Otto AMPS 437 Need help :(

[Ottoman]

My boy Otto has been struggling. On Lantus for 7 months and really no improvement. Most recently hospitalized 11/11 with DK (no urine ketones, + blood ketones, no acidosis). Labs showed AKI, high phosphorus, low potassium. Ultrasound showed pancreatitis, pyelonephritis (urine negative). No masses. He was on fluids, antibiotics, pain meds, anti nausea meds. Discharged home after 3 days on 6 units Lantus (was on 4), antibiotics (completed 11/20), gabapentin and cerenia as needed. Initially saw improvement in numbers the first night, but quickly rose to 400s.

Had first appointment with a great internal medicine vet 11/20. She felt that cause of DKA was too low of a dose for too long (see spreadsheet), and wasn't as suspicious of infection due to negative urine. The internal medicine vet noted that he is complicated due to mild CKD, pancreatitis, and suspected IBD (has had issues with diarrhea for a while). She wanted to get him on a renal and GI diet (recommended hydrolyzed protein renal diet from Hills) but I'm concerned about carb content? She upped Lantus dose to 7 units. Again, numbers improved the first day but since then reading "high" on Libre and numbers 300-400s when I check them with Alphatrak. I attached the curve from his first full day on 7 units.

We have not tested for IAA/acro partially due to cost, the hospitalization was expensive! Of note, he was scheduled for a dental but internal med recommended cancelling due to recent hospitalization/uncontrolled numbers.

Really just looking for any advice or reassurance. He does seem perkier since we left the hospital, but with his high numbers continuing I'm so scared he will end up back in the hospital. It seems like because of his multiple issues, we just can't get good control

 

[Wendy&Neko]

Hello and welcome from me. I am posting the link to your first post on Feline Health in case people want to go back and read it. New member - help needed re: shot tonight due 2 hours

You sure have your hands full with Otto. That's a lot of conditions to manage at once. Please add the pancreatitis, DKA, mild CKD (do you know the stage?) and suspected IBD to the signature. With DKA in the history, we make different decisions about his dose than a cat without that history. Are you home testing him for ketones now? You can get urine test strips for that or a blood ketone meter. Are they planning on treating the kidney infection (pyelonephritis)? DKA is a result of not enough calories + not enough insulin + some systemic infection/inflammation. The pancreatitis may have been it.

Regarding food, unless you have a diagnosis for IBD, it's hard to say if you should switch food. One thing you can do at home is to find some novel protein foods that are commercially available and try him on those. If you do that, you can only give that one protein, including the treats. A novel protein is a meat type he hasn't had before, which could be something like rabbit, lamb, venison, goat, kangaroo. There are low carb canned products available, and freeze dried or frozen raw. For diarrhea issues, you might want to try s. boulardii, a probiotic fungus. More information here. And possibly a general probiotic. I like Visbiome for my IBD (confirmed) kitty.

Sorry to hear the IGF-1/IAA tests are out of your price range right now. I would have suggested those. My girl had both conditions. It's also unfortunate about the dental, as needing a dental can make it very hard to regulate a cat. Uncontrolled numbers by themselves is not a reason to delay a dental. Maybe once your pocketbook has recovered you can reconsider. A dental specialist vet might be a good idea as they are used to more complicated kitties.

A couple comments on your spreadsheet. It'd be really helpful to add a note on the Remarks column on 11/11 that he was in hospital for DKA and they upped his dose. Otherwise people will ask about the jump in dose. Second comment about the spreadsheet is that it's a really good habit to test at night time too. As Otto showed you on the 14th, many cats go lower at night. We determine how to change the dose based on how low it takes the cat. My cat very frequently went low at night, then bounced higher numbers during the day. Daytime tests said "increase", but the night told the truth that she needed to have her dose reduced. Getting a test before you go to bed, if it's at least 2-3 hours after the PM shot, can tell you a lot. It's really possible that he is also going lower at night and you are missing it.

Here is the definition of a bounce that might explain the high numbers:

Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles).

I'll stop there, this is long enough already.

