4/6 Minnie update

Liz & Minnie

Liz & Minnie

Very Active Member
Yesterday

Just heard from the internist, she is doing much better and eating! Potassium low again, she thinks that may have caused the vomiting because her stomach wasn't emptying. She is on IV fluids, we'll have to increase the oral potassium. Now testing for Hyperaldosteronism

Hopefully home tomorrow.

Thanks for all the good thoughts and prayers and wishing well to all the other poorly kitties and their frazzled parents. :bighug::bighug::bighug:
 
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I'm so relieved to read this. I feel like my stress level just dropped down and I can breathe better. Let's hope she gets home tomorrow. I do hope they can figure out the cause of Minnie's many troubles.
 
Suzanne & Darcy said:
Does this mean that she really wasn't DKA? (I hope she was/is not).
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Oh no, she had that too! Not sure exactly what starts it all off but somehow the ketones can lead to acidosis and lower potassium. Insulin makes the potassium drop (goes into the cells or something?). Then the high BG can help cause UTI (I forgot to ask if she does have that now) but somehow the antibiotics help fight the ketones. Then as everyone here knows, fighting ketones needs fluids and food and insulin. Oh, and low potassium can cause loss of appetite. Ketones can cause loss of appetite. Low potassium can stop her digesting food which likely caused the vomiting. I am DEFINITELY grateful you all persuaded me the feeding tube was a good idea!

Oh and the triglyceride re-test was normal again so don't need to worry about the low-fat diet after all. Maybe ok to use ad, she will recommend what exactly after discharge.


I haven't read enough here about the R insulin, but according to the internist when the ketones are going up I need to give her increased insulin. She said I could go up by 1u of Levemir but if that scared me I could do the R insulin, 0.5u up to every 2hours...and if she goes hypo, feed via the tube.

I'm interested in @Wendy&Neko 's thoughts on this approach, not urgent but figured I'd ask now when I am calm!
 
Liz & Minnie said:
I haven't read enough here about the R insulin, but according to the internist when the ketones are going up I need to give her increased insulin. She said I could go up by 1u of Levemir but if that scared me I could do the R insulin, 0.5u up to every 2hours...and if she goes hypo, feed via the tube.

I'm interested in @Wendy&Neko 's thoughts on this approach, not urgent but figured I'd ask now when I am calm!
Click to expand...

Wendy's input would definitely be helpful here; I can give sort of the short version. With R, the goal is to give a dose that drops BG by no more than 100 points at R nadir (about +4, typically). The vet's dosing approach may not be optimal. The dose is different for different cats, and can even change for an individual cat. (As an example, for a while Oberon needed 2.5 U to get a 100 point drop. Now even 0.75 seems to be a bit much.) You can't really use the Lantus dose to guess what the effective R dose might be; it really varies. So what we do here is start with a very low dose, and monitor carefully until we see how the cat responds (with someone here online to help out-definitely not something to try on your own!). It's a bit scary at first, but it's also a good tool to have if you're dealing with ketones/IAA/acro.
 
You know, it's always a good idea to check blood pressure in any cat over the age of (maybe) seven. Think of how we all walk into the doc's office and one of the first things they do is check BP.
 
Liz & Minnie said:
Oh no, she had that too! Not sure exactly what starts it all off but somehow the ketones can lead to acidosis and lower potassium. Insulin makes the potassium drop (goes into the cells or something?). Then the high BG can help cause UTI (I forgot to ask if she does have that now) but somehow the antibiotics help fight the ketones. Then as everyone here knows, fighting ketones needs fluids and food and insulin. Oh, and low potassium can cause loss of appetite. Ketones can cause loss of appetite. Low potassium can stop her digesting food which likely caused the vomiting. I am DEFINITELY grateful you all persuaded me the feeding tube was a good idea!

Oh and the triglyceride re-test was normal again so don't need to worry about the low-fat diet after all. Maybe ok to use ad, she will recommend what exactly after discharge.


I haven't read enough here about the R insulin, but according to the internist when the ketones are going up I need to give her increased insulin. She said I could go up by 1u of Levemir but if that scared me I could do the R insulin, 0.5u up to every 2hours...and if she goes hypo, feed via the tube.

