911 High Urine Ketones....AGAIN!

Bill Robinson

Bill Robinson

Member Since 2019
The first trip to the Emergency Hospital a couple weeks ago was due to "SMALL to MODERATE Urine Ketones and a very lethargic Doobie with no appetite. Turns out Doobie was in crises suffering from serious DKA. The hospital staff said it was a good thing we brought him in when we did.
The second return to the hospital last week was possibly an over-reaction to "small to moderate" levels of ketones showing on the keto-diastic dip stick. Doobie had ketones but it turns out he was not in DKA. Regardless, he stayed in the hospital for 3 days and his blood Ketones were never eliminated entirely when they sent him home.
This evening, 2 days later, Doobie's Urine Ketones shot up to "moderate" on the dip-stick. He is still eating, less enthusiastically, but still eating. He isn't lethargic. But, this is the most instantaneous reading of ketones we have seen and they went right to "MODERATE +" right away.
What to do?
Should we prioritize his behavior over than the dip-stick reading and continue to monitor his outward health symptoms?
After his last stay, which seriously stresses him out, we decided we wouldn't over-react again.
Should we take him in to emergency for only a KA blood test to make sure he isn't going into crises. Once we do that, they will strongly suggest he stay for a few days "just to be sure".
Any suggestions????
 
I don't want to be an alarmist, but the swiftness of the strip reading tells me there is a legit issue here. I am not at all familiar with DKA, so you can take my advice with a grain of salt, but I personally would say it's time to bring Doobie into the ER vet. You could also call them and see what they say, but those high ketones are definitely worrying. I am so sorry.
 
Do you have fluids set up at home? His eating and not lethargic is a big plus.

I'm going to share my experience with this. I had the same reaction to instant moderate with Doc 4 years ago. My vet had me wait until the next morning which I didn't care for but it turned out to be OK. You need to get as much liquid going thru his system as possible. I gave subQ fluids at home as Doc had no heart problems, gave him huge amounts of water with syringe, mixed water with his food and watched him like a hawk. I did have to syringe feed a day or two. We were able to flush the ketones in a few days. I've seen others be able to do this same thing when they're caught early enough.

Because of this, I wouldn't jump to the ER but I'd be on my vet's doorstep tomorrow morning - that part is whatever makes YOU comfortable!!! If he stops eating, starts throwing up, acts worse or they increase, then I would go to ER.

Hugs and prayers,
 
Anything above a trace of ketones needs vet attention.
DKA can develop when there is not enough insulin, not enough food and an infection/ inflammation present.
I think you will need to increase his insulin to 0.75 units and if necessary give him some higher carb food to counteract the increase in insulin to stop it dropping too low. I would increase the dose in the morning
.ETA I’ve just realised after reading a post below that Doobie is only getting insulin once a day. Disregard what I have said above about increasing the dose... you need to be splitting the dose of 0.5 units and giving 0.25 units twice a day.
Make sure he is eating and drinking enough.
Does he have an unresolved infection/inflammation ?
I would at least ring the vet tonight to get some feedback as DKA can develop quickly.
I agree give extra fluids to flush out ketones.

Test each time he pees at the moment to monitor the ketones.
 
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I don't have any direct experience with ketones, but my understanding is that it is a problem if ketones are spilling into the urine. And, since the ketones levels in the urine seem to be increasing, that would also be concerning. Combine that with the recent DKA, your cat is prone to having DKA again.

As Julie pointed out there is a good info sheet that she included in her post. Any chance you have a store nearby that carries blood monitors? There is a novomax meter that can test blood ketones, http://www.novacares.com/nova-max-plus/

The basic recipe for developing DKA is an insufficient supply of insulin + inappetance +infection or other systemic stresses

As has been commented above by Bron and Lyresa, he needs to keep eating, and stay hydrated, you may need to syringe feed if he doesn't want food on his own. Keep adding as much water as you can if you can get him to eat. And you may need to syringe water as well.

