? Milo was hospitalized - need help w/dosing

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MayL

MayL

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Hi everyone,

Unfortunately, Milo had trouble breathing Friday evening and I took him to the vet on Saturday. The X-rays showed something in his lungs either fluid or inflammation. His stomach/intestines were also filled with gas. The vet sent me to 24 hour emergency care. He was admitted and treated for both potential heart failure or pneumonia because either one of those could cause what they saw on the X-Rays. He was receiving nebulization treatment when he hospitalized for the last two days. He was also in an oxygen tank then too, but they thought he was able to breathe on his on and released him today. He never had any open mouth breathing during this whole ordeal or even now at home.

His internal specialist did an ultrasound on his heart to rule out heart failure as the cause of the "fluid" found in the X-Ray in his lungs. It may simply be inflammation possibly from pneumonia and we are treating Milo with marbofloxacin (antibiotics). He was eating okay in the hospital but it has declined quite a bit and he's on an appetite stimulant now (cyproheptadine - which my vet told me causes increased meowing and we noticed he's yowling now, super scary to hear). He's lost almost a pound over the course of just a few days and he is pretty weak
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:( When we brought him home, we carried him out to pee and he lost his footing and stumbled and fell. This happened again when he went to pee the second time. So heart wrenching to see him like this.

So I was at 2.5 units of Prozinc right before this all happened. But I am not 100% when Milo got his shots when he was hospitalized and what his BG readings were during his stay. I do know he tested for 600 on the alphatrack around 9 am today and they had given him 4 units at 4 am. He also hasn't really eaten and there is the stress factor. So I am sort of a lost on what I should dose him now that he is home??? My vet said start him at 3 units. Thoughts???

And if anyone has experienced anything similar re: the respiratory issues I welcome your thoughts. Thank you!
 
How many hours has he been home from the vet? Since you aren't sure when he got his last insulin, I just want to make sure that it's safe to inject tonight.

As for dose, I think I'd see what he's at now that he's home and you're back to the relion, and then probably start back at your last home dose. Remember that cats run lower at home, so I wouldn't base dosing on the vet's numbers. Also, if he isn't eating well, that needs to be factored in as well.
 
I'm so sorry, but I'm going to need to log off soon, so hopefully I can answer what you need through a bit of guessing:

You said the last shot was 4am. I'm not sure what time zone you're in, so I don't know how many hours ago that was, but assuming it's at least ten hours ago, and assuming the BG is pink or red (or black), I would go ahead and shoot the 3u the vet recommended. If the BG is yellow, I would shoot 2.5 or 2.75, depending on how high of a yellow, and how willing he is to eat. If the BG is blue, then it may not have been enough hours since the last shot, or it may be because of Milo's reduced appetite. Regardless, I would wait until his BG is yellow before shooting.

I really hope something in there is what you need for tonight. And if not, I hope someone else will be around a little later. I'm sorry I have to run.

I'm also so so sorry to hear that Milo has been having a tough time. I hope that now that he's home he'll have a quick recovery and you can all relax and rest.
 
Hi @Djamila and @Kris & Teasel,

It's been a very stressful week, but happy to report that Milo is feeling better. He's eating on his own (without appetite stimulant) and he seems happier. He is peeing and pooping (he's a little constipated). We have an appt tomorrow to get his lungs re-checked to see if there is an improvement.

Milo didn't eat much earlier in the week and when he did eat it was mostly wet treats and Fancy Feast Gravy and other gravy like food. All of it had carb content over 10%. We are weaning him off that and back to his low carb diet. It's a slow process and he is still recovering from his hospitalization and preemptive pneumonia. So we are struggling to get his numbers down. The new meds that is his on are marbofloxacin (antibiotics 14 day treatment) and cyproheptadine (appetite stimulant - he had it Monday to Thursday of this past week). And remember we had just started him on budnesonide on April 19 so he was getting used to that steroid. I asked the vet if she thought the steroids repressed his immune system and that's how he caught pneumonia. She didn't think so... but I have my doubts.

Are these high numbers expected considering everything that happened? That with some sort of inflammation and illness in his body and his lack of low carb food that it's going to take possibly longer cycles to get him down to acceptable numbers. Should I keep going up in .25 after several cycles or should I stay a little longer on a dose in case when he starts feeling better he starts responding to the insulin dose?

