Luna - AMPS 528, ketones 0.9 mmol/L

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pevsfreedom

pevsfreedom

Member Since 2015
Hi all,

AMPS 528, ketones 0.9 mmol/L (blood). She was treated with fluids twice at the vet a week ago for ketones and they went down a lot.

Can anyone explain what's going on here? She has never been above 500. Ketones were 0.4 mmol/L last 2 weeks and she's spiking again. She's had ketones for months and shows no symptoms of DKA or anything (nor has she ever, active/eating/drinking/peeing just fine), but she's went from .9 to 2.1 to .4 to .5 (after treatment) to now .9 again after treatment... Why is she 500+???

I received Lantus from someone here on FDMB (1 month old vial) and shot her with that yesterday. I assume it was good because it seemingly made her BG levels drop as you can see yesterday. Is there anyway it was bad and I shot a 'blank' dose basically? Or is this some kind of bounce? I have to assume it's good because she dropped from 360 to 302 yesterday which would indicate it's good insulin right? Occam's razor tells me that this new insulin is the trouble but I don't know.

@BJM @Meya14

Started her on 5.5 units today AM with the 'new' vial of insulin I was referring too. Very worried.
 
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Hi John,

I've not got direct experience with ketones. If Luna were mine, I'd try to get a phone consult with the vet/vet out-of-hours service. Sorry I can't help more. :(
 
I don't know anything about Lantus or Keytones, but I did have some very high and unusual readings on my glucometer once and it turns out the battery needed to be replaced and the meter recalibrated. What is the cats behavior like (the 5 Ps )?? In my case the meter and the cats behavior did not agree and that's how I determined that the meter was the trouble. Hope this is helpful. Even a little until someone who knows about Lantus can assist...
 
Critter Mom said:
Hi John,

I've not got direct experience with ketones. If Luna were mine, I'd try to get a phone consult with the vet/vet out-of-hours service. Sorry I can't help more. :(
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She's had ketones for over a month now, fluctuating up and down. No symptoms of anything and she's been to the vet a few times and he wasn't worried, and we just gave her fluids. I know the usual response here with ketones is to rush her to the vet but she has no symptoms of anything and frankly it's a waste of money/time. I'm mostly concerned here with the BG levels and if this new vial of insulin is worth keeping.

Jan Radar said:
I don't know anything about Lantus or Keytones, but I did have some very high and unusual readings on my glucometer once and it turns out the battery needed to be replaced and the meter recalibrated. What is the cats behavior like (the 5 Ps )?? In my case the meter and the cats behavior did not agree and that's how I determined that the meter was the trouble. Hope this is helpful. Even a little until someone who knows about Lantus can assist...
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She's totally fine and acting completely normal. Meter calibrated perfectly with the control solution so I think battery is fine, good idea though.
 
Can you encourage her to drink a bit more water, John. Maybe some light chicken broth or flavour it with a little tuna water to make it more interesting. I've seen BJ comment that keeping a cat well-hydrated (not overhydrated) can help flush out ketones.
 
Critter Mom said:
Can you encourage her to drink a bit more water, John. Maybe some light chicken broth or flavour it with a little tuna water to make it more interesting. I've seen BJ comment that keeping a cat well-hydrated (not overhydrated) can help flush out ketones.
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Yeah I always fill her food up with lots of water and she drinks whenever she wants (hot here in LA). She's not showing signs of dehydration, etc.
 
There's also a possibility that on the PM cycle last night, Luna went a lot lower and she's bouncing today. That's why it's so important to get at least a "before bed" test every night.

Also, anytime you get a test that seems "off", immediately retest...sometimes there's a wonky strip
 
Ketones form as a by-product of fat breakdown for energy. This will happen if there isn't enough insulin available for as little as 2 weeks. You're dealing with a newly diagnosed cat.
The most critical points are that she needs to keep eating and drinking and you need to use the rapid version of the tight regulation protocol (dose changes in as little as 4 shots/2 days, based on nadir tests) to get the dose adjusted to optimal as quickly as possible. This means you must get the pre-shot and nadir tests, even if it means setting an alarm and getting up in the night.
 
