High Ketone levels?? Lantus dose

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Violet and Garland

Violet and Garland

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Garland is a DKA kitty. Shes in recovery from that and FHL. But her ketones are still high (large on the color scale strip) I asked on the other board and they said to ask you guys over here. I dont think her ketones have gone down at all since being in the ER all last week. When do they start to leave? Im so confused about all this... the vet just told me to keep tube feeding and give her insulin. He said he was more concerned with getting her past the FHL than the DKA right now? Do I change her dose?
 
Violet --

First, please get PM tests. you need at minimum, one test per cycle.

Personally, I disagree with your vet. The HL is important to address but so is the DKA. DKA can kill and it can kill quickly. Your cat should not be throwing large amounts of ketones. That cannot be managed at home. More insulin and food are both important in keeping DKA under control. I always urge people to get their cat to the ER if ketones are above a trace amount.

One suggestion, please test yourself to ketones to make sure the strips are working properly. And please make sure you are following the instructions.
 
Hi Violet,

I agree with Sienne. I'm very surprised you cat was sent home with ketones.

Please follow Siennes suggestion and test yourself to verify strips are good. If it were my cat and ketones were above trace, I would get him to the ER straight away.
 
I took her to the ER when her ketone levels showed a high level. She was there a week. They sent her home?? Told me she wasnt critical anymore and there wasnt anything they were doing that I couldnt do here (ie, her meds and tube feed) So she should still be there? They have been high since the day I took her in. They knew this when sending her home..

I followed the directions on the box, but I will test myself to make sure they are working right

EDIT: they are working when I tested on me
 
I just took a look at the posts on Health. Who suggested a 1.0u dose of Lantus? Was this what the ER suggested?

Also, are you able to test more frequently?
 
1u was what shes been on since her diagnosis in March. I have always thought it was too low. Shes never had a number below 250 (before the dka). When I had my vet discharge meeting, I asked about her insulin, and if I should change it. He said just keep her at her usual dose. When I did her curves in the past, they have always looked closer to a straight line. hovering around the 300 mark
 
From the FDMB FAQ:
A5.5. Diabetic ketoacidosis is a life threatening condition caused by an accrual of too many ketones in the bloodstream altering the pH and blood chemistry. As the condition worsens, dehydration, anorexia and vomiting usually appear. If untreated, seizures and then death occur. Crisis treatment includes restoration of the blood chemistry through hydration and electolyte replacement and returning the main fuel source back from ketones to glucose by using small doses of fast acting insulin and a glucose drip.
Click to expand...
Not something one can accomplish at home.

What did Garlands regular vet have to say about the hospitalization last week?
 
hi violet. we haven't met yet. sienne asked me to stop by. i have not read your other threads, but i agree with the others. it's not something you can treat at home when a kitty is measuring "large" on a ketone strip. garland should be under a vet's care tonight. they can administer IV fluids and aggressively treat with a short-acting insulin such as Humulin R.

this will give you a better idea what you're dealing with and what needs to be done: http://petdiabetes.wikia.com/wiki/Diabetic_ketoacidosis.

garland's dose is too low, but we can talk about that after they bring her ketone level down.
 
I know how dangerous DKA is. I watched my cat hover on the brink of death for a week in the ER. She still not doing well. Add on the FHL and the feeding tube and I know she is very very sick. I took her to the ER and we kept her there for 7 days. They told me to take her home. I took her back on Monday because I was still worried about her. They sent her home again, telling me to keep doing what I am doing. Garland doesnt have a regular vet. We moved out here and never got one. When she lost all that weight, I took her to a vet here (one we had never seen before), they ran her blood, diagnosed her, wrote the prescription and I started home testing. Garland was doing so well after that, I wasnt worried about her. It was like she was never even diabetic until this DKA happened last week

Here is the story

viewtopic.php?f=28&t=49370
 
yes, many of us are all too familiar with a kitty in DKA. we understand.
i will go read the link to your story now, but please call the ER. "large" ketones cannot be treated at home successfully.
 