Also, his insulin is 2 months old and towards the last of it. Maybe it's not as effective?

If you look at the SS, you can see lots of high PS and I am very concerned, but I am trying to remind myself he was in the hospital just one week ago.

Any insight would be reassuring!
 
Yes, illness can wreak havoc with BG numbers, as can steroids. Budesonide is supposed to have less of a BG elevating effect but it can do that still. High carb food can be what they need to get through a period of inappetance and it also elevates BG. When they're ill, though, you do what you need to do and dose around those issues. His 2 month old insulin should still be fine.

Yes, I think you should start raising his dose in 0.25 u increments starting tonight. Keep the dose only 4 cycles or so and increase again until you start seeing a lot of yellow and blue popping up. The longer he sits in high numbers the more stuck he'll get from the effects of glucose toxicity which reduces their responsiveness to insulin. Careful but fairly frequent dose increases will get him through that. Test around mid cycle as often as you can and/or get a before bed test daily. Plan to do a full curve on a day off.
 
I agree with Kris' comments. Yes, these health issues and meds can raise BG, and yes, you need to increase the insulin to meet the higher need. If you scroll through my spreadsheet for the end of 2017 (Oct+) and so far in 2018, you'll see the dose moving up and then moving back down again as Sam would have pancreatitis and then recover and get it again and recover again....on and on. It's important to give enough insulin to try to get them into the best numbers possible, even knowing that the need will change continually.

The mid-cycle tests let you know when it's time to reduce the dose, so it's important to keep an eye on those as much as you can.

I"m so glad to hear that Milo is home and doing better! You guys have really been through it lately! :bighug:
 
Hi everyone! Milo has been doing much better in terms of his other health issues, but I am still struggling to figure out what the right insulin dose for Milo is.

If you look at the ReliOn tab, you can see that I usually give him 3.5 when he's in the high 200 or above and a 3.25 or less when he's 200 or lower. I have been reluctant to go to 3.75 because you can see sometimes the 3.5 drops him to low 100 or even once below 100 PS (see June 7 and 8). I can't figure out why he's so unpredictable.

Today we tried to do a curve for my vet who wants to see the BG with Alpha Trak so please see Alpha Trak tab. 4 hours after his shot he's still essentially the same. Sitting around high 300s/ low 400s. We do notice that food does have quite an impact on his BG even though he's on low carb foods. He's also on Budesonide. He's been on it for a month now for his IBD.

Would love to get some advice and thoughts!
 
Hi @Kris & Teasel @Rachel @Djamila - did you get to see my latest update above? :) Sorry my spreadsheet looks a little incomplete as I am mixing and matching Relion and Alphatrak these last couple of days to try to get a curve for the vet. Milo's BG numbers are showing a similar pattern compared to yesterday. He started PS at 320 and then two hours at 495 and then four hours later at 399. I will prick him a couple of times, but just don't know what's going with him!

I am afraid to share these numbers with the vet because I think she will just say bump the dose up and maybe he's insulin resistant. But is he insulin resistant when some days the same dose can get me good BG numbers and then the same dose the next day gives me all high BG numbers? If these are bounces, I can't seem to predict when they will happen again. HELP!!! :blackeye::arghh:
 
He does seem pretty bouncy. I'm just going to go through a list of possible factors, and you can consider which, if any, might be at play here:

1. You're sure he isn't getting any carbs from another pet or another person? Even a couple of pieces of kibble or a high-carb treat can send some kitties bouncing like a ping pong ball.

2. Timing of the AMPS/PMPS tests. Some cats will rise over 100 points in the last hour alone, so if the test is even a little early or late it can look like they are all over the place, when really it's a matter of timing. Other cats have more flexibility. So if the timing has been a little on the flexible side, you might try being super rigid about it for a few days and see if it makes any difference.