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BJM said:
Ketones form as a by-product of fat breakdown for energy. This will happen if there isn't enough insulin available for as little as 2 weeks. You're dealing with a newly diagnosed cat.
The most critical points are that she needs to keep eating and drinking and you need to use the rapid version of the tight regulation protocol (dose changes in as little as 4 shots/2 days, based on nadir tests) to get the dose adjusted to optimal as quickly as possible. This means you must get the pre-shot and nadir tests, even if it means setting an alarm and getting up in the night.
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Luna's had diabetes for about 2 years, though I've only had her for 9 months and been monitoring her at home for about a month. She's eating/drinking.

She's at 5.5 units BID right now.. at what point is she considered insulin resistant/high-dose? I'm worried the insulin's just not working somehow as you can see from her #'s.
 
Chris & China said:
There's also a possibility that on the PM cycle last night, Luna went a lot lower and she's bouncing today. That's why it's so important to get at least a "before bed" test every night.

Also, anytime you get a test that seems "off", immediately retest...sometimes there's a wonky strip
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I'll really try harder on that. I test her so late so +2 is at 1am. I need to get her down to around 7am/7pm so it's easier. Her 2nd test strip read the same #, I tested twice.

Would you think this new insulin is 'good'? +2 she's at 416 though idk if the insulin can work so quickly and perhaps she's just coming off the bounce?
 
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If you see steadily increasing doses required on the same insulin, especially when you get up to around 6 units twice a day, start ruling out high dose conditions such as acromegaly, insulin auto-antibodies (IAA), and Cushings.
Also make sure there are no dental problems, hyperthyroidism, or other infections.
 
How can I rule out those 3 things? Her blood work is in my SS under labs and everything looked good besides liver #'s which are being treated with medication. Do you see anything suspicious under her labs?

She's been OTJ before at the shelter, and 3 units is what 'did it' back then. She went hypo 4 times at the shelter on 2-3 units BID. I can't get her under 200 whatsoever and she's gonna start 6 units BID in a day or two.

She is on antibiotics and just finished treatment today. She absolutely has dental problems but the vet wants to get rid of ketones and get her liver #'s treated before doing dental work. She has lots of plaque, tartar, and inflammation, but no signs of infection per the blood work. Would dental be a good idea despite her liver #'s/ketones? Should I just get it done ASAP to help the BG #'s?
 
It may not be possible to control the glucose until and unless the dental situation is corrected. We've seen that here in several cats.

The elevated liver numbers may reflect fat breakdown for calories due to insufficient insulin allowing use of eaten food. Discuss this with your vet.
 
By dropping that much? Absolutely.
Also, any time you get an exaggerated test value, high or low, its a good idea to re-test to confirm it. As long as the 2 numbers are within 20% of each other, you may consider them the same (on older meters which most of us have; new ones with the new standard can differ by 15% and be the same number)
 
Has anyone told you that if you want to move your shot times, you can do it by just shooting 15 minutes early per cycle? It would only take you a few days to back up your shot times by a couple of hours.

Now shooting early can act a little like a dose increase, so it's important to keep testing, but as high as she is, I doubt if that's going to be a concern for awhile.

I absolutely HATE mornings, but after trying an 11/11 shot schedule and having to stay up a few nights until 5am when China went too low, I made the switch to 6am/6pm. I can get up at 6, test/feed/shoot and usually go back to bed for a little while! It also allows me to get up to a +6 at night since I'm usually up until Midnight anyway. It's made my life a lot easier...even though I still occasionally curse the alarm clock at 6am...LOL
 
BJM said:
By dropping that much? Absolutely.
Also, any time you get an exaggerated test value, high or low, its a good idea to re-test to confirm it. As long as the 2 numbers are within 20% of each other, you may consider them the same (on older meters which most of us have; new ones with the new standard can differ by 15% and be the same number)
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Ok great. I re-tested it and meter read exactly the same. I was hoping it was a fluke.
 
Chris & China said:
Has anyone told you that if you want to move your shot times, you can do it by just shooting 15 minutes early per cycle? It would only take you a few days to back up your shot times by a couple of hours.

Now shooting early can act a little like a dose increase, so it's important to keep testing, but as high as she is, I doubt if that's going to be a concern for awhile.

