Newly diagnosed Diabetes & CKD

[Deric Smith]

Hello.

I am new to this forum - thank you so much to everyone who contributes to this invaluable resource.

I am in the UK.

My cat Boo was recently diagnosed with Diabetes, CKD - and this ontop of osteoarthritis and a gum infection which requires multiple tooth extractions!

Boo is a 14 year old BSH. He was historically fed on a dry-food only diet, but when we adopted him at 5 years old, he was fed a mix of wet and dry food.

He cannot have the teeth removed because the vet wants to stabilise him first on the insulin. He lost a lot of weight very quickly (down to 3.2kg from 5kg) and has been extremely poorly.

Due to the complicated diagnosis the vet says the treatment for one may potentially exacerbate the other!
So, according to them, we need to prioritise the CKD.
We must feed him on Royal Canin Renal food, which is low protein, HIGH carb, to support his kidneys.
We must administer 2x daily insulin injections to manage the diabetes.

I do not agree with this treatment. This effectively sentences this poor cat to a lifetime on insulin with no chance of remission.

Having done a lot of research on this subject I have found a few academic papers which stated that the Diabetes should be prioritised and one should instead feed the cat a high (animal) protein, low carb, low phosphorous wet-food-only diet. I have been following this advice closely.

Vet in the meantime started Boo off on 0.5IU of Prozinc insulin. His BG curve initially ranged from 27.3 (highest) to 16.3 (lowest). At this dose I felt Boo seemed to be getting a little better, not drinking as much water and a healthy (not ravenous) appetite.

Vet increased the dose to 1IU and suddenly the BG results shot up. BG curve done today with reading ranging between 31.4 (highest) and 23.9 (lowest).

Why has the BG increased since the insulin does was increased? I've also noticed Boo seems to drink more water (he's drinking a substantial amount of water although maybe not as much as he was just before his diagnosis), he is also hungry all the time.

I cannot say how frequently he is urinating and I cannot test the urine, because he goes outside.

Only positive thing is he seems to have put on a bit of weight since his diagnosis two months ago (although not as much weight as you'd expect given how much he's eating). He's not very active although he does seem to be more stable on his feet than he was two months ago.

I am confused by a number of things and I hope this forum might steer me in the right direction. My aim is to get Boo into remission or stable as quickly as possible so we can attend to his sore gums and remove the rotten teeth. Long term I would like him off insulin because it's a total prison sentence for both him and my partner who cannot (won't!) leave the cat for longer than 12 hours.
1. Given both CKD and Diabetes, was the vet correct to prioritise CKD?
2. If I continue on the diet I am feeding Boo, will this cause any more harm to his kidneys and is there any chance of diabetes remission?
3. Why has his BG increased? I read that ongoing infections (particularly dental infections) could lead to stubbornly high BG readings (and the remedy is NOT to increase insulin, but to decrease it) - has anybody here had any experience of this and what would you advise?
4. Given the vet will not treat the underlying dental infection, what do you advise we try to try to reduce / remove this infection so that we can eliminate this as a possible reason for the stubbornly high BG?

Thanks again for your help.

 

[FrostD]

I am going to ask @Wendy&Neko or @Sienne and Gabby (GA) to move this to our Feline Health forum so it can get more eyes

1. No - it is best to prioritize diabetes, because the unregulated diabetes continues to wear on the kidneys

2. Do you have any recent lab work? Depending on CKD stage, more than likely you can get away with a low carb low phosphorus diet,. potentially with a phosphorus binder. But that depends on lab results. I would not do anything with diet just yet (explanation to follow).

We do recommend home testing (blood, not urine). I can't quite tell from your post if he's only being tested at the vet, or if you are also testing at home. The BGs you listed really aren't that different, high is high. The only thing you can do is keep increasing until you hit what we call a breakthrough dose, which can take a little time. The trouble is, if he's only being tested at the vet, that is a very small portion of the picture and we may be missing pieces of it.