This list of tips gives suggestions on how to stimulate your cat's appetite http://www.felinediabetes.com/FDMB/threads/suggestions-on-how-to-stimulate-kittys-appetite.130770/

I know vet visits can be stressful for kitties, but my concern is he has had DKA before. Does his breath smell fruity or like nail polish remover? If yes, I'd take him in to see the vet. That can be an outward sign that ketones are building up quickly. Any chance you didn't catch the reading at 15 seconds? It continues to change colours over time, so it's important to get the reading at 15 seconds.
 
Hi Bill,

Saw you went offline. Hope Doobie is okay. Have a feeling you are on your way to the vet. Let us know.

If this seems to be a recurring problem, maybe you can learn to give sub q fluids at home to flush them out? I know initially they thought he might have a heart issue, but was undetermined, not sure about sub q fluids with any heart issues, check with the vet.

Signing off for the night.
 
If you have sub q's at home give them. If not add a lot of water to his food. You have to flush the ketones Getting the bg down is important as well! Did you get some fast acting insulin to use in conjunction with the lantus to bring down spikes? If not if go to the vet.

You may want to invest in a blood ketone meter so you don't have to wait for the cat to pee to get a reading. They work just like bg meters.
 
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Sorry I didn’t get this tag until this AM.

Bubba had moderate ketones ( measured on a ketone blood monitor). We were able to manage them at home as he was eating fine . I got a lot of water mixed into his food to flush them AND had help to get more insulin into him.
 
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@Bill Robinson I'm glad to see that you've found your way to the Lantus forum and posted.

Darn, it does appear that you've been thrown into the deep end of the pool with Doobie and his ketone/DKA issues. :-(

How is he doing? Did you end up going back to the vet or ER?

Is he currently on any antibiotics? With the recent history of hospitalizations, it certainly feels like there might be an underlying infection or other issue that might be contributing.

As others have mentioned, you have to be mindful to read the ketone strip at the correct timing (though it doesn't sound like that's an issue in your case). The near instantaneous color change is indeed worrisome. You might want to look into getting a meter that checks the blood for ketones rather than relying on the urine ketostix. The blood meters will catch ketones before the urine sticks, which can be a godsend for ketone-prone cats.

Personally, I don't think you should feel that you "jumped the gun" by hospitalizing Doobie again this past week. Ketones are never something to take lightly -- a cat can go into DKA and it can become life threatening fast. Lightning fast.

As for DKA treatment ... it can be tricky and challenging even for seasoned vets. It's important that the clinic be manned 24 hours a day and that the cat be monitored closely. A vet who closes up shop for the night is not where a DKA kitty needs to be. Most cats need an IV and electrolytes must be monitored closely as they can get terribly out of whack. Any cardiac issues need to be identified as well because pushing IV fluids to flush ketones can stress an impaired heart. Food is mandatory as is pulling down the blood glucose values and identifying AND TREATING any infections. Pancreatitis, kidney infections, UTIs, whatever ... they're all common in diabetics and they can all make you feel like you're chasing your figurative DKA tail until addressed.

Some cats need feeding tubes to get through a DKA episode. If you're ever confronted with that issue, please don't be daunted. They are lifesavers and most cats handle they remarkably well. My Charlie had three feeding tubes over the years and they saved his life. I wouldn't flinch if I had to do it again.

As for Doobie's dramatic response to small doses of insulin ... yep, I've been there. Charlie could nosedive on even 0.25u of insulin ... we spent so much time at the university vet hospital for awhile there that I became close with one of the vets there. In those early days, I warned her that Charlie's BG could drop like a rock. She nodded but didn't fully grasp the manifestation of it until the overnight vet called her at home at 3 AM when Charlie decided to "tank." I also told her he would go into hepatic lipidosis within 36 hours of not eating, despite the fact that he wasn't the classic profile. The vet also didn't believe me on that ... until Charlie proved her wrong.

