Ketones??? Help!

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Erin Lewis and Boops

Erin Lewis and Boops

Member Since 2015
Boops hasn't vomited in a few days, but isn't eating quite normally. We just checked him with a blood ketone meter and it said 3.8. Is this an emergency? I can't find anything on this! Help!
 
Erin, I don't have any experience with Ketones but I've read enough condos to know that their presence can quickly turn into a life-threatening situation. You mention that Boops hasn't vomited in a few days so that's a good thing but I would still be diligent.

If 3.8 equates to moderate on your meter (as it does on the ketone stix I have) perhaps a call to the vet or emergency animal clinic for advice is warranted. Hopefully, someone on the FDMB with Ketone experience will be by soon to advise you.

Sending stay safe vines to Boops.

You've probably already seen this but I found this through a search and thought I'd forward:

http://www.felinediabetes.com/ketones.htm

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Also see
Pet Diabetes Wiki: Ketoacidosis
A Ketone Primer by an FDMB user

What are Ketones?
Ketones or ketone bodies (acetone, acetoacetic acid, and beta-hydroxybutyric acid) are waste products of fatty acid breakdown in the body. This is the result of burning fat, rather than glucose, to fuel the body.
The body tries to dispose of excess ketones as quickly as possible when they are present in the blood. The kidneys filter out ketones and excrete them into the urine.
Should you care about ketones?
YES! If they build up, they can lead to very serious energy problems in the body, resulting in diabetic ketoacidosis, a true medical emergency. If the condition is not reversed and other systemic stresses are present, ketones may continue to rise and a condition known as diabetic ketoacidosis (DKA) may occur. This condition can progress very quickly and cause severe illness. It is potentially fatal even when treated. Recognition of DKA and rapid treatment by your veterinarian can save your cat's life.
Signs of Diabetic Ketoacidosis (DKA)
  • Drinking excessive amounts of water OR no water
  • Excessive urination
  • Diminished activity
  • Not eating for over 12 hours
  • Vomiting
  • Lethargy and depression
  • Weakness
  • Breathing very fast
  • Dehydration
  • Ketone odor on breath (smells like nail-polish remover or fruit)
Causes of Diabetic Ketoacidosis (DKA)
  • Insulin dependent diabetes mellitus
  • Inadequate insulin dosing or production
  • Infection
  • Concurrent diseas that stresses the animal
  • Estrus
  • Medication noncompliance
  • Lethargy and depression
  • Stress
  • Surgery
  • Idiopathic (unknown causes)
Risk Factors for DKA
  • Any condition that causes an insulin deficiency
  • History of corticosteroid or beta-blocker administration
Diagnosis
Laboratory tests performed by your vet are necessary for diagnosis. Depending on how sick your cat is, the testing can be extensive (and expensive). Your veterinarian will determine what tests are necessary. At a minimum, testing is likely to include a number of blood tests and a urine test.
Treatment
If the cat is bright, alert, and well-hydrated, the cat will not require intensive care. Your cat will require insulin, food, constant access to water, and close monitoring for signs of illness such as vomiting, anorexia, and lethargy.
Treatment of cats who show signs illness require inpatient intensive care. The goal of treatment is to correct dehydration, electrolyte depletion, to reverse the high ketones in the blood and the metabolic acidosis that is present, and to increase the rate of glucose use by insulin-dependent tissues.
Veterinary care for DKA involves intravenous (IV) fluids, usually supplemented with potassium, monitoring by observation and urine and blood tests, and sometimes feeding by a tube. Treatment may involve a hospital stay of five days or more and often costs about US$2000. Without treatment, "sick" animals with DKA will die.
Testing for Ketones
Simple urine tests can detect ketones. This is done by collecting a urine sample and inserting a special dip stick into the urine. Some urine ketone strips detect only ketones while other types test for both glucose and ketone levels. Urine ketone strips will detect only some of the ketone bodies produced by the body, not all of them. Strip storage, handling, and testing procedures are similar to those used for glucose test strips. Strip test results are indicated by presence of color changes, indicating presence of ketones, either quantitatively (giving you a number for the ketone concentration) or by descriptive terms (for example, negative, trace, small, or large). False positives may occur if you are also using certain medications or vitamins, or if the strips have been handled or stored improperly. If you wish to test blood instead of urine for ketones, there is a meter that allows for home testing, the Abbott Precision Xtra meter. Outside of the US, the meter is known by the brand name Precision/Optimum/Xceed. The premise behind blood testing for ketones is the same as that for favoring glucose testing of blood over urine. The Precision Xtra meter is offered by Hock's online pharmacy for US$29.95 in October 2006. The ketone test strips are about US$30 for a box of 50. The Precision Xtra also does blood glucose testing with standard blood glucose test strips made for use with the meter.
When to call the vet
In a diabetic, any urinary ketones above trace or trace urinary ketones plus some of the signs listed above, are cause to call a veterinarian immediately. If your vet doesn't offer after-hour emergency care, be sure to have the number and location of a 24 hour emergency veterinarian.
 
