? "HI" Ketone Reading on Blood Ketone Meter

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Jeremy & Kate

Jeremy & Kate

Member Since 2023
Need help on what to do for Dak. He was recently hospitalized at the local ER vet clinic for the past week (5/26 - 6/1) for potential DKA and we were not able to get him regulated on 4 units of vetsulin. He has gotten a large amount of tests done at the ER vet clinic and they confirmed he has IBD and potentially triaditis, on top of his diabetes. He seemed to be doing well the last few days since he was discharged from the ER, until around dinner time tonight. He ate about half his food and peed more than normal (in comparison to the last few days) in one visit to the litter box. We tested his ketones with a blood ketone meter and it read "HI" (KetoSens Bluetooth meter), which means his blood ketones is over the meter threshold of 8. We need help or advice on what to do next. We are actively trying to feed him some hydrolized protein wet food (Hills Science Diet Z/D) that is high in carbs, to see if it may reduce his ketones.
 
If his ketones are Hi on the blood ketone meter, he really needs to be back at the ER where he can get 24/7 care. There's a lot that's going on inside the body in a DKA and it can't be handled at home.

If money is a problem, you might try applying for Care Credit or there's a new financing option called "AllPet"....it works differently from Care Credit, but I've heard they are more likely to approve applications.
 
We called the ER clinic and they recommended that we watch him tonight (and into tomorrow) and give him a round of sub-q fluids. He is currently active and responsive, and will eat his food, if we shred freeze dried lamb liver into it. They recommended this path, based off his medical records when we brought him in the first time his meter read "HI" and all the lab results that came in when he was there recently.

Money is not an issue for us at this time, but we will definitely keep that financing option in mind, if it becomes an issue in the future.
 
Update on Dak: his blood ketone value has dropped down to 5.5 (from some value 8 or higher).

He has gotten 50 ml of sub-q fluids and a got him to eat a decent amount of pate with water mixed in.
 
@Jeremy & Kate
If your kitty has had DKA or has high ketones at the moment the following will be helpful to you (below in point form)

***However if he is at all lethargic or not eating I would take him immediately back to the ER as things can change very quickly where ketones and DKA are involved and he can go down hill very quickly.

Your signature says vetsulin but your SS says you swapped to Lantus 2 days ago. Is that correct?
What is very concerning for me is that when the swap was done the dose was reduced back to 1 unit of Lantus instead of staying close to the dose which was being given in the hospital, which was mostly 4 units but sometimes 2 and once 1 unit.
I think this is your problem and to make it worse, Lantus is a depot insulin and it is going to take up to 5 days to fill the depot and in the meantime he is not getting the full effect of the dose which is only 1 unit at the moment. Five days is too long to wait with that amount of ketones in the picture
To be honest, I would swap back to the vetsulin until you get the ketones back under control. Vetsulin is an in and out insulin and Dak will get the full effect of the dose straight away. I would ring the vet back and ask about swapping back to vetsulin at the next due dose and the higher dose of possibly of 3 or 4 units.
You can do the swap back to Lantus once the ketones are well in the rear vision mirror.

  • you need to give one and a half times as many calories as Dak normally eats. Offer snacks every couple of hours during the day and evening as well as the 2 main meals. Food is like a medicine and helps keep ketones away. If your kitty won’t eat the low carb food, feed him whatever he will eat as eating any food is better than not eating,
  • Don’t skip any doses of insulin as insulin helps keep ketones away. If the BG is not high enough to give the dose…stall, dont feed and test again in 20 minutes and post and ask for help.
  • Test daily for ketones. Put the results of the tests into the remarks column of the SS so we can see. Please report any trace ketones at all.
  • Give antinausea medication if needed such as cerenia or ondansetron.
  • Give appetite stimulant if needed after the antinausea medication
  • Give extra fluids. If kitty will tolerate warm water in the food, put a teaspoon into each snack..
  • Ask the vet about subQ fluids.i see you are giving some subQ fluids.
  • test the BG frequently
  • Post daily with updates and ask for help as often as needed.
 
Yes, we recently switched to Lantus (6/1/2024) and I had not the moment to update our signature until now. While Dak was in the hospital, they were still giving him vetsulin. Once he was discharged, the internal medicine specialist agreed that we should change over to Lantus, and they recommended starting on 1 unit of Lantus especially with his upcoming round of medicine to help control his IBD. We did ask the specialist today about swapping back to vetsulin, to help control his ketones, and she recommended staying the course with the Lantus and try to get his IBD flare-up under control and begin medication to help control it.

