6/24 Henry's ongoing saga AMPS 317 +1.5 308 +2.25 313 +3 336

FrostD said:
Also about the meters... I'm a fairly vocal critic of the Libre. I think it is a fantastic tool in the chest in this exact situation, and in situations we need to at least have an idea what's happening. But the trouble is what you're seeing - anecdotally it tends to read artificially lower below about 70, and artificially HI on the upper end. It has messed quite a few people up in terms of dosing strategy, intervening with food when they didn't need to, etc. But it's one of the many tools we have, I always say use a handheld as your primary meter, use the Libre to help fill in the gaps.
Click to expand...

Yeah, I'm only using the libre as a back indicator. Making all decision with the nova (although that was the one that just had a faulty reading)
 
I hope you have a stash of the ketone strips! They're expensive but still cheaper than the ER... you have my sympathies, she was in/out 3 times in a row over about 3 weeks last year so my bill was similar to yours. I get ketone strips from adwdiabetes.com (discount SAVE12 has worked for me for months and if you spend enough you get free shipping) or amazon (I think occasionally have been marginally cheaper but the big bonus with them if you have prime is that they arrive quicker).

Right now, I'd also stick the ketone reading in your s/s in the same cells as the BG. It might get a bit crowded when you have BG, ketone and R dose in there but it's only for now.

Also (sorry if I'm repeating myself here) if he is eating well and especially if ketones increased, I'd put a lot of water in with his food and make it nice and soupy whenever I put food down right now. I have never successfully given subq fluids so I can't help with that but food, fluids and R are the magic combo for ketones.

I didn't learn til today that 'mid-cycle' = after nadir, but if it were me I would be inclined to give 0.1u R again at +6 especially since his ketones have increased. Wendy had said 0.25u for you if BG>350 but I'm not sure if she meant that for mid-cycle as well as pre-shot. Hopefully Wendy will be back again before then to clarify. If not, post your BG and ketone reading at +6 and we'll figure out what to do.
 
Sandy and Black Kitty said:
Deep breaths…

a few questions-
Is there an underlying infection/inflammation?
Has he lost weight?
Click to expand...

Well, they looked for those things in the hospital but couldn't find anything. Still waiting on some tests to come back. He's on 2 different antibiotics (clavamox & Marbofloxacin) and he's been on them for almost a week now? He normally runs about 9.5 and he's down to the lower end of 7. This was probably all caused my the underlying diabetes.
 
John & Henry said:
Thank you, that's very helpful. I'm thinking of the pre-hospitalization numbers where he was in the 400s but the 2U of Lantus didn't touch it. Are you saying with the counter regulatory hormones I could give him a huge dose of R and it still wouldn't bring it down? .
Click to expand...
So the strength of Lantus isn't bringing down high numbers, it's strength is keeping BG relatively flat (compared to an in-and-out insulin like ProZinc). To head off the question I know is forming - no you do not want ProZinc at this point. Adds complexity while depot is draining, and often is pretty harsh and causes even steeper drops and then bounces again, etc. and it's a never ending cycle of swinging. In my opinion better to use the L+R combo.

So the 2U gave him pretty nice cycles, but no Lantus usually cannot quickly fight a bounce. Theoretically yes there is an R dose that can bring it down, but you don't have the luxury of compensating with IV dextrose at home if it's overdone. As you say, another hospitalization is not good. So you are walking an unfortunate fine line of being aggressive enough at home to hopefully keep him from DKA, but not so aggressive he ends up in the hospital from hypo.

Again with a huge disclaimer that I am not an R user - if he's above 350 at +6, I personally if it were my cat would be trying 0.25U R at about +6/+7 assuming you can monitor. Logic there is L nadir should be just about there or past, and he will either stay flat or head upwards. Liz and Suzanne have used R and said stick with 0.1U. Another disclaimer, I have always been slightly more aggressive in my dosing and not everyone is comfortable with that.
 