So I see that on your spreadsheet that he had numerous days where he went from HI (>600ish) to in the 40s or 50s. I assume you are feeding low carb food? How much per day does he eat (ounces) and how is the appetite?


#1. He needs to see a vet and monitor electrolytes and rule out infections.

#2. I suspect that he is not getting enough calories and carbs to prevent fat breakdown. With ketones, the trick to getting rid of them is to try to get their bodies to burn carbs and not fat. In order to do this, you have to increase his carb intake, and increase his insulin. The low numbers can be an indication of a starvation state (instead of an indication that the insulin is working). Increase both insulin and carbs to keep BS between 100-200. Feed as much carbs as you need to get the increased dose of insulin in him. Monitor his BS very carefully.

#3. Increase fluids if he is not drinking. 300ml is the goal, and this includes the fluids contained in the wet food. You may want to measure the water bowl and see what his intake is.
 
We are feeding FF classics. Started feeding 9 oz a day to combat weight loss. He drinks all the time, so not worried about water intake. So, should I give him higher carb food than FF?
 
You are going to have to increase his insulin intake by either 0.25 or 0.5 units to start, so he is going to have to have more carbs to handle that insulin. If his BS is not too low, continue to raise insulin by 0.25-0.5 every 6 cycles until ketones are gone.

I would start with a higher carb wet food. You can also add some dry food mixed with water to the wet food if he will eat that. It's very important to increase the insulin at this point, so do whatever it takes food-wise to keep the numbers between 100-200. Don't let them in the greens until the ketones are gone.

It's important to go see your vet, because electrolytes can be in dangerous levels (esp. potassium) and you would need to supplement based on the labs. The other things you want to mention to your vet is the vomiting, and you should have anti-nausea meds at home available in case he stops eating which is common with ketones.

Your cat doesn't have enough insulin. It's confusing with the low blood sugars he was having, but things causing starvation can mask the need for insulin and make it look like he's getting too much when in fact, it's not a reduction of insulin he needs, but increased calories. Ketones with starvation can be especially hard to get under control, because you have to figure out what is causing the need for calories/weight loss or it will keep happening.
 
Hang in there! It's a hard thing to go through, but cats can recover fairly quickly with the right treatment, and are no worse for the wear after.
 
Depending on the ketone meter you're using, 3.8 is probably right on the edge. Chances are the vet will give Boops IV fluids to help flush the ketones and run labs to see where the electrolytes are and whether there's an infection. Take it one step at a time.
 
Glad it was just a trace and you're increasing his dose. Adding water to his food, as much as he will tolerate, will help flush out ketones.

Would you please take down the 911 now that he's ok? Thanks!
 
I want to make a couple of observations.

First, great job testing for ketones! This was definitely a "better safe than sorry" moment.

When numbers are as high as Boop's have been, you need to be more aggressive about dosing. Increasing from 0.4 to 0.5u isn't going to do much when numbers are that high. Especially in the case of ketones, you need to shift your perspective a bit and you will need to be aggressive about dose. Whichever protocol you're using basically flies out the window in order to keep your kitty safe and to keep ketones at bay.

