Cat just diagnosed with diabtes got corticosteroid injection by mistake

[MaSha]

Our beloved 9 year old male was diagnosed with diabetes today at a vet clinic. Two days ago I took him to our regular vet's office because he had been scratching and had wounds on his head and had lost weight, drank and peed a lot and smelled funny. Now I want to kick myself for letting him inject him with depomedrol (0.5 ml), but what's done is done. He ignored my complaints and I really trusted him and not my guts In my defense he has been taking care of our pet for years and our friends' pets too. I just can't believe that he blew me off like that and endangered our cat.

Anyway, he started breathing fast and shallow, he was tired, he vomited and had diarrhea. After a whole load of tests at the clinic they said he was diabetic with ketoacidosis and that he'll need to take insulin. He's still there on intravenous fluid support and the vets said that he reacted extremely well to treatment. Much better than they thought he would. Apparently, things are not that bad. Serious, but not life-threatening. I'll see them again tomorrow and get all the details.

I wanted to ask if anybody had experience with this sort of error, when a vet made a mistake and gave a corticosteroid to a diabetic cat? Is there anything that we as owners can do while this shot is still active (about 3 weeks)?

Also, vets at the clinic insist he should have food available at all times and - and this confused me the most - that it should be dry food (yes! DRY FOOD) Royal Canin for diabetic cats. I mean, dry food is the CAUSE of the problem in the first place, I don't care how better or healthier it may be compared to other dry food brands. When I see them tomorrow I'll ask, but, I would really appreciate it if you could tell me what other protocol I should suggest. Which food, should it be available at all times and other questions I can't even think of.

Our cat is really strong and full of life and even at his worst he wanted to things he loves and be with us. I feel as if this is the moment where we could help him fight this disease if we chose the right protocol. I don't want to continue contributing to his illness.
I've bought a glucometer and am reading/watching on how to use it properly to regularly check his sugar levels. I am really worried about choice of food as glucose levels may drop if we opt for wet, low-carb food and that's why I want to check his levels as often as it is necessary (btw, how often should I do that? Three times a day?)

Also, they suggested using a special litter that changes color when there's blood in the urine. They had no experience with it and could not give me any more information. Does it really work and which brands I should look for?

Thank you so much for your help and advice... I am hopeful but worried not to make a mistake....

 

[Julia & Bandit (GA)]

Did he have the steroid injection before or after he starting losing weight and his pee smelled funny? I'm not sure from your time frame if the shot came before or after the diabetes diagnosis. What was he given the shot for, the scratching?

Some diabetics need to be on steroids for other medical conditions, and it does cause elevated blood glucose levels, but with good control you can often mitgate those effects. It sometimes requires freqeunt adjustments to the dose, and often cats on steroids need a little more insulin than those who are not on steroids--this can be determined through home testing.

Diabetic ketoacidosis is a dangerous condition usually caused by a combination of three things--high blood sugar, dehydration, and infection. Did they test for infection at all, or give any antibiotics?

Cats with diabetic ketoacidosis need to be treated aggressively. What insulin/dose is he on? Was he on insulin before the steroid shot? If so, how long? What was he eating at home after he was diagnosed with diabetes? It's great that you're going to test! Home testing allows you to be aggressive in getting his blood glucose down while helping to keep him sasfe from hypoglycemia.

You're right that dry food is not good for diabetic cats. If your vet wants to give a prescription food, Purina DM canned is appropriate for a diabetic. Royal Canin Recovery RS canned should also be ok to feed. Any other prescription foods, canned or dry, are going to be too high in carbs for a diabetic. You can always switch him back to a commerical diet when you get back home. However, I'm a bit concerned about your vet's knowledge of feline diabetes treatment, and without knowing what dose and insulin your vet has him on, I don't know if I'd insist on changing the food just yet? How often are they monitoring his BG?

As for the special litter--do they mean they want you to get the kind that changes color with the amount of glucose in his urine? I haven't heard of one for blood. If so, you don't need to buy that if you're home testing. Does your vet knows that you're ready and willing to home test? How often you test depends on the insulin and protocol he's on, but typically you want to test at least 3 times a day (once before each shot to make sure it's save to give insulin, and once mid-cycle). However, with cats with ketoacidosis, you really need to test a lot more frequently than that in the beginning so you can be (safely) aggressive with their dose.

