DKA coming home

[Jennicat2012]

Hello, my cat was hospitalized on the 16th after an ultrasound showed fluid in his stomach and inflamed intestines. The next day the vet said he was being treated for DKA. He was eating fine before he was hospitalized and had no other symptoms of DKA. I took him because his belly looked swollen and his stool was dark grey, almost black. They said he wasn’t eating and was being tube fed. I brought him ff a couple days ago. They said he is eating own now, but not much. They think it’s because he is so stressed being there and are going to release him tomorrow at 5pm. I would like to prepare for his aftercare. *He is very scared of people. Past pet sitters have to send picture updates from him hiding under the bed because he won’t come out. He is very food motivated and even that doesn’t help.

They did another ultrasound today and said he isn’t showing signs of inflammation of intestines anymore. I can explain more of what’s going on and his blood work if needed. The clinic that did his blood work on the 14th said there is inflammation, however, the clinic he is hospitalized with doesn’t agree. They also ran a test and said he has elevated levels that suggest acromegaly, but need to do a CT scan to confirm. I know they want to raise his dose after he is released. I am very nervous about this especially because they suspect it’s acromegaly causing insulin resistance. I don’t feel comfortable raising his dose just yet. He never got to finish his curve at 2u and if his intestines were inflamed and he had fluid that could have been the cause of his high numbers, right?

 

[FrostD]

Hello, sorry about the DKA.

Please do post whatever labs you have. You do not need a CT to officially diagnose acromegaly, what lab did they run for that? The IGF-1 test is what you'd need, that's usually pretty conclusive.

You do need to increase his dose. The longer you hold doses while he's in high numbers, the more glucose toxicity sets in. You have plenty of room to increase the dose

The recipe for DKA is not enough insulin + inappetence + systemic stresses/infection. So you do need to get him to better numbers quickly.

In the meantime, buy some urine ketone strips (from any human pharmacy). You'll want to test for ketones daily. You can also buy a blood ketone meter, I use the NovaMax Plus but the strips can be expensive.

You'll also want to keep him as hydrated as possible - adding water to his food, fluids if needed.

I'd ask for the following medications just to have on hand:

• Ondansetron (zofran) - rather, you need a prescription for this, to get at human pharmacy. They say he's not eating well, he may very well he nauseous

• Cerenia - this would be for vomiting, but also has some anti inflammatory properties. Many vets say this is good for nausea, but really ondansetron is better

• Appetite stimulant like Mirataz. You give anti nausea meds well before this, need nausea resolved before trying to get him to eat

• Bag or two of SubQ fluids, have them show you how.

• Perhaps some Hills A/D or Royal Canin Recovery food in case you need to assist feed him
• If pancreatitis is in the mix, pain medication like buprenorphine or gabapentin

I would bring him home and see how he does the first 12 hours or so. If he's still not eating, I'd start some meds.

I think I might be missing a few things, be back soon...

 

[FrostD]

Stolen from @Bron and sheba

• Make sure you are feeding one and a half times as many calories to your kitty as he would normally eat. This is important because food helps keep ketones away. Offer a snack every couple of hours except for the two hours preshot when you are hometesting the BGs.
• Do not skip any insulin doses. If the blood glucose (BG) is too low, stall, dont feed and test again in 20 minutes to see if the BG is rising…and post and ask for help.
• Test daily for ketones using a bottle of Ketostix from Walmart or a pharmacy. Follow the directions on the bottle. You will need to collect a sample of urine from your kitty.
• Give extra fluids…try adding a teaspoon of warm water to all the cats snacks
• If your kitty had an infection make sure the antibiotics are finished.
• Post daily for help and advice

 

[FrostD]

Blasted tags

@Bron and Sheba (GA)

 

[Chris and Checkers]

Hi I don't have enough experience to give you dosing advice but on this site,it is recommende to only increase 0.25 units at time. The important factor in making sure the dose isn't too high is to test his blood glucose enough.

Inflammation as well as stress could cause an increase in BG.

Once he is home it is important to test him for ketones. You can buy ketostix at Walmart and you just hold it under his urine stream for 15 seconds and compare the colour to a legend to see if there are ketones.

There are members here with experience with acromegaly that can help. But I guess you won't know for sure until he gets tested for it. Do they suspect it because of his high numbers or are there other factors? Maybe he just hasn't found the right dose yet.