FrostD said:
Theoretically yes there is an R dose that can bring it down, but you don't have the luxury of compensating with IV dextrose at home if it's overdone. As you say, another hospitalization is not good. So you are walking an unfortunate fine line of being aggressive enough at home to hopefully keep him from DKA, but not so aggressive he ends up in the hospital from hypo.
Click to expand...

I'm guessing some IV dextrose at the smaller local ER for a few hours would be much cheaper than where he has been going, getting constant blood gases, tests, fluids, etc. for days. But yeah, point taken. I appreciate your candor.
 
FrostD said:
So the strength of Lantus isn't bringing down high numbers, it's strength is keeping BG relatively flat (compared to an in-and-out insulin like ProZinc). To head off the question I know is forming - no you do not want ProZinc at this point. Adds complexity while depot is draining, and often is pretty harsh and causes even steeper drops and then bounces again, etc. and it's a never ending cycle of swinging. In my opinion better to use the L+R combo.

So the 2U gave him pretty nice cycles, but no Lantus usually cannot quickly fight a bounce. Theoretically yes there is an R dose that can bring it down, but you don't have the luxury of compensating with IV dextrose at home if it's overdone. As you say, another hospitalization is not good. So you are walking an unfortunate fine line of being aggressive enough at home to hopefully keep him from DKA, but not so aggressive he ends up in the hospital from hypo.

Again with a huge disclaimer that I am not an R user - if he's above 350 at +6, I personally if it were my cat would be trying 0.25U R at about +6/+7 assuming you can monitor. Logic there is L nadir should be just about there or past, and he will either stay flat or head upwards. Liz and Suzanne have used R and said stick with 0.1U. Another disclaimer, I have always been slightly more aggressive in my dosing and not everyone is comfortable with that.
Click to expand...
If his ketones are up quite a bit at +6 and his BG numbers are high, then it may be advisable to increase the R a little. Still a little more time to go before that time.
 
John & Henry said:
Well, they looked for those things in the hospital but couldn't find anything. Still waiting on some tests to come back. He's on 2 different antibiotics (clavamox & Marbofloxacin) and he's been on them for almost a week now? He normally runs about 9.5 and he's down to the lower end of 7. This was probably all caused my the underlying diabetes.
Click to expand...
it’s important for him to consume 1.5-2 times the calories required to maintain his optimal weight.

you are in a period of intensive care. Try not to get strung out.

Lots of moving parts. Let’s see where he’s at come +6
 
I just checked on the Ketone strips from amazon and they won't make it til monday :( So I got 9 strips from now til monday
 
Suzanne & Darcy said:
Sandy is the person we are all referred to as an example when using R. :)
Click to expand...
Wendy is not available today and I think everyone should wait and hear what Sandy has said.
I have no experience with R so I am not going to get involved with saying whether he needs a dose or not and I think that anyone else who has no experience with R should also not be giving an opinion,
 
John & Henry said:
I just checked on the Ketone strips from amazon and they won't make it til monday :( So I got 9 strips from now til monday
Click to expand...
Oh no. Do you at least have urine strips? I wish I had known. I have unopened boxes of Nova Max ketone strips her that I could have mailed. But at this point they would not make it until at least Monday either. :(
 
John & Henry said:
I just checked on the Ketone strips from amazon and they won't make it til monday :( So I got 9 strips from now til monday
Click to expand...
Have you checked Walmart by chance? They were always cheaper for me than amazon, but not usually in stock near me.

Do you have Ketostix? I know it's not as good as the blood meter, but perhaps use the urine ones when you can - and save the ketone strips for once a day + if you're trying to make an R decision.

Edit - glad you found more. Also, as everyone else has said, defer to Sandy. Glad to see she's around.
 
FrostD said:
Do you have Ketostix? I know it's not as good as the blood meter, but perhaps use the urine ones when you can - and save the ketone strips for once a day + if you're trying to make an R decision.
Click to expand...