3. Assuming that he isn't getting carbs and timing isn't the issue, I would suggest getting some middle-of-the-night tests. I know, I know, those are the worst but they can help to figure out if he's over-reacting during the night (some cats run lower at night) and then the daytime cycles can get all wonky. Wonky is a very scientific word ;):bookworm::smuggrin:

Then assuming that isn't the problem, I would maybe start to suggest trying a different insulin. I'm hesitating because i don't remeber Milo's history. Your signature says he was diagnosed in December. Has he been on Prozinc the whole time? If yes, then he's at about six months which is when we start to think about changing insulin if a kitty is still struggling. But your spreadsheet starts in March, so if he just started insulin in March, then it's a little too soon to switch.
 
So sorry! I did see your post this morning but it's been one of those days at work so I didn't have a chance to reply. I really think you're seeing bouncing. You get a blue or green number then he runs super high for the next few cycles. That's such a common bounce response. I know it's hard to see those high numbers, but a black preshot after a blue or green number just screams bounce to me.

As Djamila said, one of the L insulins MIGHT actually help level him out. We've seen it work better sometimes for bouncy kitties...you can work through bounciness on ProZinc (we had one who bounced for 2 years and then one day just headed down the scale and went OTJ...been OTJ for several years now!), but Lantus and Lev tend to give flatter cycles which can really help level out that bounciness.
 
Thank you @Djamila and @Rachel! Milo had been on Prozinc since January. I didn't know about this site and doing daily PS and hence not a lot of data before March. Milo appeared to be responding well to Prozinc going down to 1.75 units in mid-April. Please look at Relion tab. Then you can see the shaded orange row (April 19) which is when he started budesonide and then May 5 and 6 when he was hospitalized. Those two events may have derailed the poor guy! Yesterday he was at 325 at +5 using the Alpha Track and then we had to head out for dinner and didn't get to test him until around +9/+10 and he was in the mid-200 (I don't have the meter handy to input into SS) so I think his nadir happened when we were out. Today we will be home most of the day so we can see what happens.

Also, no kibble in the house or high carb treats. I think I will try to be more exact with the timing of the PS tests and do some tests in the wee hours and see what I am seeing. Keep you all posted!
 
MayL said:
Thank you @Djamila and @Rachel! Milo had been on Prozinc since January. I didn't know about this site and doing daily PS and hence not a lot of data before March. Milo appeared to be responding well to Prozinc going down to 1.75 units in mid-April. Please look at Relion tab. Then you can see the shaded orange row (April 19) which is when he started budesonide and then May 5 and 6 when he was hospitalized. Those two events may have derailed the poor guy! Yesterday he was at 325 at +5 using the Alpha Track and then we had to head out for dinner and didn't get to test him until around +9/+10 and he was in the mid-200 (I don't have the meter handy to input into SS) so I think his nadir happened when we were out. Today we will be home most of the day so we can see what happens.

Also, no kibble in the house or high carb treats. I think I will try to be more exact with the timing of the PS tests and do some tests in the wee hours and see what I am seeing. Keep you all posted!
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Well, we tested him right at the 12 hour mark and he came in at 113 on the Alpha Track! This is after we gave him a 3.5 unit last night when the PS came in at 301. We tried to stall but the little guy is very hungry and with some food and a hour later he is at 145... Thoughts?
 
I'm so sorry no one was around. Looking at your spreadsheet, it looks like you handled it really really well. Great job! :bighug:
 
Hi everyone, I've kept Milo at 2.5 units for the last few cycles and he looks more stable than he has when he was on the higher 3.5 (see ReliOn tab). His PSs have been always in the 200-300 range with no weird bounces yet. I am wondering maybe the 3.5 units was too high?
 
Hmmm...it's hard to say. How effective a dose is depends on the mid-cycle numbers, and all I see on the past few days are pre-shots. Any chance you can get some tests during the day tomorrow? That would give a better idea of how he's doing at this dose.
 
Djamila said:
Hmmm...it's hard to say. How effective a dose is depends on the mid-cycle numbers, and all I see on the past few days are pre-shots. Any chance you can get some tests during the day tomorrow? That would give a better idea of how he's doing at this dose.
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Hi @Djamila, got in some mid-cycle numbers this weekend! We got a 158 @ +5 yesterday and a 115 @ + 6 today. Do you think we can be a little more aggressive with his shot? I know ReliOn could be quite a bit lower than a reading on Alphatrack so just want to make sure we are giving Milo what he needs. Thank you!
 
