New to FDMB/Help with DKA Cat

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laylamk1

laylamk1

Member Since 2014
Hi Everyone,

I'm told this is the best place for FKA/diabetes support, and I'm new to the game. A little about me and my little girl :razz: :

I've had a diabetic cat for about two years, her name is Annabelle. I got her at a shelter and whomever surrendered her didn't tell the shelter she had health problems, so it was about 7 months before she got sick. She had a pretty bad crash at that time and was diagnosed with insulin-dependent diabetes. We caught everything early enough that time and she mad a full recovery and has been thriving on Lantus ever since, but I'll admit I haven't been too accurate with her curves and using my ipet to test before shots. Please don't judge me too harshly; she was doing really well, I don't have a lot of money and she's a scrapper and would slice me up within an inch of my life every time I tried to test. Also I think my meter wasn't all that accurate. But enough defending myself - I know where I went wrong. Despite all that, when she was seen in March by my regular vet, however, her blood glucose was normal and the vet said she looked great.

Flash forward to my current predicament: I went on vacation last weekend to Sedona and when I left Annabelle seemed great. I have pretty good trust in pet-sitter that she was administering the food and Lantus properly, but something went wrong. When I got home 5 days later, my pet sitter told me she had stopped eating her wet food or hadn't eaten much of it (she's on m/d) with her shots. At that time she seemed pretty happy, though a little quiet but I chalked it up to my being gone.

The next morning she hadn't eaten wet food again but I was pretty sure she had a couple of chomps of the dry food and some sips of water. Also drinking and peeing. A little aside: I realize now that she'd been urinating quite a bit more in the month or so before all this happened, but she sometimes does that when it gets warmer. Hindsight is 20/20 I suppose, and if she makes it trough this I will be much more careful nailbite_smile . Anyway, when I left for work the next morning despite seeming mostly ok from a vitals point of view, she did seem like she didn't feel very well. She was still bright and alert and following me around like she always did, but her meow was off and seemed to be breathing a little differently and stuffed up (she has URI problems which clear up when she's better and flare up if she's sick. I know, another sign).

My pet sitter was still watching the cats for me, so I asked her to keep a close eye on Annabelle and to look out for lack of eating or drinking, lethargy, etc. She said things were mostly ok, Annabelle came and sat with her and purred when she called, but she wasn't sure if she had eaten or drank. My pet sitter left at 3 and I was home by 6, at which time there was a definite change. Annabelle was very lethargic and had developed labored breathing and was very dehydrated. My first question for everyone here is, do you think she was sick for a while and just went down rapidly one day? Or could she have gotten sick just in that 24 hours and declined that quickly? The vets weren't even sure, but I'd sure love some opinions.

I took Annabelle to a 24-hour emergency vet, and they were pretty rough with me, telling me she was very sick, her blood glucose was over 500, creatinine wasn't even measurable, and she was ketotic. They wanted to get her on IV fluids and insulin, antibiotics, and an overnight stay, to the tune of $2000. At the time my checking account was overdrawn by $225. I'd seen her with all these symptoms and bad blood levels before with Annabelle, so I asked if there was a cheaper option. For $374, they pushed sub-q fluids and an antibiotic and sent me home, where I was to take her to my regular vet in the morning.

She declined a bit overnight, and I brought her into my regular vet in the morning, where my usual Dr. was not there so I had to see another vet in the group, one who I don't trust at all and who I think always tries to push the most expensive treatment or just kill 'em. I was so desperate that I thought I would just have to listen to her, but when she started on her usual harangue with me ($5k or let's just kill her) and I was so distraught after no sleep or food, keeping a constant vigil and not knowing what to do, I finally decided to take her home and see how she did. This vet refused to send me home with fluids or any other treatment: 5 days of hospitalization or the trash pile for her body. When I said I wanted to take her home, the vet threatened to call Animal Control on me and told me I was an awful abuser for making her suffer. I won't name names here, but if you're in the SD area and want to know who gave me this rough treatment, message me and I'll let you know.

When I got her home, I made Annabelle comfortable and got some fluids from a vet tech friend of mine. She seemed to do well Thursday night, but declined quite a bit on Friday. Friday night was really rough and I thought I was going to lose her (I'll spare the grisly details) and I made up my mind that if she got that bad again I would have a home vet service come and euth. Somehow she made it through Friday night, and we're on to today where she's perked up significantly. I'm not sure what's helping, but it looks like she's ready to fight again, so so am I. I'm just hoping the money side of it will work out, because I'm probably looking at about $600 for the fluids and stuff today.