Update for today: We tested his ketones this morning and they were in the "HI" range on the meter, so we gave him 50 mL of subQ fluids and were making sure to feed him double his normal calories. He started to trend downwards later in the day, primarily appetite, so we brought him into his primary vet to get some more subQ fluids, cerenia injection and B-12 injection (recommendation of the internal medicine specialist) and were prescribed Hills Science Diet I/D, to help with any gastrointestinal issues that may be causing Dak to not feel well also. We have not changed him over to the I/D pate yet, as we noticed an improvement in his BG tonight. To make sure he got enough calories/food in him, we create little pate balls and put them into his mouth. With the confirmation of Dak's IBD, based on the biopsy results of his endoscope from last week, the internal medicine specialist has prescribed Dak with cyclosporine to help combat/control his IBD.
 
How is Dak in himself? Is he alert or is he lethargic?
How is his appetite? Is he eating well on his own? It is really very important that he eats 1 and a 1/2 times as many calories as he normally eats. Remember it is the insulin and the food that will help combat the ketones.
What food does he normally eat…would he eat that better than what he has been giving? The most important thing as far as food goes is that he eats and eat well. Don’t worry too much about what it is…just that he eats…the food can be sorted out later when things are more stable.
At the moment with the high ketones and the low dose of Lantus, I am very worried for Dak.

I have to say I disagree with your internal medicine vet completely as far as the insulin and the dose is concerned.
I would continue to make sure he gets sub Q fluids daily while the ketones are so high.
I am going to speak to a couple of colleagues about Dak.. I am very concerned about the dose and the level of ketones.
 
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Did you get different syringes when you started the Lantus?

I ask because Vetsulin and Lantus are different “strengths” (concentrations), so require different insulin syringes. Vetsulin is a u-40 insulin and Lantus is u-100. If you don’t use the correct syringe, you might not be giving the dose you think you are (we’ve seen mixups before).
 
A couple questions. First, how was IBD diagnosed? Was a sample from the endoscopy sent to pathology? Did he have an ultrasound that showed thickening in either the duodenum or ileum and not the jejenum? What medication are they talking about using with him?

I also agree with Bron, a reduced dose is dangerous - hence the ketones. One of the factors in DKA is not enough insulin.
 
To answer some of the questions above (I am behind on responses):

Dak has been pretty active, until the last 24 hours. He had started getting a little lethargic or not running after treats if we tossed them. He is still alert and would look if we called his name. He had been on (since he initially got discharged from the hospital) Blue Wilderness Duck pate and he was eating really well. Went he started not eating it that well, we tried some hills prescription dry food z/d (free trial bag from the hospital) to see if he would eat it. He picked at it a little and then lately decided he was not interested in it. We pate ball fed Dak his dinner and late night snack last night; then did the same thing for breakfast this morning (and he got subQ fluids after breakfast this morning).

As for the insulin needles, we got U-100 syringes and have been using them with the new insulin (Lantus). We physically isolated any remaining U-40 syringes away from all of Daks meds and dosing syringes (to make sure we don't grab a U-40 syringe and accidentally use it).
 
I am very concerned the ketones are still high. Can you ring the vet back and tell him and again talk about increasing the dose of insulin?
It is food and insulin which will help bring the ketones down as well as the sub Q fluids which will also help. Leaving him with high ketones and doing nothing is risking him going back in DKA which can be deadly.
 
6/5 Update (sorry for the delayed response, been busy talking with ER staff on their nightly update phone calls): Dak seemed to not be as energetic as last night. Gave him subQ fluids and decided to bring in back to the ER this morning. He is on IV fluids at the ER (and ate a 1/3 can of science diet i/d for them at dinner) and the ER confirmed he is not in DKA (he did not go into DKA the first time we brought him in, just DK). Their protocol will be to keep him in ER tonight and then transfer Dak to internal medicine tomorrow, where they will call us and talk recommend paths to help get his system back stable, before he is discharged from the hospital. This will include how many units of insulin to do, their plan while he is at the hospital, etc.
 