I do have the urine strips and that's what the vet insists I use anyway, apparently she doesn't like the blood ketone strips because she calls them just a "snap shot" and not an overall pictures (which is the same reason she gave me for ignoring his 5.7 reading 2 days before he went DKA for the second time)
 
John & Henry said:
I do have the urine strips and that's what the vet insists I use anyway, apparently she doesn't like the blood ketone strips because she calls them just a "snap shot" and not an overall pictures (which is the same reason she gave me for ignoring his 5.7 reading 2 days before he went DKA for the second time)
Click to expand...
I did a quick edit but you were too fast - just reiterating to defer to Sandy. My intent is not to muddy the water here. Since I wasn't sure Sandy would be around, I was simply giving my thoughts as to what I personally would do. I'd rather someone have a straightforward opinion and explanation vs nothing at all to go from.

I will leave it to Sandy now as this thread is pretty busy.
 
For anyone interested here's the vet response to my email from this morning. I explained the those hypo situation and sent her the data:

Wow that is very strange for him to have such a prolonged hypoglycemia--what a tricky little fellow! He received a half unit of the regular insulin at 3pm when his blood glucose was 328 yesterday, so it's kind of weird for his readings to be so low after that. When was he eating and how much was he eating? I certainly think that continued monitoring makes sense at this time. The other thing that I was considering is if we should be checking your glucometer against the glucometers that we use in the clinic that were designed for veterinary patients; however with the Libre and glucometer readings being pretty close my guess is that they are relatively accurate. Although theoretically the glargine takes longer to take maximal effect, I have definitely seen patients that absorb some amounts of glargine quite quickly so I would hesitate to give when he is under 100, but let's keep an eye on what his blood sugars are doing throughout the day and see what happens. Just to let you know, we did receive the results of the liver and splenic aspirates. His liver did have some changes that are consistent with a vacuolar hepatopathy, which is a nonspecific change in the liver cells that we often see in diabetics. There was a little bit of inflammation in his liver as well, so I do wonder if he has a chronic inflammatory condition affecting both his liver, GI tract, and pancreas, which is quite common in cats. In some cases we'll consider treating with steroid therapy or other immunosuppressives, but this is obviously less ideal in an unregulated diabetic patient as it has the potential to push them into DKA. It is also a little hard to determine on aspirates alone whether the inflammation truly is widespread or we just hit a pocket of inflammatory cells. His spleen samples did come back normal.
Click to expand...
 
John & Henry said:
For anyone interested here's the vet response to my email from this morning. I explained the those hypo situation and sent her the data:
Click to expand...
I lied, I'm back.

...she's describing triaditis. I am not 100% sure on the treatment for that, but I *believe* you should have been able to use budesonide (which typically does not affect BG) to help with the inflammation (quick Google says yes). Other than that it's just managing any nausea, inappetence, pain, and fluids with various meds.
 
I regards to the message back from the vet.
In my experience with my meters v the vets meters I found they were always different. And it also depends on whether they are using a pet meter or a human meter or are measuring it on a machine. All give different results. Don’t let them talk to you into a pet meter. We are much more used to human meters here and a pet meter would only complicate things.
I’m glad Sandy is helping you
 
John & Henry said:
She prescribed 60ml of subQ fluids. Is that a standard amount?
Click to expand...
Does he have any cardiac issues? Most vets and specialists I’ve worked with go with at least 100ml at a time, assuming no heart problems. So 60ml sounds safe, though it probably won’t dent the BG.

I’ve administered subQ fluids a lot over the years, including in my diabetics. They can be a good tool in the arsenal. SubQ and oral water intake have the same net goal but work on different “pathways” to achieve that goal. I’d do the subQ soon to try to help flush the system. Even though 60 ml might not do much, it’s something.

You can use opposite sides for insulin shots/fluids or gave the fluids slightly farther back. As long as they’re not given in the same spot, you should be fine.

Also, has he been tested for hyperthyroidism?
 
