Sasha - Ketones - Help on Switching Insulin, Other Qs

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Susan D

Susan D

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Hello to you and your beloved kitties,

Sasha of late has been having many, many more good days than bad. But suddenly on Tuesday, he backed off his food and later that night registered as having "moderate" in the level of ketones in his urine. (I test him on nearly a daily basis.) He also had a "large" amount a month ago and I was able to get him to a negative level and back on track through a combination of insulin, assist feeding, subcutaneous fluids, and some meds (Pepcid AC, for example). The members of FDMB helped me so much, and thank you! I tested him for ketones today (as I have been doing multiple times each day), and he now has a "small" amount as compared with "moderate" on Tuesday and Wednesday. He is still eating very little, and has a bit of weakness in his back legs -- presumably from low potassium, for which he was hospitalized and received IV fluids recently.

I am frightened, very tapped as to what I can spend on vet payments, and hoping to restore his health. He has had these problems since being diagnosed w/ chronic pancreatitis about seven months ago. Thankfully, I have been able to get him on a good path mostly but now the ketones and potassium deficiency have been problems for the little guy. We are seeing the vet today, and I consulted with my holistic vet on Wednesday.

Three basic sets of questions:

*** My vet has been reluctant to change insulin -- which I asked to do before. He is on Humulin N, but I want to get him off this insulin to a better one, such as Lantus or Levemir. What can I say to my vet about this? What should I expect in terms of the process of changing? Can I do this with home care?

*** Does anyone have a suggestion about what I might look to for the causes of the ketone susceptibility? Sasha's BG numbers have been staying at around 170 to200 at 12 hours past his insulin injection. I test him every other day. His BG numbers have come down a lot and his health appeared to be getting much better with a switch to a 90 percent grain-free wet food diet.

*** Getting his potassium up to a healthy level has been a challenge. When it was severely low, in mid-April, we did three days of "outpatient" IV treatment at my vet's and then one overnight. The vet gave Renal K gel to me, but Sasha has gotten nauseated and vomited when I gave it to him recently. My holistic vet just recently gave Mount Capra Mineral Whey, with a good amount of potassium in it, to sprinkle on his food (1/4 tsp twice per day). She said that would address his potassium deficiency. I gave about 150-200 ml of subQ fluids to Sasha each day, in two sittings. I have thought about getting potassium supplementation to put into his subQ fluids. Has anyone used this?

My boy has been a fighter, and I was so happy to see him in better and better health lately, with more energy, a wonderful appetite, and loving life. We've had quite a bit of success by using daily fluids, a regimen of vitamins and supplements, and the changeover to grain-free foods. I also have been using some homeopathic remedies from my holistic/homeopathic vet. This has been a tough setback. I would welcome hearing from others who have dealt with this, so I could know what to do and what other causes I might look at.

Thank you, and bless you and your kitties!

Susan
 
*** My vet has been reluctant to change insulin -- which I asked to do before. He is on Humulin N, but I want to get him off this insulin to a better one, such as Lantus or Levemir. What can I say to my vet about this? What should I expect in terms of the process of changing? Can I do this with home care?
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Tell your vet you want the insulin changed; no discussion. The insulin you are using is old school.
Can you do a curve and test every 3hrs on a cycle before going to the vet? Test at amps, +3, +6, +9, and pmps. The numbers can be shown to your vet and say you want an insulin that has been proven to be better, with many cats going off insulin. Lantus is good, but there are a fair number of cats who do better on Levemir. My Oliver was the same on both, pretty much, but my Shadoe was definitely better on Levemir. The curve is longer lasting, very gentle and no extremes in the numbers. As for the differences with using Lantus or Levemir, there are forums here with all the info you need, and the members posting in them can help you with an easy transition.
The other issues I cannot comment as I have no experience, but the ketones I am sure you know must need to be watched and kept in control. Ketones recipe, I am told is not enough insulin + not enough food + infection. It seems that some cats are prone to ketones and they can occur even at lower BG, while other cats can be hanging in the 300s and higher for long stretches of time, but never have ketones.