I'm interested in @Wendy&Neko 's thoughts on this approach, not urgent but figured I'd ask now when I am calm!
Click to expand...
I'm just not used to thinking that a cat can go home that soon after being diagnosed with DKA (I DO WANT MINNIE to come home though as long as it's safe).
 
Lisa & Oberon said:
Wendy's input would definitely be helpful here; I can give sort of the short version. With R, the goal is to give a dose that drops BG by no more than 100 points at R nadir (about +4, typically). The vet's dosing approach may not be optimal. The dose is different for different cats, and can even change for an individual cat. (As an example, for a while Oberon needed 2.5 U to get a 100 point drop. Now even 0.75 seems to be a bit much.) You can't really use the Lantus dose to guess what the effective R dose might be; it really varies. So what we do here is start with a very low dose, and monitor carefully until we see how the cat responds (with someone here online to help out-definitely not something to try on your own!). It's a bit scary at first, but it's also a good tool to have if you're dealing with ketones/IAA/acro.
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Thanks. I think she is doing the same calculations you describe because she was asking me when I had given R and how much the BG dropped and when. She just doesn't seem as bothered about when it's given. After the last week and that hypo, and with having the feeding tube and Libre (and of course the help here) I feel a bit more equipped to manage the juggling act - during the day. Argh, if only I'd known the other day to feed her when I first saw her BG dropping I might have avoided the hypo! But can't fix the past, at least learn for the future.
 
Suzanne & Darcy said:
I'm just not used to thinking that a cat can go home that soon after being diagnosed with DKA (I DO WANT MINNIE to come home though as long as it's safe).
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I am completely with you on this. They keep saying it's ok for her to be home with ketones, they wouldn't do any different than I am doing. They seem so calm about these things that get me so anxious and everywhere says require trip back to emergency - hypo: don't worry, just feed her. Yeah, 32 is low. Just feed her. Ketones increasing in the urine / meter - just give fluids, feed and increase the insulin. I am not cut out for this!!!
 
Sigh, typed this earlier and didn't press Post.
:banghead:
Liz & Minnie said:
I haven't read enough here about the R insulin, but according to the internist when the ketones are going up I need to give her increased insulin. She said I could go up by 1u of Levemir but if that scared me I could do the R insulin, 0.5u up to every 2hours...and if she goes hypo, feed via the tube.

I'm interested in @Wendy&Neko 's thoughts on this approach, not urgent but figured I'd ask now when I am calm!
Click to expand...
In my time here, I've never seen anyone be so aggressive with the R. Frankly, it scares me to do it so often. And that's not even considering we don't have a good handle on how Minnie responds to R yet and what her R scale should be. It probably makes sense in a vet's office, where they can just throw on a glucose drip to balance it off.
 
Liz & Minnie said:
Yesterday

Just heard from the internist, she is doing much better and eating! Potassium low again, she thinks that may have caused the vomiting because her stomach wasn't emptying. She is on IV fluids, we'll have to increase the oral potassium. Now testing for Hyperaldosteronism

Hopefully home tomorrow.

Thanks for all the good thoughts and prayers and wishing well to all the other poorly kitties and their frazzled parents. :bighug::bighug::bighug:
Click to expand...
Hope all is well and bless y'all
 
Wendy&Neko said:
Sigh, typed this earlier and didn't press Post.
:banghead:
In my time here, I've never seen anyone be so aggressive with the R. Frankly, it scares me to do it so often. And that's not even considering we don't have a good handle on how Minnie responds to R yet and what her R scale should be. It probably makes sense in a vet's office, where they can just throw on a glucose drip to balance it off.
Click to expand...
Got it. It terrified me even more when she casually said to bump up the Levemir by 1u when she has ketones!

I am going to ask her for more precise instructions then bounce them off you here. How quickly (and safely) do you think we can figure out appropriate dosing for Min when I get her home? This is what we got from our experiment on 3/31

Wendy&Neko said:
Typically we'll do a couple cycles with the same R dose, cause you are looking at the action of L + R, and more data is needed to tease out what you are seeing with R. Maybe try a bit of a scale.

