Options for treating trace ketones?

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heatherh

Member Since 2012
Leko is 19, BG not well controlled, on Lantus. His back legs seem to be getting worse over the last several days. Bloodwork from vet visit yesterday shows trace ketones.

Do I have options for treating it at home? Vet has offered hospitalization, but isn't pushing it. Not sure if we've hit the end here or what... could use some perspective. :(


Edit - added candle icon. Carl
 
We discussed methyl B-12 at the appt and the vet thought it was fine to try, but perhaps not the first thing to worry about. She didn't seem familiar with using it for this purpose.

We are already doing some sub-q fluids (75ml 2x per week or as needed. Usually if he eats less than usual, that's a sign he needs fluids). We're planning to do more daily (50ml every day). She suggested increasing his insulin. Which wouldn't generally be indicated here... his mid-cycle numbers seem low enough that it could be a bit risky... I did increase his shot this morning and will likely do it tonight and just keep an eye on him.

I'll go read that link. Thank you.
 
That post was helpful. "fluids, insulin, and food"

OK, so he seems like he's interested in food, it's just hard to *get* to it. He's tired and his legs are giving him grief. I squirted some water into his mouth and I think I'm going to try spoon feeding him. BG currently at 150. I think I may see if I can get some B-12 locally to try. I've heard 1.5mg for cats < 10 pounds. I'll try to get a urine sample if I can to test for ketones... at least maybe get a baseline so I can tell if he's still trace.

Even if we're able to resolve this on our own... how long do the ketones stick around enough to make a test strip read trace?

I'm having a hard timing knowing if we should continue treating or have him euthanized.
 
Okay I'm curious...I just looked at Leko's spreadsheet and see where he hit the 30s back in Feb on .5u which should have earned him a reduction in dose but you held the dose and then eventually raised the dose...Am I missing something that would have caused you to hold that dose and then eventually raise it?

Also by looking at his spreadsheet I'm not seeing what low midcycles you are talking about...do you have more numbers that aren't in his spreadsheet that you can share with us so we can figure out the best way for you to help him?

Mel, Maxwell, Autumn & The Fur Gang
 
I don't have any personal experience with Ketones, but from what I've read, they are nasty and really require getting flushed out at the vet. Since your vet sort of recommended this, but was not sounding urgent about it, maybe it's worth another phone call? Hopefully by my responding, it will re-kick this message back to the top and someone who has experience can comment.

As far as the food, I assume you've raised up the food dish to chest level so baby doesn't need to bend over for it? And maybe using a small plate instead of a bowl? And, I assume you are feeding a low carb, non-grain food so it doesn't spike the blood sugars?

I hear you on increasing the dosage. Originally, that's what my vet wanted me to try. However, thanks to this group, I learned that what I really needed to do is back down the dosage by .25 instead of increasing it. That lasted a few days and then I had to back it down another .25 units. Then, my girl finally regulated. Now the vet's happy with me. Go figure. So, maybe you are in the same boat if you are getting those big bounces. Did you post your numbers for the experts here to comment? If you wish to do so, you might what to start a new post asking for numbers help.

As far as B12, a very informative link for you on the dosing and types: http://www.felinecrf.org/vitamin_b.htm#methylcobalamin

Regarding your decision, only you can decide when it's time. It all boils down to quality of life, and sometimes, that means the parent's quality of life also. If your kitty doesn't seem to be in pain, you can afford getting the ketones flushed, and you have the energy and desire to try, then proceed, yes?

However, if you feel in your heart that it is time to say goodbye, then I know there is no one here who would fault you on that decision. I can only dream that my kitty will live 19 long, wonderful years. Obviously, you've done an incredible job taking care of your baby.

Here is a good link for you to peruse. It might help you make that difficult decision, or at least help you prepare for that day if it ends up being in the far future: http://www.felinecrf.org/saying_goodbye.htm

Hugs, DZ and Sarah
 
Even if we're able to resolve this on our own... how long do the ketones stick around enough to make a test strip read trace?
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It takes a few hours to make it from the blood to the urine, so if you see "trace" on the urine sticks, you might have seen it a few hours earlier on a blood test.