The suggestion to increase carbs isn't exactly on point. Ketones develop for the following reasons:
  • not enough insulin
  • the presence of an infection or inflammation
  • not enough calories
If Boops isn't eating well, which can happen when ketones are present, then you need the biggest bang for the buck in order to get food AND sufficient calories in. (I've been known to suggest an ice cream sundae if that's what a cat will eat!) So from that perspective, carbs and calories are related. The point is that calories are needed otherwise, rather than metabolizing food, your kitty will metabolize stored fat, a by product of which is ketones.

I know you said the Boops drinks a fair amount. That's most likely because he's not well regulated yet. If you're not already adding water to her food, please add as much water (or broth as long as it is just a protein with no onions in it) as he'll tolerate.

If you wouldn't mind, would you change the color-coding back to turquoise for your PM dose? Many of us skim spreadsheets and the shade of green you're using indicates numbers that are below 100. It can lead people to misread your data.
 
In the hospital, the way we treat humans in DKA is by giving them a dextrose IV and additional insulin (usually much more than they get at home). The extra sugar available in the bloodstream allows for much larger doses of insulin to be given without the threat of hypoglycemia. This is called "substrate". This process helps to change the metabolism away from burning fats.

I usually suggest adding extra carbs because some cats who have blood sugars on the lower side with ketones still need that extra insulin, and adding extra sugars to the diet allows you to give more insulin. However, Sienne is correct, the -cause- of the ketones can be a lack of calories overall in addition to other things.
 
If your nadirs are still above 200 by tomorrow, I would raise to 1U. Are you still checking for ketones?
 
I'm very late to this discussion but finding it very helpful. My vet told me that only 2 of the 3 ketones show up in the urine dipstick test (acetone and acetoacetic acid) and that acetone does not cause affect DKA. He also said that the third type, B-hydroxybutyrate is the type that becomes elevated and causes DKA, and that it is only visible on a blood ketone test. Can anyone tell me if this is correct (I've had a couple of vets who didn't even MENTION testing for ketones and I had to find out the hard way when my cat went into DKA.) My cat also has chronic pancreatitis and the vet said he feels her continuing to periodically show trace-mod. ketones is when her p-titis is flaring. But no matter WHY the ketones show up, aren't they dangerous and what is the best way to keep ahead of them? She eats great, never has an appetite problem and is only on low-carb canned. If anyone can comment on the things my vet said and if I understood him right, I'd be so grateful. These ketones have me in a panic all the time, so I can relate to others going thru the ketone worry. Thanks so much.

Molly
 
That is correct. And if you sniff the breath and smell a fruity or vinegary scent, that can be ketones; it isn't foolproof as only 2 of them have a detectable odor.

Ketones form as a by-product of fat breakdown for calories. This may happen in starvation, and in diabetes because the glucose doesn't get used so fat stores are used.

Slight traces are a warning indicator; moderate or higher levels of ketones means vetting for treatment of possible diabetic ketoacidosis. The entire metabolism can become deranged and must be treated carefully to avoid extreme metabolic responses.
 
Hi Molly! There is a very good post in the New to the Group? sticky that is specifically on ketones and diabetic ketoacidosis. I think you'll find it helpful to look there. At the bottom of that page there are several links to previous conversations about ketones that you'll probably want to read too.

And yes, any ketones have the potential to grow quickly so they are not taken lightly. There are plenty of cats on here that do not have ketones but have chronic pancreatitis. I have not heard that there is a link between the two conditions. I would definitely want to address the ketones.

There are also things you can do to help resolve pancreatitis. It can make a cat nauseated and ill, depending on how bad it is. We gave Punkin Vit B12 shots, subq fluids, Cerenia for nausea and Buprinorphin for pain and all of those definitely made an improvement in his condition. Here is the Primer on Pancreatitis that i think you'll find helpful as well.
 