 

[Bron and Sheba (GA)]

Hi Jennifer and Cairo,
Melissa has given you the information needed to continue to treat Cairo once he comes home from hospital.
I agree that the dose of insulin most likely needs to be increased. But we don’t know what’s happening in the pm cycle at all. The BG could be dropping lower then bouncing back up in the am cycle. Are you able to test during the pm cycle? It’s just as important as the am cycle and gives you the other half of the picture.
Testing daily for ketones will help us know if you are feeding enough and giving enough insulin.
Did Cairo come home on any antibiotics?

Tagging @Wendy&Neko re the possible acromegaly diagnosis.

 

[Jennicat2012]

Hello, sorry about the DKA.

Please do post whatever labs you have. You do not need a CT to officially diagnose acromegaly, what lab did they run for that? The IGF-1 test is what you'd need, that's usually pretty conclusive.

You do need to increase his dose. The longer you hold doses while he's in high numbers, the more glucose toxicity sets in. You have plenty of room to increase the dose

The recipe for DKA is not enough insulin + inappetence + systemic stresses/infection. So you do need to get him to better numbers quickly.

In the meantime, buy some urine ketone strips (from any human pharmacy). You'll want to test for ketones daily. You can also buy a blood ketone meter, I use the NovaMax Plus but the strips can be expensive.

You'll also want to keep him as hydrated as possible - adding water to his food, fluids if needed.

I'd ask for the following medications just to have on hand:

• Ondansetron (zofran) - rather, you need a prescription for this, to get at human pharmacy. They say he's not eating well, he may very well he nauseous

• Cerenia - this would be for vomiting, but also has some anti inflammatory properties. Many vets say this is good for nausea, but really ondansetron is better

• Appetite stimulant like Mirataz. You give anti nausea meds well before this, need nausea resolved before trying to get him to eat

• Bag or two of SubQ fluids, have them show you how.

• Perhaps some Hills A/D or Royal Canin Recovery food in case you need to assist feed him
• If pancreatitis is in the mix, pain medication like buprenorphine or gabapentin

I would bring him home and see how he does the first 12 hours or so. If he's still not eating, I'd start some meds.

I think I might be missing a few things, be back soon...

Hi Jennifer and Cairo,
Melissa has given you the information needed to continue to treat Cairo once he comes home from hospital.
I agree that the dose of insulin most likely needs to be increased. But we don’t know what’s happening in the pm cycle at all. The BG could be dropping lower then bouncing back up in the am cycle. Are you able to test during the pm cycle? It’s just as important as the am cycle and gives you the other half of the picture.
Testing daily for ketones will help us know if you are feeding enough and giving enough insulin.
Did Cairo come home on any antibiotics?

Tagging @Wendy&Neko re the possible acromegaly diagnosis.

Thank you. I have updated my spreadsheet with his labs. They are from and Italian lab, so I did my best to when transcribing them.
From the previous vet where blood work and urinalysis were done on the 15th.

“As you can see urine culture is negative, and there is moderate inflammation. It’s important to schedule the ultrasound to study the condition of pancreas and liver. other investigations like IGF-1 and a LDDS can be done after ultrasound if negative. For now you can add some pro-prebiotics to the diet and start with Semintra syrup for the mild proteinuria.” (I’m extremely upset about this because his urinalysis done by them in September showed urinary proteins at 52.32 and his January test showed 51.79). Nothing was ever said to me in September about mild proteinuria. I was told his results were normal and his urinating outside the litter box was likely environmental since blood work, urinalysis, and ultrasound were all normal.

The clinic where he is hospitalized doesn’t agree. They said there is no more inflammation and are leaning towards acromegaly. I never got answers for the elevated values from his previous visits which is why I’m a little apprehensive about raising his dose.
But of course i will if recommended and with guidance. Thank you!

 

[Bron and Sheba (GA)]

Hi Jennifer, thanks for adding the lab results. I am going to tag @Marje and Gracie to have a look at them.
I see he had negative ketones in 15 Jan but you say he was admitted to hospital and being treated for DKA. Can you ask the vets when he started to get the ketones and when it progressed to DKA? He would have had to have the ketones first and if he was hospitalised I would have thought they would have been able to manage the ketones before it led to DKA.

When he gets home, if you could get some of the tests I mentioned in the pm cycle so we can see what happens at night, that would be a big help.
Make sure you get some ketostix before he comes home so you can test the Urine daily for ketones.
If he’s still not eating well, ask for some cerenia or ondansetron as cats who are nauseated won’t eat.
Do you have plenty of food to offer him for when he comes home? He could be picky with what he eats so get a variety.

Have a look at our two dosing methods. I think the TR would be best with DKA in the picture as long as you are not feeding dry food.
Dosing methods

Let us know when he comes home so we can help you.