So Garland needs to go to the ER for fluids until she's not showing ketones? How can she then make sure that it doesn't come back. Did it come back because Lantus was under dosed? Now that she has found Lantus Land she will have handholding to find the right dose and do her own curves. Obviously her vets haven't been hands on so far which is why so many of us found FDMB in the first place.
 
violet, do you have venita's phone number? you might want to call her to see if DCIN is able to help again. i have no idea if more donations came in or not.
just a thought...
 
I called the ER vet she stayed at. Her DR that took care of her all last week wont be in until tomorrow morning. So I told them to have him call me first thing. The tech I spoke with looked up her chart and said her ketone levels havent been checked since the 10th?? But she couldnt tell me the results bc they had been sent out for testing. Shes going to call me back with those numbers
 
violet, talk to any of the doctor's there. any ER vet should know how to treat ketones and they'll know "large" ketones is not treatable at home. they're used to this kind of stuff.
 
Violet, you need to take her now! I didn't realize they were at large. Last time you waited too long, don't do it this time. She needs to be hooked up to regular insulin until the ketones leave and her dose of Lantus needs to go up, you need to be her advocate! you can do this, you can! We didn't steer you wrong last time ....
 
I talked with the vet. He said they checked her ketones on the 10th and they were at a 1 (i guess thats right above trace?) He told me that the reason DKA gets out of control is bc the cats are usually not eating or drinking and vomiting a lot. He said since Garland is getting nutrition from her tube and has a potassium supplement that the ketones should correct. And when I was asking about her dose, he (in not so many words) left that up to me. He said, you could go up to 1.5u 2x a day ,or even 2u 2x a day. Or if I wanted do 1.5u in the morning and 2u at night. etc..

I kept pressing him about the ketones, he said if I wanted we could do a urine sample and get it sent out for testing. He would call an internalist (?) for a more expert 2nd opinion.

Sigh.. im so worried and so confused about all this.

Venita- Ill call you in a few minutes. Im gonna get the kids a snack to occupy them
 
Violet:

Just keeping sweet Garland and you in our prayers.

I don't understand why they have to send a test for ketones to a lab??? I don't know that much about it but perhaps it is more accurate? I'm hoping Jill or Sienne will pop in to help you and this will bump you up.
 
First things first - I would personally take that dose right on up to 2u right now. She needs more insulin. Since she is getting food through the feeding tube, then it is likely a case of not enough insulin right now. Do you still have some fluids around from when Patricia visited? Is it possible to give her 50-100ml today?
 
Just checking in on Garland. Have you been able to get to a vet or administer any sub q fluids?

Please don't wait....It will be much easier to treat the ketones now.
 
violet826 said:
I talked with the vet. He said they checked her ketones on the 10th and they were at a 1 (i guess thats right above trace?) He told me that the reason DKA gets out of control is bc the cats are usually not eating or drinking and vomiting a lot. He said since Garland is getting nutrition from her tube and has a potassium supplement that the ketones should correct. And when I was asking about her dose, he (in not so many words) left that up to me. He said, you could go up to 1.5u 2x a day ,or even 2u 2x a day. Or if I wanted do 1.5u in the morning and 2u at night. etc..

I kept pressing him about the ketones, he said if I wanted we could do a urine sample and get it sent out for testing. He would call an internalist (?) for a more expert 2nd opinion.

Sigh.. im so worried and so confused about all this.

Venita- Ill call you in a few minutes. Im gonna get the kids a snack to occupy them
Click to expand...

ketone levels can change in as much as a few hours. garland's ketone levels on the 10th have nothing to do with where they are today. have you been able to get a ketone test today or better yet... is garland being treated at the ER? i/we are very, very concerned about that reading of "large" ketones last night.

the recipe for DKA is insufficient insulin + infection + inappetance/not getting enough food.

garland should be receiving approximately her normal amount of calories plus about half that amount within a 24 hour period. this could mean tube feeding every 3 - 4 hours 'round the clock until garland begins to eat on her own. how many calories have you been able to get in her a day? those who have been in your shoes have found it helpful to modify their spreadsheet by adding lines to record when kitty was fed and how many calories were fed at each feeding time. the food lists can be used to calculate number of calories.

was an infection found and is garland receiving an antibiotic to rid the infection?

is garland receiving denamarin or denosyl to support her liver?

obviously, the dose has to be increased, but the most important thing now is to have garland treated professionally to bring down that ketone level. once she's released ketone free we can work with you on dose.

increasing the dose, administering subq fluids at home, and making sure garland is receiving enough food may help and is definitely worth trying if hospitalization is absolutely impossible, but it's a poor substitute for remedying the problem. garland's best chance is hospitalization followed by intensive home care until she gets back on her feet.

sending hugs and positive thoughts...
many of us have a good idea how stressful and difficult this can be.
 
