GA Cat with constant high values, rhino, now wont eat

Hi guys,

I have been helping my cousin's friend with her diabetic cat and I have to admit that this is the toughest case I have ever dealt with. Look at his spreadsheet :
https://docs.google.com/spreadsheets/d/1VyhSyXYGX59Bv59EUtDG1N8AS7Q8ZiOTqdVm66zhLzM/edit?usp=sharing

The first couple of weeks were the worst, it was just as if he was eating dry kibbles (worst roller coaster effects I have even seen) and then he finally got a little bit more stable but with still very high values. He is eating Canipro which is raw meat with zero carb and his receiving Lantus twice a day.

Since May 27th he stopped eating and sort of started sneezing, and his Bg values didn't get any better! I wanted to be careful and asked for the dosage to be lowered a little bit since he is not eating, but now his values are even worse. He still pees normally but didnt poop yesterday (kind of normal since he didnt eat for over 2 days). His breath smells ok. He looks like he doesnt have any energy now (sleeps all day). He licked a little bit of tuna with water on the 27th but now refuses everything he is presented with (fish, meat, other canned food etc...)

The vet said he has a rhino and put him on antibiotics and antacids. That was yesterday and now the owner started to use a syringe to force a minimum of food and water. Poor cat, he is still pretty young and his last blood test didnt reveal anything wrong except his diabetes.

What would you guys do? Should we increase or lower the insulin dosage? And what about the food and water problem?

 

please push the syringe feeding -- this is starting to sound like what happened when I lost Krispy to hepatic lipidosis (fatty liver)

I do not want you to deal with what we had to ...

at least call the vet and explain the symptoms -- this truly is a 911

 

The cat did go to the vet yesterday and was examined... it seems like the vet did not link the lack of appetite with the high BG values at all (maybe because the cat has had these high values since the beginning?)..
I’ll search for the fatty liver symptoms, but in the meantime can you tell me what the cure is?

 

not so much a cure as a prevention -- cat needs the food, water too but mostly food, the lack of appetite and lack of energy pushed some buttons for me, I am hoping this is NOT what is going on

obviously you don't want to administer insulin if cat isn't eating

by "rhino" did the vet mean rhinotracheitis? has the cat been immunized against that?

can't be of much help, have more questions than answers, hoping someone else comes in with additional information that I don't have myself

 

Oh good golly that's UGLY! Very first, please check ketones every pee if possible, at least once a day if nothing else. If you can get hold of a blood ketone meter, ketones will show there first. Right now that poor baby's body is all messed up. I imagine the 'rhino' is just references a 'cold' but I suspect a Respiratory tract infection or at least inflammation instead. Those antibiotics will help. Right now kitty can't SMELL food therefore isn't eating - syringe feeding is definitely what needs to happen right now to avoid that Hepatic Lipidosis or DKA. Remember, the recipe for DKA is not enough food + not enough insulin + infection/inflammation. Right now you have 2 of those stacked squarely on top of each other. If you withhold insulin, that stacks that third one right on top pretty well sealing the deal. 10ml of food is 1 tablespoon. Right now it would be better to chase possible lows than do without insulin as long as she continues to feed via syringe. Even just a half dose is better than none. This WILL NOT last forever!!! In about 2 1/2 to 3 days, the situation should be much better.

Now for LATER - that Lantus dose is being wiggled around so much that the depot is all screwed up. Just about the time something should start settling in and working, a change was made. Shooting more and more isn't the answer - IMHO, that poor cat is so overdosed it's liver can't save it for much longer. It's on a perpetual bounce but the liver can only convert more glycogen/secrete counterregulatory hormones so long before it just can't any more. As soon as the glycogen expires, kitty drops horribly like a rock straight down the cliff, the liver jumps into action dumping all the sugar it can zooming right back up. That tests just like glucose, you just can't shoot it down with insulin. The likely much better dose was WAAAAY back there around 1.5 - 1.75u's. When she's over this URI, you might want to roll back and HOLD that dose for a good 7 days to let that depot drain/top off and stabilize THEN move forward again. I know this isn't the usual approach mentioned here but sometimes when one thing doesn't work, doing the same thing again expecting different results just doesn't work..