@Wendy&Neko Here are the answers to your questions (I went ahead and numbered them based on the sequence of you asking them):
  1. Dak's IBD was confirmed with a round of various testing and labs (ultrasound, GI panel samples collected and sent to Texas A&M, FNA on a few nodules and enlarged lymph nodes that were seen on his ultrasound, endoscopy)
  2. Yes, they sent out samples from his endoscopy to their pathology lab. The results confirmed he had IBD, centralized in his small intestines (vet compared it to Crohn's disease in humans). In the endoscopy, they visually saw a cobblestone like appearance and blunted villi.
  3. His ultrasound confirmed that there was thickening in the muscular layer of his intestines (I can't recall which portion they mentioned about where this indication was present on his ultrasound). There were also indications from the ultrasound that showed signs of pancreatitis in the past, indications of triaditis and some sludge in his gallbladder.
  4. With the results of all of the testing, the vet recommended starting Dak on cyclosporine (Atopica) and not pursue steroids at this time. We started his Atopica last night (6/4/2024), and the hospital is continuing this medication and the other medications he is currently on.
 
Jeremy & Kate said:
His ultrasound confirmed that there was thickening in the muscular layer of his intestines
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You mean muscularis layer? That region cannot be sampled by endoscopy, regardless of section of the bowels. If there is thickening there, you need a surgical biopsy to sample it.
Jeremy & Kate said:
FNA on a few nodules and enlarged lymph nodes that were seen on his ultrasound,
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Was PARR (clonality) testing done on them?

Sorry for the 20 questions, but you do want to make sure it's just IBD you are dealing with and not SCL (small cell lymphoma) too. Some cats can have both, as I have experience with. Cyclosporine is an option for IBD, but does not work on SCL. If he responds to a food trial, that can be a positive sign it's just IBD.

An alternate medication often given to diabetic cats with either IBD or SCL is budesonide. Which is a steroid, but locally acting on the GI. My Neko didn't have any impact on her blood sugars with the budesonide. If the cyclosporine doesn't work, budesonide is a good option.
 
Based on the biopsies taken, they were able to confirm he does not have SCL. We appreciate all of the questions. In our research about IBD, we did see budesonide mentioned and will keep that in mind, depending how the cyclosporine goes. About the muscularis layer, we are not sure on that one.
 
Jeremy & Kate said:
Their protocol will be to keep him in ER tonight and then transfer Dak to internal medicine tomorrow, where they will call us and talk recommend paths to help get his system back stable, before he is discharged from the hospital. This will include how many units of insulin to do, their plan while he is at the hospital, etc.
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I am glad to hear you have taken Dak back to the ER
Please talk to them about increasing the number of units of lantus to address the ketones
While lantus is a great insulin for cats…it is a depot insulin which means it takes several days for the depot to fill and the full effect of the dose to be felt. While vetsulin is not the best insulin for cats….it is an ‘in and out’ insulin, which means the dose you give is what is used each time which is better for cats with ketones. Another ‘in and out’ insulin is prozinc
Reducing the dose of lantus to 1 unit when he was getting 4 units of vetsulin beforehand means he was getting 1/4 of what he was needing and if you take into account, that Lantau needs days to fill the depot, he was getting less than 1/4 of the dose needed. That is inviting ketones back into the picture.
The way to treat ketones is to give insulin (and increase the dose if the ketones are not responding to the dose) and give lots of food.
Please take this information to the internal specialist…and ask how experienced he is with diabetic cats with ketones. It is never a wait and see scenario. It must be treated as an urgent matter for the cat to survive.
I hope it all goes well for Dak. Please keep us updated as we worry about our kitties.:bighug:
 
6/6 Update: Based on the morning check in call with the ER staff, Dak is acting like a happy cat and eating on his own. He has been transferred over to internal medicine department. We talked with them about their plan and their main goal is to focus on his DK and get his ketones down, and get his diabetes somewhat regulated as a close 2nd in priority (IBD is on the back burner for now). They are going to increase his dosage of insulin and work on finding the right dosage amount for him (finally!). They did go ahead and put a freestyle Libre on him (increase shaved spot count on Dak to 10 spots now ) to help with the insulin dosage increase they are doing and better monitor his values throughout the day.
 
I am very glad to read your update and hear Dak is doing better and also they are increasing the dose and concentrating on getting rid of ketones. I hope you will be able to find a good low carb wet food Dak can eat. It doesn’t need to be prescription food.