I also got some more great advice from Marjie, not sure of her handle on here, letting me know that a cat CAN come back from 3 days of being ketotic with proper care, and she also advised me to come talk to you lovely people. A vet tech friend also told me it's possible, just takes time and round-the-clock care. I'd love to hear any suggestions: questions to ask the vet, things I should look for to see improvement, etc. I will post up-to-date news as I'm at the hospital (I won't leave her side) and when I get home, and anything you all can tell me along the way is much appreciated.

Thank you for reading my story and I look forward to lots of info and support from the forum as well as hopefully supporting those of you going through the same thing. Thanks again to Marjie for showing me the boards! :-D

PS: If someone could teach me, I'll post lots of pics of my little viking.
 
Proper care is really in a hospital with IV (vice sub-Q) fluids with electrolytes if necessary. Also, a fast-acting insulin like R is used to low BG. Frequent monitoring of BG and dose the R as indicated by BG and time.
Syringe feeding may also be required.
 
Glad you found us, Layla.

DKA results from infection + too little insulin + too little food/water. It's very difficult to speculate when she started getting ill or if it happened quickly. It's likely she was showing some ketones in her urine. Once you start to see trace ketones, it can balloon quickly into full-blown DKA if not addressed immediately. If you don't have any ketostix (urine ketone test strips), you should get some at Walmart and test her urine. We recommend that everyone with a diabetic cat keep a check on their cat's urine ketones. It allows you to catch any problems early.

As Larry said, the best treatment for them is IV fluids in the hospital where they can dose a fast working insulin like R to bring the high numbers down. If you can't afford that, then I would discuss with my vet the following home treatments to try and support her as much as possible. Again, my advice is predicated on working with your vet.

--subq fluids; you will need to know how much to give, how often, and which type. When dealing with DKA, you have to address the electrolyte imbalance and certain types of fluids might be more warranted than others

--insulin; is she currently getting lantus? If so, what dose? Are you shooting it every 12 hours? I'd discuss with the vet if it's best to give lantus as a basal insulin and then R as a bolus or, since lantus is not able to yank high numbers down, just use R alone as a bolus to get the numbers down. You will need to get specific instructions from them. We can help you once your vet has told you how he would like to proceed. Please note that using R alone or lantus/R in combo must be done extremely carefully. You cannot allow nadirs to overlap; R is a very quick acting insulin and must be monitored very, very carefully or you could cause her to dive into hypoglycemic numbers. So your vet must be on board and discuss with you the options and the doses. If he wants you to go the route of using R, you can buy Novolin R at Walmart....it's cheapest there. But again, you really must have the vet's input on this.

--in order to do the above, you must be home testing. Relion (Walmart brand) makes a variety of glucose meters that are inexpensive. I believe someone told me the Relion Prime about $16 and a box of 50 strips is $9.00. There is a difference between human and pet glucometers but we can also help you with that. Most of us use human glucometers.

--food; if she were my cat, I'd get a prescription for Iams Maximum Calorie or some other really high calorie, but fairly low carb food. You need to get as many calories into her as you can but somewhere in between 1-1/2 to 2 times what she normally gets. If you are syringe feeding her, I'd go to the pharmacy and buy the 10 or 12 ml syringes; the 3 ml syringes are too small. You need the larger ones because you'll need to feed her often. Keep in mind that 10ml is roughly 2 tsp of food. I'd also add water to the food to get more fluid into her since she is not going to be on IV fluids.

--if she is nauseous or vomiting, you will need to ask the vet for meds like ondansetron which is best for nausea and cerenia which address vomiting. She will do better with her food in the long run if she's not nauseous.

--antibiotics; what is she on and did any vet note the particular source of the infection such as teeth? UTI? How long is the course of antibiotics you are supposed to give.

--do you have her labs? Many of us can help you decipher what the numbers read. You said her creatinine was off the charts. In March, did your vet do a full panel of labs (cbc, superchem, urinalysis) or did he just check her BG with his Alpha Trak meter? Did they diagnose chronic kidney disease?

We also need to get a Spreadsheet set up for her. If you look to the right, under my Gracie's photo, there is a small box that says "PM". If you click on it, you can send me a private message and I can set up a spreadsheet for her in no time at all and link it to your signature here so that you can put her BG readings on it.

I'm going to see if a couple other members who have DKA experience can also drop in. Sending prayers for Annabelle.
 
Actually with DKA usia a bolus insulin is not used, instead, R is given frequently in small doses. Also using a long-lasting insulin complicates knowing what R does to give.
 