I cant take her back to the ER. She was there a week last time. We cant afford more thousands and thousands of dollars. But I have been in contact with Ventia. She is walking me through some aggressive at home treatments. I just checked her BS and it was 404, so Venita said to give her 1.5 u. I am about to feed her, then I am going to get some R insulin to use. Im hoping to be able to get another sample for another ketone test soon. but its hard to know when shes going to use the litter box...
 
just remember that lantus is 12 hr intervals - i'm not sure what schedule you're on, but it will get tricky with lantus nadirs overlapping if you're not sticking pretty closely with 12/12. there are people who use R to pull down the high numbers til the lantus can "grab a hold" of the high BG.

is that what she's helping you with? there are several people who have experience with using the R as a secondary that could be flagged to come and help you if you need it.

:YMHUG: this has gotta be stressful - you're an angel to be doing all you can with garland.
 
I just feel so bad for her. She is so sick. I hope shes not suffering to much. Am I being selfish trying to save her?



She got in the box and peed and of course was finished by the time I got the strip there. But I stuck it in the wet litter (which im sure probably messes up results) and it seemed much lighter. But all those pink colors are hard to decifer

Yea, we gave her the lantus bc thats all I have right now. But Venita wants me to get some R to use to get her numbers down
 
Violet,

Please answer the questions below -

Was an infection found and is garland receiving an antibiotic to rid the infection?
What is Garlands ideal wieght?
How many calories are you managing ito get into Garland in 24 hours?

As Jill said earlier:
garland should be receiving approximately her normal amount of calories plus about half that amount within a 24 hour period. this could mean tube feeding every 3 - 4 hours 'round the clock until garland begins to eat on her own.
Click to expand...

Remember - the recipe for DKA is insufficient insulin + infection + inappetance/not getting enough food. All these must be overcome in short order.
 
She did get an antibiotic while at the ER (they didnt tell me why though, not sure if something was found, or if it was just done automatically)

Normal weight? No idea. She was always overweight for her frame her whole life (maybe 14 pounds?). Then when diagnosed she had lost a lot (down to 7 pounds) and after starting insulin she got back up to around 12 pounds. She lost a little while at the ER bc she wasnt eating, I think she is 10 pounds now

I feed her at 7, 11, 3, 11, 7 They told me to feed her 30CC, 5 x a day and going from 12-7 during the night was fine. She gets about a can (5.8oz) of the recovery a day (Maybe a smidge more)
 
Ummm.. i cant tell on the can?? maybe 183kcal? does that sound right?

She will not eat/drink anything on her own

She only moves to go to the litter box or change positions.
 
Yes, Venita said to bc we needed to give her more (her numbers are sooo high) 404


That was 1 hour 45 minutes ago. I just checked again. its 374 now
 
How many test strips do you have? Do you have karo syrup? Do you know what carb % the food is that you're feeding? How long has it been since you gave the 1.5 units?

Giving an extra dose at +6 is not something that we recommend. Lantus creates very long cycles and a lot of overlap. Yes, Garland's numbers need to come down, but using R would be much, much safer than giving extra doses of Lantus. Lantus can hang out in the system for a long time, so if her numbers start to drop you could find yourself testing and feeding every half hour for 16-24 hours. Please be sure you have lots of supplies. That might not happen, but you need to be prepared. I'm concerned that this might be too much of a dose increase. I'm not trying to worry you unnecessarily, sometimes overdoses turn into a non-event, but you need to be prepared. The last thing you want is to run out of test strips at 3 in the morning.

