Need input on trace/low ketones & general management

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Niki & Ephalba

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Hi all,

I'll apologize upfront for the information dump, but more details are better, right? :smile:

First, my quick question. For better or worse, Ephalba has decided she likes to pee on the kitchen linoleum. Upside--I get to test her ketones! I just tested her and she is showing trace/low ketones on the dipstick. All other behavioral indicators which she usually shows if she's going ketotic are not there. She's eating, affectionate, cleaning herself, eating well. At what point is it critical for her to go to the vet? Is there anything I can do to lower ketones at home? We've spent most of our savings and borrowed from family to pay for her care (details below) and I really don't know if I can come up with another $800-1500 for another ER trip. Advice?

I'd also like some input on how to get her diabetes under control--we just haven't managed success yet.

Ephalba is around nine years old, give or take a year, and was diagnosed December 2009 after what turned out to be a bout with ketoacidosis. Since that time, we've really not been able to regulate her for more than 3-4 months at a time. She's been hospitalized for being ketotic 4 times and has never had a hypo episode. Due to scheduling factors with me and my husband and it taking two people to do a bgc test on her, we do not test before every shot, but I do try as often as we are able (usually weekends). I'm continuing to work on it as I know it's important, so please, no harsh words about that!

She was eating Wellness dry before the dx and now eats 1 1/2 cans of high protein/lo carb wet Friskies per day (no free feeding). She'll eat the other cats' food if I don't watch her. She fluctuates between being a normal body weight and being thin. She drinks and urinates a ton. She currently gets 3u twice a day (in a 100u needle) of ProZinc. She started on 1u twice a day (in a 40u needle) and has had as much as 4u twice a day (in a 100u needle). Here's a recent breakdown of history/doses/curves:

In early April, she was hospitalized for being ketotic. After being stabilized she was at a dose of 4u 2x/day (100u needle). Mid-April curve after two weeks on 4u dose: 6am: 384, +3: 433, +6: 304, +9: 287, +12: 295, +15: 314. She also had her teeth cleaned a week after she was out of the hospital (they needed it!) because the vet was concerned she might have a low level infection that could be causing issues. Urine culture was clean, but she was put on a month of clavamox 2x/day just in case. After this ketotic episode she started showing signs of diabetic neuropathy, which is actually looking better now, but still somewhat present.

We did a curve again in early May, still on 4u dose: 6am: 272, +2: 459, +4: 543, +6: 453, +8: 416, +10: 339, +12: 355. After reporting the curve the vet recommended we actually decrease the insulin to 2u per shot because he thought Ephalba's body might be trying to overcompensate for too high of insulin which was driving the numbers up. I've never heard of this and we were going on vacation two days after, so he recommended 3u per shot and to go to 2u per shot when we were back home.

We've been gone for 1 1/2 weeks and had someone stay with the kitties until yesterday who reported no ketones and no unusual behavior while we were gone. I did the dipstick today, which is when I came up with the trace/low amount. I'm afraid the lower insulin, even though it's a really small change with the 100u needles, led to the issue. I'm also pretty nervous to go to a lower dose if we're seeing ketones. The vet has told me repeatedly, when I've felt the curves are too high, that it's much better to be underregulated than too tightly regulated. I agree a hypo episode is more dangerous than ketosis, but I hate that Ephalba keeps having to go through this and we just can't afford repeat ER trips.

We've had two rounds of blood/urine/stool testing since she was diagnosed to look for underlying infection, check thyroid/liver/kidney, etc. She's also had an x-ray and some kinds of scan I don't remember the name of to check for masses. Everything has come up clean.

Some of the questions I've wondered but haven't gotten a clear answer about . . . Should she be on a much higher dose? Lower dose like the vet says? Should we try another insulin? Is she eating too much--would less food change things? Are there other things we should test her for? What would you do if Ephalba was your lovely kitty?

Let me know if you need more info! Thank you from me and Ephalba!

Niki
 
I don't really know much about the insulin that you are using as my guy was a Lantus kitty. But a couple of things that come to mind that 'm sure someone will ask...

How old is the bottle of insulin, could it have lost its punch? Also if I'm remembering right Prozinc is a U40 insulin which you are using u100 syringes right? Which is fine but you need to convert the dosage, did your vet give you a conversion chart? If not there is a conversion chart here http://www.felinediabetes.com/insulin-conversions.htm

So if I'm reading everything correctly, 3u of a u40 insulin in a u100 syringe is only 1.2u as a true dose. It is hard to tell if that is enough or not enough, since it isn't like she is on a super high dose, but then again it could be too high for her.

Sorry I can't be more of a help, except to say you might want to post over on the PZI support group here and ask them as they all use your insulin.

Also while I have seen cats that do well on PZI it doesn't seem like we have many, most of the ones that I have seen on here that have been either well regulated or like my guy gone into remission have been on either Levermir or Lantus. Also I have experience on Ketones as my guy went into remission so quickly that Inever had to catch pee.

Really sorry you guys are having such problems, hopefully someone will be along shortly that can answer your questions better.

Mel, Maxwell and The Fur Gang
 
Hi!

