8/16 Charlie: Bouncy-boi prone to ketones-AMPS 165/stall 185; +2 398; +3 386; +9 291; PMPS 308

[Sarah & Charlie-cat]

I'm currently stalling a 165 amps, he looked so sad when I snatched his food up, which I out down while I tested and he happily started tucking in.

Mad at myself for not testing him at midnight when he meowed at me as if hungry but didn't follow me into the kitchen, he merely seemed to be requesting mom. I laid next to him for and hour and then went to to bed. Arg.

 

[Sarah & Charlie-cat]

Stall was 185. Gave full dose and will make sure to test at +4 and +6.

And update the spreadsheet wasn't top of mind in the Target parking lot where he got him PM shot last night

 

[JL and Chip]

Did you say you went to Iowa State vet school yesterday? How did it go?

 

[Sarah & Charlie-cat]

I did! He cried the whole way there, 3.5 hours!

It was... Ok. They did an ultrasound and found... Drumroll... pancreatitis. Yes, thank you, I was aware. Although she said it looked like acute and we're two weeks out from his last flare and he hasn't had any symptoms so that was interesting. Turned up that the first part of his small intestine was "corrugated" but that apparently could mean many things, including pancreatitis or neoplasia. She did think it unlikely he has large cell lymphoma or pancreatic cancer (we both thought he'd probably already be dead). The full report will be early next week.

Did a thyroid and that was fine. Was ok with me saying listen, I have two blood tests from two weeks ago, so can we just use that?

They seemed more reasonable about diabetes management. Although I did have to flap my AAHA report at her and a paper on tight regulation at her She wants us to do a libre and send her data. She was fine with us putting it on ourselves and listened with interest about how we got it to stay for 12 days. So, we need to slap the last one we have on him. She said on glargine insulin, yes you can feed him multiple times a day (yes, I know and I do, lynx). She did think VCA was wrong to tell me to halve his insulin after I pulled out the ol' spreadsheet and rattled off his recent numbers and said, why don't you go back to 5u. And would you know this morning he was 165? Wut?

But then she wanted him on Hill's W/D and I looked at the carbs and the ingredients and said no. The vet student couldn't get a hold of the resident again and was not prepared to go 10 rounds with me on it. So I left it there. He had some nice Stella and Chewy chicken pate and Weruva chicken pate last night and his normal raw rabbit this morning.

And I got to give him his insulin in the back of the car in a Target parking lot after having to purchase a new meter at the Walmart because it was the one thing I forgot to pack. So much fun!

At least the resident didn't treat me like an idiot, so there was that.

 

[Sarah & Charlie-cat]

I went to test him at +2 and he's clearly bounced, 398. He was grouchy and the rims of his eyes were getting pink so I tested for Ketones. 2.7. Omfg. He just ate some more food and i gave him a 100 ml of fluids, which usually helps get those down. Fingers crossed that they come down because I dunno what else to do try to get him into our regular vet or ???

 

[Sarah & Charlie-cat]

Thank dog, they came back down to 1.0-something and then 0.1, The pinkness around the rims of his eyes cleared up and he's not grouchy the way he seems to get when he's developing ketones. He's eaten ok today, but been higher than I would like in the BGs, rubber boy gotta bounce.

 

[Sarah & Charlie-cat]

Hi again. Let me reintroduce myself (Sarah) and my sugar baby, Charlie. We live in Lincoln Nebraska with Cat Dad (my husband, Kevin) and five other cats, all of whom were strays at one point in their lives, four girls and one other boi.

I’m going to try to post more here on the very wise suggestion of Margaret (and Pearl), Kim, and Karen from the FB group as they think y’all will better be able to right the ship that is my brain on 9 months of rollercoaster ride that this has been. Not that they and Chris haven’t been extremely helpful, and Tonya who is so supportive and also makes me laugh…My apologies for such a long post, we’ve been through a lot, and I am struggling. There's a TL;DR version of his history below and an ask for help with dosing below.

Background

May 2019: Charlie was the first cat at the humane society and he was so pretty. We visited with him and he curled right up in my lap. He was sweet to Kevin, at the time my boyfriend. He was found as a stray, very skinny, wondering the streets. He wasn’t fixed, so he could have gotten out, but I also wonder who wouldn’t have come looking for such a pretty, sweet cat. He joined my two female cats, who I had since they were kittens from a street colony. It was not an easy integration and they didn’t really accept him until we moved in with Kevin and his two cats.

July 2020: Dx with a blood clotting disorder after I took him to the vet for vomiting and inappetence. Put on an every increasing dose of prednisolone (his new regular vet has confirmed he does not and has never had a blood clotting disorder).

