8/24 Tillman AMPS 195;+4 419! dosing suggestions?

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Allison and Tillman

Member Since 2014
ketone-prone, so having to supplement with R for the spikes. Any thoughts, suggestions?? On the fifth shot of 2.5U of Lantus this AM. I'm having to head back to work tomorrow and will be unable to supplement with the R mid-day, or test as frequent! (Also, is currently on 100cc LRS/day to hopefully prevent ketones.)

08/23/14
AMPS 111 (2.5 Lantus); ate
+3 209
+5 321 (1U R) ;ate; neg for ketones
+7 328 (1U R)
+9 358
PMPS 214 (2.5 Lantus)
+3 176
+5 148; ate
(seems like he cruised through the night pretty well...)

8/24
AMPS 195; (2.5 Lantus); ate
+4 419 (2U R)
+6 355

[any use of R on my SS is via protocol from the specialist, this is not necessarily the dosing others suggest on the board (usually see smaller doses), but this is what works for him. I do not suggest copying this protocol without vet supervision]
 
Here's your last condo. we link them because it can be really helpful for people going back to see what was already advised or explained.

I think i'd hold the 2.5u Lantus dose and be ok with not having R tomorrow. When you increase a dose, it can take several cycles to see what it can really do. The Lantus depot has to adjust relative to the new dose. You've got 4 shots at the 2.5u and you're seeing blue nadirs in every cycle at the moment.

IT looks like Tillman is trying to bounce today - you cut it off with the R so he may come down.

It'd be helpful to put test results for ketones in the spreadsheet. Good news that he's negative!

Increasing the dose:
Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
if your cat is new to numbers under 200, it is recommended to hold the dose for at least 8-10 cycles before increasing.
when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing.

After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.

After 3 days (6 consecutive cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.
Click to expand...

Looking at Tillman in these last few cycles since you went to 2.5u, he's having nadirs under 200, so I'd give him a minimum of 6 shots at this dose before changing it, unless he goes below 50.

Are you familiar with watching out for coinciding nadirs when you're using R?
 
Hi Allison

Welcome to LL for you and Tillman.

Julie and I have been discussing his SS and dosing. I'm a long-time R user as well but I haven't had to deal with DKA (anti jinx and touch wood). I know you said he had a UTI and chronic pancreatitis. Obviously, the UTI would potentially cause ketones and DKA if not addressed. I just wonder if there can be some other infection occurring somewhere or the UTI did not get resolved? Did the vet do another cystocentesis after a couple weeks off the a/b to be sure the bacteria isn't coming back?

I'm concerned that the use of R is muddying the waters quite a bit. We can't really tell if the nadirs on lantus are because of the lantus dose or because of the R. As Julie said in the 8/22 condo, the best scenario is to get to a good lantus dose and supplement with R. When kitties are in the hospital with DKA, quite often the vets will just use R to get the numbers down and when the DKA is under control, start the basal insulin (lantus) back up. You are giving pretty hefty doses of R within short timeframes and it isn't really moving the BG much in some cycles. That makes me think he's really bouncing hard and the R is just keeping it from getting out of control or the lantus dose just isn't enough. Or potentially both.

I think as Julie also mentioned, the picture is muddy because of inconsistent lantus dosing and, as she said, the more you can consistently shoot the lantus, the more stable the depot will become. You are definitely doing a better job at that and also at testing. Well done, you!

I do think it would be worthwhile to hold the 2.5u lantus dose and try not to shoot the R for just a bit if so we can see what he's doing. I'd really stay on top of the ketone testing and the fluids, though. I'd probably even ketone test twice a day. I'd be sure he's getting extra calories as well at least until the ketones are negative and stay there.
 
Thank you both for the responses!
Well, going back to his hospitalization. I originally had brought him in because he was showing a spike in BG's and we did a cyto...because the initial thought was he had a UTI. However, the culture and spec were clear, but trace ketones. Then he started the vomitting, lethargy, etc the weekend following the Friday cyto...and went into DKA. The vet's theory is pancreatitis caused the elevated BG levels, resulting in the DKA attack. While hospitalized he did show blood in the urine, and later elevated WBC (bacterial cystitis was suspected). He was treated with antibiotics and the bloodwork was rechecked several weeks until normal WBC was restored. We continued the fluid therapy weeks following the DKA, and the Lantus was begun. However, the veterinarian wanted me to stop the fluid therapy and see how he did. I'm thinking that was a bad call especially while we are still fighting to get regulated. So, after his ketone episode 8/12, and a lot of reading that fluid therapy is helpful with chronic pancreatitis I shared with her, she has agreed we should keep him on 100cc LRS/day at least until we are getting better control. But--after 8/19 when he tested positive again for ketones, of course I'm fearful of him remaining too high. Thanks for the great advice! I will continue the 2.5U of Lantus the next couple of days, while being sure to continue the fluids and up his caloric intake. I won't be able to continue the R this week anyway, so hopefully he wont spike to much and can get a better idea of this dose. Thank you again!!