 

[Ottoman]

Hello and welcome from me. I am posting the link to your first post on Feline Health in case people want to go back and read it. New member - help needed re: shot tonight due 2 hours

You sure have your hands full with Otto. That's a lot of conditions to manage at once. Please add the pancreatitis, DKA, mild CKD (do you know the stage?) and suspected IBD to the signature. With DKA in the history, we make different decisions about his dose than a cat without that history. Are you home testing him for ketones now? You can get urine test strips for that or a blood ketone meter. Are they planning on treating the kidney infection (pyelonephritis)? DKA is a result of not enough calories + not enough insulin + some systemic infection/inflammation. The pancreatitis may have been it.

Regarding food, unless you have a diagnosis for IBD, it's hard to say if you should switch food. One thing you can do at home is to find some novel protein foods that are commercially available and try him on those. If you do that, you can only give that one protein, including the treats. A novel protein is a meat type he hasn't had before, which could be something like rabbit, lamb, venison, goat, kangaroo. There are low carb canned products available, and freeze dried or frozen raw. For diarrhea issues, you might want to try s. boulardii, a probiotic fungus. More information here. And possibly a general probiotic. I like Visbiome for my IBD (confirmed) kitty.

Sorry to hear the IGF-1/IAA tests are out of your price range right now. I would have suggested those. My girl had both conditions. It's also unfortunate about the dental, as needing a dental can make it very hard to regulate a cat. Uncontrolled numbers by themselves is not a reason to delay a dental. Maybe once your pocketbook has recovered you can reconsider. A dental specialist vet might be a good idea as they are used to more complicated kitties.

A couple comments on your spreadsheet. It'd be really helpful to add a note on the Remarks column on 11/11 that he was in hospital for DKA and they upped his dose. Otherwise people will ask about the jump in dose. Second comment about the spreadsheet is that it's a really good habit to test at night time too. As Otto showed you on the 14th, many cats go lower at night. We determine how to change the dose based on how low it takes the cat. My cat very frequently went low at night, then bounced higher numbers during the day. Daytime tests said "increase", but the night told the truth that she needed to have her dose reduced. Getting a test before you go to bed, if it's at least 2-3 hours after the PM shot, can tell you a lot. It's really possible that he is also going lower at night and you are missing it.

Here is the definition of a bounce that might explain the high numbers:

I'll stop there, this is long enough already.

Thank you for this info. Very helpful! I don’t currently test for ketones but will probably add that to my kit. He didn’t have urine ketones even with DKA, so will likely go with blood test option. They did treat the pyelonephritis with IV and oral antibiotics.

Novel protein might also be a good idea, he is a picky eater and tends not to like chicken. Something new might help! I’ll definitely consider the additional tests at our next visit, especially if no movement in his numbers.

I will update spreadsheet as well with additional comments. Going low at night could definitely be contributing. I haven’t seen any nighttime lows yet on the Libre, but he could be bouncing now as we’re only 5 doses out from his last “low” (normal) numbers. Thank you again!!

 

[Wendy&Neko]

Chicken, beef, and fish tend to be the common allergens for cats. A lot of the FF have fish in them, even if not in the name of the product. I have a fish and beef allergy here so am very aware. Sometimes the allergy is to another filler like one of gums.

Info on urine testing and blood ketone meters here: Ketones, Diabetic Ketoacidosis (DKA), and Blood Ketone Meters. Some people use the Keto Mojo meter so that's also an option. And I think the test strips are cheaper.

When was the Libre placed? If would show you if lows are there.

 

[Staci & Ivy]

Thank you for this info. Very helpful! I don’t currently test for ketones but will probably add that to my kit. He didn’t have urine ketones even with DKA, so will likely go with blood test option. They did treat the pyelonephritis with IV and oral antibiotics.

Novel protein might also be a good idea, he is a picky eater and tends not to like chicken. Something new might help! I’ll definitely consider the additional tests at our next visit, especially if no movement in his numbers.

I will update spreadsheet as well with additional comments. Going low at night could definitely be contributing. I haven’t seen any nighttime lows yet on the Libre, but he could be bouncing now as we’re only 5 doses out from his last “low” (normal) numbers. Thank you again!!

Hi Sophie, I use a Libre for Ivy and it would show you lows overnight it Otto had them.
That's the good thing of a Libre, there's data to show you what happened while you slept.
Also, the low glucose alarm would sound (and it's pretty loud) if he went low.