Early December 2022: DX with diabetes along with pancreatitis

February 2023: Tried to wean him of the prednisolone only to end up with hairballs, vomiting and developing ketones, which landed him in the ER in March, which was followed by an IBD dx via ultrasound and a food switch to novel protein (duck, lamb, and rabbit)

Mid-May 2023: DKA, which escalated very quickly from inappetence to vomiting what I syringe fed him, basically in 4 hours. A physical exam and ultrasound found a mass… bloodwork suggested pancreatitis and large cell lymphoma (although apparently, that blood test is not actually very useful for diagnosing lymphomas).

June: Oncologist didn’t find a mass. Tried a number of raw food brands and proteins before settling on Fetching Foods: https://www.fetchingfoods.com/

July: Initial visit with VCA in Omaha, possible pancreatitis again, vomiting, inappetence, dehydration (our AC was out in a heat wave), early ketones, another very expensive ER visit at VCA. They were truly awful and we didn’t go back.

August: Initial visit at Iowa State and… you guessed it, pancreatitis! And a suggestion to put him on Hills W/D as a low fat food to get his elevated triglycerides down to see if it helps the diabetes. So far, I’ve refused, its 37% carbs and has corn, rice, wheat, and powdered cellulose. I am open to trying a homemade cooked or raw lower fat food but not that kibble.

Biggest concern

Ketones. They are my nemesis. He seems to develop them quite frequently and I’ve been trying to do the blood test every day or every other day. I can tell when they are high, the rims of his eyes turn pink and look inflamed. He also gets really grouchy! IM vet suggested we stop testing for ketones because its too much data. In my head, I suggested she go stuff herself. Today, he was up to 2.7 with red eyes, gave him an extra breakfast and fluids and he went down to 1.0-something and then to 0.1. She also suggested I stop giving him daily fluids, but I would swear in court they have been a game changer for keeping him stable. He doesn’t even fight me on it anymore, he’s just like, filler up, mom! I cannot afford another long hospitalization and even the ER visits to get him stable are burning through the extra money I made teaching this summer. I worry if he has DKA again, I will have to let him go.

Taking him off Prednisolone… both our regular vet and the IM vet want to get him off pred. We tried in February and all hell broke lose. This past month, I took him down from 10 to 7.5 mg of transdermal and we just went down to 5. I am worried that I’m about to unleash another hell storm. There is a definite tension between taking him off it because of diabetes and keeping him on it because of the potential of IBD.

What I’ve learned

That I can increase his regular Zofran and Cerenia if he’s getting nauseous. And I now have gabapentin and buprenorphine at home for pain. And I can bump his fluids to 150 1X a day or 2 by 100 if he’s really bad. Personally, given no one has ever said boo about his heart, the risk of not giving him fluids currently seems higher given the ketones monster. Especially with chronic pancreatitis, it seems some just need extra fluids to keep everything trucking along ok-enough.

Dosing help

We need help. I had been SLGS, which works for my general life (when I’m home I can test a lot but I often have to travel a day or more for work) and the deficiencies in my brain (I have ADHD, but instead of hyperactivity, my brain doesn’t switch well between tasks, including being awake and being asleep). I did try TR after May’s DKA on the suggestion of his regular vet to try to get his BG down…and even consistently getting a +2 has been hard on me. I would like to go back to SLGS for my own sanity.

He was up to 6.5u recently but with no real change. The VCA suggested that I go down to 3.5 or 4 because they thought I was giving him insulin resistance, and he actually did end up having a green number before I decided to go back to SLGS and I ended up going down not up.

The IM vet said well, let’s go up to 5. And dear reader, he bounced like the rubber ball he is last night (which probably contributed to this morning’s ketone monster). I don’t know why I let either vet bully me into a dose change, but I think I’ve just become unmoored in my own brain about what to do with him. I am questioning whether the insulin is even getting into the cat, even though I know rationally that it is. I don’t smell the nasty Band-Aid smell or feel wet (except twice recently when he was being a butt head and I got partial doses in him). We got a new bottle of Glargine in May because I hoped that would help. Dear reader, it has not.