 

[Jennicat2012]

Hi Jennifer, thanks for adding the lab results. I am going to tag @Marje and Gracie to have a look at them.
I see he had negative ketones in 15 Jan but you say he was admitted to hospital and being treated for DKA. Can you ask the vets when he started to get the ketones and when it progressed to DKA? He would have had to have the ketones first and if he was hospitalised I would have thought they would have been able to manage the ketones before it led to DKA.

When he gets home, if you could get some of the tests I mentioned in the pm cycle so we can see what happens at night, that would be a big help.
Make sure you get some ketostix before he comes home so you can test the Urine daily for ketones.
If he’s still not eating well, ask for some cerenia or ondansetron as cats who are nauseated won’t eat.
Do you have plenty of food to offer him for when he comes home? He could be picky with what he eats so get a variety.

Have a look at our two dosing methods. I think the TR would be best with DKA in the picture as long as you are not feeding dry food.
Dosing methods

Let us know when he comes home so we can help you.

Thank you! I’m not sure when DKA started, i was surprised when they told me they were treating him. He was eating great before he was admitted. He was originally admitted to place a neogastric tube to drain the fluid and treat the inflamed intestines. When i called to check on him the next day they they informed they were treating for DKA. They have been using strips to test each morning, so i haven’t seen any results showing ketones. I will ask when it started. Another ultrasound was done yesterday and they said there is no inflammation anymore, but no other treatment has been done because they were focusing on the DKA. I want to double check this.

I do have some ketostrips on hand. I can definitely get some pm cycle tests. I have the alphatrak now, but ordered the relion, just waiting for it to get here. I do have food on hand and will pick up more ensure he’s getting enough. Thank you so much!! I really appreciate the help.

 

[Jennicat2012]

Hi I don't have enough experience to give you dosing advice but on this site,it is recommende to only increase 0.25 units at time. The important factor in making sure the dose isn't too high is to test his blood glucose enough.

Inflammation as well as stress could cause an increase in BG.

Once he is home it is important to test him for ketones. You can buy ketostix at Walmart and you just hold it under his urine stream for 15 seconds and compare the colour to a legend to see if there are ketones.

There are members here with experience with acromegaly that can help. But I guess you won't know for sure until he gets tested for it. Do they suspect it because of his high numbers or are there other factors? Maybe he just hasn't found the right dose yet.

Thank you! He was increased .5u to 2u a couple days before he was admitted. That was my concern because we never got to complete the curve at 2u and he had inflamed intestines when admitted.

 

[Bron and Sheba (GA)]

Thank you! I’m not sure when DKA started, i was surprised when they told me they were treating him. He was eating great before he was admitted. He was originally admitted to place a neogastric tube to drain the fluid and treat the inflamed intestines. When i called to check on him the next day they they informed they were treating for DKA. They have been using strips to test each morning, so i haven’t seen any results showing ketones. I will ask when it started. Another ultrasound was done yesterday and they said there is no inflammation anymore, but no other treatment has been done because they were focusing on the DKA. I want to double check this.

I do have some ketostrips on hand. I can definitely get some pm cycle tests. I have the alphatrak now, but ordered the relion, just waiting for it to get here. I do have food on hand and will pick up more ensure he’s getting enough. Thank you so much!! I really appreciate the help.

Thanks for that information. It sounds as if they might be testing daily for ketones in the urine. If they are, can you ask them for the results as it would be good to be able to see them moving forward.
I wonder if they give him antibiotics for the inflamed intestines.. if so you will need to continue them at home.
I would also ask them what insulin they were giving him in the hospital when they were treating the DkA. They often switch to a faster acting insulin.
You will need to make sure you are giving enough insulin and enough food to prevent the ketones from forming again. You don’t want to be skipping any doses of insulin at all. If you are unsure what to do at shot time, you can stall, don’t feed and post and ask for help. Change the subject line to reflect your question to alert us.
If you follow the instructions above @FrostD gave you, you should manage well.

 

[Jennicat2012]

Thanks for that information. It sounds as if they might be testing daily for ketones in the urine. If they are, can you ask them for the results as it would be good to be able to see them moving forward.
I wonder if they give him antibiotics for the inflamed intestines.. if so you will need to continue them at home.
I would also ask them what insulin they were giving him in the hospital when they were treating the DkA. They often switch to a faster acting insulin.
You will need to make sure you are giving enough insulin and enough food to prevent the ketones from forming again. You don’t want to be skipping any doses of insulin at all. If you are unsure what to do at shot time, you can stall, don’t feed and post and ask for help. Change the subject line to reflect your question to alert us.
If you follow the instructions above @FrostD gave you, you should manage well.