There may be a link between DKA and the pancreatitis for 2 reasons:

1. Inflammation can increase insulin need/metabolism and can cause fat to breakdown
2. In acute flares of pancreatitis, the pancreatic enzymes may not be released into the digestive tract properly. These enzymes help breakdown food so the digestive track can absorb. Without them, a cat might have loose stools or poor absorbtion which can lead to starvation/ketones. I don't know if others here have used enzyme supplements, I'm not sure if they are of value in cats.
 
Thank you, BJM. I really appreciate the additional explanations. One question--if a kitty with diabetes is a little chunky and could stand to lose a few ounces (slowly and safely) wouldn't the fat being used up in weight reduction cause ketones? It seems like whenever I reduce Donut's food slightly, the ketones increase and the vet said it's the same effect as a human being on the Atkins diet. Is it possible for a cat to have too few carbs? Dumb question, I know but I'm finding this fat breakdown/ketones/carb thing very confusing. Thanks for anything you can tell me.
 
Meya14,
Thank you for the explanation about pancreatitis and the DKA connection. I read somewhere that a cat with pancreatitis, because of the inflammation, will almost always throw ketones. So how in the world do I keep ahead of them and get them out of the blood? Thanks for your help.
 
Hi Julie,
Thanks so much for the links on Pancreatitis and Ketoacidosis. I cannot understand the cavalier attitudes of most of the vets I've dealt with (regarding ketones.) Some of them don't even recommend monitoring them and some say that if the cat is eating and drinking then not to worry. Weird thing is, a few weeks ago Donut was showing 3.8 on the blood ketone meter and I freaked out because I had read that around 2.5 was where ketone buildup started threatening to turn to DKA. Donut was eating and drinking fine, playful and alert but in a panic I rushed her off to the vet who placated me by running a full blood and urine panel and all of the electrolytes, etc. were fine. The vet could find absolutely nothing wrong and Donut never developed a problem. He had no explanation and I certainly don't. So after that, I don't know when to rush her to the vet and when to just observe. Can anyone give me any guidance on that? The vet is NO help and thinks I'm the ultimate ketone-obsessed kitty mom. Thanks so much.
Molly
 
So, ketones can happen in planned weightloss, usually these are easily flushed out in the urine. Anything more than "trace" in this case is cause for concern. Either the weight loss is too quick, or there is something like dehydration concentrating the ketones. Maybe you can look at what you feed her now and find the calories (usually on the can or package). Food varies significantly on the calorie content, and you may be reducing the food too drastically and not realize it. With the pancreatitis, she may have problems digesting certain foods (diarrhea?) and that decreases calorie intake too. Extra fluids mixed in with foods can help to flush them out.

"Trace" ketones can happen without any effect on the cat as long as the underlying cause doesn't continue and the cat is well-hydrated and otherwise healthy. The problem is it's hard to differentiate the cause initially, and DKA can occur quickly. If you notice changes in appetite with the ketones, that is cause for action. It's good that you are monitoring this.

The last thing, the ketones may mean she needs more insulin. If her blood sugars are >200 at her nadirs, you may want to consider increasing her dose.
 
Meya14 said:
In the hospital, the way we treat humans in DKA is by giving them a dextrose IV and additional insulin (usually much more than they get at home). The extra sugar available in the bloodstream allows for much larger doses of insulin to be given without the threat of hypoglycemia. This is called "substrate". This process helps to change the metabolism away from burning fats.

I usually suggest adding extra carbs because some cats who have blood sugars on the lower side with ketones still need that extra insulin, and adding extra sugars to the diet allows you to give more insulin. However, Sienne is correct, the -cause- of the ketones can be a lack of calories overall in addition to other things.
Click to expand...

Potassium is also extremely important. The insulin and glucose drive potassium intracellular. These patients are often hugely depleted on a total body basis. Sometimes we use that to clinical advantage to temporarily lower a serum potassium in a dialysis-dependent patient whose potassium is high and where the operative case isn't truly elective. Standard trick for us. Headache in treating DKA. Hydration is vitally important in DKA as well.
 
Yes, weight loss will create ketones. This is why it is important to lose the weight slowly in the cat, so the ketones don't develop into diabetic ketoacidosis. Dr Pierson discusses helping cats lose weight at Cat Info on this page.
 
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