I absolutely HATE mornings, but after trying an 11/11 shot schedule and having to stay up a few nights until 5am when China went too low, I made the switch to 6am/6pm. I can get up at 6, test/feed/shoot and usually go back to bed for a little while! It also allows me to get up to a +6 at night since I'm usually up until Midnight anyway. It's made my life a lot easier...even though I still occasionally curse the alarm clock at 6am...LOL
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Yeah I've kind of been going 15 minutes later each day instead of earlier. Woops. My wife works at 7 so I think I'll just start testing/shooting @ around 7:30 since it would be easier at night to test. I'm but a boring graduate student so most my time is at home/reading. I got enough of my fill waking up early during my time in the military (4am!!!!)
 
For more details on glucometers, and feline-specific reference numbers, see my signature link Glucometer Notes.

Do the time change slowly!
 
pevsfreedom said:
My wife works at 7 so I think I'll just start testing/shooting @ around 7:30 since it would be easier at night to test.
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What time are you shooting now? You don't want to "just start" at a new time if it's very far off your current schedule (unless you skip a shot for some reason...then you can change your shot time to any time you want it to be)
 
I shoot at about 11 now. I was gonna slowly move it closer to 7:30, not just start at that, I made a post asking for advice the other day and that's what they said to do.
 
How are you testing for ketones? If you are testing with a ketone meter, the reading you are getting is not a worrisome number. There are two articles in this link on ketones and their measurement in the section on "When do ketones show up on a blood ketone meter such as the Nova Max Plus or Precision Xtra meters?" that will give you some guidelines on when ketones are an urgent situation.

As others suggested, adding as much water as possible to Luna's food will help to keep them flushed out of her system. I'd also encourage you to talk to your vet. From the way you made it sound, her teeth are a mess. She may need to be on antibiotics to keep any inflammation/infection in check and to prevent ketones from becoming a bigger problem. Unfortunately, ketones levels can rise very quickly so it's important that you keep an eye on Luna's levels, especially given what you've said about her teeth.

With regard to shooting early, given where Luna's numbers have been, you could move her time by as much as an hour. I would not do this on successive days. However, you could easily move her shot time by 30 min each day.

 
Sienne and Gabby said:
As others suggested, adding as much water as possible to Luna's food will help to keep them flushed out of her system.
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When adding a lot of water to the diet, keep an eye on B vitamin levels (e.g B12/folate tests). B vitamins are water soluble and are excreted via the kidneys. If necessary, it's straightforward to supplement diet with B complex (e.g. Jarrow B Right).
 
I'd change your shot time in a heartbeat. Without a test every pm cycle, we can't be sure there aren'thidden lower numbers in there. If she's over 300 at +11 today, AND you can test her in the pm cycle, I'd shoot an hour early.

The reason you are uncertain what's going on is because we need just 1 test in the pm cycle to clarify the situation.

There is a good link in the "new to the group?" Sticky on ketones, near the bottom of that page. You don't need to run to the vet, but you do need to do the things to clear out the ketones. One of those things is being aggressive with the dose, but you can't safely do that without the pm cycle tests every evening. It might be time for you to start subcutaneous fluids with her. That can make a huge difference. The vet would have to get you started with that - it needs a prescription as far as I know.

We don't consider high dose conditions until a cat passes 6u per shot. She's getting close, but the important thing is to just give her what she needs. At this point, knowing whether or not she has acro is unimportant.
 
Sienne and Gabby said:
How are you testing for ketones? If you are testing with a ketone meter, the reading you are getting is not a worrisome number. There are two articles in this link on ketones and their measurement in the section on "When do ketones show up on a blood ketone meter such as the Nova Max Plus or Precision Xtra meters?" that will give you some guidelines on when ketones are an urgent situation.

As others suggested, adding as much water as possible to Luna's food will help to keep them flushed out of her system. I'd also encourage you to talk to your vet. From the way you made it sound, her teeth are a mess. She may need to be on antibiotics to keep any inflammation/infection in check and to prevent ketones from becoming a bigger problem. Unfortunately, ketones levels can rise very quickly so it's important that you keep an eye on Luna's levels, especially given what you've said about her teeth.