I don't know much, but I've learned over the years that every cat is different and that we "tuned-in" owners know our cats best and can truly be an asset to their care You mentioned you and your vets being a "care team" ... I like that concept very much.

I hope you get to the bottom of what's going on with Doobie. It looks like he's responding to the insulin, although most cats DO need twice a day shots as they metabolize much faster than humans. I know that your vet is being conservative with dosing given Doobie's strong response, but it might be worth discussing splitting that 0.5u dose into a dose of 0.25u twice a day. There are many posts on this site about how to give small or even micro doses of insulin.

It might also be worth discussing whether you should administer sub-q fluids at home (caveat being that there are no heart issues). SubQ fluids can be extremely beneficial in flushing ketones and helping an ill cat remain hydrated and recover. I was actually somewhat surprised that the vet sent Doobie home when he still had ketones and you WEREN'T given subq fluids.

Others have managed ketones at home successfully so hopefully they'll chime in with their experiences and tips.

Again, best wishes and please let us know how things are going. I am, quite honestly, holding my breath right now...
 
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@Bill Robinson
I agree with @JL and Chip that Doobie should be getting the dose of insulin twice a day, especially with ketones in the picture. And I agree with 0.25 units twice a day to start with.
Please disregard what I said in my first post above about increasing. I didn’t realise that the bd dosing had stopped in the last few days.
 
My kitty survived DKA. IMHO, for a cat that keeps developing ketones, a blood ketone meter is a good investment. Urinary ketones are fine to test once you're past what amounts to an unstable situation. It sounds like Doobie is ketone prone.

Ketones can be a life threatening emergency. My rule of thumb is that if ketones are greater than trace, your cat needs to be evaluated by a vet. What is trace on a urine ketone strip can be lots higher on a blood test. (Urinary ketones tell you what the level and the level is hours old given that the kitty needs to metabolize food and produce and collect urine.) Have you noticed an acetone-like smell on Doobie's breath? If so, go to the vet now.

Do you have labs that are more recent than April? Has the vet tested for infection/inflammation -- especially pancreatitis? As others noted, the recipe for ketones = not enough insulin + not enough calories + infection/inflammation.

Please keep us posted on how Doobie is doing.
 
His spreadsheet shows Urine Ketone = Trace @ 4:30. Yay! I agree with the blood ketone monitor. The test strips are about $2 each, but so worth it rather than waiting anxiously for a pee sample. My kitty also survived DKA.
FYI, when I tried to get a blood ketone monitor quickly (I don't have amazon prime), I called around to the local pharmacies and they had the monitor but not the test strips for ketones but said they could order them and have them for me in 24 hours.
 
So glad to see his ketones came down.

Definitely see about splitting his dose 12/12 hours instead of once a day, with the cats metabolism it is much better for stability in BG and may also help in preventing ketones if sugars are better controlled. Lantus is a depot insulin also and works differently than Prozinc. Honestly many vets are not as up to date or knowledgable with certain insulins as the group here that has hundreds of hours of “in the field” experience so to speak. Some vets know more than others and some mean well, but you would be shocked at the lack of knowledge in some cases.

I also noticed you had a curve done at vet. You can do those yourself on a day you are home. Don’t waste money paying the vet, those are also not very reliable because stress causes BG to rise and if cat is at vet all day, you know they are stressed. So essentially vet is charging you for data that is likely not very accurate. Kitty is less stressed at home with you poking him. Plus I know you have shelled out a lot of money so far.
 
How are things going? My cat survived DKA barely. I didn’t sleep hardly for over a month nursing her back to health afterwards, because I didn’t know before the DKA what was happening, why she was getting so sick... with the caveat that ECID, I have since had Alice’s ketones test occasionally somewhere between small-moderate and in those cases I keep up testing, and make sure she eats, I make her food mashed up with a decent amount of water, or hand feed her or hold a spoon out for her if I have to. And I never skip her insulin.