HUGS! Thank you for helping Symba.

 

Has your vet checked for ketones? I am worried about DKA which results from infection + lack of calories.

Does she have any ketone strips available?

 

Nope the vet did not test for ketones. I just asked Emily to buy some ketodiastix strips so she will test that by herself. But I did ask her to smell her cats breath and she says that it smells nothing special.

 

I know this is not the main concern right now, But have you noticed how we tried low dosage at the beginning and he was in the highest numbers? I know he is receiving a lot of insulin but we started small and normally stay with the same dose for 5 days before increasing and things got a tiny little bit better during the last weeks (not much better but a little and atleast more stable). Giving him less insulin will bring back the ugly black numbers again and how is that going to help? I know that this case is a complicated one but I don’t get how less insulin is going to make him feel better if he stays in those black values.

 

But the situation is very different now - yes in the beginning not only were you dealing with having no insulin for a while, he also wasn't getting much nutrition from food. After starting insulin, that part of the equation slowly changed for the better. This changes how his body is able to use glucose, is able to use the secreted digestive enzymes correctly and make each cell work together correctly again.

Giving less insulin does NOT mean ugly black numbers will appear again. Too much insulin closely resembles too little with the exception that the numbers just continue to climb...and climb...and climb...with a heavy dive when the liver can no longer keep up. It's the liver's responsibility to keep that 'living' balance between the food energy/glucose and the amount of insulin needed at what time. When it's the own body's insulin, it isn't secreted at higher and higher doses due to high numbers - it's balanced. There's a whole lot more technicality involved but, at the level we're concerned about here, that's a good way to think of it. Just shooting more and more just keeps that liver panic driving harder and harder.

More hugs for helping!

 

Ok then now I’m scared! All the numbers are black now (always 33.3 which is the highest the glucomètre can record and it remains 33.3 no matter when she tests!!)The next shot is in 2 hours. What dosage should we give and stick to?? I want atleast this to be right for the poor cat!!

 

Hi there,

What a tough situation your friend is in. I hope the kitty pulls thru.

Food and extra water is the No. 1 medicine for cats when fatty liver or DKA threats are real – and that’s the case, unfortunately. If kitty was DKA up to 170 ml extra water / 24 h is recommended – given that he or she already eats wet food with at least 70% moisture . I hope the syringe feeding goes well. Sometimes if you start syringe feed and then offer a bowl with favorite food cats start to eat on their own. I think we syringe fed Ducia 30 ml of food per sitting – to add to 200-250 gr of food / 24 h.

I am not able to offer your dosing advice but I had a thought that I think worth mentioning. You posted that the kitty eats 0% carbs food, correct? Is it the only food?

I wanted to suggest to try feeding slightly higher carbs foods but still in the Low Carbs (<10%) range. @Squeaky and KT (GA) IF this is totally wrong, please, correct me right away.

It turns out that some cats utilize their insulin doses better/ more efficiently if there are some carbs present when the dose kicks in. It seems that my cat is one of those; perhaps your friend’s too? I thought it was easy enough to try at home for a couple of days and see if it helps.

Wishing the very best for the kitty!

 

Understand I'm going to give you my opinion here and it won't be according to any 'protocol' but is from lots of experience with overdosed cats. That depot is horribly huge and unstable. A Lantus depot works by 'melting' small crystals from each shot slowly over 3-ish days much like a hard candy 'melts' over time. Each dose given does this - thinking of that candy again, not only do you have each piece 'melting', those pieces are different sizes all slowly melting. <-- THIS has to get down back down to a decent level along with a dose reduction as it will affect numbers and Mr. Liver too.