With regard to shooting early, given where Luna's numbers have been, you could move her time by as much as an hour. I would not do this on successive days. However, you could easily move her shot time by 30 min each day.
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Hi thanks. I'm testing her blood for ketones with Precision Xtra meter. I had never heard the readings were different for blood or urine I'll definitely check that out. Her teeth ARE a mess. I'm on hold on phone with them right now actually regarding getting her teeth cleaned. She just finished 3 weeks of antibiotics (precautionary, no evidence of infection). Thanks for all the info.
 
julie & punkin (ga) said:
I'd change your shot time in a heartbeat. Without a test every pm cycle, we can't be sure there aren'thidden lower numbers in there. If she's over 300 at +11 today, AND you can test her in the pm cycle, I'd shoot an hour early.

The reason you are uncertain what's going on is because we need just 1 test in the pm cycle to clarify the situation.

There is a good link in the "new to the group?" Sticky on ketones, near the bottom of that page. You don't need to run to the vet, but you do need to do the things to clear out the ketones. One of those things is being aggressive with the dose, but you can't safely do that without the pm cycle tests every evening. It might be time for you to start subcutaneous fluids with her. That can make a huge difference. The vet would have to get you started with that - it needs a prescription as far as I know.

We don't consider high dose conditions until a cat passes 6u per shot. She's getting close, but the important thing is to just give her what she needs. At this point, knowing whether or not she has acro is unimportant.
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I'm gonna get her dental done Monday. If the BG's don't start lowering after that I think I'll start looking into more info on high dose conditions. She's been in remission twice before, can a high-dose condition develop over time?
 
Cats with acromegaly have a tumor on the pituitary gland that puts out a hormone that blocks the cat's own insulin from being able to get into the cells. That tumor is called a 'pulsating' tumor....it can ramp up or wind down. Cats with acro can go otj when the tumor quiets down and need insulin if it ramps back up.

That said, cats without acro can also heal and go off insulin for intervals as well. So this alone doesn't tell much.

The best, most recent research on acro is in the New to the Group? sticky, near the bottom of the page. There are multiple entries about the topic.

I don't know if a vet would do a dental while there are ketones present.
 
You would have to schedule the dental too, and either reduce or skip insulin the morning of the dental, depending on your vet's directions.
 
Her liver #'s are a bit high per her labs in my spreadsheet and she has ketones. Vet said bring in in Wednesday AM for quick blood panel and they'll do dental unless something is horribly off with her #'s. Gonna give her fluids throughout as well and antibiotics to come home. He said skip food and insulin on that morning and continue regularly after procedure.
 
I'm not convinced these aren't highs from bouncing.... although the presence of ketones tells us there isn't enough insulin.

If the vet thinks she isn't stable enough for the dental, I would ask about an antibiotic to address her teeth issues. That could be the source of the infection that's causing ketones. A good AB for mouth infections is Clindamycin because it works against anaerobic bacteria, which can often be found in oral cavities like abscesses. It can cause diarrhea though, so a probiotic can be smart to prevent that.

Fortiflora is a probiotic for cats and you can buy it from vets or online. I'd get some now and start her on it.
 
julie & punkin (ga) said:
I'm not convinced these aren't highs from bouncing.... although the presence of ketones tells us there isn't enough insulin.

If the vet thinks she isn't stable enough for the dental, I would ask about an antibiotic to address her teeth issues. That could be the source of the infection that's causing ketones. A good AB for mouth infections is Clindamycin because it works against anaerobic bacteria, which can often be found in oral cavities like abscesses. It can cause diarrhea though, so a probiotic can be smart to prevent that.

Fortiflora is a probiotic for cats and you can buy it from vets or online. I'd get some now and start her on it.
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I think the ketones are mostly from me doing such a bad job before I started home testing. We were blindly shooting 1 unit for a few months and I'm sure her numbers were horrible, but she never had symptoms of anything. We've quickly been increasing her insulin as you can see, and have managed to drop from 2.1 to .4 mmol/L in ketones. I feel stupid for doing such a bad job for so long but nobody told me any of the stuff I've learned on this forum!

She just finished amoxcillyn for 2 weeks, and they're sending her home with antibiotics after dental. Good info regarding probiotics thanks.
 
Also with my monitor it measures .4, .9, and 2.1 mmol/L readings (varying of course). Are these #'s reliable, or are they too low for the Precision Xtra to accurately detect?
 