I'm glad you found this board, and I too am praying for Annabelle.
My kitty is a DKA survivor. He wouldn't eat for the 8 and 1/2 days that he was hospitalized, so he came home with a feeding tube. The hospitalization was expensive, but less than the $5K your vet quotes and included at least 2 transfusions, and all else that he went through. He was at the University Of Pennsylvania School Of Veterinary Medicine. If there are any vet schools within driving distance (I had to drive one and half hours each way), I would recommend them because they hopefully have the latest knowledge and should be less expensive than a regular ER.
Ondansetron can cost a lot. My local grocery store pharmacy charged me $3.33 per pill. At the Costco Pharmacy (where you do not have to be a member to use their pharmacy, which I am not), they charged me under $30 for 90 pills. That's less than $0.33 cents per pill, so if giving the normal recommended dose of 1/4 pill twice a day, under $0.17 cents per day.
If your vet decides to try an appetite stimulant, you can try Cyproheptadine which I just paid under $14 for 20 pills and again if giving the normal recommended dose of 1/4 pill twice per day, about $0.35 per day.
We can try to help you save money in other ways too.

I hope your vet visit goes well, and you get a wise and compassionate vet that helps you to help your cat.
 
Sorry, Larry, you are correct. I said bolus but I meant they give it as you stated......every four or more hours to bring the numbers down. We did have a DKA cst in LL where they gave both.
 
Thank you everyone for your support, kind words, and information. There's a lot of tips here and I plan to use almost all of them! Now for the updates: I just got back from the vet, and the numbers have improved crazily. Just a few highlights:

- When I took her to the ER vet, her creatinine levels were off the scale - normal range is .8 to 2.4, their scale measured up to 8, and so she was off that scale. Now they are at 3. Still high but what a difference!
- Her blood glucose on Weds was 512 (I know!) and now it's a little low due to what my vet thinks is too much Lantus, but definitely not as bad as it was on either side. Interesting side note, I know cats can sometimes go into remission, so maybe her dosage is too high right now? I'm definitely doing a curve once we get her somewhat stabilized.
- Her BUN on Wednesday was 81, now it's down to normal range
We didn't get enough urine for her ketones, but it's likely those are still pretty high because she feels pretty crappy right now. I'll be taking her back to check on Monday or Tuesday.

So the plan of attack as it stands right now is to continue to push sub-q fluids at home today and Sunday and possibly Monday. Depending on how much she perks up and if she's eating by Monday, I'll either take her back for a re-check and a round of IV fluids and R insulin. I'll also try to have them do a blood glucose curve on that day and see if we can get a better snapshot of what her Lantus dosage should be, AND get them to help me fix my freaking ipet!
Today we also did an injectible anti-nauseac, appetite stimulant and broad spectrum antibiotic which stays in her system for 2 weeks. The vet also told me to try lots of different types of food to get her to start eating and get as many calories in her as we can. Lots of stinky stuff and to heat it up so there's more smell.

I've definitely learned a lot of lessons from this and that diabetes is nothing to be trifled with. Trying to save a few bucks here and there is nothing compared to the horror of watching a cat struggle and almost die an feeling completely helpless. I know we're far from out of the woods, but I think it's nothing short of a miracle that she's made it this far on only sub-q at home, Lantus, and a small dose of antibiotics. Cats really do have an amazing ability to heal themselves with proper treatment. Thanks again for everyone's support and I'll keep the updates coming!
 
Oh, forgot to mention the fun stuff: her personality is coming back - I'm seeing little glimmers! She used to be a little purr machine (literally all the time) and I haven't heard her purr since Wednesday morning. She also got VERY mad and struck at the vet while he was examining her belly, and she was not too happy with me when I tried to move her after that, expressing her loudest and grumpiest meow in 4 days as well. It's so nice to see little glimmers of the old Annabelle coming back, and besides the hard numbers being on the upwsing, that's the thing that gives me the most hope.
 
I'm glad her creatinine and BUN are coming down.

What was her BG that the vet thought it was too low? What is her Lantus dose? The vet should have been able to check her blood ketones....he doesn't have to do urine. There are actually blood ketone meters that are similar to glucometers.

Is he just talking about giving a one time shot of R? I doubt that will do much over the long run. Also, if you get a meter, you don't need to pay him to run the curve. We also find that curves run at the vet's office can be very deceiving. For one, if she's stressed, her numbers will be higher. Secondly, if she has come down lower and then the liver has released hormones and glucagon, her numbers might appear to be high but she won't necessarily need more insulin. You will get much better data by doing spot checks on her at home.