He received a half unit of the regular insulin at 3pm when his blood glucose was 328 yesterday
Click to expand...

Granted he was very low last night, and it was a bit of a battle since I'm such a noob at this, but we managed it with just 1.5ml of corn syrup. I'm not saying that .5U R is the answer (although his discharge instructions explicitly say "Give .5U regular insulin if BG >300 6 hours after Lantus dose"). I feel like .25U may not even be enough, but I won't give more than that. I really feel it's necessary. 15 minutes til +6 and reading

JL and Chip said:
Even though 60 ml might not do much, it’s something.

You can use opposite sides for insulin shots/fluids or gave the fluids slightly farther back. As long as they’re not given in the same spot, you should be fine.

Also, has he been tested for hyperthyroidism?
Click to expand...

Thank you for that. I guess I'll give the subQ on the back where I normally give the insulin, and can put the insulin on his sides? The libre is near his rear end. She put it there in hopes the subQ wouldn't interfere with it.

edit: yes, he was tested for hyperthyroidism and he was fine
 
John & Henry said:
Alright. +6 was bad. very bad. Ketones are up from .6 a little over an hour ago to .9 now. BG is 398. I'm giving the .25U R and praying its going to be enough.
Click to expand...
John & Henry said:
Alright. +6 was bad. very bad. Ketones are up from .6 a little over an hour ago to .9 now. BG is 398. I'm giving the .25U R and praying its going to be enough.
Click to expand...
His ketones really are rising steadily. I understand this decision on R. I’m praying it’s going to bring the numbers (and ketones down too.)
 
A couple of observations:

  • When the vet showed me how to draw the Lantus she pulled an amount of insulin from the pen with the syringe (past the target unit marking) and then adjust it to the proper marking (thus pushing insulin from the syringe back into the pen). I now know this is improper and can denature the insulin.
  • My refrigerator is very cold (or well was, I turned it down last night). It is very rare that anything ever froze, but his clavamox had frozen when I went to use it yesterday. The insulin is stored in a seperate part of the fridge with a plastic divider door and I've never seen the insulin frozen, but it makes me wonder... Could it be too cold? could it have damaged the insulin?
  • It's been a little over 30 days now since I first started using the Lantus pen. I know they're "supposed" to only be good for 30 days, but some people use them up to 6 months (my vet says 3)
  • I've left it out of the fridge 3 times for 12 hours each time.
Considering all of the above, should I request a new bottle? With the little effect it has seemed to have lately it really makes me wonder if it may be bad?
 
John & Henry said:
A couple of observations:

  • When the vet showed me how to draw the Lantus she pulled an amount of insulin from the pen with the syringe (past the target unit marking) and then adjust it to the proper marking (thus pushing insulin from the syringe back into the pen). I now know this is improper and can denature the insulin.
  • My refrigerator is very cold (or well was, I turned it down last night). It is very rare that anything ever froze, but his clavamox had frozen when I went to use it yesterday. The insulin is stored in a seperate part of the fridge with a plastic divider door and I've never seen the insulin frozen, but it makes me wonder... Could it be too cold? could it have damaged the insulin?
  • It's been a little over 30 days now since I first started using the Lantus pen. I know they're "supposed" to only be good for 30 days, but some people use them up to 6 months (my vet says 3)
  • I've left it out of the fridge 3 times for 12 hours each time.
Considering all of the above, should I request a new bottle? With the little effect it has seemed to have lately it really makes me wonder if it may be bad?
Click to expand...
This is same vial used on the 20th/21st? It was definitely working then. Also appeared to be working last night. When did you find the clavamox frozen, yesterday morning sometime? Was it also in the door? Door tends to be warmer.

Human diabetics store it at room temp (actually what the insert says too) so I wouldn't worry about the times you left it out. Ive been around here two years now and I've yet to see it lose efficacy before the 3 month mark (unless of course it froze or overheated, etc).

