the 3rd DKA roller coaster ride

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TammyRingLeader5

Member Since 2019
Hi all,

I'm new to the forum and have spent all evening researching my current situation and came upon this site. What has brought me here is that I have a diabetic cat currently hospitalized for DKA for the 3rd time! The very first time was about 8-9 months ago and the thought was that a UTI sent her over the edge. She was diagnosed with diabetes about 18 months ago and it has never been super well controlled (She is actually our 2nd diabetic, the first was diagnosed about 4 years ago and has been very well controlled on Lantus). the roller coaster run that the latest events have caused is killing us:

After not achieving super great control on 6 units of Lantus, our regular vet decided to try and switch to PZI starting with a low dose and see how that worked. After only 2 days, cat was hospitalized at an area 24/7 emergency vet with DKA that they were blaming on changing insulin. She remained there for 2 nights and sent home; brought her back less than 1 week later for a BG curve and initial visit with their internal medicine specialist (we usually do BG curves at home, went along with this one there to get the opinion of the specialist). Fine in the morning before drop off, kind of mopey after pickup, next day hospitalized again for DKA (they consider this a 3rd DKA, wondering if the 2nd was not really resolved). In a nutshell, the big concern this time was low blood pressure. A repeat ultrasound found nodules on the liver (that hadn't been found during the 1st ultrasound 10 days earlier). The roller coaster ride begins: she's not improving, we're very concerned, and we might "need to make a decision", then she's improving and she looks okay, followed by she's great alert and starting to eat, we're preparing her to go home, and finally a repeat bloodwork before she's discharged shows low %RBC, low potassium, low phosphorus, and attempts to return her to Lantus on the last dose she was on dropped her BG to 40 (from what had typically been 250-400) she's definitely not going home today. And the specialist is stumped and fears if kitty comes home that she'll crash again if they can't fix this. I asked now if we no longer are considering the original insulin switch to PZI as the trigger and was told that it may have been for the last DKA but this is something bigger that they're missing. The "last" DKA was 5 days before the current, I kind of consider them the same. Has anyone experienced anything like this before? This is so exhausting (mentally and financially). I don't know what to do.
 
Hi I am sorry you are experiencing this with your kitty.
In my opinion, reading through your story, I think the DKA was triggered by the vet dropping the dose low when he swapped to PZI. I would go back to Lantus insulin myself. And I think the DKA is still definitely a continuation of the second DKA when the vet dropped the dose....not a 3rd DKA.
DKA happens when there is not enough insulin, not enough food and an infection or inflammation.
Did the vet have you testing for ketones every day once she came home last time?
Have the vets taken steps to correct the low %RBC, low potassium, low phosphorus? These are treatable.
As far as your kitty dropping to 40 on the last dose she was on, that is probably because she is not eating as much as she was when she was on the 6 units before the change of insulin. When a kitty has DKA their appetite is usually off because they are nauseated. Have the vets given her any anti-nausea medications like cerenia? It could be days or longer before she wants to eat much. You will just need to try and tempt her or she may need syringe feeding or tube feeding. They could also give an appetite stimulant but only if they have given an ant-nausea medication first. As far as the "crash" is concerned, your kitty probably just needs a small reduction in the dose of Lantus from 6 units to 5.75 or 5.5 units. I would not call a kitty dropping to 40 'crashing', they should have been monitoring the blood glucose more often to have caught the drop sooner. We have kitties drop to 40 here and we give them high carb food or honey/karo and while it is not ideal, I don't think it is 'crashing'.
We have had really sick DKA kitties here who have pulled through, so don't loose heart.
There is a lot you can do when she gets home to help her recover. We can help you with this. I am going to tag @AliceMeowliss&Cassandra who has just been through DKA with her kitty who was really sick and is now well again. She will be able to give you hope and support and lots of ideas I am sure.
Please keep in touch and let us know how your kitty (name?) is doing
Bron
 
I’m so sorry you and your kitty are going through this. I don’t have any experience with DKA but you have come to the right place - everyone on this board is so supportive and I’m sure someone who knows more than me will come along soon with some good advice. Bron is right - don’t lose heart, you are doing all you can for your kitty and fingers crossed she’ll pull through
 
I cannot advise on issues like the nodules, nor do I have experience directly with the lab results like low %RBC.