If he were mine, I would roll all the way back to 1u and hold that for 7 days. The first 3-4 days the numbers are going to wobble all over the place as that depot depletes all that big stuff AND the liver continues to panic trying to control what's happening but a bit uncertain as to which way to turn. I'd also religiously check for ketones. At day 7, I'd reevaluate how the overall week has gone including how the whole cat is feeling/acting and decide whether to keep it at that level for another 2-3 days or up it by .25units right then. At day 7, you will truly only have probably 2 'true read' days after all that other 'stuff' has settled but that varies by each cat.

Does all this make sense?

 

Since the situation is a complete mess right now, I think trying anything in terms of insulin makes sens!

 

Hi Kim

You are so kind to help your friend with Symba. I hope the vets will give him something to make him feel better and eat. I’m going to focus my comments on the diabetes.

I know the opinion and advice I’m going to give you will cause you some consternation because it is the antithesis of the advice you’ve been given today. I’ve been here a very, very long time; I’ve been mentored by the best and most experienced members; and I helped Lyresa when she was new

When the suggestion is made to drop a dose back this far to 1u and “start over”, we call it a rebound check. While there have been a few circumstances over the years where it was warranted to do a rebound check, the majority of time, it is not. And that’s what I find to be the case here. You can see you’ve dropped the dose to 3u and Symba is in solid black.

While it “looks” like he earned several dose reductions with lime green numbers, closer inspection shows that his SS is not properly coded or formatted. If he’s not eating dry food at all anymore, his reduction would be below 50 mg/dL or 2.7 mmol/L. In that case, the dose was taken down every time with one exception. That one missed dose reduction on 4/8 did not cause him to be overdosed.

This reinforces the fact that a rebound check is unnecessary because you increased doses systematically by 0.25u and held doses longer than we would have suggested in some cases.

I do want to point out that if you give insulin to a cat, feed one meal of zero carb food a cycle, you are going to potentially see some low numbers especially if the kitty is bouncy, which Symba is. I see this every day where CGs don’t slow the bounces down with food and the kitty drops into reduction numbers. They reduce the dose but then have to take it back up because bounce clearing cycles are extremely active ones and the BG can drop rapidly if the right amount of food at the right time is not fed. A rapid drop starts another bounce.

Symba’s insulin needs have changed and increased. My suggestions are:

• Return the dose to 3.75u twice a day.
• Encourage the caregiver to get a +2 test every cycle and if the +2 is less than the preshot, test sooner rather than later and feed carbs to control the drop.
• Find a 6-10% carb food Symba will eat; divide the total portion he gets each cycle into mini meals fed at PS, +1, +2, and +3 to start; this might need to be modified for him but the goal is to front load the cycle with enough food to slow the drop of the BG and flatten the cycle.
• On cycles where the PS is a lot more than the +2, the CG might find she needs to stick with a 10% food and test enough to increase the amount of food at that specific time.
• Reduce the dose by 0.25u any time he drops below 2.7.
• Increase the dose by 0.25u every six cycles if his nadirs are above 11 (assumption here is that he’s not eating any dry food).
• Post in the Lantus, Basaglar, Levemir forum every day, if possible. The most experienced Lantus users post there, not in Main Health.

I would also like the opportunity to fix his SS. It would help if the formatting and the ranges are correct, which they are not. It would give a very different impression of what’s going on. Also, we need to add a US tab to his SS, which I can do, since we use those numbers here. You can continue to enter numbers on his World tab and the US tab will auto convert them. If you are going to post for your cousin’s friend, the SS link should be in your signature block. If you’d like me to fix his SS, please send me a private message but I would ask that you do it immediately as I will be leaving town on Monday for several days. I’d like to fix this for you first.

Please let me know your questions.

 

I'm forever thankful for Marje's guidance when we began this dance. She's one smart lady and wonderful person to boot!!!

