? 8/27 - update and question re: 8/5 Relapse after almost three years in remission

Discussion in 'Lantus / Levemir / Biosimilars' started by Amy and Hershel, Aug 5, 2020.

  1. Amy and Hershel

    Amy and Hershel Member

    Joined:
    Oct 7, 2017
    Hi everyone, I joined this forum in 2017 when Hershel was first diagnosed. It was a scary time and I was so grateful for all the support I received. He has been off insulin for almost three years (he only was on 1u of Lantus for a week before he began to regulate himself), and I now only check his levels intermittently while monitoring any changes in behaviour. He exclusively eats Friskies pate. Yesterday, he vomited up his food in the morning, and then pooped outside the litter box, and possibly peed outside it too, though that may have been my other cat's doing. He threw up some bile around 2pm, and then began acting lethargic. I was about to head out of town for 4 days, and my boys have a way of expressing their displeasure when they sense I'm about to leave, so I wasn't too concerned until I checked his BG at 6:30PM and it was 21.4mmol/L! He hadn't eaten since breakfast and I was shocked. I hadn't seen numbers that high since his diagnosis. I took him to the emergency vet and canceled my trip.

    The EV kept him overnight and put him on an IV. They got his blood sugar down to 11mmol/L by this morning, and they are keeping him for the rest of the day to do a BG curve, urinalysis, and full bloodwork panel. They said I will hopefully be able to pick him up later this evening, but they might want to keep him overnight again. I've asked them to discharge him as soon as possible, because I know he is terrified there, and I would feel more comfortable doing the curves myself at home. I wanted to transfer him to my regular vet this morning, but they didn't have the capacity to monitor him as frequently as the ER would so I agreed to keep him there.

    I'm so scared and am wondering how common a relapse after this much time is, and if it's possible he'll just need another short course of insulin before his diabetes can be managed with diet only again. I feel confident I can manage his diabetes at home with insulin even if it's for the long-term, I guess it's just a matter of waiting for the vet to tell me what dose they are going to start him back on and see how he reacts to it. I also am wondering if if it's reasonable that the EV wants to keep him there for 1.5-2.5 days to monitor him, or if once the urine and blood tests are complete I should feel confident in bringing him home.

    Thank you so much for any insight and support you can provide.

    Herhsel's spreadsheet:
    https://docs.google.com/spreadsheets/d/19AWhU_3mEU_ovp1TAXNo73Y58TASG8AdDueH2UMOVFs/edit?usp=sharing
     
  2. Olive & Paula

    Olive & Paula Well-Known Member

    Joined:
    Sep 6, 2015
    Is the ER checking for infection anywhere? Or bad teeth?. Those are the usual things that knock a cat out of remission.
     
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  3. Amy and Hershel

    Amy and Hershel Member

    Joined:
    Oct 7, 2017
    I believe the urine and blood panels are meant to screen for infection and organ function, but I hadn't considered that it might have something to do with his teeth so thank you for that suggestion - I'll make sure they look into it!
     
  4. Wendy&Neko

    Wendy&Neko Senior Member Moderator

    Joined:
    Feb 28, 2012
    Bad teeth is one of the most common reasons cats get knocked out of remission. I agree with you, he'll probably do better at home.

    By the way, the spreadsheet in your signature works, the one you linked in your first post doesn't have the permissions for us to read it.
     
  5. Sam&Milo(GA)&Singha

    Sam&Milo(GA)&Singha Member

    Joined:
    Jul 2, 2020
    I’m sorry to hear about your kitty. I hope you can get him home soon and manage the diabetes yourself.

    My vet mentioned that my kitty’s teeth aren’t great. He put him on antibiotics but didn’t want to try and tackle them until we get the diabetes under control and he’s in better shape. Can dental issues cause diabetes in the first place?? Can doing the dental work reverse his diabetes? At what point is it safe to consider having the procedure done, I wonder?
     
