High ketones when reducing Lantus, but better bs

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AnnieTime

AnnieTime

Member Since 2013
Hi there,

I asked for your help a several times before when I had my diabetic tom cat Horst.
Meanwhile my beloving Horst has gone to the rainbow 1,5 years ago :(
Last year my tom cat Salem became the diagnosis diabetes and since then he´s suffering from ketones from time to time.

Right after diagnosis 3 teeth with FORL were removed. Teeth are all good now, control after 6 month. He has no cystitis (bacterial control every 2 months). He apparently has no exocrine pancreas insufficiency, pancreas enzymes have no influence to the ketones.

I usually give 0,5 -0,7 IE Lantus, bs is between 260 and 180 mg/dl (14,4 and 10 mmol/l). That´s ok for him , seems he doesn´t tolerate lower bs, bs raises "instantly" up to 400 mg/dl (22,2 mmol/l) if bs goes lower than about 160 mg/dl (8,9 mmol/l).
This dose works for about 2, max. 3 weeks, after that ketones raise up to 2,5 mmol (highest level I measured before I increased dose).
Problem: With increasing dose, bs becomes worse up to somogyi, bs raises up to 400-450 mg/dl (22,2 -25 mmol/l). But ketones are going low (under 0,7 mmol) even if bs gets worse.
There´s no use in feeding more oder feeding food with more carbohydrates, even grain or sugar can´t always stop the bs from falling down too fast, sometimes he even gets a hypo with a dose of not more than 1,3 IE.
And at this point, the first hypo after increasing dose, I am able to reduce dose for about 2-3 weeks, and then...it´s always the same..ketones raise, increasing dose, hypo, reducing dose and so on.
Seems Salem needs more insuline to stop the ketones, but less to have better bs.

I´ve asked vets and human doctors, even the best vet according to feline diabetes in germany, nobody knows why Salem is getting ketones again and again. If there is any infection then nobody can find it.
I don´t know what to do anymore. I don´t want him to overdose again and again just to get rid of ketones, but I apparently have no choice.

Does anyone of you have an explanation for the ketones?

Thank you and sorry for any mistakes in my text. Google translator really isnt´very helpful :D

Greets, Annie
 
Ketones form as a by-product of fat breakdown for calories.
Is he losing weight? That could increase ketone production. If he needs to lose weight, that should be done slowly so too much fat doesn't overwhelm the liver and cause hepatic lipidosis.
Is his diet higher in fat? Maybe try adding 1 ounce plain lean meat or poultry to 5 ounces of regular food, mix well and portion out. That may help a bit.
 
The increase in blood glucose that you see after he goes lower than his usual numbers is called bouncing, not Somogyi. It happens when the numbers drop quickly, too. Compensatory hormones release stored glucose (glycogen) and the blood levels shoot up for up to 3 days. You just have to wait it out.
If the glucose drops lower than 50 mg/dl following the Lantus Tight Regulation protocol or 90 mg/dL on the Start Low, Go Slow protocol, the dose gets reduced by 0.25 units.
 
Guten Tag Annie and Salem!

I'm so sorry for the loss of your beloved Horst. :bighug: But happy that you came back here for help with treating Salem!

I think Salem is not getting enough insulin. The rises you're seeing after he goes under 160 are more likely to be bouncing than Somogyi. Bounces happen because his body isn't used to being in lower numbers any more and it takes time for a cat to stop bouncing and "remember" that normal numbers are safe for him to be in. When a bounce happens, what you really need to do is keep his dose the same and wait for his numbers to come back down instead of reducing the dose and letting him settle back into numbers that are above the normal range for a cat. The reason he gets less ketones, even while he is bouncing is because the higher insulin dose is what he needs. If he is only getting to 160 on the higher dose then it definitely is not an overdose and he is not having hypo events - 160 is still above the normal range that he needs to be in.

Your post makes good sense in English - it was easy to read.
 
Thank you both, BJM and manxcat, for your answers.

Yeah, Horst got a pneumonia after a medical operation, due to this a ketoacidosis, and not to mention when the vets xrayed his lungs, they found a big tumor in his lungs which was also full of metastases. I decided to let him go to the stars. Wohoo, still can´t think about it without holding back the tears. Worst day in my life.


Salem lost weight, at the beginning and a few month after the diagnosis. But now his weight is stable, controlling once a week.