People have been able to manage "trace" readings at home, and sub-Q fluids are one of the tools you'd use. I think someone has already mentioned the "ketone" formula which is usually
Not enough food
Not enough insulin
An infection of some sort present.

I'm not familiar with the details of Leko's diabetes journey, but looking at his SS, it does look like he could use a dose increase. You've seen some green and blue numbers on occasion (and at inconvenient times like at shot times), but mainly pink and red numbers.

If his back leg issues are due to neuropathy, the Methyl B-12 has helped lots of kitties with that. If he's got low potassium levels, that can cause muscle weakness and supplements can help (need a blood test to verify his levels are abnormal). If his numbers were more regulated, just that will help with neuropathy too.

Like I said, I don't know his history. But I do think that if you could get his numbers down overall, and that may require "more insulin", his overall condition would improve. I've had cats live 19 years and longer, but they weren't diabetic. No matter how long our babies live, it's never "long enough" when they are so loved.

Carl
 
On 12/21, I skipped AM dose because he was 53 at +11. On 12/30, I skipped AM dose because he was 130 at +13. Not really mid-cycle, but weird in between shots.

I've wavered on dose changes. Plus the cautious influence from the vet (until now, when she wants to increase him)... I've just been kind of floundering, yk? I considered reducing his dose, but I haven't caught low enough numbers to warrant it since then.

Thanks for looking closely - I appreciate you taking me seriously and trying to help.

So far, he's good on today's dose. I might do another slightly larger dose like this morning and see how he does tonight... given the urgency, maybe that will help keep his numbers down (good for getting rid of ketones)... if he goes < 50, I'll probably reduce from there. FWIW, he's never seemed symptomatic when he's gone low...

I got some B12 and I'm giving him 2mg daily (given the pills, that's more doable than 1.5mg). He's taking water from a syringe, and he'll take some food from DD (good job for a 3YO who wants to help). I did get a urine sample, and the ketone stick shows trace. Barely.

But he hasn't walked to food or litter box since this morning. I helped keep him steady for the urine sample.

When you say getting the ketones flushed, you mean at the vet?

Looking at the other link...

Carl - I think that's what we're trying. Encouraging food and water, more sub-q fluids and keeping tabs on BG after a small dose increase.

Thanks you guys.

Edited to add: His food is on the floor in a plastic shallow dish. I might try making it more accessible... maybe that would appeal enough to get him over there. He's on Nature's Variety Instinct - one of the lowest carb and also fairly kidney friendly.
 
Just checking - you got the METHYL- B12, (methylcobalamin) and not the CYANO - B12 (cyanocobalamin), right?
 
When you say getting the ketones flushed, you mean at the vet?
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I think when we say "flushed" it just means that the added fluids will cause more urination, and the more he pees, the better off he'll be. If ketones are higher than "trace", that usually means a vet stay, and they would probably do more fluid treatments. They'd also use most likely a short acting insulin more often to try to force his numbers down.

My cat, Bob, was diagnosed "DKA", which is life threatening. His ketones were out of control. He was given several shots of insulin per day, and got fluids a lot, for 3 days and nights. He survived it. Had I not brought him to the ER, he would not have survived. When he came home, I was giving him 200ml of fluids per day for a couple days, then he got 100ml per day for a few more days. He also got potassium which was added to the fluids, because his potassium was too low. After that, he never showed even "trace" amounts of ketones. At the vet, the treatment is much more aggressive, which is because the ketones are worse than "trace" usually. Any level higher than trace really needs vet attention.

Another way to get fluids into Leko would be to add some warm water to his food, make it sort of mushier. If he'll eat it that way, it will help hydrate him.

Carl
 
Yes, Methyl B12. I found a sublingual tablet that has only the vitamin, lactose, and one other ingredient. (Side note: it's pretty horrifying that so many of them have xylitol, which is toxic to cats. Eek.)

Yes, the vet indicated that they would use short-acting insulin and IV fluids if we hospitalized him.

I'm just trying to get any food in him. And using a syringe for water - he'll drink that off the end and I'm trying to push a little more than he wants.