There's your 2 approaches and the 2 explanations of what each of us believe is the best path. I know each is very different - it's ultimately your choice. Both of us have the same goal - to get kitty back to 'good'.

HUGS! We'll support whichever way you go...

 

This is not necessarily true and could cause more problems than shooting “some” insulin. Here’s a good discussion on that very topic.

 

Good point. Nice catch!
This makes a big difference when analyzing Symba's spreadsheet!

I'd like to add to Marje's astute assessment/analysis/plan for moving forward...

We must also remain aware of the possibility of glucose toxicity. Once glucose toxicity sets in, usually the only way to break through the high numbers is by increasing the dose until a break through is reached. Now once the break through occurs, kitty may need several fast dose reductions, but that's why we test. The thing is reducing or sitting on a dose won't cause a break through. Instead, it allows kitty to become comfortable in high numbers.

This was written for humans, but we've also found it to hold up for cats...
Case Study: Glucose Toxicity: Type 1 or Type 2?
Clinical Pearls (near the bottom of the web page - emphasis mine):

"Glucose toxicity can be reversed by aggressive treatment of severe hyperglycemia with insulin. The goal is to return blood glucose to near-normal values for several days or weeks to allow restoration of islet-cell insulin production. When this occurs, then diet, exercise, and oral antidiabetic medications may be sufficient to allow the patient to maintain near-normalization of blood glucose for extended periods of time."

Whether glucose toxicity has set in and/or it's simply a matter of Symba's insulin requirements having changed for what could be several different reasons, I agree with Marje on returning to the 3.75u dose followed by her suggestions for food, feeding, testing, dose increases, and posting.

Last, but not least...
As previously mentioned, the recipe for developing DKA is not enough food + not enough insulin + infection/inflammation. Unfortunately, under similar circumstances, we've seen too many kitties lose their lives to complications arising from DKA after reducing the dose for "rebound checks".


Just my 2 cents...

 

thank you, I learn more every day; so glad you all chimed in with better information; I was reacting to the statement that cat had not eaten anything in two days; obviously I didn't understand the context

 

Has the vet prescribed anything for nauseous and an appetite stimulant? These may help the cat want to eat. If you friend is not already doing this, she needs to start syringe feeding. These may be higher in carbs but but Hills A/D and Purina CN foods are both prescription foods that have extra nutrition for sick cats. Dilute the food enough that it can be fed through a syringe. I found that by enlarging the tip of the syringe opening helps to get the food out.

 

You’re welcome. There is a lot of information on this board to help you in your quest. Many of the links are in the New to the Group Sticky but you can find things in the Health (not Main Health) and Think Tank forums as well.

 

Symba past away an hour ago.. we don’t know what happened exactly and Emily is in shock, she can’t really explain what the vet said. All I know is that they kept him for a night and were glad to see that he made it through the night. They did more blood test and an ultrasound of his kidney because they thought he had some kind of kidney infection (no fatty liver though).
Poor Emily, she thought he was going to get better.
Thanks to you all for your help and guidance from both of us.


PS : I want to remove the “911” from this post but I don’t know how.

 

((((( Emily and Kim )))))
I'm so sorry.

Fly free, little Symba... Land softly.

 

-- we were all rooting for another outcome, so we are grieving with you --

-- fly free, Symba

 

I am so very sorry, Emily and Kim. My very deepest condolences for your heartbreak.

Gentle journey, sweet Symba.

 

I'm SO SO sorry it was Symba's time to cross...big looong hugs Emily and Kim. I've had his spreadsheet up all day watching for updates and was getting more and more worried... Soar high on your new angel wings sweet boy...land softly back in all your family's broken hearts.

More hugs,

 

I am so sorry.
Fly free Symba

 

I am so sorry to hear this news.

Fly free Symba and keep watch over everyone who loves you.

 

Sending purrs and prayers at this difficult time.

 

I'm sorry to hear of your loss. Fly free sweet Symba, you were loved.

 

Thank you all for the kind words.