Hence why I say not to change food just yet - changing carb % can drastically affect BG, so it is better to be home testing to make sure he isn't going too low.

3. No, you absolutely do not want to decrease insulin during infection. Diabetic Ketoacidosis (DKA) is a very serious and life threatening complication for diabetic cats, and the recipe for that is not enough insulin + inappetence/not enough food + infection/inflammation/underlying systemic stress. So until that can be taken care of, you need to manage BG as best you can with methodical insulin increases.

Now - if he undergoes a dental, then yes that is when you would want to be proactive because BG may drop quite a bit after that as well. The diabetes alone is not a reason to skip a dental, in fact it is usually better to get that taken care of IF he can safely undergo anesthesia and the procedure.

That said, he's pretty underweight. I'd consider consulting a dental specialist if you have them vs your regular vet.

One possible option for cats that cannot have a dental is pulsed antibiotic dosing. You could ask about that. And if you start that, same thing as above, you'd want to be home testing and watching BG closely in case it starts to drop as infection is treated.

Is the 5kg his ideal weight? Are you limiting his food intake? How many calories a day is he eating?

You mentioned "more stable on his feet". Is he showing signs of diabetic neuropathy? That can be treated with methyl B12 - in the states we use Zobaline. It takes some time but in most cases it does help.

 

[Deric Smith]

@FrostD thank you for your detailed response. Just to reply to some of your important questions:

We are performing the BG tests at home using an AlphaTrak Blood Glucose Monitoring kit. At first I thought the monitor was faulty because the readings were so high! On a couple of occasions, first reading would be in high 20's and second reading taken just minutes later was a good 10 points lower. We are only testing him every two weeks so far; should we be testing more frequently?

Thanks for your advice re my 3rd question. I will not decrease the insulin dose un-advised. The vet has said he can administer a course of amoxicillin and clavulanic acid to treat the dental infection, which is often used in cats with kidney disease, and would be unlikely to cause kidney failure or interfere with blood glucose. He has said this will not clear the infection up but will likely allow us to ascertain whether the infection is causing elevated BG readings. In any event he has said he thinks it unlikely that the infection will have a material effect on the BG readings - but this is contrary to what I have been reading elsewhere. Do you agree with the vet's medicine prescription above?

4.5 - 5kg was Boo's normal weight prior to this illness. He eats on demand, we do not limit his food or water intake at all. He's presently eating a combination of Aatu wet food (AATU Wet Cat Food – AATU Pet Food), Carnilove wet food (Carnilove Cat Pouch Multipack (12 x 85g) - Carnilove.co.uk), Blink wet food (Blink! (blinkcats.co.uk)) - I have contacted the manufactures of all products and confirmed that the phosphorous content is well below 0.5%. Presently he is eating between 4 - 7 pouches a day in addition to drinking a substantial amount of water.

He has been unstable on his feet, stumbling over when jumping off the sofa for example, and seemingly disorientated at times. But that has improved. His muscle in his back legs also quickly wasted away which led to difficulty jumping (pulling himself up by his front paws). He is picking up weight but still has a long way to go.

I am not clear what you mean by "lab work"? What tests should I get done?

Thank you!

 

[Diane Tyler's Mom GA]

@Deric Smith
Hi Deric until you hear back from Melissa
@FrostD
You can set up your signature
If you can fill out what we call our signature and information about Boo , that will be helpful,it's at the end of everyone's post in gray can you also put live in UK

To set up your signature which you will see is at the end of everyone's post in gray, click on your name up top and then tap on the word signature and add this information

• Add info we need to help you:
  • Caregiver & kitty's name
  • DX: Date
  • Name of Insulin (do not include dose or frequency)
  • Name of your meter
  • Diet: "LC wet" or "dry food" or "combo"
  • Dosing: TR or SLGS or Custom (if applicable)
  • DKA or other recent health issue (if applicable)
  • Acro, IAA, or Cushings (if applicable)
  • Spreadsheet link. Please put the signature link on the bottom line of your signature information, on its own, so it is easy to find.
  • Please do not put any information about your location in the signature for security reasons. If you wish to add your country location, please add it to your profile.