Sure thing thanks for all your comments. I just hope wednesday they CAN do the dental and not send us home because her #'s are bad. Her liver #'s are elevated as you can see from the labs so hopefully it's not a waste of time/money. Really want her to get dental done but am still scared of anesthesia.. funny because I've had so many surgeries I never thought twice about going under but terrified for my cat.
 
Punkin had 7 anesthesia and was fine. You just want someone who know what they are doing. It's not without risk, but I think experience matters in this case.

Punkin's first dental was done by a pretty low tech vet. I liked the vet, but punkin ended up with an infection, 40 days of antibiotics, diarrhea and c. Diff from it.

The next dental was done by a veterinary dentist. Expensive but worth my peace of mind.

The other 5 anesthesias were done at university vet schools. They definitely knew what they were doing.
 
I think this guy is good. My mom brought their dog in there for a total hip replacement and he's walking like a young pup now. I hope it all works.
 
You also have to weigh the risks...while anesthesia does have some risk involved, they're a lot safer than they used to be. Have a serious discussion with your vet about the type of anesthesia he/she uses, what other alternatives there are and what kind of monitoring they have available while Luna is under

The risks of the continued high blood glucose and the ketones have to be taken into serious consideration
 
John said:
Also with my monitor it measures .4, .9, and 2.1 mmol/L readings (varying of course). Are these #'s reliable, or are they too low for the Precision Xtra to accurately detect?
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Given that numbers above about 2.55 on a Precision Xtra is where you need to be concerned about ketones, the 0.9 is small and reliable. I'm not sure what the equivalent would be with urinary ketone testing -- probably at trace or below. One of the articles I mentioned found that in a one of the groups of diabetic cats included in the study -- the group that were not ketotic -- their ketone levels ranged from 0 - 0.9mmol/L (median was 0.1). The other article concluded that the meter you're using is very reliable.

There's also information on dentals in this link.


 
Chris & China said:
You also have to weigh the risks...while anesthesia does have some risk involved, they're a lot safer than they used to be. Have a serious discussion with your vet about the type of anesthesia he/she uses, what other alternatives there are and what kind of monitoring they have available while Luna is under

The risks of the continued high blood glucose and the ketones have to be taken into serious consideration
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Will do.

Sienne and Gabby said:
Given that numbers above about 2.55 on a Precision Xtra is where you need to be concerned about ketones, the 0.9 is small and reliable. I'm not sure what the equivalent would be with urinary ketone testing -- probably at trace or below. One of the articles I mentioned found that in a one of the groups of diabetic cats included in the study -- the group that were not ketotic -- their ketone levels ranged from 0 - 0.9mmol/L (median was 0.1). The other article concluded that the meter you're using is very reliable.

There's also information on dentals in this link.
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That information is relieving. Worst I've seen her on blood meter was 2.1 mmol/L and we got her to the vet that day.
 
The 0.9 isn't too concerning (probably trace to none on urine ketones) as long as she's eating and drinking. Chronic low-level ketones however, can be indicative of an underlying issue that is causing altered fat metabolism such as infection, starvation, cancer, planned weight loss, or other chronic illness. My guess is if you know the teeth are bad, they are probably even worse then you think. Dental infections will come right back after antibiotics are stopped because there is a biofilm on the teeth, so you may be seeing this reflected in the numbers. When you do get the dental watch her sugars -very closely- the next few days. All the fluids and the anesthesia can drop sugars, and so can getting rid of bad teeth. This can happen really quickly.

Whether she is high does or not, the treatment is to continue to raise the insulin dose to her needs. Eventually, if you do continue with the high doses, getting tested for the disorders might be a good idea, because there are some other long term issues that go along with them. You may just need a lot to break through the glucose toxicity as well.

As far as "bouncing" is concerned, I'm in the camp that doesn't really believe that this happens as often as people think. Most causes of high blood sugar is not enough insulin, and not the other way around. Especially if there are ketones. It is, however, good to get some PM tests to see the entire picture.

Hydration is the other issue. I don't know where you live, but it's been HOT here most of the week. With the high sugars, she's more at risk for dehydration. Keep adding the fluids. Dehydration will concentrate blood sugars and ketones in the blood so these numbers can elevate from dehydration alone.
 
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