250-300 0.5 R
301+ 0.75 R

I also want to see where she goes when she clears this bounce, but at some point an L increase is in order. Generally we don't give R on the same cycle as an increase, cause sometimes that's a little more active with L by itself.
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Liz & Minnie said:
I am completely with you on this. They keep saying it's ok for her to be home with ketones, they wouldn't do any different than I am doing. They seem so calm about these things that get me so anxious and everywhere says require trip back to emergency - hypo: don't worry, just feed her. Yeah, 32 is low. Just feed her. Ketones increasing in the urine / meter - just give fluids, feed and increase the insulin. I am not cut out for this!!!
Click to expand...
Oh. I am with you 100 percent.
 
Wendy&Neko said:
Sigh, typed this earlier and didn't press Post.
:banghead:
In my time here, I've never seen anyone be so aggressive with the R. Frankly, it scares me to do it so often. And that's not even considering we don't have a good handle on how Minnie responds to R yet and what her R scale should be. It probably makes sense in a vet's office, where they can just throw on a glucose drip to balance it off.
Click to expand...
Funny... that’s exactly what I was saying to my daughter a few nights ago.... that it’s all very well for them to tell Liz to give Minnie the R this frequently... but they can just put her on a glucose drip whenever they need to! Angelica follows along with me about the kitties here and she will ask me ... how is Minnie? Or, how is Susie? ... if I don’t mention them.
 
If you are interested, there is a description of a protocol for use in the clinic of R on DKA cats listed here, the first case study: (2020) Updates in Feline Diabetes Mellitus and Hypersomatrotropism It talks about subq R every 6 hours. But they also talk about continuous drip insulin.

As for increasing the Levemir, that is an option, if, and only if, you stick with higher carb food. So that is a consideration for the shorter term to get more insulin in her. The other option is to keep the Levemir dose and dose R more frequently - once we figure out what the R scale should be. You do want to maximize the amount of insulin you can safely give and carbs is part of that equation. It could be, as I've seen others joke, that she gets ice cream sundaes, not chocolate of course. :p
Liz & Minnie said:
How quickly (and safely) do you think we can figure out appropriate dosing for Min when I get her home?
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Ideally you would have data when R is given at preshot, as well as at mid cycle. Assuming giving R every six hours. Ultimately we want to build an R scale. See Black Kitty's SS for an example of that. As Lisa said, the amount of R dose varies by cat, and by dose they are on. I've see a 30 unit L cat need no more than 0.5 units of R. Too much R and dropping more than 100 points in a short time period sets up a huge bounce and you are back in high numbers again. Our goal is to prevent that.

I'd like to see a number of R doses at a particular preshot to see how she responded and subsequent BG tests at R+4/+5. So, if you have data such as (making this up), 0.25U R given at 200-250 at preshot, after 4 hours her drop was X points. The test 4-5 hours after giving R gives us an idea how well that dose is doing, is it too much or too little.
 
Wendy&Neko said:
If you are interested, there is a description of a protocol for use in the clinic of R on DKA cats listed here, the first case study: (2020) Updates in Feline Diabetes Mellitus and Hypersomatrotropism It talks about subq R every 6 hours. But they also talk about continuous drip insulin.

As for increasing the Levemir, that is an option, if, and only if, you stick with higher carb food. So that is a consideration for the shorter term to get more insulin in her. The other option is to keep the Levemir dose and dose R more frequently - once we figure out what the R scale should be. You do want to maximize the amount of insulin you can safely give and carbs is part of that equation. It could be, as I've seen others joke, that she gets ice cream sundaes, not chocolate of course. :p

Ideally you would have data when R is given at preshot, as well as at mid cycle. Assuming giving R every six hours. Ultimately we want to build an R scale. See Black Kitty's SS for an example of that. As Lisa said, the amount of R dose varies by cat, and by dose they are on. I've see a 30 unit L cat need no more than 0.5 units of R. Too much R and dropping more than 100 points in a short time period sets up a huge bounce and you are back in high numbers again. Our goal is to prevent that.

I'd like to see a number of R doses at a particular preshot to see how she responded and subsequent BG tests at R+4/+5. So, if you have data such as (making this up), 0.25U R given at 200-250 at preshot, after 4 hours her drop was X points. The test 4-5 hours after giving R gives us an idea how well that dose is doing, is it too much or too little.
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This is great, thanks so much. I will have to read a few times to digest properly but it all makes sense.