According to Somogyi: We meant the same. In Germany, Somogyi-effect is a term used for what you call "bouncing". It happens e.g. when numbers ( another word I learned now :) ) fall too fast, but also after a hypo.

manxcat419 said:
When a bounce happens, what you really need to do is keep his dose the same and wait for his numbers to come back down instead of reducing the dose
Click to expand...
I´m confused. This is what I´m explained NOT to do. When a bounce happens, it´s a sign for too much insuline and the dose needs to be reduced. We call it "shooting away bouncing" and this method ain´t common, even not recommended in Germany.

But thinking about it, I understand the sense behind this procedure. May this be the reason why I barely find a lower number when increasing the dose, because his body "protects" him from lower numbers before it comes to it at all? Yeah, maybe that´s the reason why a drop of more than 30 mg/dl per hour leads to a number twice as high as before. I always wondered about that, because 30 mg/dl an hour is generally not too fast. But for him it is. For him it´s best when bg won´t fall more than max. 25 mg/dl an hour. I discovered, the slower the bg drops the smaller the risk of bouncing.

I always assumed an insuline resistence, caused by too much insuline, because most of time glucose won´t drop much on higher dose (what may be a sign for too much insuline). That´s why I said, with less insuline his bg is better, because I can see the bg fall. Slowly, but it does. And no numbers of 400. (But it´s true, also no numbers lower than 160.)
And then, what i told before, when holding the higher dose, one day he suddenly is having a hypo --->bg < 40 mg/dl--->next bg is over 400--->reducing dose.

At current time I´m holding dose of 1 iu for 4 days, and bg is getting worse than ever. Many many numbers of 400 and higher and even with less insuline he´s not getting that high. You really wanna tell me this has to be that way, before it comes to better bg?
Dealing with bad bg was hard for me, it took a long time before I was able to stand it, not getting frustrated about failure. I don´t know if I can bear this getting more worse bg. I´m so sorry for Salem, seeing him getting thirsty under this high numbers.
But maybe you´re right. Maybe it´s worth a try.

manxcat419 said:
The reason he gets less ketones, even while he is bouncing is because the higher insulin dose is what he needs
Click to expand...
And that it what I couldn´t explain. How is it possible that ketones get low even if Salem is bouncing? This is paradoxical! Yes, I realized Salem needed more insuline...somehow...at least to get rid of ketones. But I never realized why numbers increase if he really needs more insuline. That makes no sense. If more insuline is needed, I suppose bg is getting better, not worse.
But maybe it´s really because his body isn´t ready for lower numbers.

How long should I try with higher dose? What if he is having a hypo? Not reducing? This is completely new to me.

Thank you and greetings,
Annie
 
The reason that Lantus takes time to have an effect is because it is a depot insulin. What happens is that, over the course of the first few days on Lantus, the cat builds up a supply or "depot" of insulin in their body. This helps to work at keeping their numbers stable even when the last insulin dose they had is starting to wear off. At the moment, if Salem is used to numbers over 200 for most of the time, his body can think that anything less than that is too low, even though that is when he is just starting to get towards healthy numbers. It does sound as though Salem bounces more easily than some cats and from smaller drops in his BG but this too will slow down and then stop with time and patience. :)

A bounce can take up to 6 full cycles to stop. During this time, you can very easily see nothing but higher numbers. When that happens and you also reduce the dose, he will then stay in higher numbers after the bouncing has stopped because then he is not getting enough insulin to keep his numbers lower after he has stopped bouncing.

Holding the same dose for 4 days will let you see what that amount of insulin is really doing in his body. If his BG does not reduce after he has stopped bouncing then what he actually needs is an increase in his insulin dose not a decrease. Once you can find a dose that brings him into the normal BG range for a cat and can keep him there, then the bouncing will gradually get less and then stop as his body will remember that these lower numbers are safe. His body, or at least his internal organs, are always better off for being in lower numbers. It just takes time for his liver to remember that and stop sending his numbers back up! :)

It is difficult seeing numbers staying the same day after day. I do understand that - if you look at Rosa's spreadsheet in my signature you can see that she was in very high numbers to begin with and it took more than one increase in her insulin dose to start bringing those numbers down. And then when they did come down she bounced. But gradually she started to need less insulin and bounced less until she was in normal numbers all the time. That is the way Lantus works for a lot of cats.