Thank you! They said they’ve been testing ketones in his blood. It was at 3.8 yesterday, but 7.1 when they started treating. I will ask which kind when i pick him up. I’m not sure if they are going to send him home with antibiotics. I asked if he had been receiving them when i brought food because that was the original plan, but they said no they’re focusing on treating the DKA. Sorry, they haven’t really told me much. I’ve been trying to get more information, but the language barrier and distance from the hospital has made it difficult. I will try to get as many records of what was done as possible. I’m picking him up in 4 hours

 

[Wendy&Neko]

Can you tell me what the IGF-1 value was? That's the test for acromegaly. As Melissa said, most people don't get a CT scan to confirm, unless they are going ahead with treatment such as surgery or radiation therapy. The CT scan is expensive and means anaesthesia, and I would rush to do that if the cat really had acromegaly. Plus there are a few known cases where the pituitary tumour didn't show up on the CT scan or even the MRI.

I also agree that he probably needs a Lantus dose increase, up by 0.5 units. If all he is showing is higher numbers, our dosing methods are OK with a larger increase. If it does turn out that Cairo has acromegaly, it's possible he does need considerably more insulin. A recent study at the Royal Vet Clinic in the UK found one in 4 cats has acromegaly, with doses ranging from 1 to 35 units. We have seen even higher here, though rarely. The average dose in the RVC study was 7 units. My acro girl got up to 8.75 units.

If they suspect proteinuria, they need to run a urine protein/creatinine ratio test first. Then take his blood pressure. There are a couple different sources for proteinuria, so they need to first confirm it. Usually you do a couple UPCR tests a couple weeks apart to confirm. The blood pressure test is used in the proteinuria diagnostic, to make sure they do the right type of treatment.

 

[Jennicat2012]

Is there a way to upload pictures? We just got home about an hour ago and I’ve been looking through all of his paperwork. I will do my best to transcribe onto my spreadsheet, but there is a lot. Unfortunately I didn’t find out what type of insulin he was given while there. When asking she said they followed the ketoacidosis protocol. They are very short and don’t go in to much detail. The doctor seemed annoyed with all my questions.

He did have an IgF-1 test done. His results are IgF-1 (ng/ml) 1000. min 28 max 165.

He started Caninsulin on November 25th 2021 and was switched to Lantus on December 28th 2021. Is this too early to test for acromegaly? He was also hospitalized for inflammation which could have been keeping his numbers high.

The vet said he likes dry food and only wanted to eat that there. She suggested Royal Canin gastrointestinal moderate calorie. She didn’t approve of the ff that i brought in.They tried to give him the Purina diabetic wet i also brought, but said he wanted dry which isn’t surprising. They took him off the iv insulin earlier today and gave him 3u Lantus at 12pm. He was at 2u when admitted.
The drive was over an hour and i opened a can of ff after we got in the car and he immediately ate the whole thing. He ate another can when we got home. He looks okay right now, but i will continue to keep a close eye on him. I have my ketone strips, plenty of food, and his insulin. What does should start with? We were only at 2u for 4 days when he was hospitalized. I know a raise of .25 to .5 is suggested, but I’m not sure right now. There has been so much happening so quickly.

 

[Wendy&Neko]

His results are IgF-1 (ng/ml) 1000. min 28 max 165.

Sorry, that doesn't make sense. Was the blood work send to the Royal Vet Clinic for analysis? Or to Michigan State University? The ng/ml reporting is done by MSU but that seems a long way to send blood for test. I would have thought they'd send it to MSU. The min/max aren't right for either place.

He started Caninsulin on November 25th 2021 and was switched to Lantus on December 28th 2021. Is this too early to test for acromegaly?

The current research from RVC is that you can get false negatives if you test too early, within 73 days of starting insulin therapy. He hasn't been on insulin long enough.

Is there a way to upload pictures?

Copy and paste into the text box, or if on a laptop you can drag and drop. What we'd be most interested in is his blood sugars when they tested him, and dosing of Lantus (if any) while there. If they didn't give Lantus, that's also good to know. Hard to say what to dose with those blank days in there. Him being DKA means his dose was too low at 2.0 units. I'd tend to stick with 3.0 units for now.

gave him 3u Lantus at 12pm.

Ugh, is 12AM/12PM going to work as a 12 hour schedule for you going forward? You can move it back a 1/2 hour per day. Perhaps as much as an hour if really high. Post here and we can help you with that schedule.

 

[Jennicat2012]

Sorry, that doesn't make sense. Was the blood work send to the Royal Vet Clinic for analysis? Or to Michigan State University? The ng/ml reporting is done by MSU but that seems a long way to send blood for test. I would have thought they'd send it to MSU. The min/max aren't right for either place.