Please keep posting with updates :bighug:
A big Pat for Dak
 
Yeah, it was a sigh of relief for their plan. As for low carb food, we have been looking into a few options (with his IBD we may have to go LID novel protein route, low carb for his diabetes), and we currently got a case of Hounds & Gatos duck pate to do a trial with him. We also looked at Koha pate, Instinct LI, and he was eating Blue Wilderness duck pate to see if he liked duck protein and didn't upset his IBD. Ha we have a living word document with all the applicable info for the food options for Dak.
 
We are glad too on his improvement. Latest update of Dak is that the hospital have him clear of DK and are working on finding his happy dose of insulin right now and getting a potential IBD flare up under control. They transitioned him to Hills D/D duck, to how he likes it and starting to give him probiotic with his food (fortiflora). They have decided to stop his cyclosprine regiment, as it seems not necessary right now. We do not have a day yet on when he plans to be discharged. Us and the internal medicine folks want to get IBD and glucose regulated (find ideal starting dose for his Lantus and novel protein for his IBD) before discharging him (so we don't have to go back to the hospital for a fourth time in a month).
 
FortiFlora is not a great probiotic. It has a very limited number of strains compared to other probiotics (e.g., Visbiome, Proviable, ReNew Ultimate). I'd suggest reading this website on Raw Feeding for IBD Cats. You don't need to transition to a raw diet -- although I have an IBD cat and he is on a combination raw diet. I make some of his food and use Stella & Chewy's freeze dried raw. The information on the site on medications and supplements is excellent. The website also has a Facebook group that is very responsive to questions. My cat has problems with poultry. Both of my cats get a raw diet of either pork, venison, or bison (they are in the grocery store where I shop) that I combine with a pre-mix and then freeze in ice cube trays. (A pre-mix is a dry add in that contains all of the supplements to make a raw diet nutritionally complete. I use EZComplete from FoodFurLife.) Gizmo has had only two or three IBD flares since he's been on a raw diet and one of those flares was due to one of the vet techs at the vets office giving him as many chicken flavored treats as he could eat when at an appointment.
 
Update 6/11: When we talked with the vet last, they did tell us no ketones present, but when we picked him up yesterday (he was discharged from the hospital) he had trace ketones in his blood. They ran a CBC on him yesterday (before discharge) and his values looked good and blood ph was in normal range. The vet/internal medicine specialist wants to do a food trial with Hills D/D duck and Royal Canin PD food (currently both are pate, as Dak surprisingly turned his nose up to the dry food, considering he has been a dry food lover before his diabetes). They want to keep his insulin dose at 2 units, twice a day (started the 2 units, twice a day on 6/8/2024). My wife and I agreed that we will stick to the food trial, but plan to adjust his insulin dosage based on the Lantus guidelines. We are thinking of adjusting his dosage tomorrow (6/12), so he gets a full day at home and see if his numbers drop a little before adjusting. Do yall think that is a good path, or should we adjust tonight (he is looking at a 0.5 unit increase, based on numbers the last few days)?

@Larry and Kitties, I will definitely take a look at that group and see if they will let us in. We do have confirmation that he has IBD and not SCL.

We have ordered a better probiotic than Fortiflora and should be getting it in a day, and then start mixing it into Dak's food.
 
The SS is not up to date by the look of things so it’s hard to say what to do. What dose were they giving in the hospital and do you know what the BGs were at all..?
With the blood ketone readings it is common to get readings of 0.1 to 1 and this is ok. It doesn’t mean there are any ketones.
 
The small cell lymphoma group on groups.io is for kitties with confirmed small cell lymphoma, not IBD.

The D/D duck is 17% carbs which is considered high carb food for a diabetic.
 
The SS has been updated, including the information that the hospital gave us (via morning and evening check in calls/texts). His values are most likely high due to him being on a Hills D/D duck pate and Royal Canin select protein PD pate 50/50 blend, with some Hills Z/D and Hills D/D venison dry food on the side as a snack (to increase his caloric intake with a GI tract sensitive food). We are aware of the high percentage carbs of the prescription food Dak is on, and plan to very slowly transition him to a lower carb food at one point (looking at Hounds & Gatos duck and some other companies), but are working with the internal specialist to try to get his IBD under control. Given how sensitive his GI tract is at the moment, the specialist wants us to stick with the prescription food to see if he improves. The specialist wants us to keep the 2.0 units of insulin for the next few weeks while on the high carb prescription food. We do plan to increase his insulin dose by 0.5 units in the morning, to help combat the high BG numbers (this is what we feel is our compromise with the internal specialist orders that were given to us, to keep the high carb food but adjust his insulin dosage per the protocols).
 