I would keep Salem on 1 unit for 5 days without any reductions unless he gets a BG reading of 50 mg/dl (2.8 mmol/l) or less on a human meter (68 mg/dl (3.8 mmol/l) or less if you are using a pet meter). At the end of the 5 days, we will be able to help you work out what to do with his dose next based on the numbers he is getting at the lowest point in his cycle. :)

The two main protocols we use for Lantus are here:-
http://www.felinediabetes.com/FDMB/threads/lantus-levemir-tight-regulation-protocol.1581/
http://www.felinediabetes.com/FDMB/threads/lantus-levemir-start-low-go-slow-method-slgs.129446/

And an explanation of how the Lantus depot works is here:-
http://www.felinediabetes.com/FDMB/threads/lantus-levemir-what-is-the-insulin-depot.150/
 
Somogyi is different from bouncing. Somogyi is chronic overdosing of insulin, not a 1 time thing. You don't see low numbers ever in Somogyi, whereas if you just hang in the 3 days, the bounce clears and the numbers settle down without reducing the dose.
 
With ketones, there is a condition called "Euglycemic Ketoacidosis" which is the extreme form of what maybe happening to you. In this condition, blood sugars are normal or close to normal but ketones show up anyways. This is because we are controlling diet very well (or due to weight loss/starvation), so blood sugars are lower, but the cat still does not have the insulin it needs to have a normal metabolism.

Remember, insulin has many functions, only one is to lower sugar. Insulin is critical for the metabolism in almost all cells of the body.

Your cat needs more insulin.
 
Sorry for my late answer and thank you all for your input.
I´m now trying with more insulin (1,25 u), see what will happen. Yesterday he bounced; in the evenig bg fell from 430 to 282 at +5,5. Today´s happening nothing: Pre 347, +3 336, +5 337. Just ordered a huge bag of patience :D

Gonna hold this dose for at least 5 days and come back for your help after this...or before if anything uncommon will happen. If I may!?

Greets,
Annie
 
If he is sitting in the middle of the pink zone and stays there for the next few days then it is likely that he will need another increase in dose in a few days time. We will be able to tell from what happens with his numbers over the next 3 or 4 days. :) If you are able to put his numbers on a spreadsheet and link it to your signature, that will make it much easier for us to see what is happening with each dose. The instructions for that are here http://www.felinediabetes.com/FDMB/...te-a-ss-and-link-it-in-your-signature.130337/

And please keep asking for help - we are here to help you get Salem regulated and get those ketones to stop appearing. :)
 
Today seems to be a good day, at least so far. :joyful:
Pre was 296 (although yesterday evening I thought he´d be bouncing because of raising bg), +5 199, +8 214. Best numbers in the last few days. I´m so happy about this little success.
Hope ketones will disappear soon. I´m wondering why they are still that high, yesterday 1,1 mmol at pre. I´ve never given more than 1,3 u insulin and it always made fall ketones to about 0,7. Now I´ve nearly reached the highest dose I´ve ever tried and ketones won´t fall under 1 mmol. Strange.

Please wish me luck for the rest of the day, no bouncing please!
 
You got room to increase further. If blood sugars are high for any length of time it can harm the cells in their pancrease that produce insulin, causing them to need more. My cat was up to 7U twice a day at one point, so your dose seems small in comparison. Cat's insulin needs can change a lot for no good reason.
 
The numbers you're getting today do sound like more of a normal Lantus curve. Now you're looking to have the same sort of curve in slightly lower numbers. As @Meya14 says, that will need more insulin. At this point, he's probably about ready for an increase to 1.5 units per shot.

It looks like you have your spreadsheet set up but it won't let me view it - it says I need permission. If you can select the option "share with anyone who has the link" then we'll all be able to see it and help you better work out what's going on with his doses. :)
 
You now can view Salems spreadsheet :)

Yesterday and today he bounced. Yesterday noon looked good, but within 4 hours bg raised. Didn´t expect that. Well...

Do you think I should increase insulin now or wait until he won´t bounce anymore with the current dose?
I´d feel more comfortable to increase dose less, I think of 1,4 u. Like I said before, I´ve never given more than 1,3 u because after some time he always fell <50.

Ketones were under 1 mmol yesterday :)
 
He looks like he still has some room to increase. If he is sensitive to insulin changes, you may want to hold each change a little longer 4-5 days. Sometimes cat's needs change, and a dose that sent them to 50 now doesn't do much. You may want to check the ketone strips on yourself, because if they were old they might not be accurate. If you get a positive reading, on yourself, toss em, and get new ones.
 
Good evening!

Just wanted to tell you that Salem is now at 1,8u and he´s doing fine :) Ketones are at normal range und his numbers are much better than before.
The morning pres are often still high, but at least no more 400 numbers -thought bg would never stop raising that high. Seems like he´s still bouncing in the night..or what do you think?