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  6. Amy and Hershel

    Amy and Hershel Member

    Joined:
    Oct 7, 2017
    I just brought him home from the vet - his bloodwork and urinalysis came back normal - they are still waiting on the results of the urine culture. Last night he'd been showing trace ketones but those are gone today. They gave me these discharge instructions:

    If BG <15 and Hershel does not eat - do not give insulin
    If BG <15 and Hershel does eat - give half dose - 0.25IU
    If BG >15 and Hershel does eat - Give 0.5IU insulin
    If BG >15 and Hershel does not eat - give half dose - 0.25IU

    The last time they administered insulin to him was this morning 7:40AM and they skipped the evening shot because he wouldn't eat. It's now 11:30PM and his BG was at 16.2 when I tested him an hour ago. He isn't touching his wet food and I'm unsure if I should give him a half dose tonight and monitor BG every 2 hours, or wait until the morning, check BG then and reassess insulin at that time. Any help would be appreciated, thank you!
     
  7. Wendy&Neko

    Wendy&Neko Senior Member Moderator

    Joined:
    Feb 28, 2012
    Neko was very unregulated when she had her first dental. Depends on the comfort of the vet. After that she went to a dental specialist who had a lot of comfort with the animals with other conditions. Bad teeth can make it very hard to get regulated. So not treating the teeth is like a catch 22. Can't get regulated without a dental, some vets won't do a dental without cat being regulated.

    Lantus does better with consistent dosing. People here are more familiar with mg/dl, so that 15 = 270 for others. We dose based on nadirs, or how low the dose takes the cat, not the preshot values. If you dose now, your next shot will be 12 hours from now. Because he was showing some ketones yesterday (please keep testing daily for a while), I'd be inclined to shoot. You could give that half dose, if you can monitor. Can you assist feed him if needed?
     
  8. Amy and Hershel

    Amy and Hershel Member

    Joined:
    Oct 7, 2017
    I tried all sorts of things to get him to eat his wet food, sprinkled some parmesan on top, mixed it with warm water, different locations and positions, but he won't go for it, or even his brother's dry food which he is always trying to steal. He is such a sensitive kitty and I naively thought his appetite would come back once the terror of being at the EV was over and he was back home. I didn't end up giving him his shot last night, or this morning as his BG was 14.6mmol/L and he hasn't eaten since yesterday at 7am. I don't have a syringe to try assist feeding so I decided to bring him to his regular vet this morning. They are keeping him for the day and want to redo all of the bloodwork that was done at the EV yesterday, including for pancreatitis, which I'm not sure if the EV did or not but am assuming they did since they said "full bloodwork panel." This is because apparently the EV cannot (will not?) send over the results of the tests for 24-48 hours. I'm so frustrated - I spent $1860 at the EV - can't they just read my vet the results over the phone?! My vet said they will try and obtain the results so that they don't have to redo all of them, I think they felt sorry for me because I was crying on the phone. I really can't afford any of this, but don't have much of a choice at this point. :(
     
  9. Sienne and Gabby (GA)

    Sienne and Gabby (GA) Senior Member Moderator

    Joined:
    Dec 28, 2009
    Amy --

    Please get ketone strips ASAP. If Hershel was showing trace ketones, you do not want this to become a problem. Remember, the recipe for ketones is infection/infammation + not enough calories + not enough insulin. The lack of food and insulin are risk factors. You may also want to speak to the EV or your regular vet about an appetite stimulant to get your kitty eating again once he's home.

    Why won't they sent the results to you? You paid for them and by rights, they are yours. The right of privilege (medical language) is yours. Short of threatening the EV with a lawsuit, you might point out that they are denying you what belongs to you and they are preventing your cat from getting appropriate care, two items that the veterinary licensing board might be interested in knowing about. Likewise, it is certainly possible that your vet would never refer a client to the EV due to this behavior (and you may want to drop the hint that you actively use social media, even if you don't.) Once you have the results, you can send the results to your vet.
     
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  10. Amy and Hershel

    Amy and Hershel Member

    Joined:
    Oct 7, 2017
    Thank you, Sienne. I called them and got them to forward the test results to my vet - they claimed they had already sent them, but my vet had not received them. They have them now. I trust my own vet slightly more than the EV, but it was my own vet that said it would take 1-2 days for the EV to get the results to them, so maybe they just wanted to charge me to do their own tests. It all feels like a racket to me, preying on the anxieties of worried pet owners.

    He has not been seen by the vet yet, and she might not be able to get to him for another two hours unless she can squeeze him in between other appointments. They haven't even tried to feed him because they want him to be examined first. They told me to bring him in right away this morning, but I know he would be more comfortable at home. It's so hard not being able to be there with him, they wouldn't even let me come into the clinic because of Covid.