If the vet won't switch insulin from N, find another vet.
 
Susan D said:
*** My vet has been reluctant to change insulin -- which I asked to do before. He is on Humulin N, but I want to get him off this insulin to a better one, such as Lantus or Levemir. What can I say to my vet about this? What should I expect in terms of the process of changing? Can I do this with home care?

*** Does anyone have a suggestion about what I might look to for the causes of the ketone susceptibility? Sasha's BG numbers have been staying at around 170 to200 at 12 hours past his insulin injection. I test him every other day. His BG numbers have come down a lot and his health appeared to be getting much better with a switch to a 90 percent grain-free wet food diet.

Thank you, and bless you and your kitties!

Susan
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Hello Susan,
I cannot answer most of what you asked but will only focus on the ketones and what I have come to realize with Sneakers (so may be different with Sasha but could be the start of a good and reasonable argument with the vet). And this is VERY laymans terms and simple concepts that I grasped and held onto.

Ketones are present because of
1- not enough insulin (such as Sneakers was)
2- underlying illness
3- not enough food

Sneakers showed ketones until her level of insulin was large enough to hold them at bay- and that was PZI (later levemir). Humulin N is not a long lasting insulin and wears off quickly in cats and leaves them with no insulin for hours- that is what Sasha is probably reacting to- the number 1 line. Tell the vet you want a longer lasting insulin and take articles with you on the insulin you want.

Insist on it as humulin is not helping. It seems as if the vet is taking good care of Sasha except in that one area. There is article on here of WHY Humulin isn't a goot insulin and several on the good ones, so finding (if someone doesn't link you to it) and printing that off to take to your vet.

You could also ask the vet if all they are doing is milking you for the money and not caring to do the research so that ends up killing Sasha. That is basically why I left my last vet- he never bothered to do research on it and then tried to tell me high bg levels were not a big deal and nothing to worry about (ketones? Nothing is wrong with them, either- not dangerous at all). Yep, he was gone.

Is there any other vet you could go to that could handle all of the problems with Sasha if you had to leave?
 
Gayle,

I expected that you might write -- I know you had urged me to switch when I posted in early April. I've had some tough family issues in the meantime as well as dealing with Sasha's potassium deficiency.

I agree with you that it is not a matter of me asking my vet to change insulin, but saying I need to do this...PERIOD.

As for the BG curve, I cannot do it now since I will be going to the vet soon. I will check out the other forums as you suggested. Thank you!

With the ketones, I know how serious this is, and it is crucial for me to be on top of it with every hour and to keep doing the balance of fluids, food, and insulin. Sasha has been prone to them, since February (three times of elevated ketones). I am going to get a recheck of him for infection, though he was clear on that before. He will get a B12 injection today at the vet's, too.

Thanks so much, Gayle, and hope all is very good with you!

Susan
 
Humulin N is not a long lasting insulin and wears off quickly in cats and leaves them with no insulin for hours- that is what Sasha is probably reacting to- the number 1 line. Tell the vet you want a longer lasting insulin and take articles with you on the insulin you want.
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Hello to Sneakers' loving owner,

Thank you. You hit the nail on the head. Your points as stated will really help me in what to say. The idea to take the articles and/or provide the links to them (about why Humulin N isn't effective, etc.) is an excellent one. I've asked before, twice, and the vet has said ...why do you want to do that now? Sasha has been on this insulin for over 5 years, it's a complicated process, etc.

I can certainly look for other veterinary help if need be. These vets have been good in a lot of ways, but I feel concerned and frustrated. My holistic vet has been such a help on a bunch of matters, too.

It is definitely important, called for, and worth doing.

As for the ketones, I definitely understand that formula. I've read that kitties with chronic pancreatitis can be susceptible to ketones, and his first incidence of this happened as he was dealing with the chronic panc.