He got 75ml sub-q fluids (no potassium - not sure if that was part of our lab work yesterday) yesterday. We'll do 75 again tonight. Vet suggested 50ml per day after that - I guess too much can be bad for their heart? AFAIK his heart is OK, but his heart rate has been elevated, so maybe she was being cautious.
 
I guess too much can be bad for their heart? AFAIK his heart is OK, but his heart rate has been elevated, so maybe she was being cautious
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Yes, my understanding is that if any heart problems are possible, fluids can be an issue. Which is why we don't advise giving sub-Q fluids unless advised to do so by your vet.

CArl
 
Hello there, just quickly popping in to say I hope leko feels better soon.

If you do increase his dose its always a good idea to hold it for 6 cycles (unless he drops under 50 for a new diabetic,under 40 for a long term) to let the dose settle.

Also could be an idea to do a few spot checks at night to see what's going on there.
 
Strip test from very early this morning showed no ketones (or very little trace? Definitely a different color than before) and he just tried to get up to eat with some help to steady him. Little bit perkier than yesterday.

He went down to 34 overnight. Too low to shoot now and I really should be leaving in an hour... Thinking I'll drop him to .5u, but not sure how the timing will work out. May cancel my plans so I can shoot him before he goes too high.
 
If he went down to 34, you by all means should (need to) reduce the dose.

Carl
 
Hi Heather,

I saw that you were waiting to shoot when you saw that 138 AMPS this morning. And then it looks like he went up to 321 by +4. but I don't see any mention of if you gave insulin and when...

I'm thinking that the jump up to 321 was a "bounce" from going so low overnight, so easily explained and expected. Your thinking on reducing the dose is correct too.

How's things?

Carl
 
Just updated the spreadsheet. I gave .5u once he went higher and I was home. At this rate, he'll get next insulin in the middle of the night.

He's not getting up at all. He'll take food and water if we feed him and I'll do some sub-q later.

Added: Haven't been able to get a urine sample for ketones test all day.
 
Down to 43 at +6 after late AMS today.

Hmm. Will check and plan to give insulin at 12-14hrs. Leave dose or drop it again...?
 
Wow. I will try to answer. It looks like Leko cleared the bounce very quickly. I hope that you fed something when you got that 43.

Because Lantus is a depot insulin, what I believe you're seeing is that he's still being influenced from the cycles where he was on .65 and .8 doses. The way it is usually put is "his depot hasn't caught up to the new dose yet."

What's amazing to me is the "all of a sudden" improvement. It is possible that he's been seeing lower numbers that you haven't "caught" on the meter. If I had to guess, it would during the PM cycles where you haven't gotten data until recently. It could be that the daytime numbers you've been seeing - the pink and red ones - are due to his going "low" at night.

I don't know what to tell you about the "next shot". This shot was late by 4 hours, and the effect of a late dose is usually that it acts as a reduction. So not only did you lower the dose, but in effect. lowered it "more" by shooting late. And yet he still dropped into the 40's.

Two choices. Well 3 really.
See what sort of number you get at shot time. You can shoot the .5 again, but only if you would be able to do some mid-cycle testing to see if he goes low or not.
Or, you can reduce further, like to .25u, but I would still recommend a couple of mid-cycle tests to see what happens.
Or, you could skip the shot.

A lot will depend on what numbers you see between now and PMPS. I'm hoping someone will be around to see any questions you might have at that time.

Were you able to get him to pee on a stick? Is he eating okay?

Carl
 
So here's my thinking... In the interests of keeping his BG down as much as I can, I'm trying to give insulin when he needs it... I was expecting 10 hour spreads. I think a lot of his issue is the insulin doesn't last the full 12 hours (under "normal" circumstances, which this is not). But instead we're coming down off the increased dose, maybe a bounce, plus he's eating a lot less than usual. Less eating is definitely contributing to the low numbers.

I've been checking on him, helping him to the litter box, changing his bedding, pushing oral fluids and food, every couple of hours. Any time I check BG, I push fluids and food. He'll usually take a few bites (or a few spoons) of food and a few big syringes of water. I haven't managed to catch urine all day, but I keep trying.