(Thanks for linking the condo. I'm still learning the lingo, and posting tricks on the board.)
 
i do want you to be aware of the issue with coinciding nadirs when you're using both R and Lantus. When you're just using R it's not as much of an issue, but with Lantus & R in use at the same time, you want to avoid both nadirs coinciding and having Tillman go too low. does that make sense to you?

It may be that he'll need more insulin - i wouldn't be surprised. Yesterday between the Lantus and the R he had 7units total. But it's hard to see exactly what's going on at this point.

Tomorrow when you get off work if it's between +6 and pmps for Tillman, and if he's over 300, you could still use R then. You'd want to make sure he's not coming down from a bounce so you don't send him down too fast. But if it appears to be a normal Lantus cycle where his BGs are rising towards pmps, then it would be appropriate.
 
hi Allison!

Would you send a personal message to Jill and ask for her to help you? She has a lot of experience with ketones as well as with FD in general, and I think would be the best person to assist you right now. You can find her listed in the yellow stickies above as "Jill & Alex" in green bold letters.

Also, until you get past this crisis it's really going to be decisions made cycle by cycle, so it's going to be very helpful if you keep his spreadsheet up to date and post daily. I don't see anything on his ss right now past mid-day yesterday. He's likely going to need his Lantus dose adjusted as the R use is decreased.

julie
 
Thanks! I absolutely understand the coinciding nadir. It could be possible he had a bounce last night? as He was 132 when I went to sleep, and 320 this am. He did eat between these times, but it could be possible he continued dropping last night. I did get to come home now at +9, and he is at 469.So any thoughts on R right now at +9?
 
I would go ahead and give him R according to the scale you've been using. that's pretty high.

Will you also contact Jill? Sandy is another person who might be able to advise you.
 
i just noticed from the ss that you're giving the subq's at the same time as the shot. My understanding is it could have an effect on the strength of the insulin if they are given at the same time and at all close to each other. Probably if you shoot the insulin in the flank (for example) and subq's in the scruff you'd be ok. But if you're giving both near the same area (scruff?) then you might try separating the time.

Punkin got insulin with amps/pmps and subq's at pm+3 with a second dinner. You can combine the two 50s into one 100 dose of fluids.

Also, if your vet thinks this is caused by pancreatitis, are you giving Tillman anything for pain? Marje compiled a good post on Pancreatitis that may offer some ideas. Was he tested for pancreatitis?
 
I am actually doing the fluids in the scruff or flank, and shots in the abdomen. Hopefully that hasn't been affecting it. However, my husband will be doing the PM shots for a few days a week,and he will be shooting in the scruff most likely (because he's more comfortable with that). So I don't know if I need to transition to the scruff for every shot? Then I will just have to be sure I do the fluids in the opposite area OR could do try to do them at a different time.

He's not on anything consistently for pain, and the vet doesn't think he needs to be on anything daily. He did get some bup, the last time he had the attack on the 8/12.

Unfortunately, I had a bad experience with the original veterinarian which hospitalized him who did not give him anything for pain nor gave him appropriate treatment for the ketones (no reg insulin), or nausea. Unfortunately, he was not tested with the the fPL test because they did not have access to it. The ultrasound was negative at the original vet, but the specialist thought it likely pancreatitis from the labs, and was going to do another ultrasound because she didn't trust that. Unfortunately, we could not afford the ultrasound at the internist. But--from the continued labs with a new vet, that treated the WBC/antibiotics they thought it was likely pancreatitis which started the DKA episode. After these few other episodes, they think it likely chronic pancreatitis, but have not done the snap test. I am also looking into the cyano B12 injections for the chronic pancreatitis, because I've read they can be helpful.
 
the vitamin B shots can do wonders. I gave them to punkin too. I'd definitely look into that.

You don't have to always do the insulin shots in a particular area - some people rotate them. I just wouldn't shoot the insulin AND the sub-qs at the same place and time.

Marje is very good at interpreting labs, if you want another opinion with them. Many people add a tab to the spreadsheet and put labs on them. If you want to do that, you can copy the columns from punkin's ss and it will save you a little bit of time entering all the different labs. Watch on the reference ranges, however, because they vary from lab to lab.
 
i'm thinking you might be getting ready to shoot. Could you post with his pmps before you shoot if you see this? Sandy & I are wondering if it would be a good idea to increase his Lantus. She's going to post to you.
 
Hi there :cool: My Black Kitty went a couple rounds with DKA - and lived to tell about it ;-)Glad to see Tillman has 6 cycles on 2.5u.
I think the R given on AM cycles may be setting him up for visits to the lowlands on the overnight cycles.

The goal is to get a safe distance between Tillman and ketones and accomplish that in a safe manner.
It's a balancing act - you must guide your kitty safely to shore while ketones are close behind like a riptide looking to pull him back the other way.

Is Tillman underweight? Is he eating well? What kink of food does he eat? How often are you checking ketones?
It may be a good idea to get a meter that reads blood level ketones as well as BG, ketones appear first in the blood.