Good for you that you got the veterinary help that you needed when your own vet wouldn't do the research!

Thank you so much.

Susan
 
Hi Susan,
I can give you a little input on the potassium thing. My cat, Bob suffered for months with low potassium levels. The primary sign was muscle weakness in his back legs. In his case it wasn't neuropathy, but low potassium (which causes muscle weakness). The biggest concern is the heart, since it is muscle, so it is important that their potassium be within the normal range.
Bob received sub-q fluids for a couple of months, and the potassium was added to the fluids. My vet recommended tumil-k tablets, which can be crushed and sprinkled into the food. I stayed away from the gel, because most gels are sweetened. I think the whole point is that the medicine (whatever kind it is) tastes terrible, so they hide it in a "palettable" paste in order for you to convince kitty it's good for him or her. If Sasha didn't like the paste, then the tablets might not be a good option either.
Adding potassium to the fluids worked in Bob's case, but it took about 4000 ml (4 bags) over the course of three months to get his levels into the normal range. Not sure if there are stronger concentrations that would accomplish it quicker. One issue with potassium is that above normal is just as bad as below normal, so it is something that you have to get rechecked (I did so every three weeks maybe) periodically to make sure it doesn't go too high.

*** My vet has been reluctant to change insulin -- which I asked to do before. He is on Humulin N, but I want to get him off this insulin to a better one, such as Lantus or Levemir. What can I say to my vet about this? What should I expect in terms of the process of changing? Can I do this with home care?
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It sounds like generally, you like your vet and have been using them for quite a while. I know it's easy to say (and people say it probably way too often here) that you need to dump your vet, or switch vets or whatever, but in practice it's not really just that simple. The best thing to try to do is to "educate" your vet. Get him on your side, encourage him or her to take a refresher course on feline diabetes. Not only will that make your life simpler, but it will also benefit every other diabetic cat your vets ever see in the future.
Here is a link to the AAHA guidelines for feline diabetes. Share this with your vet. It explains the best insulins to use, correct dosing, and explains why an insulin like Humulin is not recommended for use on cats. Maybe if he reads it from his "peers" it will make an impression. Also, the way I would answer his question "why do you want to do that now? Sasha has been on this insulin for over 5 years,"? I'd say, "well, that's is why. Sasha has been on it for 5 years. Kitties go into remission often on other insulins and there are studies that prove that. I want my kitty to have a better chance at remission". That should make him understand "why".
Insulin therapy in the cat
The insulin preparations with the appropriate duration of action in most diabetic cats are glargine (U-100) or the veterinary-approved human protamine zinc insulin (PZI U-40). This panel does not recommend the veterinary-approved porcine zinc (lente) insulin suspension as the initial treatment for the cat, because its duration of action is short and control of clinical signs is poor. This insulin should be reserved for cats in which other insulin choices have not yielded satisfactory results.
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https://www.aahanet.org/PublicDocuments/AAHADiabetesGuidelines.pdf

Brand Names and Other Names

This drug is registered for use in humans and dogs only.
Human formulations: Humulin® R (Lilly), Humulin® N (Lilly), Humulin® U Ultralente (Lilly), Novalin® N (Novo-Nordisk), Iletin® II NPH (Lilly), Regular Insulin (Novo-Nordisk), and various generic preparations. Please note that Humulin® L and U are going off the market fall 2005.
Veterinary formulations: Vetsulin™ (Intervet) (porcine insulin zinc suspension)
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http://www.petplace.com/drug-library/insulin-humulin-iletin-vetsulin/page1.aspx

Carl
 
Here is another paragraph from the University of Queensland about when it's necessary to switch insulins for cats:

Lente insulin is only recommended as a first choice of insulin in countries where an insulin registered for
veterinary use is required to be used initially, and PZI is not registered for veterinary use. If remission has not
occurred in 6-8 weeks after initiation of lente therapy, the insulin should be changed to glargine or detemir.
Remission rates decrease with time after diagnosis, so early control of blood glucose concentrations is
imperative for maximizing the probability of remission. NPH insulin is only recommended when no other longe-
acting insulin is available.
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There is no reason for a cat to remain on an NPH type insulin when better ones with greater chance of remission are available. The complete paper is here: http://www.uq.edu.au/ccah/docs/diabetesinfo/link2.pdf

Good luck, you're doing a great job taking care of Sasha!
 