When can you get the R? And please don't give another shot of Lantus in 6 hours, get the R instead. It is quick in, quick out so if you make a mistake with dosing you don't have to fight against it for so long. That's why they use R at the hospital. Don't misunderstand - R is a very powerful insulin and tiny, tiny amounts can have a huge effect. Don't give more than 0.1u for your first shot until you can see how it works in Garland. At the vet hospital they give larger amounts, but they also usually have the cat hooked up so they can give a glucose drip if needed.

I don't know how many calories are in the Recovery food, but when Lucy was recovering from DKA/HL I was told to feed her every 3 hours. You want to keep a constant supply of food going. Fluids too, very important.

I really, really think Garland needs to be in the hospital, but if you can't do that then you have to keep the food, insulin, and fluids coming (but be careful with the Lantus).
 
With shooting early you really need to check her BG frequently.

Are you feeding her Royal Canin Recovery? That's 172 kcal per can on the list, but if the can says 183 that is probably correct. General rule of thumb is 20 kcal per pound ideal weight. If she is under weight it would be more. So 10 pounds now, times 20 is 200 kcal and you should be giving her half again that amount for the DKA as Jill said, which is 300kcal. You should be trying to get her to eat 1 1/2 to 1 3/4 cans a day.

Hugs for you and prayers and scritches for Garland.

ETA: If it is the Royal Canin, it is 6% carbs.
 
Like Ann said, you need to check Garlands BG frequently since you overlapped doses. You probably are at +2.5 or +3 (from the 2nd shot) about now? Good time to check.

And how wonderful - Ann did all the math on the calories and the carbs!
As Libby suggested, feeding around the clock is best.

Listen to the advice given here Violet - It's from folks who have been where you are. You have probably figured out that the ER vets knowledge is limited. Here you have the many voices of experience.
 
When I am kind of desparate to check pee for ketones, I move the litter box to be right next to me (like next to my computer or wherever I am sitting, even in the middle of the living room). I also use a very small cup to hold under J.D.'s tail when he's peeing. Some people use something like a soup ladle. I am still following all your posts and wishing you the best.
 
violet, please get some varieties of high carb food to have on hand. like libby said, lantus can create long cycles and a lot of overlap. best to be prepared with plenty of test strips, karo, and high carb canned food since garland was dosed again with lantus at +6 today.

here's a few examples of high carb canned food which can probably be picked up at any grocery store:

Fancy Feast Grilled Beef Feast - 18%
Fancy Feast Grilled Chicken Feast - 18%
Fancy Feast Grilled Turkey Feast - 18%

9-Lives Chicken & Cheese Banquet - 23%

Special Kitty (Walmart) Chicken Hearts & Livers - 19%
 
Royal Canin Recovery. 172 calories per 5.8 oz can. Carb 6%.

Folks have been saying that Garland's insulin dosage was too low. Violet gave 1U this morning and based on my suggestion at +6 and a BG level of 404, Violet gave another 1.5U of Lantus. Violet's husband would not be able to get home with the R for several hours after the +6 shot.

Violet has honey. She also has high carb dry food that she can "melt down" with the Recovery and water if high carb is needed. I really doubt that we are going to see a low BG event from the insulin Violet has given Garland thus far today.

I just spoke with ER vet, Dr. Hill. He said that on Monday, he suggested that Violet raise Garland's Lantus dose to 1.5U BID. Today, he said he suggested to Violet that she raise Garland's Lantus dose to at least 2U BID. He also agreed based on the information I gave him that it would not be a bad idea to add some R into the mix as needed. He said that when he saw Garland on Monday, he thought her breathing problem was nasal congestion. He thought Garland's hydration on Monday looked good, based on the water added to her food. He said that he wasn't really sure that SubQs were needed based on the hydration level he saw on Monday. He also said that he suggested that an outside lab perform the urinalysis because there is a chance that the bilirubin from the fatty liver is "staining" the ketone stix and making the ketone level appear higher than it is.

Violet and her family, and DCIN's suporters, are tapped out on the $ it would take to send Garland back to the ER. More ER money is not do-able, unless we find a true sugar Momma or Daddy.

