ketone prone-dosing?

[Allison and Tillman]

Hi everyone! My ketone-prone, chronic pancreatitis boy has been on Lantus since his previous bout of DKA. However, I'm having trouble regulating him. He had ketones last week, that we fought through and flushed with LRS+regular insulin. However, I went three days on Lantus again, and he tested positive again for ketones. We got back on track, and I am now doing daily fluid therapy (100cc/day), and smaller, more frequent meals. However, I'm scared to leave him on the Lantus solely without monitoring him. I have been supplementing with the regular insulin when he has been getting too high. He has just moved up to a 2.5 dose of Lantus this PM dose. Also, he does have pretty significant food spikes...but the smaller-more frequent meals seem to be helping with that as well. My work schedule did not previously allow me to do good curves, but I have been home (THANK GOODNESS because he had the ketone issue!) and have been closely monitoring the last two weeks. Unfortunately, I get back into my regular schedule Monday, and monitoring this closely is going to be difficult. Any suggestions remaining safe for ketone-prone kitty, while trying to figure out dosage?

Thanks!!

 

[julie & punkin (ga)]

the recipe for ketones is not enough insulin + infection + not enough food. It sounds like you're working on addressing the insulin issue with using Lantus & R, but has Tillman been treated for an infection? Is he eating enough? It's critical to get enough food in him, even if you have to assist-feed him. There are videos on youtube on assist-feeding cats.

Looking at his spreadsheet i have a couple of observations.

Lantus dosing needs to be every 12 hrs - when you skip Lantus shots you're allowing it to wear off and his blood sugar to rise. It looks like for the past several days he's only had 1 shot of Lantus per day - is that right?

R's effects only last about 4 hours from the shot. If you're relying on the R as his primary insulin, you're going to have to shoot every few hours around the clock or have his BGs go high.

Cats have fast metabolisms and they really benefit from long-lasting insulins (like Lantus). I think you're going to have the best success if you give Lantus every 12 hours religiously and then use the R to bring down the highs while you get the Lantus to an appropriate dose. As long as you can monitor, you can work up to shooting the numbers you are currently skipping - those preshots less than 100. Experienced Lantus users will shoot most preshots over 50 - but you want guidance from experienced people when you're ready to do that. Here is a recent discussion about Shooting Low.

There's a huge difference between the amount of testing in the past week and before that. Are you able to test multiple times a day in the future? that's what is going to help you get to the right dose and keep him safe. You can't know what the dose is doing, if it's too much or not enough, if you don't check mid-cycle.

what is Tillman eating?

We can help you get Tillman regulated so that he's not going to be at such a risk for ketones. Some kitties are more prone to them than others. I'd encourage you to post every day so we can teach you how Lantus works and how to keep him safe. Sounds like you've had a difficult week - i'm glad he's doing better now.

 

[Allison and Tillman]

Thanks for the reply! He's been eating on his own since the dka the end of June.When he had the ketone issues and vomiting last week, I flushed with LRS and administered regular insulin per the protocol from the internist he saw previously. For the hours he wasn't eating I did syringe-feed but he bounced back quickly once his BG came down+fluids and was eating on his own. He's currently on Sheba Pates. When he had his previous episode with DKA where he was hospitalized , it was determined it was brought on by pancreatitis and an acute bladder infection that he was treated for. However, it was determined he does likely have chronic pancreatitis that results in making him more difficult to regulate, and thus also more prone to ketones. I have been shooting R when he has risen over 250 throughout the last couple days, and tried to also give the normal 12 hour lantus dosage. But I did skip some morning doses 8/17, 8/20 because the lower numbers (which I now realize should have shot from watching the curve) and this am due to a high number that I had to jump on with the R. I can monitor the spikes and administer R through the weekend but on Monday I won't be able to continue the heavy monitoring. My concern is if I am administering R on the spikes as well as lantus bid, how do I know if the lantus dosage is accurate? Also his lantus onset seems to be later than some mention (+2-) and not on board to respond to his am/pm food spikes...so I'm just not getting good overlap. Obviously I need to hold the dosage at least three days, but after last week'a episode I'm afraid to leave him spiking and being wonky.

 

[julie & punkin (ga)]

you have a valid concern about how you know when you've got the right Lantus dose. it can get confusing to figure out what's what when you've got both R and Lantus in the picture, and especially when the Lantus doses are skipped. I'm not blaming you - i'm just explaining.

One risk of using R is that you can set up "R-bouncing" where the R brings the numbers down fairly quickly, and the cat subsequently bounces from the fast drop. Then you have a high number. Then you want to use more R. It can set up a situation where the R can make things worse.

Lantus doesn't work quickly with high numbers, but it has great long-lasting staying power. You want the Lantus dose to be fairly close to a good dose so it does most of the work and the R is just tweaking things. I've used both as well and the best situation, once you're past the ketone emergency, the Lantus dose does most of the work and the R use is occasional.

Do you have a timed feeder? They are essential for helping when you are working. We had a recent discussion on them here.

You want to continue testing frequently for ketones right now.

How is he behaving overall? Is he playing? peeing & pooping ok? preening? purring?

I'd like to get input from some other experienced users as well to help you get the best possible advice.

 

[Allison and Tillman]

Thanks!! I'm definitely going to get a timed feeder! After reading how beneficial the smaller meals are for pancreatitis I had been looking into it. Thanks for the link! He's bounced back great and is back very active, alert and playful. Normal urination and bowel movements.

 

[Sienne and Gabby (GA)]

In addition to Julie's suggestions, I'd encourage you to review the Tight Regulation Protocol sticky. Your last Lantus increase was by 0.5u. When you're seeing nadirs that are below 200, the recommended dose increase is 0.25u. Just like bouncing off of R, Tillman can also bounce off of Lantus. In addition, if you increase the dose too aggressively, you may end up bypassing what could be an effective dose of Lantus.

With going back to work, I would also encourage you to get at least one test in addition to your pre-shot tests, during each cycle. I realize your work schedule may not permit this but getting at least one test during the PM cycle is critical. This is even more the case with a ketone-prone cat.

Do you know the carbohydrate count on the Sheba foods? They may be higher in carbs than is typically advised. We consider low carb as under 10% although, most of us feed LC that's around 5% or lower.