Susan, you can save some money by getting a vial of B12 and giving Sasha weekly shots at home.
The B12 shots I gave Shadoe helped her a great deal as she frequently had pancreatitis issues.

Best of luck with this vet; push for a good insulin.
 
Gayle, is that B-12 or Methyl B-12? Is one for p-titis and the other for neuropathy?

Carl
 
Way back when, J.D. was hospitalized with DKA, and upon release the doctor and I were discussing switching him to a different insulin. I think he was on Prozinc at the time, and I said I would like to try Lantus, and she agreed and wrote me a prescription. J.D.'s regular vet is a devout "PZI Man", and I was his only patient on Lantus. As J.D. continued to bounce around for years, one day I said to him, I want to try Levemir, and he wrote me a presription. I didn't ask, I said, "I want to try Levemir". Maybe that will help.

In March, J.D. was tested positive of Cronic Pancreatitis. I told my vet I wanted Buprenex, Ondansetron, and Cyproheptadine. He really only was off his food for a day, so I soon stopped the cypro. But then, I heard about Vitamin B12, and called my vet and said I wanted a prescription for Vitamin B12 injectable. I was able to get a vial at Costco for $10 and change, and I use my insulin syringes to inject it. You do not need to be a member of Costco to use their pharmacy, but you do need to have a prescription for the vial. The prescription was for cyanocolabamin.

I wish you the best of luck in getting those ketones under control, again. That should be your top priority right now.
 
Everyone,

Thanks for all of your helpful info, support, and encouragement, and hugs to your kitties. Here is what happened at the vet's yesterday, etc.

INSULIN: I will definitely provide those links to my vet, Carl and Vicky, and you and Gayle and Dyana provided great points and excellent info. My vet said yesterday she was very reluctant to do any change in the midst of seeking to clear ketones and let's revisit the topic once we handle this situation. (Any thoughts on this?) Also, she said their whole veterinary practice uses Humulin N, which raises a big flag for me. She noted it would be difficult to do it now if Sasha is susceptible to ketones because there are times that one has to back off to get the right dosage and it risks hyperglycemia (and vulnerability to ketones). I believe at this juncture it would be worth doing.

Also, the way I would answer his question "why do you want to do that now? Sasha has been on this insulin for over 5 years,"? I'd say, "well, that's is why. Sasha has been on it for 5 years. Kitties go into remission often on other insulins and there are studies that prove that. I want my kitty to have a better chance at remission"
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Very true, Carl.

VETS: I agree with you that it is not simple to change vets, and I have actually had great fortune with Sasha by working with a holistic vet in concert with this vet I have been seeing and their practice (going there for five years). I would like to have a discussion with her that is along the lines of shared info and will see if that works. (I saw your links last night after I returned from the vet's.) That said, I am strongly considering a change now.

For example, B12 injections: I brought that to the vet and said "I would like this." Same thing with doing subcutaneous fluids, which I started back in February. When I discussed getting the potassium supplementation yesterday, her response was very ho-hum...like "eh, it could help but may not do much." I am a very proactive person, so I get concerned about that response. Dyana, I agree wholeheartedly that it is up to us to say this assertively and not "ask." Believe me, I do that, and am doing it more and more.

Gayle, I will follow up on the B12 vials -- time to do that rather than get the injections at the vet's.

Thanks again to all! Believe me, I am no shrinking violet at the vet's. I am good for at least 15 questions and follow-ups to exchange info and I definitely am persistent. It is the least I can do on behalf of my little boy!

Gratefully,
Susan
 
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