kitties. we've come a long way, but i can't wait to see more changes and improvements made for our kitties and caregivers alike!
 
I really appreciate the great info and discussion on this condo today. I also continue to learn daily and appreciate those who teach (Jill for one).

I was on the same page as Sienne in my dosing recommendation because I know of Jo's concerns as she articulated. However, if you are home the next couple of days, Jo, and can do the monitoring, then I can definitely see the justification for going up 1u.

Good luck....I hope Scratchie feels better each day and the numbers start to come down....and ketones stay negative.
 
alex has been on and off insulin for years. i stopped calling all my screw-ups "mistakes" a looooooooooooong time ago. it took awhile, but i finally figured out every mistake i make is a learning experience. :mrgreen:

good luck with the new dose! let us know if there's anything we can do to help.


(((((hugs)))))
 
Ditto on what Marje and Jill said. And like everyone, reading condos and spreadsheets and participating in discussions like this one is a shared opportunity to learn.
 
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