    I will definitely get ketone strips.
     
  11. Sam&Milo(GA)&Singha

    Sam&Milo(GA)&Singha Member

    Joined:
    Jul 2, 2020
    Oh, Amy... I am so very sorry. What an ordeal. It’s so stressful when they get sick and the vet bills. I’m glad you have the bloodwork results now and I trust the vet has seen kitty by now and has tried feeding him.
    If it’s helpful at all, I spent the same last summer on my kitty when I really didn’t have the money. In the end, I found savings month by month and I have a healthy, happy guy now. I have never looked back on my choice. Your investment is testimony to your care and love. I wish you all the best and please keep posting Hershel’s progress.
     
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  12. Amy and Hershel

    Amy and Hershel Member

    Joined:
    Oct 7, 2017
    Thank you so much for your words of support, Sam - your cats are stunning and it's encouraging to hear your ordeal had a happy ending! And yes, no matter what happens I know I won't regret doing all I could do help him. The vet has now seen Hershel and I am so much more confident in her abilities than the EV's, who it turns out didn't actually do the bloodwork to test for pancreatitis o_O So my vet is doing that today, and is going to try a whole bunch of different foods on him to see if he'll go for any of them. His BG is holding steady at 14mmol/L even without insulin for the last 32 hours. The rest of his blood panel and urine tests were normal so it's still a mystery why he's on this hunger strike. She says if the pancreatitis blood test comes back negative but he is still not eating, there is still a chance he could still have pancreatitis. She would then want to do an abdominal ultrasound to get a better look at his organs and to see if it might be cancer, which as you can imagine scared the @#$! out of me. But one thing at a time, and at least I feel he is in good hands now. I am picking him up in 2 hours and she is sending me home with appetite stimulant and anti-nausea meds.
     
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  13. Red & Rover (GA)

    Red & Rover (GA) Well-Known Member

    Joined:
    May 18, 2016
    If your vet is leaning towards pancreatitis, ask for pain meds and possibly subq fluids as well.
    I've had pancreatitis. Pancreatitis makes childbirth look like a walk in the park.
     
  14. Sam&Milo(GA)&Singha

    Sam&Milo(GA)&Singha Member

    Joined:
    Jul 2, 2020
    I guessthat would explain not wanting to eat due to pain... what is the treatment for pancreatitis?
     
  15. Sam&Milo(GA)&Singha

    Sam&Milo(GA)&Singha Member

    Joined:
    Jul 2, 2020
    I’m glad you feel more confident with your vet. Try to keep your chin and up and take it one day at a time. *Try* not to worry about the “what if’s” right now. I’m new here too but the collective knowledge and wisdom is a godsend. I’m sure lots of people will be able to support you as you get a few more answers.

    I guessthat would explain not wanting to eat due to pain... what is the treatment for pancreatitis?
     
  16. Red & Rover (GA)

    Red & Rover (GA) Well-Known Member

    Joined:
    May 18, 2016
  17. Amy and Hershel

    Amy and Hershel Member

    Joined:
    Oct 7, 2017
    Hershel came home this evening and although he's definitely not back to normal he is way more energetic than he was this morning, AND he went straight to his food bowl and ate some of his usual Friskies pate! Not a ton of it, but I'm so glad he finally got some food in him, and he keeps going back to nibble, taking bigger bites each time - probably 1/4 can in total. His PMPS was 17.5mmol/L so I felt comfortable giving him 0.5IU of Lantus tonight. I have enough anti-nausea meds and appetite stimulants for the next few days. I'm really starting to think that he must have had a terrible experience at emerg and that was what at least partially responsible for his low appetite.
     
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  18. tiffmaxee

    tiffmaxee Well-Known Member

    Joined:
    Nov 15, 2013
    I’m sorry he’s not feeling well. I would call your regular vet and get either cerenia or an RX for ondansetron or both. I know it’s been suggested. Since it appears he wasn’t tested for pancreatitis you might even want to gave your vet do that as well as give a shot of cerenia to help the nausea. Even if not pancreatitis cats here have been very nauseous from ketones. I’m glad the blood tests were normal. Did they give you a copy? If not have them email to you. I’ve been told blood tests are fine and then when I look I see things to keep an eye on. In the meantime try baby food or purée chicken.
     