I am willing to take phone calls from Violet whenever needed, and assist her with understanding BG numbers and Lantus and R dosages. Violet is putting her heart into Garland!! Violet has SubQ fluids and the admin line and needles that Pat left with her, but Dr. Hill doesn't think SubQs were needed, based on her hydration level on Monday.

Violet is feeding Garland 5x/day. Violet spends an hour each time she feeds Garland.
 
Violet:

Let's try to summarize what needs to be done. If you need help with trying to get this all fit into a schedule that allows you to spend time with your kids, let us help. Is there a family member or friends that can give you a hand with the kids or with other responsibilities until Garland is past this critical point? The latter is just something to think about so you don't wear yourself out.

  • Feeding times:
    7:00
    11:00
    3:00
    11:00
    7:00
  • Can you increase the amount of food to 1.5 cans per day? This would mean giving 1/3 of a can (1.5 - 2 oz or 45 - 60 cc) at each feeding time. Alternatively, is it possible for you to feed every 3 hours. This would be 8 times per day. If you feed 8 times per day, you would be feeding about 1 oz of food each time. This is pretty much what you're feeding now. (FYI - 30 cc is the equivalent of 1 oz.)
  • What is your preferred shot time? I think it might be easiest if you were to shoot at one of the times where you're feeding -- probably at 7:00 -- but we've also got to figure out what time your next shot needs to be. Most likely 12 hrs from your shot at +6 today. We will probably need to work on getting his shot times back to a point when it's convenient for you. As Libby said, DO NOT give another Lantus shot at what would be your PMPS.
  • What meds (by name) are you giving Garland and how many times a day do you need to give him his meds? We'll want to work this into the schedule, too.
I would strongly advise you to work with Libby around getting Garland on a dose of R ("Regular" insulin). As she noted, R is very, very powerful. You only need a very tiny amount -- far less than the amount of Lantus you're giving Garland.
 
I can support 1.5u because of the ketones. I can't support 1.5u at +6, but let's work on supporting Violet and Garland now.

Violet, here are some "recipes" for an A/D slurry that I was given in my foster training. It is intended to get as many calories into the cat as possible, understanding that it can be hard to syringe enough calories worth of regular food. I'm sure you can use the Recovery food as a base instead of A/D, if that's what you have. You might have to put it into a blender or add more water/Pedialyte to get it to go through the tube. Usually it's better to feed more small meals than a few larger ones. The added benefit of using Nutri-Cal and karo is that the extra carbs will give some room to give more insulin, helping to combat the ketones.

A.
1 can A/D or Max Cal food
1 generous squirt of Nutri-Cal
1 spoon of Karo syrup
Rebound – stir in enough to make this a slurry that will go through a syringe

B.
1 can A/D or Max Cal food
1 generous squirt of Nutri-CaL
½ Jar turkey baby food
Pedialite - stir in enough to make this a slurry that will go through a syringe
 
Ive been feeding at 7, 11, 3, 7, 11

Ive been giving her lantus at 7 and 7

Her meds: at 7am: lantus, 2.34ml potassium gel, 1/4 tablet Famotidine, 1/2 tablet Metoclopramide

at her 3pm feed- 1ml Petinic

at her 7pm feed: lantus, 2.34 ml potassimium gel, 1/2 tablet metoclopramide

I was giving her an appetite stimulant every 3 days, but didnt do her last dose based on recommendations here


I am about to head to walmart to get more strips. What else do I need to get? Is it expensive? We do not have a lot of extra money
 
I don't know if they would have Nutri-Cal at WalMart (if so it would be in the pet section). Maybe some Pedialyte and karo to help add calories and nutrition to her food. You can buy Humulin R there at the pharmacy. I bought mine at a different pharmacy and I paid around $40, but others have gotten it cheaper at WalMart. I think someone recently said it was around $25-30.

You might pick up a couple of jars of all-meat baby food in case she can be tempted to eat a little on her own. Make sure you get one without onions or garlic. What finally got Lucy eating on her own was store-bought reduced sodium chicken broth. I would heat it up and use it to water down her A/D. One day all of a sudden she decided it was good! She also went for rotisserie chicken heated up.
 
I think the last time I checked which was only weeks ago, the R was about $28.00 at WalMart.
 
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