No one seems to want to test him for acromegaly, even though he has uncontrolled diabetes, is male and neutered, and has big paws. He’s always had big paws, but I dunno if they’ve gotten bigger. I also can’t tell if his face has changed at all other than he was skinner when I got him and he was just neutered. I would love to see him comfortably in the blues and darker greens at least. I do not think we will get remission at this point, not with his pancreas being such a mess and the disaster that has been his control since those blissful early days of blues and greens on a drop dose. A drop dose!

https://felinediabetes.com/FDMB/thr...treating-ketones-at-home.279839/#post-3090807https://felinediabetes.com/FDMB/threads/charlie-ketones-2-1-at-2-pm.279838/#post-3090367
Most recent previous posts ^^^

 

[Bron and Sheba (GA)]

Hi Sarah,
I disagree with the IM vet who said to stop testing for ketones. I think it is important we know the ketone status as it can get out of hand quickly and I don’t agree with head in the sand mentality. So I would keep testing for ketones. If you are finding the blood ketones meter is too expensive to run, you could try using Ketostix with urine testing. That is reliable.

I also can’t understand the vet suggesting going back to 3.5 or 4 units with DKA in the recent past. That is inviting ketones back into the
Picture. Also giving 6 units won’t cause insulin resistance….but if you are giving too low a dose and no raising it or holding it too long…that will cause insulin resistance.

With sub Q fluids…do you give them every day or just when you are concerned?
I would be inclined to give them every day but a smaller amount such as 50 or 75 mls.
I think giving 150 or 200 in one go is too much for any cat to manage.

What foods are you feeding? …I’m thinking about you doing TR if you are not feeding dry food. What is your concern about the TR? You don’t have to increase every 3 days if you you are away or busy if there is no threat of ketones at that time.

Why does the IM vet and the regular vet want to get him off prednisolone? If he needs it, then we can work around it. I don’t like pred but if a cat really needs it, then he needs to stay on it.

 

[Sarah & Charlie-cat]

I agree on the testing for ketones. Does it cause me anxiety? Yes. Is he still alive? Yes. I cannot manage to get a pee stick under him to test. But yes, the strips for the meter are pricey.

The VCA people seemed to be even worse on diabetes than our local vet. We will not be going back. Which sucks because the local ER vet is bad too and when I brought him in talking about ketones, they let him sit for hours without testing him for ketones and his regular vet was irate. That was the time he was in hospital for five days.

I was giving sub Q every day. He is a big male cat. 15lb is a little chonky but not that chubby. His vet said 100 once a day. The VCA emergency vet said 100 twice a day when I brought him home after refusing to leave him there the three days they wanted. Which is what the local ER vet said the night they were full and there was nothing else we could do. His old vet said 150. That's also what they told me for our other male who is 22lb (he's a chonk). I don't want to overload him, true, but it definitely seems to help reduce the ketones in his blood. This is one that maybe I need more clarity on still.

The amount of testing for TR, especially testing in the evening is too much for me. He's eating raw food. I worry about TR because with his IBD, I worry about feeding him a medium carb food that sets him off. I have one that's rabbit and peas but it's not really gravy in case of a hypo. I also see people staying up all night testing and I can't do that. I'm not functional if I don't get enough sleep. Like a danger to myself and others. Enough sleep for me is a minimum 8 hours, which usually takes 10 hours in bed. So, I'm already struggling with a +2 and getting up to feed him.

I think they all want him off the pred because pred causes diabetes. But I agree with you, if he needs it he needs it. And he seems to need it. Could we be on less, maybe. But I don't know we get all the way off.

It's just a lot.

 

[Wendy&Neko]

Yes, this is a lot, but I see some issues that are complicating things.

which was followed by an IBD dx via ultrasound and a food switch to novel protein (duck, lamb, and rabbit)

because of the potential of IBD.

Either he has IBD, or he doesn't. IBD can be managed, but doesn't go away. You can also have IBD flares, and pred is a tool to help with that. In fact, you do not have a diagnosis for IBD either. It cannot be diagnosed via ultrasound. You need to have another testing method (endoscopy, surgical biopsy, FNA + PARR test) to differentiate between IBD and SCL (small cell lymphoma). As I know too well, a kitty can also have both. If he's responding well to the novel protein diet, that's a good sign there is IBD present. Is he also on a probiotic? Visbiome is a good one made especially for IBD. Some people give Proviable, but the concentration is less so you have to give more of it. Some psyllium husk fiber is also good to add to his diet.

I think they all want him off the pred because pred causes diabetes.

Not always. Have had two cats on pred for GI issues, neither developed diabetes. Neko actually had budesonide for a couple of reasons. We could not diagnose her properly due to her heart condition which meant she could not have the endoscopy or biopsy. The heart condition also meant she could not have prednisolone. So we tried budesonide. it's a steroid locally acting in the gut, and for some cats it does not impact the BG, which it did not for Neko. It also reduced her bowel inflammation. We've had some cats switch from pred to budesonide and go off of insulin, or at least go to a reduced insulin dose. By the way, you can get pred compounded into a chew treat, which makes it much easier to give. And a much more reliably even dose than what you get from a transdermal.