A LOT turned around for her by switching to Lantus. I also strongly recommend dosing twice a day versus once a day. Depending on the situation, and with DKA history and anorexia (loss of appetite), sometimes low carb doesn’t matter as much as making sure kitty eats, but I don’t feel confident to recommend a higher carb, more enticing food, without more information.

I hope the situation has improved since your last posting!
 
Here's my 2 cents - my kitty, Tigger, also survived DKA, and it was BAD - (like "the vet hinting at us not to try and treat because of his age and how sick he was" bad)
After reading the articles on here and realizing with 2 cats, 2 litters, and Tigger being a little shy and sly about his toilet habits, urine sticks were not going to work for us.
I bought the Precision Xtra meter (it also does BG!) and a 30 pack of strips is about $30 on amazon. When intuition tells me something is up I test daily (or more).
When things are smooth and regulated for a while I test every 3 days maybe . . . but that's just personal preference. It is WELL WORTH IT for our situation.
Tigger's DKA anniversary date of 1 year in coming up and I can't believe we've been doing this dance that long already. For a cat like mine, who REFUSES to get regulated,
the blood ketone monitor is like extra reassurance on days the BG is up or bouncy or all over the place.
 
Moms2Tigger&Blu said:
Here's my 2 cents - my kitty, Tigger, also survived DKA, and it was BAD - (like "the vet hinting at us not to try and treat because of his age and how sick he was" bad)
After reading the articles on here and realizing with 2 cats, 2 litters, and Tigger being a little shy and sly about his toilet habits, urine sticks were not going to work for us.
I bought the Precision Xtra meter (it also does BG!) and a 30 pack of strips is about $30 on amazon. When intuition tells me something is up I test daily (or more).
When things are smooth and regulated for a while I test every 3 days maybe . . . but that's just personal preference. It is WELL WORTH IT for our situation.
Tigger's DKA anniversary date of 1 year in coming up and I can't believe we've been doing this dance that long already. For a cat like mine, who REFUSES to get regulated,
the blood ketone monitor is like extra reassurance on days the BG is up or bouncy or all over the place.
Click to expand...
I
My DKA experience was equally bad, no one thought she would make it. I thought she would die in our arms on the way to the ER vet.
And now you have *me* pretty convinced a ketone monitor sounds amazingly easier, and necessary. I never want to live that over again. Never.
 
AliceMeowliss&Cassandra said:
I
My DKA experience was equally bad, no one thought she would make it. I thought she would die in our arms on the way to the ER vet.
And now you have *me* pretty convinced a ketone monitor sounds amazingly easier, and necessary. I never want to live that over again. Never.
Click to expand...
It takes a little more blood than an AlphaTrak or similar nano droplet type monitor, but when I know I'm going to use it I just warm up his ear a little and poke
once for both the BG and the Ketone monitor. Peace of mind. Just remember to read the articles and not let yourself get scared by certain numbers you will see.
According to the study a 0.4 is the same as 1.8 . . . its not until the blood level reaches above 2.4 that ketones would show up on a urine stick.
There's more to it, like trending up and watching the cat for physical signs but you'll read that.
 
@Bill Robinson
Just saw that Doobie is hospitalized AGAIN for high ketones (3rd time in the past month) and that the vet is suggesting endoscopy and/or liver aspirate. I might have been stalking your spreadsheet :) (we get vested in these kitties, ya know?)

I'm glad to see that they've succeeded in getting Doobie's BG down with fast-acting insulin and that he's eating again. Sorry you're going through this.

I'm sending positive vibes and hoping the docs get to the bottom of this soon. Please post updates as you can. Head scritches for Doobie ... sounds like he's being a trouper through all of this.

(Many of us leave a t-shirt we've worn recently at the hospital for our kitties to curl up with in the cage ... Has our scent on it and sometimes helps ease the stress. Just a suggestion.)
 