Sometimes evening pre was "low", so I was scared to inject the full dose and reduced. Still got my problems with fine-tuning, guess I just have to try and see what´s happening. For the moment I´m pretty satisfied with his numbers. First success after a long time :)

I´m really glad I asked for your help. People kept telling me to reduce insulin because of the bouncing, what made me that insecure that I was actually about to reduce.
Thank god I didn´t listen to them, but to your advice. Seems you were all right!
I do believe that it won´t take long to get him at normal numbers most of the time.

Thank you all for your help. I´ll keep trying to find the right dose and come back for help or just to tell you what´s going on :)

Greets,
Annie
 
Great!

When you have a moment, could you add a few tidbits to your signature? It will help us give you feedback without having to go look in all your past posts.

Editing your Signature

In the upper right corner of the screen, within the dark blue bar, you will see ID, Inbox, and Alerts

Click on your ID.

On the left, under Settings, Click on Signature.
This is where you will put information that helps us give you feedback.
This is where you paste the link for your spreadsheet, once it is set up.
Add any other text, such as
your name,
cat's name,
date of Dx (diagnosis)
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any other pertinent issues like if there are any food issues, history of DKA, hepatic lipidosis, pancreatitis, allergies, IBD, etc.
Click the Save Changes button at the bottom.

Always click the Save Changes button at the bottom when you have changed anything.
 
Those numbers are looking a lot better. :) And getting rid of the ketones is great news! :D Thank you for trusting the information you got here - I'm so glad to hear the dosing method we use here is working better for him. And please do keep asking questions if you're not sure what to do next with his dose. :)
 
Does anybody know how to dose glucose fluid?
Yesterday evening Salem stopped eating and at +3,5 his numbers were already down to 75. He was dizzy, had a wobbly gait and still refused to eat, so I injected 1 ml glucose fluid, hoping this would be enough. Further I injected MCP (a medicine for nausea), didn´t help..and after that he wouldn´t let me touch him anymore, ran away and hide from me. Couldn´t even take any blood test.

In the morning I gave him Vomacur (another medicine for nausea), usually it helps within 15-20 minutes, not this morning. He ate just a little bit all day long until I gave him another pill of Vomacur at the evening shot. Now he seems alright, eating just as normal. I let him eat everything he wants, today bg is bad anyway.:blackeye:
 
Good evening!
Back again now. Salem was sick, didn´t eat without medicine against nausea. It took 2 weeks, but after injecting MCP (metoclopramid) it got better within 3 days.
Now he´s alright again, thank God!

Would you please take a look at the spreadsheet? He was sick from 06/08 till 06/22, so sometimes when numbers were low I reduced insulin, because I never knew how much he would eat.
He always bounced at these low numbers, or was it somogyi? Or too less insulin? Never found the right dose...What do you think?
How should I go on when numbers are low like today in the morning? I was afraid of injecting the full dose, so I reduced. But numbers were high this evening and I don´t know why.
 
Remember that Lantus is adjusted based on the nadir, not the pre-shots, so testing in the +5 to +7 hour post-shot period gives you the data you need to adjust the dose.
 
Hi everyone,
here I am again needing your advice.

Salem suffered from pancreatitis last month, so I reduced insulin because he wasn´t eating well at all. After getting better I increased dose again.
Now I´m looking for the right dose again and need your feedback.

It´s especially Aug. 23rd and 24th I worry about. To me it seemed the evening pres were toward regulations that´s why I reduced dose. But with less insulin bg is getting worse. May it be the numbers were bouncing and not toward regulation? Is it possible Salem needs to get used to lowers numbers again, (while sickness numbers weren´t good, always about 300) ? I would have thought once bouncing stopped he would never bounce again.

Should I increase dose to 1,4 iu again and hold for a few days? I´m very insecure at the moment. What do you think?


Greets, Annie
 
Hi Annie!

First, it looks like you've only been "routinely" testing the last week, but the way you have your spreadsheet set up, it's kind of hard to tell. You have it set up differently from the one most of us use.

That being said, it looks like Salem was getting better numbers on the 1.4, so I'd suggest going back up

The 87 back on the 23rd was a nice safe number.
 
Chris, thanks for your feedback :)
I´ll try again with 1,4 iu.

Yes, the last weeks I´ve been sloppy writing down numbers :facepalm:
I´ve been very busy and to be true, when Salem was sick, I didn´t want to always see those bad numbers he had. I knew he was getting too little insulin at this time and knew bg wouldn´t be good. But I´m too scared to shoot the a higher dose when he´s not eating and I´m not at home.
 
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