DH is going to check his BG around 5am (pacific time) - that's +14. If he's 220 or above, I'll give him insulin then. If not, I'll check again at 7. With a bit of luck, maybe he can get urine to see if we still have ketones. Depending on timing vs plans for tomorrow, I may stick with the .5, try to push food more, and test more. If timing sucks and I'm worried I can't test enough, I'll seriously consider a .25.

Would you please explain more about a late shot being like a reduction? I haven't heard that before. I'm really curious since I'm trying *not* to skip shots since high numbers can add to the ketones.
 
Carl posted a note on the Lantus board asking if we'd stop by.

I've got a couple of questions. How is Leko's weight? Is he a thin kitty and has he lost weight as he's gotten older (or because it's been more difficult for him to get around)?

Physiologically, age effects the way drugs are metabolized due to wear and tear on the liver and kidneys. Some of the issues with Leko's numbers may be due to his being an elderly kitty. Likewise, if he is very thin, this may cause his numbers to vary. Lantus forms microcrystals that deposit in the fat tissue that then slowly dissolve. If there's limited fat tissue, there's no place for the crystals to deposit.

However, the more likely scenario may be that what you're seeing are bounces. Without getting routine PM tests, you don't know if numbers are dropping at night and then bouncing into high ranges much like you saw on 1/9 - 1/10. The lows may also reflect Leko's not eating well. Frankly, because of the ketones, I wouldn't worry if you need to use a higher carb food in order to get him to eat. The food will be important both in order to keep the ketones at bay and to keep his numbers from dropping too low.
 
Would you please explain more about a late shot being like a reduction? I haven't heard that before.
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I'll try my best to explain. Lantus and Levemir are both long acting types of insulin. The duration is, in part, due to their both being a depot-type of drug. The presence of the depot allows for overlap between doses. So, if you can picture the image of two circles overlapping and time being a factor in how much overlap there is, the more time there is between doses, the less the overlap. This results in what could effectively be considered a dose reduction. On the other hand, if you were to shoot early, there would be greater overlap between the circles with the net result of the early shot acting like a dose increase.
 
Yes he's very skinny.

Ketones showed definite negative this morning.

I may try a little high carb wet food close to his insulin peak if it looks like he'll go as low as before.
 
Fur shot. Grr. :( Just shot again. He's about the same as yesterday. I was hoping he'd seem like he's feeling a little better if we got the ketones cleared.
 
Are you positive this morning was a fur shot? Did you feel wet fur? The numbers today could be that, but they could also be bouncy numbers from the lows yesterday.
Let me make sure I have the shot sequence right.
Last night, you shot at 16 hours after his AM shot, .5u, right?
And today, you shot 11 hours after that shot, with the same .5u dose?

Just my suggestion, but even if you see numbers higher than you want them, try to give it 12 hours between shots. "More time" is okay, but less than 12 hours apart is more problematic. What you can end up with is the 2nd dose kicking in while the 1st dose is still tapering off (which is why an early shot has the effect of a dose increase). Might not be a huge problem, but it makes it harder to make sense of the numbers you get, and it makes it hard to evaluate how effective a dose is.

Carl
 
I didn't feel wet fur. So far, he seems to be dropping a little more slowly, so I'm still thinking it might have been a fur shot (not as much in depot?).

Your summary of timing and dosage is correct.
 
Leko died last night. He just wasn't improving.

Thanks for helping us out this week. I appreciate the support during what has been a difficult week.
 
Heather,
I'm very sorry to hear this, and very sad for you.
Fly free, sweet Leko

Carl
 
I am so sorry that it was Leko's time to leave you. May all the wonderful memories of the time you two shared together comfort you in these sad days ahead.

wings_cat Fly free Leko and use those new wings to visit your beans dreams often.

Mel, Maxwell,Autumn & The Fur Gang
 
I am so sorry for your loss of sweet Leko. While you may have felt helpless and wondered if there was more you could do....please don't! My goodness 19 is a pretty good run and you were doing everything you could think of. So sorry it was time to go, wings_cat fly free sweet angel Leko.
Sending wishes of comfort and sympathy.
 
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