Kitty with ketones concern

[Stef]

Hi, I just joined the forum so I apologize if this is not the place where to ask this. My cat was recently diagnosed with diabetes on 11/27/23. We first started her treatment with Vetsulin for a few days and then after some research, talked to the vet and switched her to Lantus. We started with 0.5U and every ~10 days increased it with either 0.25 or 0.5 U (based on the lowest value in the cycle, similar to the Roomp and Rand protocol).

At the beginning of the year I purchased a blood ketone meter and every time I tested her, she tested between 2.5-4.5 mmol/L. I read that this was extremely elevated and she might go into DKA so I went to our regular vet where they ran a bunch of tests and besides small traces of ketone in urine and a slightly lower than normal potassium level (3.3 instead of 3.5 mmol/L) they could not find anything (she did not present any symptoms like vomiting, diarrhea, not eating or lethargy; her energy level might have been lower than before the diabetes diagnostic but I read that is normal until they regulate). They told me to go to emergency care to get her on fluids and a continuous insulin drip, but after they ran some more tests where they saw the pH of the blood was normal and only the fructosamine was elevated (~561 umol/L), they just told me to increase the dose. Both our regular and the emergency vet were not very helpful in trying to find out what is going on..

After that, based on the protocol mentioned above we started to increase the dose every 3 days (which is fast, I know, but I am monitoring her BG closely). She is currently on 4 units of Lantus and still not responding.

I accidentally came upon one of your replies to an older post on this forum where you mentioned that your cat has elevates ketone levels that were lower at the end of the insulin cycle (before the insulin dose) and higher in the middle of the cycle. This is exactly what I observed happening with my cat (which doesn't make any sense since insulin and food should bring those values down). You also mentioned that your cat has IAA. I scheduled an appointment with a feline diabetes specialist next week and I hope I get some answers on a possible acromegaly, IAA or something else.
Has your cat ever got her ketone levels down? Has he ever gone into DKA? Please let me know how things are going for you as I am extremely concerned and trying to make sense of all that's going on. Any advice or details on your experience would be greatly appreciated!

See her BG sheet in my signature.

 

[Stef]

This was directed @Lisa & Oberon, I am still figuring out how the forum works.

 

[Lisa & Oberon]

Welcome! Yes, Oberon had issues with ketones early on, but I'm not sure his experience was typical. Blood ketones were elevated initially, and that got us a visit to the ER, fluids, and a lot of attention. What I discovered with him is that he would have ketone levels that were considered to be high (I think his max was 8), but never really showed any symptoms. Once we started to get to an effective Lantus dose, he cleared the ketones any time his BG dropped below 200 (or so; I don't remember details now), but then they'd creep back up when BG went up again. Once we got things under better control, ketones dropped to near 0. Now I very occasionally do a spot check if BG stays elevated over 300 for a few days, but haven't had any issues.

Having said all that, ketones are definitely something to take seriously; Oberon had no symptoms at ketone levels that definitely affect other cats. In other words, ECID (Every Cat Is Different). So know the symptoms and watch for any problems.

Looking at your SS, my guess would be that you just haven't gotten to an effective dose yet. In my case, we had to ramp up to 10 U (over about 3 months) before we got to a good dose, and once we hit that breakthrough dose his dose actually dropped pretty quickly. Then back up again, then down again, over weeks/months. We eventually got to a sort of level dose, and then switched to Levemir, which worked a bit better for Oberon (less extreme BG swings). It's an ongoing process. (In addition to the main SS, I've been graphing his data, so you can see about 4 years of BG, Lantus/Lev dose, ketones, etc. at a glance in the "BG vs. date- All" tab, to get a sense of what it's been like.)

You might want to post over in the Lantus/Levemir forum if you haven't already. It's pretty active and you'll get good advice about dose and other stuff from some of the long-term members there. I think I can honestly say that they saved Oberon's life; I had no idea what I was doing at first and my vet was pretty "by the book." Good luck!

 

[Wendy&Neko]

Hello and welcome.

I am still figuring out how the forum works.

We ask that people post first in the Feline Health forum, and introduce your kitty and issues. To start a new thread, look at the top right for the Post New Thread button and click it. It then will ask for your subject title, see the rest of the forum for the general style. There aren't any guidelines in this Feline Health forum for subject line content, but there are in the Lantus forum due to how busy it is.

Good to see you've got the spreadsheet up and running and your subject line setup. That just makes it easier for us, cause otherwise we'd all be asking the same questions. I'm glad you reached out to Lisa. @Suzanne & Darcy , if she has time to pop in, also had a similar situation with her Darcy.

A suggestion about testing - it is really beneficial if you can get a second test after shot time each and every night. Many kitties go lower at night, and we determine how to change the dose based on how low the dose is taking the cat. Hence the desire to see what is happening at night. Also, the Tight Regulation protocol, (aka Roomp and Rand) requires those tests so you can see what is happening at that dose.

What percentage of his diet is currently dry food? Some of our members find that the Dr. Elseys seems to impact their cats blood sugar numbers.