I should have mentioned that we typically recommend you do not allow them to give her a Convenia shot which is the two-week antibiotic. I thought she was on an oral a/b. The Convenia might be effective for two weeks but it actually stays in the body much longer. The problem with that is if she has any reaction to it, you can't get it out. I'd just be sure and keep an eye on her. The other thing about Convenia is it is not a broad spectrum a/b. It is primarily used for skin infections. It's important to know the source of her infection so you can target it with the correct a/b.

You said she was upset when he touched her belly. Did he mention anything about pancreatitis?
 
I already have a meter I just don't know how to use it, and her Lantus dose is 2 units 2x/day. The vet told me to reduce it to less than 1 unit if she's still eating very little. Thanks for the suggestions about blood ketones and the pancreatitis. Her belly is always a bit distended and it's gotten worse with this episode, so maybe that's something to look into. He said the Covenia was a broad spectrum antibiotic, so I'll check in with him on that. Seems like she's doing ok with it but I'll keep an eye on her. Last thing I need is another reaction to something.
I'm sorry I left my labs from today in the car but when I get them I'll pm you so you can set up the chart and we can interpret more data. This has all been so helpful, thank you!
 
I'm concerned about the vet's suggestion to decrease the Lantus dose. What have Annabelle's BG levels been testing at? As Marje noted, one factor that contributes to DKA is not enough insulin.

It's imperative that if you are going to try to manage the ketones at home that you start to home test and to test often. Cats that are hospitalized are monitored around the clock. You need to know whether there's a response to the antibiotic which causes a drop in BG but, more importantly, you need to get BG numbers into a consistently better range in order to decrease the potential for ketones. Also, as Marje noted, testing foe ketones is critical. Ketones can be present regardless of whether numbers are high or low.

You don't need a pet specific glucometer. The cost for strips is much higher than with a human meter. Most people here use a human meter. Walmart's Relion meter and strips are inexpensive and good.
 
You might want to read through this Primer on Pancreatitis. It will give you the most updated info on pancreatitis.

Human glucometers are easy to use. They should work just like the iPet. You just stick the strip in which should turn it on, let the strip fill, and it will give you the number. They all come with detailed instructions so you can be cognizant of things like whether it needs to be coded or not, turning on/off beeps, etc.

How is Annabelle today? Is she eating more?

We'd love to know what numbers you've been getting or the vet has that would make him reduce the dose by that much, we typically raise and lower doses by very small amounts (0.25u) based in the way the insulin works. There are some times when a cat has been put on too high of a dose of insulin by a vet and we will ask that it be decreased by more than 0.25u but with a DKA cat, we would like to see the numbers as close to normal (50-120 mg/dL on a human meter) even if you have to feed higher carbs until the ketones are gone. But she needs to be eating. It's a balancing act.
 
In my signature link Secondary Monitoring Tools are some tips for ketone and/or glucose urine testing, along with some ways to check for dehydration. As you've seen with some of the blood work, when dehydrated, the relative concentrations may be increased.
 
Hi All,

I know everyone's coming from a place of wanting to help Annabelle and I really appreciate all the help and tips. Please remember I'm still in the middle of this and thus very emotional, sleep-deprived, down about 7 lbs, you name it. I know no one intends anything to come off this way but it's starting to be a little much for me on the "shoulds" and "you musts". Please consider my emotional state and the fact that I'm doing everything I can with the very limited resources I have. I know many if not all of you have been there and I do desperately need your help and advice so I know the right questions to ask so I hope no one gets mad at me for saying this. It would be great if answers were posted with that in mind; bullet points would be great also because this is a lot of info for me to take in in two days and no sleep or food, being totally new to this and knowing nothing. Thanks!

So to answer the questions I got:

-Glucose meter and lab work: at this point I don't think I'll be getting a human BG meter, because I already have the ipet. I just need to get a new battery and to get it to work properly. My reason for not spending extra money on a human monitor, no matter how cheap, is that I am in a very bad place financially because of all this and if I'm going to launch myself further into debt, even by $20, I'd rather put it into a day or two of hospitalization. I know this may be frustrating for some of you, but when you're looking at the rest of my answers please bear in mind that I probably won't be able to do regular testing until Monday and I won't have all her labs available until then either.