Is he on any anti nausea medication, such as ondansetron? Being very hungry but needing coaxing to eat sounds like nausea.

Are you testing him daily at home for ketones? I'd want to do that once or twice a day while he's in such high numbers. Good to hear you plan to increase in the AM. Do try to get to mid cycle tests each time. Even a +2 or +3 before bed is a helpful bit of info at night as it can tell us if he's at least trending down. Many cats go lower at night.
 
He has been prescribed Cerenia on an as needed basis (1/2 of a 16mg tablet a day). Yeah, we are thinking we may need to start back on it. He is also on Mirataz twice a day. We had been testing his blood ketones daily, but got the electrical error message on the meter last night, which means we need to get a replacement meter as the old one will no longer work. Yes, we typically test Dak before every meal (AMPS with breakfast, lunch @ +5 after AMPS, PMPS with dinner, late night snack @ +3 after PMPS). We are working on getting back into that trend, since getting Dak back from the hospital again. Mainly been using his normal Contour Plus glucose meter to verify the Freestyle Libre values (hospital installed the Libre on him during his latest visit), since returning from the hospital. Last night, the Libre did show that his nadir was around 435 (+7). We have not moved all of the Libre data over to the SS yet. We just tested him at +3.5 and he was 447 (from the 525 that he was at PMPS).
 
You should give an appetite stimulant after an anti nausea medication, otherwise you can get food aversion developing. Since he's on a limited diet, you won't want him to start avoiding one of the few foods he can eat. I suggest Cerenia on a daily basis until he's eating well on his own. I'd stop the Mirataz first and see how he does at that point, then back off the Cerenia. Though truth be told, I find ondansetron a better anti nausea drug than Cerenia.
 
Jeremy & Kate said:
He has been prescribed Cerenia on an as needed basis (1/2 of a 16mg tablet a day).
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Ondansetron is a lot less expensive. Less than a minth ago I purchached a 30 count bottle of of 4 mg tables for $9.99 w/GoodRx coupon. Dose is 2 to 4 mg 2-3 or even 4 times a day (vice the cerenia dosing of once daily). I have seen it from on-line pharmacies for $6 for 30 count bottle of 4 mg tablets.
 
@Wendy&Neko, Dak has been on topical Mirataz (twice a day) for a while now. We did have to give him a Cerenia yesterday, as it seemed that he was a little nauseous after throwing two "hairballs" of wheatgrass (so no more wheatgrass for Dak for a while to just munch on). We will keep Ondansetron in mind, once we use up our thing of Cerenia at the house.

Latest update on Dak: (Crossing our fingers and praying everyday) Dak is seeming to have a really good appetite, as he has been eating almost every meal in one sitting and is wanting more food (been feeding him a little over 1.5x the recommend caloric intake for his ideal weight of 13 lbs). More of his personality has returned (audible meows, scratching on the scratching posts, doing laps around the living room when it is meal time), and his Freestyle Libre fell off over the weekend (was nice to have, despite being almost 100 units off from the contour next meter we have been using for him, as it showed us his curve during the night when we are asleep). We have bumped his Lantus shot amount up to 3.0 units, to help compensate for his high numbers due to the high carb wet food he has been on.

We are getting ready to slowly transition (currently looking at making the transition over 8 days) him from Hills D/D Duck pate (~17% carbs) to Hounds & Gatos Duck pate (~2% carbs). We do plan to keep his 3.0 units of Lantus during the transition (instead of increasing it per the TR protocol) due to the drastic change in percentage carbs of the wet foods. We are open to any recommendations you all have about this transition (I plan to make a new thread post in the Lantus group about this transition), and we are already thinking that there may need to be a few nights we will need to get up around the +7 or +8 mark and check his BG value.
 
I would start posting over on the Lantus forum all the time now as you are set up fully. You will get more on you over there.
Just transition slowly and monitor closely.

Have a look at this Link about transitioning from high carb to low carb
 
My cats that have been nauseous were not helped by any appetite stimulant until the nausea was under contr The last one needed ondansetron every 6-8 hours. It has to be often enough and the right dose to work. She was only 7 3/4 pounds and needed 2 mg.
 
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