Be sure to click the 'Save Changes' button at the bottom. If you need help urgently it is important we know these things at a glance. We don’t want to waste valuable time finding out information.

Take a look at mine


We also use a spreadsheet to track our cats BG so we know how the insulin is working and how low they are dropping so we know when to either increase or decrease the dose
We adjust the dose by 0.25 units at a time . We don't adjust the dose by going by the Pre Shots

About the spreadsheet
AMPS - means AM Pre Shot the first test you take in the AM ,you need to withhold food 2 hours before testing so it's not food influenced

Units is where you would put how much insulin you gave
+1 is one hour after giving insulin if you were to test then that's where you enter his _BG number
+2 two hours after giving insulin. ditto
+3 and so on until you get to PMPS - PM pre shot withhold food 2 hours before testing

+1 same as you do for AM cycle

We don't give times because we are all in different time zones that's why we use the + numbers
I'll give you the link to set it up , if you have trouble just ask and we have a member who will gladly do it for you


You can look at any members spreadsheet to see what it looks like, it's at the end of everyone's signature just tap on it

Link to set up spreadsheet ,if you have trouble setting it up just ask we have a Member who will be happy to set it up for you

 

[FrostD]

Tagging @Suzanne & Darcy for thoughts on dental/CKD/the pulsed antibiotics for his mouth.

Ok,.glad to hear food isn't limited. Diabetics don't fully process food and often need quite a bit - and still have a hard time maintaining weight.

Link for neuropathy - https://www.felinediabetes.com/FDMB/threads/feline-diabetic-neuropathy-weak-back-legs.178252/

Link on dentals, though not sure if it will have anything specifically about the situation you're in - https://www.felinediabetes.com/FDMB/threads/info-on-dental-procedures-including-pictures.144338/

As for testing. Yes, the AlphaTrak reads higher overall. Most of us use human meters because they're cheaper. Vets tend to prefer the pet meters for whatever reason, but we've found it really doesn't make a difference. The dosing methods we have account for the differences in readings anyway.

We recommend testing before each shot to make sure it's safe to give the shot, then again as needed. This means getting at least a few AM and PM tests a week around nadir (lowest BG) - on ProZinc, this is typically 4 to 6 hours after you give a shot. We dose based on nadir, as that's the most important number. Some people also choose to do full curves once a week, testing every 2 hours. Downside to that is you may be catching him on a bounce day - where he went lower in one of the cycles before, then liver panicked and dumped stored glycogen and counterregulatory hormones in order to spike BG back up. That effect can last up to 6 cycles/3 days.

Lab work - how was the CKD diagnosed? Do you have a CBC, chemistry panel, kidney panel...? Typically that's diagnosed based on things like phosphorus, creatine, BUN. And the values for those determine what stage the CKD is, and also what to do about phosphorus.

 

[Deric Smith]

@FrostD Thanks again for the advice. Our vet advised performing the BG curve as you described (every two hours) every two weeks. I see from your explanation above though that this really isn't ideal so I will try to perform more daily tests. One before the AM insulin shot, one at the midpoint between AM and PM shot and one before the PM shot. Have I understood your advice correctly?

Thank you for the links on weak back legs and dental care for cats. I am so furious with myself for not picking his dental infection up earlier. We had his teeth cleaned about 5 years ago and that was such a traumatic experience we decided instead to feed him those crunchy biscuits that claim to clean teeth... Obviously didn't work.

I have an appointment to take Boo back to the vet on Friday for a checkup. I shall ask then about the CBC, chemistry panel, kidney panel. I know blood tests were done previously so I'll ask for the details.

I look forward to any feedback @Suzanne & Darcy can offer on the antibiotics suggested by my vet for treatment for the dental infection.

 

[FrostD]

Correct! If you can, one midcycle during nighttime as well, maybe twice a week. They often go lower at night, so it's good to have those spot checks every so often.

And sounds good!