No one seems to want to test him for acromegaly, even though he has uncontrolled diabetes, is male and neutered, and has big paws. He’s always had big paws, but I dunno if they’ve gotten bigger. I also can’t tell if his face has changed at all other than he was skinner when I got him and he was just neutered. I would love to see him comfortably in the blues and darker greens at least.

Neko did have acromegaly, but I had to beg and plead with the vet and ask her to humour me to get the tests. She was more surprised than me on the test results. By the way, Neko was female, did not have big paws, no change in her face except at the very end, over 5 years into the disease, and the changes were mostly in her mouth, not visible outside. Not to scare you, but I've seen a lot of heart issues sneak up in acros, including Neko. Kitties with heart issues it can be dangerous to give fluids - again Neko as an example, went into heart failure for fluids for her kidneys. Thankfully she recovered the first time.

The amount of testing for TR, especially testing in the evening is too much for me. He's eating raw food. I worry about TR because with his IBD, I worry about feeding him a medium carb food that sets him off. I have one that's rabbit and peas but it's not really gravy in case of a hypo. I also see people staying up all night testing and I can't do that. I'm not functional if I don't get enough sleep. Like a danger to myself and others. Enough sleep for me is a minimum 8 hours, which usually takes 10 hours in bed. So, I'm already struggling with a +2 and getting up to feed him.

Going to an SLGS dosing method doesn't guarantee he won't go low at night, that's when many cats do go low. It has nothing to do with dosing methods. If you can get that +2, at least you'll get a clue if he's diving and can leave higher carb food to help keep him safe. Carbs are not necessarily in the gravy. You can get high carb pate products too, often they'll have potatoes or peas in them making them HC.

 

[Sarah & Charlie-cat]

There hasn't so far been a lot of stomach, no pun intended, for scoping him for a definitive IBD diagnosis. Having to get him off pred and fast him. The IM vet mentioned it, though. I have used Proviable and I just switched to Feline Gut Soothe. I don't always remember it for some reason. O have been meaning to add psyllium husk but not sure how much how often. At least some of the raw commerical food has it listed as an ingredient. Viva, I think. I'd have to check.

I can back down on the fluids. But it does seem to help.

I did mention budesonide to his regular vet the first time she said IBD but she said she hadn't seen good results. But since the IM said it was his duodenum, maybe it would work better since it won't have to travel as far in his intestines. Charlie doesn't do well with oral meds. I can't imagine him eating a chew treat on his own and we stuck with transdermal because there's a limit to how many pills I can get him. Pill masker, gel caps, we've tried everything. Liquids get spat out frequently. There's still Zofran splatter all over his favorite window spot.

How far down a +2 would be a dive? I've really been trying to test more before bed but the other day his +4 went from 515 to 336 so waking up to a 165 was very surprising!

He looked a little crummy this morning and I have to drive my mom an hour each way for cataract surgery follow up. Ug

 

[Bron and Sheba (GA)]

How far down a +2 would be a dive? I've really been trying to test more before bed but the other day his +4 went from 515 to 336 so waking up to a 165 was very surprising!

Usually if the +2 is lower than the preshot BG that is a good indicator that the cycle will be active and the BG will most likely keep dropping.

 

[Sarah & Charlie-cat]

Ok, so like last night he was PMPS of 308 and his +2 was 256. He got his regular food at 2 am, which I got up and gave him. He didn't bother me for food at 4 am and I didn't wake up until it was too late to feed him before his 2 hour fast before his AMPS. Should I have given him a higher carb food or not? He was 298 or 289 this morning, I didn't get it in the spreadsheet yet.

I don't usually get many +2s during the day, but the lost recent curve he only dropped from 298 to 276 and then he was pretty flat the rest of the day.

 

[Chris & China (GA)]

Let me reintroduce myself (Sarah) and my sugar baby, Charlie. We live in Lincoln Nebraska with Cat Dad (my husband, Kevin) and five other cats, all of whom were strays at one point in their lives, four girls and one other boi.

I've got to slow down when I'm reading. The first time I read this sentence, I thought you were talking about children (all of whom were strays at one point in their lives).

I did immediately re-read it slower because I was thinking "she didn't just say that, did she"?....LOL

 

[Sarah & Charlie-cat]

I mean, they are MY children

They're just small furry children. One was found as a kitten in a grocery store parking lot. One was from a community colony on a college campus. Two came from the humane society, one from a local feline rescue, and one was a stray who kinda came with our house.