 

[MaSha]

Thank you so much Julia & Bandit for your quick and detailed reply!
First, I'll give you more details.
He had received the corticosteroid TWO days before it was discovered that he had diabetes (his blood glucose level was 3.42 g/L ; urine 1000 mg/dL and fructosamine level: 573 μmol/L ). So he got the cortico. shot on Wednesday and yesterday (Friday) was admitted to a clinic where they did all the analysis and put him on treatment. I will post bellow the initial results that were above/bellow the limit. At the clinic, they told me how worried they were about the cortico. shot and that it added gasoline to fire. Because of this we need to monitor him closely.
Also, when they checked the blood glucose after a couple of hours of starting the initial treatment it fell to 2.6 g/l which is still high but they took it as a sign that he was reacting well.

Our cat is supposed to receive insulin twice a day, each 12 hours. It's 1.5 Units of mixed "fast" and "long" insulin (I'm trying to translate from French). I can't find the name of the insulin brand (I'll find it when we get back home with him tonight), I'll be using a VetPen.

For first five days he will also take twice a day before meal:
1. Phosphaluvet 3ml - to cal down his stomach

2. Emeprid 1,5ml- against vomiting

FOOD: I asked this morning about the food and got the same answer that the prescribed vet dry food (Royal Canin for Diabetics) is as good as wet food. He discussed mostly the commercial aspects and I had to underline how worried I am about the dangerous carbohydrate load of the dry food. Well that didn't help, he said he could sell us wet food but that would seriously put pressure on our budget and that it wouldn't really help. He has seen, apparently, 1 in 3 cats get off insulin using only prescribed dried food (Royal Canin Diabetic).
Also, they said he should have food available at all times (I'll check but I guess that they meant the daily allowance not enormous quantities) after the initial 5 days where he needs to take the two meds before meals.

Because there is a higher risk of hypoglycemia (due to cortico. shot) maybe we need to start with prescription dry food and slowly introduce (after a three week period which is the duration of the cortico. shot) wet food?
They also suggested a trick in case our cat feels hungry (or more accurately if he feels his stomach is not full): cutting organic zucchini into small cubes and boiling it in soup stock for a little than giving it to him.

Btw, now when he lost weight he has 5.9 kg (13 lb)

I am absolutely confused

I know that losing weight is priority (which can be done on wet food too!) but I'm also thinking about the "chemistry" and all the stuff in the dry food that cats do not need and that is bad for them.

Glucose testing: So I need to test BEFORE the hsot to see if it is safe to give him one and should I also test after the shoot to see how low his glucose is (if yes how long after the insulin)? I'll test him mid-day too to see how things are and of course keep a detailed journal.

I was thinking of buying a special water bowl that allows measuring quantity of water he drinks (I hope it exists) or I'll make one to keep track of his drinking habits.

I would really like to give him the best possible chance for recovery.

Thank you again for all of your help and advice!

RESULTS:

ProCyte DX (April 8)

LYMPH: 0.86 x 10^9/L

MONO: 0.70 x 10^9/L

NEUT: 5.08 x 10^9/L

BAND CELLS: suspected

Non-segmented granulocytes

BASO: 0/37 x 10^9/L

Catalyst DX (April 8)

ALAT : 134 U/L

GLU: 3.42 g/L

TBIL: 10.9 mg/L

Analyser UA

PROT: 30 mg/dL

GLU: 1000 mg/dL

CET: 50 mg/dL

BLD (barely detectable): 10 Ery/μl

S.G. > 1040

Catalyst UA

FRU: 573 μmol/L

 

[Capoo]

Hello MaSha,

I understand from your post that you're French. Me too. Where do you leave? I leave in Paris.
From what you said, I guess that you're using Caninsulin (branded Vetsulin elsewhere).
Be careful with the Vetpen, I had encountered some problems with it, thinking that dose had been given, but in fact, nothing was injected.
I had also begun with this insulin in November 2015 (have a look at my spreadsheet) and my Cat metabolizes it too quickly.
There was a huge drop only 2 hours after the shot, but normally, the drop should occur after 4 hours. So, in my opinion, you need to test prior to inject, and in the first days, you need to test quit often just to see when this drop occur.
Regarding the weight of your cat: I would consider this as the second priority. The first priority is to regulate the BG of your cat. If you try now to restrict his food, you take the risk of having another ketoacedosis crisis, or an hypo, and so I think it is better to feed him ad libitum at the beginning. And concerning the type of food (wet or dry), I'm currently doing a test this week-end. My cat used to eat Orijen dry food, with 18% of carbohydrates, and starting from yesterday evening, I only give him wet food, with less than 10% of carbohydrate. The insulin of my cat is now Lantus, a long acting insulin, but you can have a look at my spreadsheet to see the impact of the food, even if my SS is still under construction ;-).
By the way, no need to buy a special bowl to measure the water intake. Just take a measuring glass, note the amount of water in it, put then the water in his bowl. Then, 24 hours after, measure the water left in the bowl, and you will have the amount of water consumed per day.