  19. Amy and Hershel

    Amy and Hershel Member

    Joined:
    Oct 7, 2017
    The vet gave me a 10 day supply of Mirtazipine and a 4 day supply of Cerenia, I have to wait 2 more hours to administer them today. He ate about a 1/4 can of wet food last night and a few bites this morning along with some treats. And I do have a copy of the blood tests, I just have no idea how to read them.
     
  20. tiffmaxee

    tiffmaxee Well-Known Member

    Joined:
    Nov 15, 2013
    Post the labs here. Some of us can read them. You might want to get an RX for ondansetron as for some cats it works better than cerenia. Four days of cerenia will not be enough so get more if you see it works. Nice he starts eating you need to keep him on support meds for several days and gradually withhold one thing at a time so you learn what works and what he still needs. Mirtazapine pills or ear gel? The pills can cause a reaction in some cats. I prefer cyproheptadine but the gel mirtaz works for many without side effects. I gave the pill to Tiffany and she became agitated and very vocal so never used it with Max.
     
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  21. Amy and Hershel

    Amy and Hershel Member

    Joined:
    Oct 7, 2017
    The mirtazipine is the ear gel. Here are the labs:

    The insulin seems to be having no effect. I think 0.5 is too small a dose (he was started at 1u when he was first diagnosed and it worked immediately), but I'm afraid to up it since he's barely eating.
     

    Attached Files:

  22. tiffmaxee

    tiffmaxee Well-Known Member

    Joined:
    Nov 15, 2013
    The labs look really good to me. They were a little hard to read because they came out blue and were hard to enlarge though but what I saw looked good. There was protein his urine that could be a one time thing. If he has pancreatitis it would not show up in the labs. The cerenia is more important than the appetite stimulant. If nausea is controlled you won’t need an appetite stimulant.
     
  23. Amy and Hershel

    Amy and Hershel Member

    Joined:
    Oct 7, 2017
    Thank you that's reassuring to hear. I gave him the Cerenia about 30 mins ago but it doesn't seem to have kicked in yet. Giving him the Mirtazipine now, and here's a clearer copy of the labs. Thank you SO much for having a look at them.
     

    Attached Files:

    Last edited: Aug 7, 2020
  24. tiffmaxee

    tiffmaxee Well-Known Member

    Joined:
    Nov 15, 2013
    Other than protein in the urine and high glucose the only other thing is potassium is a little low. That’s likely due to lots of urinating due to high glucose and should not mean anything. It says urinalysis culture requested but urine not delivered yet other than culture which takes time you have urinalysis results so perhaps it was sen after all but they didn’t see it at first. I wish they had tested for pancreatitis but the treatment for that is just to treat the symptoms so the only benefit would be a firm diagnosis. I wouldn’t go back for that. Treat the symptoms and hopefully he will feel better in the next few days. Pancreatitis can take longer than that to resolve though. You just need him to eat normally. :bighug:

    I’m sure others might chime in if they see anything I missed.
     
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  25. Amy and Hershel

    Amy and Hershel Member

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    Oct 7, 2017
    So it turns out Hershel does have pancreatitis, which probably explains why his BG spiked suddenly after so long in remission. I'm somewhat relieved to finally have a diagnosis, devastated thinking of how much pain he must be in, and so annoyed that the emergency vet didn't catch this. He's going on Bupenorphrine twice daily. Hoping this will bring his appetite back and lifts his spirits.
     
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  26. tiffmaxee

    tiffmaxee Well-Known Member

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    Nov 15, 2013
    I’m glad you know. For Max nausea control was crucial. Ondansetron worked well for him so if Cerenia doesn’t work I’d get some.
     
    Last edited: Aug 27, 2020
  27. Amy and Hershel

    Amy and Hershel Member

    Joined:
    Oct 7, 2017
    Update and question:

    Hershel's mood, energy and appetite returned to normal after three days on the Bupe, Cerenia and Mirtazipine. He has no residual symptoms or unusual behaviours, which is amazing, but his blood sugar still looks slightly too high. I use SLGS and an AlphaTrak 2 and I know the protocols here are based on human meters, so I've been conservative with the insulin and sometimes don't know if I should give him his dose based on the pre-shot numbers and nadirs. If you could look at his spreadsheet and offer any advice, it would be greatly appreciated. Should I be trying to get him into the greens? Do some cats BG levels just run slightly higher? And again, I want to thank you all for helping us so much.
     

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