If his ketones are negative and his appetite is good and you are able to monitor some tonight you might consider an to increase the Lantus by 0.25u.
Then as long as ketones remain negative and the numbers don't take your breath away, try and string a couple cycles together with no R.
If you have to use some you want to use the smallest amount possible.
 
I wouldn't give fluids in the flank. If you envision a saddle on a cat, you can give fluids anywhere the saddle is. Perhaps you mean you just give them further back along the spine?


I'd be happy to look at his labs. I can also set up a lab tab on your SS for you if you need it.
 
Thanks guys! Sorry to just be getting back to you. Unfortunately, my husband had to shoot at normal time without getting a test in. So he got the 2.5U at normal time. I got a +2 as soon as I got home, he was at 326.
 
Marje and Gracie said:
I wouldn't give fluids in the flank. If you envision a saddle on a cat, you can give fluids anywhere the saddle is. Perhaps you mean you just give them further back along the spine?


I'd be happy to look at his labs. I can also set up a lab tab on your SS for you if you need it.
Click to expand...

Yes, I really meant the hips. Thanks, I can definitely post the labs for your thoughts!
 
in response to allison's PMs...

hi allison. i'm sorry i can't give you the attention you and tillman deserve right now. i'm nursing one of my non-diabetic kitties. honestly, i'm having a hard time focusing at the moment. her time is limited at best. so much so that i've already made an appointment to set her free for tomorrow.

the good news is that julie, marje, and sandy are right on track! your R doses are similar to what is commonly given by a vet while kitty is hooked up to a glucose drip and in the vet's care.

i'll try to offer something in a few days...



i just noticed from the ss that you're giving the subq's at the same time as the shot. My understanding is it could have an effect on the strength of the insulin if they are given at the same time and at all close to each other.
Click to expand...
yes, if they're given in roughly the same place at nearly the same time.
alex will often get squids immediately prior to her insulin shot. squids act as an appetite stimulant with her.
squids go in on one side. insulin on the other side.
 
Jill & Alex said:
in response to allison's PMs...

hi allison. i'm sorry i can't give you the attention you and tillman deserve right now. i'm nursing one of my non-diabetic kitties. honestly, i'm having a hard time focusing at the moment. her time is limited at best. so much so that i've already made an appointment to set her free for tomorrow.

the good news is that julie, marje, and sandy are right on track! your R doses are similar to what is commonly given by a vet while kitty is hooked up to a glucose drip and in the vet's care.

i'll try to offer something in a few days...



i just noticed from the ss that you're giving the subq's at the same time as the shot. My understanding is it could have an effect on the strength of the insulin if they are given at the same time and at all close to each other.
Click to expand...
yes, if they're given in roughly the same place at nearly the same time.
alex will often get squids immediately prior to her insulin shot. squids act as an appetite stimulant with her.
squids go in on one side. insulin on the other side.
Click to expand...




I really appreciate the response, Jill. Prayers for you and your kitty, as you make this tough decision!
 
Sandy and Black Kitty said:
Hi there :cool: My Black Kitty went a couple rounds with DKA - and lived to tell about it ;-)Glad to see Tillman has 6 cycles on 2.5u.
I think the R given on AM cycles may be setting him up for visits to the lowlands on the overnight cycles.

The goal is to get a safe distance between Tillman and ketones and accomplish that in a safe manner.
It's a balancing act - you must guide your kitty safely to shore while ketones are close behind like a riptide looking to pull him back the other way.

Is Tillman underweight? Is he eating well? What kink of food does he eat? How often are you checking ketones?
It may be a good idea to get a meter that reads blood level ketones as well as BG, ketones appear first in the blood.

If his ketones are negative and his appetite is good and you are able to monitor some tonight you might consider an to increase the Lantus by 0.25u.
Then as long as ketones remain negative and the numbers don't take your breath away, try and string a couple cycles together with no R.
If you have to use some you want to use the smallest amount possible.
Click to expand...

Thanks Sandy! It is definitely a balancing act right now! He is not underweight, but did lose 2lbs quickly with the original DKA, and has maintained that weight since. (He needed to lose those 2lbs, but not in muscle and not that quickly!) He has some rear muscle weakness...I'm looking into the b12 for that too. I'm currently trying to check ketones daily with urine. He's eating really well. He is always hungry, though, even with the smaller, more frequent meals. He has always been a beggar, but I'm trying to increase his caloric intake now as well. Hoping that helps...

Thoughts on 2.75U tomorrow AM?
 
Yes I would increase to 2.75u tomorrow unless he comes down. Once we see what he does without the R, we will be able to see if his nadirs are above 300 and he needs larger increases.
 
We've thrown a lot of questions at you in this thread. When you get a chance would you go back through and see if you can answer them, please?

If you google "nova max blood glucose ketone monitoring system free" you'll find a deal for a free meter with purchase of strips for $25. That may help in getting current ketone tests.
 
julie & punkin (ga) said:
While I was posting, you were already answering. Thank you.
Click to expand...

Thanks! Will try the 2.75u in the AM! Put out a frozen puck for tonight. Waiting on the automatic feeder to come in, should be here by Wednesday!
 
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