A ta disposition si tu as plus de questions.

Sophie

 

[Critter Mom]

Our cat is supposed to receive insulin twice a day, each 12 hours. It's 1.5 Units of mixed "fast" and "long" insulin (I'm trying to translate from French). I can't find the name of the insulin brand (I'll find it when we get back home with him tonight), I'll be using a VetPen.

Caninsulin (also sold under the brand name Vetsulin)?

Vetpen pictures and info from Merck website

Sophie's post above has a lot of valuable information about using Caninsulin and is very similar to the experiences I had when treating my cat with Caninsulin. I managed to get her switched to Lantus and she did much better on it.

As you noted above, when doing a switch to a wet low carb food - especially from a dry, high carb food - it is critically important to test very frequently during the period of the transition: the change can really drop blood glucose levels so testing will allow you to keep your boy safe. You would need to test before each dose and then several times between each dose during the transition period. If you can confirm that your cat is being treated with Caninsulin we can give you more specific recommendations on when to test.

With regard to when to feed, if your cat is on Caninsulin then it is better to give at least half of the food you allow for 12 hours before every injection and then wait 20-30 minutes before giving the Caninsulin injection. This will allow time for the carbs from the food to become available in the body ready for the hard, fast onset typical of the first type of insulin in the dose (the amorphous fraction) to work on. Again, Sophie makes very valuable comments about your cat's DKA. Right now and through his post-DKA recovery it is vital that he gets enough calories every day as well as enough insulin. Food transitions can trigger digestive upsets and the last thing you want right now is for your cat to go off his food. From the medications you listed above (more about that to follow) your cat already has a fragile digestive system so all the more reason to be careful not to make that worse. I also think it might be a good idea to make sure your kitty is well and truly stable and fully recovered from the DKA before making food changes. (Other members here may offer different opinions.) With regard to weight concerns, if your cat is running in higher blood glucose numbers he is more likely to lose weight than gain it because his body won't yet be able to get maximum benefit from the food he's eating. You actually want him to have a good appetite at the moment to aid his recovery from DKA.

From your opening post you mention that your vet wants you to test for blood in the urine. If your cat has a urinary tract problem it is doubly important to keep on top of that because any infection or other systemic stressor (e.g. bladder inflammation/cystitis) leaves your cat more vulnerable to producing ketones again. You can test your cat's urine with human urinalysis reagent strips. I use Bayer Multistix 10SG strips (I get them off ebay but you should be able to pick up similar from a pharmacy). They include, among other things, tests for blood in the urine and, most importantly, ketones (which you will need to test for at least once a day for the time being). You can collect a sample of urine using non-absorbent litter such as Catrine or Katkor (again, I get mine off ebay).

With regard to ketone testing it is also possible to use a meter similar to a glucometer to test your cat's blood for ketones. The strips are pricey but in your situation may well be worth the expense. My cat (not naturally ketone prone) had a serious operation recently. She had a UTI and wasn't drinking or eating much so urine testing would have been a nightmare. I bought a blood beta ketone meter and it made it a breeze to test her for ketones twice a day. Saoirse had all of the risk factors in place for potential DKA - infection, not eating enough, not getting enough insulin at one stage, and also dehydration. With the help of the meter I was able to keep on top of the ketone situation while minimising stress to my cat, and she did not go on to develop DKA. I'm so glad I got the meter; she would not have been strong enough to survive DKA treatment. If it's an affordable option for you, I can't recommend using a ketone meter highly enough (if only to use for intensive monitoring during your cat's recovery period).

More to follow ...


Mogs
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[Critter Mom]

I was thinking of buying a special water bowl that allows measuring quantity of water he drinks (I hope it exists) or I'll make one to keep track of his drinking habits.

Another easy way to monitor water consumption is to fill the water bowl and then weigh it (in grammes) before you put it down for your cat to drink from, then weigh it again before refreshing it. The difference in grammes is the equivalent of how much your cat has drank in between in millilitres (1g water = 1ml) less some evaporation (negligible at fairly normal room temperature but you would need to adjust it a little to account for evaporation loss if the room is hot or drafty).