- Insulin: The vet wanted me to reduce her lantus dose because her BG was pretty low when he saw her, and because I was only able to get a couple of teaspoons of food into her per day at that point. He said if we can't get a decent amount of calories into her, the Lantus could drop her BG suddenly and signifigantly and she could seize or feel even worse. I think I remember Marjie saying something similar to me on FB pms so correct me if that's wrong. For the dosage, the doctor said if she's only eating a couple of tablespoons a day, to do the reduced dosage. If she starts eating much more, she can go back to the original 2 units. Does this sound ok to everyone, or is there some other option I should run by my vet? Also can someone explain this "R" insulin a little more deeply? I'm a little confused because I thought this was the injectible medication that goes with the IV fluids in the hospital, but now I've seen some people talking about an at-hope derivative that is better at stabilizing BG than Lantus? I'd love a good cohesive explanation of the differences, what each is used for and when it's advisable to use it so I can better understand this piece of the puzzle.

-Annabelle herself (thanks for asking Marjie): seems to be feeling pretty good, breathing is good, a little tired (I think that's from the anti-nauseac) but bright and alert. Her personality is coming back a little in that she's purring all the time again and kneading (she kneads all the time, even on hard surfaces and in the air) when she's happy. When I'm poking at her she's fighting back a little more which I take as a good sign, and I've never been so happy to be covered in claw marks. However she still isn't eating and drinking on her own, which is worrisome especially since I have to go back to work tomorrow. I'm hoping I can get her to at least drink by the end of the day.

Thanks again for your support everyone!
 
The manufacturer of Lantus says:
Indications and Usage for Lantus® (insulin glargine [rDNA origin] injection)
Lantus® is a long-acting insulin analog indicated to improve glycemic control in adults and pediatric patients with type 1 diabetes mellitus and in adults with type 2 diabetes mellitus. Lantus® should be administered once a day at the same time every day.
Important Limitations of Use: Lantus® is not recommended for the treatment of diabetic ketoacidosis. Use intravenous short-acting insulin instead.

http://www.lantuspro.com/?WT.mc_id=PSLH ... 1t2-VQ16-c
 
OK..I don't think the intention is to use the lantus to treat the ketones, just to regulate her blood sugar while we work on the ketones with fluid.
 
Humulin or Novolin R (same stuff just made by different companies; the Novolin is cheaper at Walmart...by a lot) is a fast-acting insulin; it's typically in/out in four or so hours. It is more effective at bringing high numbers down than lantus. Lantus is a depot insulin and if you reduce the dose, skip a shot, etc, then you aren't going to get the numbers down like you will with R. Bringing numbers down with lantus takes time. The R is injectable, just like lantus, and they can give it every four or so hours as needed (or if your vet teaches you, you can give it but you absolutely have to test her frequently because it can drop her quickly). So, instead of giving the lantus, you would give the R in the hopes of pulling those high numbers down. You start with a small amount and see how she does. You don't want it to make her numbers crash; you just want to see a downward trend.

I am not aware that they give R in an IV bag. I've never heard of that. They can give dextrose in an IV bag if her numbers are too low. But, as far as I know, if you are trying to get numbers down, you must give a subq injection of a certain amount. Putting it in an IV bag would dilute it. Keep in mind that when I say a small amount, I'm talking about 0.1u (not 1u but 0.1u) to start with to see what it does for her. Again, you need to work with your vet on that.

The reason we have been suggesting the human glucometers is because the strips are phenomenally less expensive than the strips for the iPet. The cheapest I've seen strips is $22 for 25 strips. If you and your vet agree you should shoot R, you are going to have to test a lot and use a lot of strips. If you buy a Relion prime, you can get the meter AND a box of 50 strips for about what you would spend on 25 ipet strips and you also have to buy a battery. PLUS if you start to run low on Relion strips, you can just run to get them at walmart. I do not know what local places carry the iPet strips or if you have to order them. We aren't trying to be pushy; we're just trying to save you money because we know that's what you need to do.

I hope you can get her to start eating on her own.
 
Hi Marjie,

Those are all good points on the monitor, and I will definitely consider buying a human once when I run out of test strips. I have like a hundred right now. Also I didn't think anyone was being pushy, I knew I was just taking it that way so thanks for being patient with me. I've got all my labs now so I'll send them to you shortly, and on her last visit Annabelle's BG was 170 and her ketones were 2+, down from 3+ so we're still moving in the right direction. She ate a lot on her own today and is getting stronger but still not drinking much without help. Could that be because of all the fluids? I'm going to try my darndest to start a curve with the ipet tomorrow and give you those numbers for the worksheet in the next couple day. Thanks again for all your help!
 
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