One more question, why did you switch to the Pettest meter from the Relion?

 

[Suzanne & Darcy]

Hello. My cat did go into DKA and high ketones for quite a long time afterwards, even though he never had another DKA. He still had high ketones for a considerable time afterwards, until his insulin dose was raised quite a bit to a very high dose — but he had acromegaly.). As long as he ate well and was not lethargic, I managed it at home with sub-q fluids if his ketones were high and I made sure he was eating really well. If anything seemed “off” or hos appetite waned, I had him at the vet for bloodwork. Sometimes his white count was elevated and we had to do a course of antibiotics. I had to make sure that an infection would not push him into another DKA. We never did discover the source of his periodic elevated white count. Some cats seem to produce more ketones than others — particularly those who seem to need higher doses — although it is NEVER something to be taken lightly, as you already know.

 

[Stef]

Welcome! Yes, Oberon had issues with ketones early on, but I'm not sure his experience was typical. Blood ketones were elevated initially, and that got us a visit to the ER, fluids, and a lot of attention. What I discovered with him is that he would have ketone levels that were considered to be high (I think his max was 8), but never really showed any symptoms. Once we started to get to an effective Lantus dose, he cleared the ketones any time his BG dropped below 200 (or so; I don't remember details now), but then they'd creep back up when BG went up again. Once we got things under better control, ketones dropped to near 0. Now I very occasionally do a spot check if BG stays elevated over 300 for a few days, but haven't had any issues.

Having said all that, ketones are definitely something to take seriously; Oberon had no symptoms at ketone levels that definitely affect other cats. In other words, ECID (Every Cat Is Different). So know the symptoms and watch for any problems.

Looking at your SS, my guess would be that you just haven't gotten to an effective dose yet. In my case, we had to ramp up to 10 U (over about 3 months) before we got to a good dose, and once we hit that breakthrough dose his dose actually dropped pretty quickly. Then back up again, then down again, over weeks/months. We eventually got to a sort of level dose, and then switched to Levemir, which worked a bit better for Oberon (less extreme BG swings). It's an ongoing process. (In addition to the main SS, I've been graphing his data, so you can see about 4 years of BG, Lantus/Lev dose, ketones, etc. at a glance in the "BG vs. date- All" tab, to get a sense of what it's been like.)

You might want to post over in the Lantus/Levemir forum if you haven't already. It's pretty active and you'll get good advice about dose and other stuff from some of the long-term members there. I think I can honestly say that they saved Oberon's life; I had no idea what I was doing at first and my vet was pretty "by the book." Good luck!

Thank you so much for all the details! I really hope I get some answers on Tuesday.

 

[Stef]

Hello and welcome.

We ask that people post first in the Feline Health forum, and introduce your kitty and issues. To start a new thread, look at the top right for the Post New Thread button and click it. It then will ask for your subject title, see the rest of the forum for the general style. There aren't any guidelines in this Feline Health forum for subject line content, but there are in the Lantus forum due to how busy it is.

Good to see you've got the spreadsheet up and running and your subject line setup. That just makes it easier for us, cause otherwise we'd all be asking the same questions. I'm glad you reached out to Lisa. @Suzanne & Darcy , if she has time to pop in, also had a similar situation with her Darcy.

A suggestion about testing - it is really beneficial if you can get a second test after shot time each and every night. Many kitties go lower at night, and we determine how to change the dose based on how low the dose is taking the cat. Hence the desire to see what is happening at night. Also, the Tight Regulation protocol, (aka Roomp and Rand) requires those tests so you can see what is happening at that dose.

What percentage of his diet is currently dry food? Some of our members find that the Dr. Elseys seems to impact their cats blood sugar numbers.

One more question, why did you switch to the Pettest meter from the Relion?

Thanks for letting me know! I am getting occasional readings at night as well, nothing seems to change though. I try to feed her mainly pate but she became picky since the diagnosis and I saw that she prefers dry food so I am giving her some if that as well (about 1-2 tablespoons a day). I did not see any change in the BG after I feed her dry food (when I measure 1-2 hrs afterwards), compared to when she is fasting for 2 hours. I switched back to PetTest just to get a better idea of what is going on. I kept increasing her dose with 0.25U based on the fact the nadir was lower than 300 when measured with Relion. But in "reality" she needed 0.5U dose increases. So until I regulate her I will probably keep using the PetTest meter.

 

[Wendy&Neko]

What dry food are you giving her now? Have you ever tried freeze dried raw or air dried like Ziwipeak?

When people are feeding dry food that means they have to follow the Start Low Go Slow dosing method. Following Tight Regulation (Roomp/Rand) means an all low carb wet food or raw diet. SLGS means holding the doses for 7 days.

 

[Stef]

I am giving her a mix of Epigen 90, Dr. Elseys chicken and Young Again Zero Mature. She is mainly eating wet food though.

 

[Sienne and Gabby (GA)]

If you read the Roomp & Rand Tight Regulation Protocol, one of the guidelines is a low carb, canned food diet only. Even though the dry food you're using is lower in carbs, the Protocol disallows for dry food.