For first five days he will also take twice a day before meal:
1. Phosphaluvet 3ml - to cal down his stomach

2. Emeprid 1,5ml- against vomiting

I'm not familiar with Phosphaluvet but Emeprid (metoclopramide) is not the greatest treatment option for a cat with nausea - cat's don't have many of the receptors it targets for nausea control. It speeds up gastric emptying which can be advantageous as a very short term acute treatment for a cat with temporary, severe motility problems and constipation therefrom but it may worsen things for a cat with diarrhoea or stomach acid problems. Metoclopramide has some very nasty side effects - it really mucks around with dopamine levels and the nervous system: it can cause movement disorders (tics, tardive dyskinesia) which may not resolve upon cessation of treatment. It can also lower the seizure threshold.

Cerenia is a much better anti-nausea treatment for cats, especially if non-constipation-related vomiting is a problem (only available as an injection in the UK so I'm assuming because of EU rules the same would hold true in France). It can help a lot to provide a cat with fairly fast-acting anti-nausea support but its benefits may wear off fairly quickly.

Generic ondansetron is an excellent anti-nausea medication for cats (it targets the right receptors in the cat) but it can take several doses before its full benefit is manifested. (My cat has chronic pancreatitis and early stage renal insufficiency and ondansetron has saved her life.) Ondansetron is available in tablet form so it's ideal for at-home administration. (NB: Zofran, the branded version of ondansetron is crazily expensive in the UK - GBP 90.00 - 100.00 for 30 tablets! Over here you can get 30 tablets of generic ondansetron for less than GBP 10.00. If you can get it, the Bristol Laboratories generic ondansetron tends to agree better with cats. Ondansetron can be very constipating. Other ondanetron generics (Cipla in particular) have caused constipation problems for Saoirse but she gets on very well with the Bristol Labs version. I order it from Pharmplexdirect. (They offer worldwide shipping. If you do want to order from them be sure to ask your vet to specify 'Bristol Labs Generic Ondansetron' on the written prescription. If you need to call Pharmplex I've always found the staff to be very helpful, and they ship quickly, too.)

My cat has long-term issues with nausea. I found the information on symptoms and treatments provided at the following links to be extremely helpful in learning how to identify the clinical signs and also the best treatments. I hope they might be helpful to you, too.

Nausea / Inappetence Symptoms and Treatments

IDEXX Pancreatitis Treatment Guidelines (The focus is on pancreatitis but the anti-nausea treatments are beneficial to cats with a range of conditions where nausea and inappetence symptoms need to be addressed.)

If there are times when your cat's appetite wobbles a bit, there are helpful suggestions on tempting him to eat at the following link:

Persuading your cat to eat

Raising food and water bowls can be a great help when a cat is nauseated.

Sorry for carpet bombing you with so much information all at once but I've got long-term health problems which makes my functioning intermittent: if I were to try to split the above into more manageable chunks you might not get it at all. ( ) I hope you can use the above as a handy reference source to digest gradually and dip into as and when you need it.

Bon rétablissement à votre chat! (Sorry for the lousy French: school was a l-o-n-g time ago. )



Mogs
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[MaSha]

Dear Sophie and Mogs,

Thank you soooo much for you kindness! You have helped us to understand better what we are facing and what our priorities are. Not to mention all the valuable advice! I’ll start a chart using Sophie’s as an example and as Mogs has suggested I’ll order the testing stripes for blood in urine and a meter for ketones. Thank you again both so much!

Sophie is right, we do live in France (Puteaux, near Paris) and the insulin prescribed is CANININSULIN.

I had a chat with the vet on duty when we went to pick up our boy about testing BG before giving insulin and she gave us the following instructions:

- BG above 2: 1.5 U

- BG between 1.5 and 2 : 1U

- BG between 1 and 1.5 : no insulin

I forgot to as what if it falls below 1. Is it hypoglycemia? Should we put honey on his gums?

I also do not know which the good ranges are for BG after the insulin has been administered. For example, when I tested before the evening meal the BG was 3,1. I gave him the shot (1.5 U) at the clinic but he jumped! Not even the nurse could be sure that he really got the right dosage. Now, 2 and half hours after, the BG is 3.3. I have no idea what it should be, but it’s weird that it’s higher than before the shot. Or am I just uninformed?

As you have suggested, we decided to minimize the stress and continue with dry food for the time being and bought from the clinic the Royal Canin – Diabetic crackers that he has been eating for the past two days. Btw, a couple of months ago we tried switching to the Orijen low-carb food that Sophie mentioned and I wish we had been more stubborn. He wasn’t eating well and we gave in.