I've always liked to keep a spare pen for the "just in case" (aside from having a high dose cat anyway). Most of the time the expiration date is 1-2 years away.
 
FrostD said:
This is same vial used on the 20th/21st? It was definitely working then. Also appeared to be working last night. When did you find the clavamox frozen, yesterday morning sometime? Was it also in the door? Door tends to be warmer.

Human diabetics store it at room temp (actually what the insert says too) so I wouldn't worry about the times you left it out. Ive been around here two years now and I've yet to see it lose efficacy before the 3 month mark (unless of course it froze or overheated, etc).

I've always liked to keep a spare pen for the "just in case" (aside from having a high dose cat anyway). Most of the time the expiration date is 1-2 years away.
Click to expand...

Yes, same I've only had one vial ever (before getting the R yesterday that is), and yeah, i guess your right. It did seem to work last night even, so I guess it must be good. Not sure why I didn't realize that. I need sleep. lol. Thanks for pointing that out.
 
Good news is we're on the upswing! That .25U of R @+6 brought his BG down 106 points at +7 to 292! I just took the +8 and it moved up a bit to 309, but still better than pushing 400. Hopefully this will also help gauge his reaction to the R in the future as well.

I gave 60ml subQ fluids @ AMPS +8.75 This was my first time giving subQ fluids. I was scared he wasn't going to like the 18g needle they gave me. That thing scares the heck outta me! My first two attempts I shot through the skin and got myself all wet (didn't lose that much). I hope I haven't been doing that with the insulin! I think I figured out how to avoid that ever happening in the future now tho. He was great about it. It was the first time he ever even flinched accepting a needle. By my third attempt he thought, "Uh, I think I'm going to go now" but my wife was there to keep him put. He was still very good about it.

He just finished his 4th can of food for the day. Hasn't drank much at all.

edit: libre is still reading over 400
 
So a drop of 74 from 0.25u R mid-cycle, nice.

I'm heading to bed now, hopefully Wendy will check in on you. If not (and if @Sandy and Black Kitty are not around either) at PMPS I would check ketones again and stick with Wendy's R guidance from before i.e.
>350 0.25uR
300-349 0.1uR
<300 0uR
I would stick with the 1.75u L.

Same drill as before, monitor BG hourly - the R should last about 4 hours and we're looking for a drop of around 100 in those 4 hours. If he drops a lot in the first hour, I would give slightly higher carb food to slow it down. Hopefully you'll also see a drop in ketones thanks to the subq fluids - congrats on that, I haven't managed it myself yet!

At this time of night (you may know this) your best bets for online support are @Bron and Sheba (GA) and @Bandit's Mom. There may be people in Europe coming online soon, too though I'm blanking on any names at the moment.

Good luck and hope you get some naps. You're doing great, whatever your inside voice might be saying...don't listen to it.
 
A word of caution when working with a rapid onset and slow onset insulin at the same time-
Make certain that you are fully present when preparing syringes. develop some sort of cross check to verify which insulin is in which syringe and that the doses are correct. You do not want even a shadow of a doubt. I’ve seen it more than once over the years where a caregiver using both L and R (for example a kitty with a high dose condition) realizes that instead say 6u L and 0.25u R they shot, or may have shot 0.25u L and 6u R.
 
Sandy and Black Kitty said:
A word of caution when working with a rapid onset and slow onset insulin at the same time-
Make certain that you are fully present when preparing syringes. develop some sort of cross check to verify which insulin is in which syringe and that the doses are correct. You do not want even a shadow of a doubt. I’ve seen it more than once over the years where a caregiver using both L and R (for example a kitty with a high dose condition) realizes that instead say 6u L and 0.25u R they shot, or may have shot 0.25u L and 6u R.
Click to expand...

Yes, that would truly be awful. Point taken and I'll be installing a big billboard with flashing lights in my brain shortly. Thanks for the warning.
 
You must log in or register to reply here.
Back
Top