The current research from RVC is that you can get false negatives if you test too early, within 73 days of starting insulin therapy. He hasn't been on insulin long enough.

Copy and paste into the text box, or if on a laptop you can drag and drop. What we'd be most interested in is his blood sugars when they tested him, and dosing of Lantus (if any) while there. If they didn't give Lantus, that's also good to know. Hard to say what to dose with those blank days in there. Him being DKA means his dose was too low at 2.0 units. I'd tend to stick with 3.0 units for now.

Ugh, is 12AM/12PM going to work as a 12 hour schedule for you going forward? You can move it back a 1/2 hour per day. Perhaps as much as an hour if really high. Post here and we can help you with that schedule.

Thank you! I’ll get on my laptop to upload them. I’m sorry, i forgot to to mention, i currently live in Italy. That’s why I’ve been struggling with his blood work and getting all of the information from the vet clinics. There is an American vet by my house who said i can bring my paperwork by tomorrow and he’ll help go over it with me.

He only received Lantus today, he has been on IV continuous insulin. I use the US alphatrak spreadsheet because mine is mg/dL.

 

[Jennicat2012]

A

Thank you! I’ll get on my laptop to upload them. I’m sorry, i forgot to to mention, i currently live in Italy. That’s why I’ve been struggling with his blood work and getting all of the information from the vet clinics. There is an American vet by my house who said i can bring my paperwork by tomorrow and he’ll help go over it with me.

He only received Lantus today, he has been on IV continuous insulin. I use the US alphatrak spreadsheet because mine is mg/dL.

No, that time doesn’t work with my schedule. I was giving insulin at 7:30. We spoke yesterday and the doctor asked what time i dose so we can align with my schedule, but they still gave it at 12

 

[Wendy&Neko]

i currently live in Italy.

I saw that, and that's why I thought they would have send the IGF-1 test blood to RVC. It and MSU are the only two places that test for it. Greater than 1000 is positive if test is done in UK. Might be worth redoing the test in a month as it might have been early. If the test is done in the US (MSU), over 100 is considered positive. Hence the interest in knowing where it was done.

I though midnight/noon might be tough. Since he's recently DKA, I would want to skip and restart in the AM. If you can test at +11 tonight (11:00PM) and he's over 400, you can give insulin then. You can't move it an hour each day, but occasionally with some guidance here we can get you back on schedule.

Do you know what type of insulin they were giving by IV?

 

[Jennicat2012]

Okay, thank you! He just ate about 30 minutes ago and it’s 10:30 now. I don’t know which kind, but I’ll see if the vet looking over my paperwork can call and ask them tomorrow.

 

[Suzanne & Darcy]

Hello, my cat was hospitalized on the 16th after an ultrasound showed fluid in his stomach and inflamed intestines. The next day the vet said he was being treated for DKA. He was eating fine before he was hospitalized and had no other symptoms of DKA. I took him because his belly looked swollen and his stool was dark grey, almost black. They said he wasn’t eating and was being tube fed. I brought him ff a couple days ago. They said he is eating own now, but not much. They think it’s because he is so stressed being there and are going to release him tomorrow at 5pm. I would like to prepare for his aftercare. *He is very scared of people. Past pet sitters have to send picture updates from him hiding under the bed because he won’t come out. He is very food motivated and even that doesn’t help.

They did another ultrasound today and said he isn’t showing signs of inflammation of intestines anymore. I can explain more of what’s going on and his blood work if needed. The clinic that did his blood work on the 14th said there is inflammation, however, the clinic he is hospitalized with doesn’t agree. They also ran a test and said he has elevated levels that suggest acromegaly, but need to do a CT scan to confirm. I know they want to raise his dose after he is released. I am very nervous about this especially because they suspect it’s acromegaly causing insulin resistance. I don’t feel comfortable raising his dose just yet. He never got to finish his curve at 2u and if his intestines were inflamed and he had fluid that could have been the cause of his high numbers, right?

Okay. It would be helpful if you could share bloodwork first of all. Also, to confirm Acromegaly you need an IGF-1 test which is sent off to Michigan State University. That test is conclusive. You do not need to spend money on a CT SCAN at this point.

 

[Suzanne & Darcy]

Now, before bringing your baby home, make sure he is able to eat on his own. When I brought my Darcy home from DKA and hepatic lipidosis, after a week in the hospital, he had a feeding tube placed.
Is your kitty eating on his own?

 

[Suzanne & Darcy]

align with my schedule, but they still gave it at 1

Argh! That’s what they do!