He has some sort of urinary infection. We will redo a urine test (bacteriogram + antibiogram if necessary in 10 days) to see if the antibiotic has cleared it. We’ll also use the stripes to look for blood and ketones.

Even before reading your posts I had a doubt regarding Phosphaluvet and Emeprid. Since he hasn’t vomited since Friday morning (and he vomited only once), I am not too keen on giving him these meds. Anyhow, the vet said that she would be surprised if we managed to give him the meds successfully – apparently they had difficult time handling him, which is strange because outside the clinic he’s a big baby J They didn’t give him these meds while he was in there as far as I could see – we went for the insulin injection at meal time three times. However, after having read the links that Mogs’ have posted I am worried that our boy could be nauseous without vomiting.

I loved your ideas for measuring the water intake! So simple and efficient J I have measured the water I gave him when we came home and in less than 2 hours he drank 150 ml. He’s interested in the environment but a bit tired (he doesn’t act the way he usually does). However, he grooms normally and goes to toilette (we haven’t found the special litter, but we’ll go for non-absorbent litter and use the stripes) and reacts when I go into the kitchen.

I am sorry if my writing is disorganized. If I could summarize, I would ask you (and so sorry if I’m bothering you) the following questions:

BG levels:

1. What is the BG level that signals immediate vet’s attention, both too low and too high?

2. What should be the normal/expected BG level after insulin shot and how long after it should I measure it?

FOOD:

1. How do I know that he has eaten the way he should? He’s not too crazy about the new food and I know that he MUST eat sufficiently when he takes insulin. Even if I divide his 2 meals into two parts each (1/4 of a daily allowance before insulin and ¼ after, as Mogs suggested), how do I know if he had enough? He’s a nibbler (at least with the food he’s not crazy about). He eats a little then does something else, than eats a little more then has a bite. It took him almost 3 hours to finish the prescribed 25 gr of crackers (one meal) and there’s still a little bit food left in his bowl.

And I must say how much I admire your knowledge!

I am sorry to hear Mogs that you have long-term health problems and don’t worry about carpet-bombing me with info, I appreciate it immensely!

Thank you both once more and bonne nuit!

 

[Tuxedo Mom]

- BG above 2: 1.5 U

- BG between 1.5 and 2 : 1U

- BG between 1 and 1.5 : no insulin

Welcome to FDMB!! I was just browsing your post and I see you have had some wonderful advice from some of the members. The glucose levels you mentioned with the dosing suggestions are not in the correct format. I believe France uses the mg/L measurement. If so then the glucose levels your vet suggested should be:

-BG above 200: 1.5 U

- BG between 150 and 200 : 1U

- BG between 100 and 150 : no insulin

It is normally suggested for newer members not to shoot under 200 until they are home-testing and have some data on how the insulin works with their own kitty. Since I don't use Caninsulin I will leave the advice up to more experienced members who are familiar with this insulin type.

 

[Critter Mom]

Our vet gave me 3.9 - 8.3mmol/L (70 - 150 mg/dL) as the normal range for a non-diabetic cat when it is measured on equipment calibrated for veterinary use. (I use an Alphatrak 2 pet glucometer.) If you're using a pet meter, ask your own vet for the correct reference range to use with your meter.

Most FDMB members use human meters to measure their cats' BG levels (the test strips are much cheaper than those for pet meters). Human meters typically read lower than pet-calibrated meters. FDMB uses 2.8 - 6.7mmol/L / 50 - 120mg/dL as the normal reference range for cats when measured on a human meter.

Depending on which type of meter you use you should choose the appropriate reference range in order to understand your cat's BG data properly. If you're using a human meter you need to intervene to raise BG if the level goes below 50mg/dL (on Caninsulin with little or no data I would be concerned if levels went below 80mg/dL). If you're using a pet meter then you need to intervene if numbers go below 70mg/dL (but again with little or no data I would be concerned about any number below 100mg/dL).

If you're using a human meter that measures in mmol/L and you see American human meter reference numbers you can calculate the equivalent value in mmol/L by dividing the mg/dL value by 18, e.g. 50mg/dL / 18 = 2.8mmol/L.

Here are links to two vitally important forum stickies with information on what to do if BG levels are low:

How to treat hypos - print this out!

Hypo toolkit

Also, here is a link to the FDMB spreadsheet template and instructions on how to set one up for your kitty so that you can record and share his BG test results. If you get stuck just holler and one of the members here will help you with the set-up.

FDMB Spreadsheet Template and Instructions



Mogs
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