My hunch is that you could raise to 2.75u, although there are a couple of caveats with that. There wasn't a PS number listed with the 115, so I'm not sure how steep the dive was. Also, when you did the cycle for the vet with lots of tests, it looks like Milo continued to drop until late in the cycle, which means that if that is a typical pattern for him, he may have actually gone lower than that 115 in which case raising the dose could be a little risky.

If it's a cycle you can monitor, I'd say go ahead and raise it and see how he does, but I wouldn't recommend raising until you can be around to do a couple of tests and make sure it's really okay.
 
Djamila said:
My hunch is that you could raise to 2.75u, although there are a couple of caveats with that. There wasn't a PS number listed with the 115, so I'm not sure how steep the dive was. Also, when you did the cycle for the vet with lots of tests, it looks like Milo continued to drop until late in the cycle, which means that if that is a typical pattern for him, he may have actually gone lower than that 115 in which case raising the dose could be a little risky.

If it's a cycle you can monitor, I'd say go ahead and raise it and see how he does, but I wouldn't recommend raising until you can be around to do a couple of tests and make sure it's really okay.
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Thanks @Djamila for the quick response! Too quick actually haha. I realized I forgot to enter the PS number for today - it was 332 and had just entered it when you replied :) Sorry about that!

When Milo continued to drop late in the cycle (during the curve for the vet) that was with 3.5 units. So my thinking was the dose was too high if the duration of the insulin was going on passed the 12 hour mark. That's when I started with the 2.5 units. In general, I do not believe it's typical for him to drop late in a cycle.
 
Perfect! Thanks for clarifying. I still like to do increases when I can be around to make sure my cat doesn't over-react, but that extra info makes me feel a little more confident that Milo is ready for an increase.
 
Djamila said:
Perfect! Thanks for clarifying. I still like to do increases when I can be around to make sure my cat doesn't over-react, but that extra info makes me feel a little more confident that Milo is ready for an increase.
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Totally agree! I will be working from home earlier this week so I might do an increase at that point, but feel okay with 2.5 in general right now :) Milo just isn't jumping around like he was when I had him at the higher dose. I think his illness really made his BG wild and now that he is feeling better I hope we will keep moving the dose down to his pre-hospitalization days. Fingers crossed.

When you look at the PS of 332 and then compare it to the 115, what helps you decide if an increase is okay? I think I read you want to make sure the cat isn't dropping like 50% in a certain time frame?
 
50% is a "good" drop. More than that can be a little steep and cause bouncing, but it depends on the cat. Less than that and they probably need more insulin (exception being in lower numbers where you do want less than 50%). So 332 to 114 is on the steep side. If that was all I had to go on, I'd say wait a little longer to increase. However, the day before, we can see that he was flatter and that the insulin ran out rather early, so in putting both of those together, and that they are both blues and not greens, I think he can take a little more. My hope is actually not so much that he'll drop more, but that he'll get longer duration. (although a little lower would be nice too).
 
Djamila said:
50% is a "good" drop. More than that can be a little steep and cause bouncing, but it depends on the cat. Less than that and they probably need more insulin (exception being in lower numbers where you do want less than 50%). So 332 to 114 is on the steep side. If that was all I had to go on, I'd say wait a little longer to increase. However, the day before, we can see that he was flatter and that the insulin ran out rather early, so in putting both of those together, and that they are both blues and not greens, I think he can take a little more. My hope is actually not so much that he'll drop more, but that he'll get longer duration. (although a little lower would be nice too).
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A longer duration is better because it shows Milo's response is more stable? Rather than getting bigger dips and drops?
 
You ask great questions! When you get longer duration, the pre-shot numbers start to come down because the insulin isn't all gone. So for example, if the insulin is gone by +10, then the last two hours, they just rise and rise. If it lasts until +14 (about max for Prozinc), then you get to shoot at lower numbers because the BG is still being held down by the insulin. Then when one dose wears off by +14, that's when the next dose is kicking in (usually around +2 for most cats), so you end up with a slightly flatter, more stable cycle as the insulin overlaps a little between shots. Not all cats can get to that point - some of them just use up Prozinc too fast and there isn't anything you can do about it (except suggest they try Lantus or Levemir which last longer) But some cats, as you increase the dose, will get that longer duration.
 
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