We have a lot in common! My cat, Kitty, is on 4 units of prozinc twice a day and she survived DKA.

I am not an expert, but I will give you my thoughts.

First, supposedly PZI does not expire until it reaches the expiration date.

If you see an inverse curve, it is normally interpreted as too much insulin. Flat curves normally mean not enough. It appears you have an inverse curve, which would support your vet's idea of reducing the dose. In fact, I am impressed that the vet said to reduce on the higher test-- most just want to increase.

You can add water to the food to help get fluids in. The fluids are good for warding off ketones. Nancy and Payne are well versed in ketones and hopefully she will be around to help with your concerns there. My only additional thoughts are to continue to test for ketones frequently.

The ketone history does make lowering the dose scary-- but the inverse curve suggests to lower.

Good luck and hopefully some others will have more advice.
 
Ephalba (fortunately) peed on the floor again and her ketones went from low to trace. Plus there is less of an acetone smell on her breath. Whew. Hopefully I'll be able to test again tomorrow morning and there won't be any ketones. It might sound silly, but I think she's much more prone to issues when I'm gone.
 
Hi Niki,
I am putting kids to bed but a couple of things jumped out at me ....

She has had 4x DKA? or once DKA and other times high ketones only? She is still drinking and peeing a lot? Did it ever get better? then worse? In early April she was in ER for DKA or high ketones? And I am not going on .... but you should never give her a shot without checking her BG # ..... if you put all those #'s together in a spreadsheet, then I think you could talk about changing her dose. A curve done near a visit to ER and one done without additional daily info. is not much help. Did you do the curves?

Why are you going back and forth between U40 and U100 syringes? you are using a good conversion chart? Has she always eaten a lot of food or just since her Dx? Also, if she is hungery, you should be feeding her more, once she is regulated she will even off.

Until you have an idea where she is #'s wise EVERY DAY, I would not change her dose or insulin. And just because she has not hypo'd in the past, doesn't mean she can't or won't at any time, we get them here all the time ..... "but I shoot the same every day, why do I need to check?" because your cat is not the same every day, so each time you give her a shot you are playing Russian roulette, ok I'm done.

Trace ketones need to be watched, especially in a cat that has had DKA but if she is eating, playing and all I wouldn't be as concerned. I would be concerned that she is still doing many things that are saying she needs help and the only way you can help her is to keep records. Actually that is the cheapest .... they interviewed a man who has lived as a diabetic for 85 years and wanted to know his secret. He said that he keeps very precise records, knows his BG #'s always, the food he eats, exercise, etc. "Knowing all this has helped me keep my insulin as close to what my pancreas would do, as I can."

It is like playing detective, putting it together and making you cat as healthy as possible .... much cheaper than living in ER.

Nancy and Payne
 
Hi - I apologize if this is a repeat - I thought I'd posted this but it never showed up...

Anyway - I agree that the ProZinc dose might be too high. My cat, Argyle, switched to ProZinc in April so I started looking through the PZI board. It seems like most of the cats there are receiving smaller doses than 1.4 or 1.6 units twice a day. Even the original 1 unit twice a day may have been too much. The lack of movement in your cat's BG when you did the curves does suggest that the dose is too high. Her insulin requirement might have also decreased after the dental work.

Argyle was in the hospital twice for DKA in March, and I was really freaked out because I couldn't afford another hospitalization ($$$!!!). After the last one, I got some regular, fast-acting insulin (Humulin), which is what the hospital uses to resolve the DKA. I also got some Normosol fluid to administer subQ to flush out ketones. If Argyle's ketones ever get above 'trace' on the dipstick, I give her a little Humulin and some fluids to keep things from getting out of hand. Since your cat is also prone to ketones, I would recommend getting these tools (regular insulin and fluids), which will let you handle problems before they get so bad that you have no choice but to go to the hospital. It also makes it easier on you to make adjustments in her ProZinc dose if you know that you have the tools to handle it if her ketones start rising.

Another thing I wonder is whether your cat is getting enough food. You said that she varies between being of normal weight and being skinny. I don't know what she weighs, but the Friskies can suggests from 3/4 to 1 oz of food per pound of weight. One cause of ketones can be 'fasting'. When Argyle starts showing 'trace' ketones, I always give her a little snack. I don't know how scientific this is, but I figure that it's better for her to be digesting cat food instead of digesting her own tissue. That depends upon their being enough insulin on board, of course...

Just a couple thoughts. Hope I can figure out how to post it successfully this time. Good luck with your kitty!
 
If she isn't regulated, I'd free feed. Otherwise, she is literally starving when the insulin is insufficient to allow her to use the glucose digested in her food.
 
Mentioning the use of short acting insulin to manage ketones has been a taboo topic in the past. However,some cats who get DKA are prone to getting ketones later. Infections and other factors besides high BG can cause ketones to rise.Last time Nomad had ketosis his BG was only in the 120s.Ask your vet if he or she would help you learn how to use NPH or another short acting insulin when your cat has low ketones. If the ketone level is moderate or above then I would take to the vet.
 
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