Thanks all.
Doobie WAS back in the hospital again. Sunday AM he threw up all of the food he ate on Saturday, undigested. He was refusing food or water. He tried to hide from us in the most inaccessible places he could find. His urine ketones went off the chart during the night. He does NOT have DKA. The Vet staff is baffled. They stabilized his BG with short acting insulin every 4 hours, testing every 2 hours. kept him in the 100s. Blood Ketones remained elevated, however, and still remain above-normal to this day. He IS eating and drinking again. BG is somewhat controlled.

Everyone is out of ideas having ruled-out most every typical underlying condition. Although ultrasound showed normal organs, the internist suggested an endoscopy and liver aspiration in the morning to rule-out IBD and Liver issues. After that.....? The Internal Med specialist and the specialists they have sought council from are at a loss as to what is causing his ketones and insulin instability. Numerous Internal Med specialists have reviewed his records and offered suggestions for tests to run to pinpoint a cause. They all agree that there is little that is consistent with the norm or with any common underlying causes. He is melting away at under 7lbs today (was a very healthy 12 lbs 3 months ago)

Baffling, sad, and a very costly month of care for both Doobie and us. We will have spent just under $17k to end up with no answers for my little buddy. This is a highly rated, reputable emergency hospital, so i don't question their efforts to find a solution. They have been very good to deal with, calling us 4 or 5 times a day letting us know Doobie's status and what they are trying next to find a clue.

We made the tough decision tonight to forgo another night at the hospital, anesthesia and biopsies in the morning. Just in case he has IBD, they put him on steroids, anti-nausea med and back to his .5U d 24hrs Glargine. We know steroids will make BG harder to manage so we hope to get a second opinion before any more doses of steroids are due. We are going to call some of the cat-only vets who claim to deal with DM frequently and see if we can find one that will work with us on very structured and aggressive home therapy and testing approach.
 
So sorry to hear Doobie is in the hospital but it's great that he's getting the best treatment! :bighug::bighug::bighug::bighug::bighug::bighug::bighug::bighug:

Ming is on steroids for chronic pancreatitis and on the lowest effective dose (1.25 mg pred BID). In terms of his BG... he's a huge bouncer but we get nice numbers when he's not bouncing. His dose is high and I suspect it's because of the pred and also because of his bad pancreas. He's negative for acro. I've also heard there is transdermal pred and you can give even LESS than a quarter tab of prednisolone. So there are options if it comes to Doobie needing steroids.

In terms of how I feel about the pred... well, we did a specFPL about a month after starting pred daily and it was normal. Then we did another specFPL about 5 months later and his number was 34.1 (normal is 0 to 3) but he wasn't displaying any symptoms. Do I think the pred is working? I don't know. Probably but I've also been way more aggressive with his FD and treating his vomiting days. Of course, I'm talking about pancreatitis and Doobie is suspected for IBD (I don't know much about IBD to be honest but have heard pred has worked for some kitties on this board).
 
Crista & Ming said:
So sorry to hear Doobie is in the hospital but it's great that he's getting the best treatment! :bighug::bighug::bighug::bighug::bighug::bighug::bighug::bighug:

Ming is on steroids for chronic pancreatitis and on the lowest effective dose (1.25 mg pred BID). In terms of his BG... he's a huge bouncer but we get nice numbers when he's not bouncing. His dose is high and I suspect it's because of the pred and also because of his bad pancreas. He's negative for acro. I've also heard there is transdermal pred and you can give even LESS than a quarter tab of prednisolone. So there are options if it comes to Doobie needing steroids.
Click to expand...

what about Budesonide? SUPPOSEDLY it works almost as good as pred with less effect on BG . . . . Full disclosure though, Tigger never really took it. The vets switched him when first diagnosed with FD but he never ended up taking it. Any we got it compounded and mail ordered for nothing . . . but I guess technically "we have it if we need it" now
 
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