Which of the two options would you suggest for us when she comes home - more L or more R? Assuming the feeding tube - I have 8% TicTacWhoa and 25% WD (possibly will have 12% AD as an option) and how she responded to the HC during the hypo the other day...though I wouldn't wait so long to feed her next time.

ETA - Looked at Black Kitty's dosing chart. Would it make sense for me to also add a column for blood ketone readings? Or is that just going to make my head explode / be too complicated / not add any value?
 
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WOW. Black Kitty's s/s is an inspiration, I just looked at the whole thing. They went from max dose of 13.5uL + 4.5u R to OTJ. Amazing. I'm so impressed, what a lot of hard work.
 
Suzanne & Darcy said:
You know, it's always a good idea to check blood pressure in any cat over the age of (maybe) seven. Think of how we all walk into the doc's office and one of the first things they do is check BP.
Click to expand...
I asked for a baseline for Max when he was about 1 and my vet and I were surprised that he had primary high BP and started amlodipine. He was not hyper-t and not CKD at the time.
 
Liz & Minnie said:
Which of the two options would you suggest for us when she comes home - more L or more R? Assuming the feeding tube - I have 8% TicTacWhoa and 25% WD (possibly will have 12% AD as an option) and how she responded to the HC during the hypo the other day...though I wouldn't wait so long to feed her next time.

ETA - Looked at Black Kitty's dosing chart. Would it make sense for me to also add a column for blood ketone readings? Or is that just going to make my head explode / be too complicated / not add any value?
Click to expand...
Last question first - I've seen a few people have a column for blood ketone readings. If you think it'll be useful, go for it. Might be useful to see a correlation between blood ketones and BG/dose. You can delete it later if you don't like it. As for option A or B, I'm a fan of more R personally. R gives you the option to not give it. The depot can be a pain. Sandy once described using L and R as like using an Etch a Sketch (hope I'm not dating myself). You have two knobs to turn to get the ideal result. But you have to know how they both work on their own, to figure out how they work together. So figuring out the right dose of R to not cause a huge drop is key.

Do you know what Lev dose she's getting (if any) at the vet clinic?
 
Time to get some sleep, Liz, hoping Minnie is home safe and sound tomorrow. Picking up some A/D really is a good idea, most kitties really like it, and as has been noted in the past, it is so smooth it works really well with assist and/ or tube feeding.
 
Wendy&Neko said:
Last question first - I've seen a few people have a column for blood ketone readings. If you think it'll be useful, go for it. Might be useful to see a correlation between blood ketones and BG/dose. You can delete it later if you don't like it. As for option A or B, I'm a fan of more R personally. R gives you the option to not give it. The depot can be a pain. Sandy once described using L and R as like using an Etch a Sketch (hope I'm not dating myself). You have two knobs to turn to get the ideal result. But you have to know how they both work on their own, to figure out how they work together. So figuring out the right dose of R to not cause a huge drop is key.

Do you know what Lev dose she's getting (if any) at the vet clinic?
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I guess my ketone column depends on getting enough blood to get a reading, now I think about it. I'll track it if I can. And I think I must have had a big shocked intake of breath when she suggested increasing Lev by 1u which made her suggest the R as an alternative. HA. I remember etch a sketch so if you're dating yourself, I'm there with you!

I don't know if they are giving her 4.75 or 5 in there but I will ask. If I was a betting person, I'd guess it's 5 because I can't imagine them spending the time to measure out 4.75u. I haven't phoned much today because there's not much I can do but I'll get one more update before bed.

Christie & Maverick said:
Time to get some sleep, Liz, hoping Minnie is home safe and sound tomorrow. Picking up some A/D really is a good idea, most kitties really like it, and as has been noted in the past, it is so smooth it works really well with assist and/ or tube feeding.
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I did get a few cans of A/D yesterday on the off-chance they approved it. Will get more if internist gives it the ok, and ask them for another batch of syringes - they gave me 2 of every size, so I'll want another batch so I can have H/M/L carb tubes.

Thanks again. You are all amazing, I'm so grateful.
 
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