What I can say is this.... yes it is SO tiring, but SO, SO worth it.

I agree with Bron, as soon as I read your vet suggesting you drop the dose when changing insulins.... yep. That reduced dose, especially since you have a long-term diabetic, is going to cause problems! :(
When I switched from NPH she got a total of 9.5u daily, split into three doses, and I switched her to about 8u total/day of Lantus (two doses). Even though it is a different kind of insulin, if you’re using a lot.... you still need a lot.
Also, someone else correct me if needed, once a cat is up to 6u don’t we want to start looking at additional conditions like IAA and acromegaly?

I’ve read that Levemir is a good option to consider when Lantus is not regulating well enough, too. I’m trying to remember some of the Levemir users to tag....

Alice was severely emaciated, down to about 4lbs, now she is about 7lbs. I sat by her side and fed her by hand, mixed lots and lots of water into her food, and basically just poured myself into her.
Here she is in the hospital and then now:
 

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Kitty's name is Mojito. She's been with us since she was about 5 weeks old and she's almost 11. I'll provide some more info to hopefully address some of the questions:

The reason for the original switch from Lantus was because the "baseline" BG (typically in the 200s during an entire 12 hour curve) was rising and increasing the # of units was not helping much. Additionally, a routine urinalysis showed ketones in her urine, although I'm not sure of the level. The intent was to start with a lower level of PZI and do an at home curve after a week. to see how to adjust. Regular vet had suggested a specialist if this didn't work.

The "2nd" DKA was the same symptoms as the 1st back in October with the addition of green vomit (we've gone through the questioning about rat poison, we don't have any). The ketone number was reduced during a 2 night stay at the emergency vet and they sent her home(too soon in my opinion). But they also changed the insulin again to ProZinc with a dose somewhere in the middle of the PZI and Lantus dose. Appetite increased over the next 5 days until the day of the in hospital BG curve. The vet did not have us check for ketones during the 5 days she was home. We do have test strips that check for a variety of things including ketones. catching a cat in the act though is difficult.

The emergency vet has taken steps to correct issues. Initially the low potassium was a concern early on with this 3rd hospitalization (which has now officially lasted a week) as was the low blood pressure. The blood pressure took a few days but did seem to be corrected which was encouraging and Mojito became more alert and responsive. The low potassium was being addressed with IV supplement, but they took her off it in preparation for sending her home and the last bloodwork showed it low again. They were going to try oral supplements that we could continue at home but the specialist seemed to feel that oral supplements are not typically sufficient. That was supposed to start yesterday and we're still waiting to hear how she did overnight. Yesterday was the first we've heard that the %RBC was low (like really low, said typical is 38%, inability to get oxygen to organs is 15%, she was 17%).

I have been doing what I do when these things happen: get online and research. A lot of what I've found lists these issues as related to the DKA or hepatic lipidosis (liver nodules seen during the 2nd ultrasound). Maybe she hasn't completely recovered yet? Or also send mention of kidney disease. Specialist had mentioned more severe liver disease. I just don't get it, she was so slow to recover this time the critical care doctor and tech were starting to give up hope and then she turned it around so quickly. The word "shocked" was mentioned often about the turn around and she has been described as being "feisty" which is such an improvement over a few days ago when she just looked like a vacant shell. To hear now after such an improvement that they're afraid to send her home (I believe the possibility of not ever going home was mentioned), is such a crushing blow after we had our hopes up.

Just hanging out now waiting to hear how she did overnight with oral supplements and Lantus at 4 units instead of 6. (After switching to PZI and then ProZinc, we requested a return to Lantus as long as the doctors didn't feel one insulin was a better choice over any other). Fingers crossed. Thanks for all your help!
 
I hope Mojito improves for you.

The number of times I have seen cats surprise vets—it makes me wonder why any vet is still surprised when they turn around and get better!!!

There is a link on hepatic lipidosis in the health links section. I was trying to find a page with suggestions on catching pee for ketone tests for you but my FDMB search skills aren’t working right now!

It does sound like you have some underlying issues. Was there any infection present in the last lab work?
 
The latest is this: Mojito looks like her typical self. Her %RBC is still 17% but as at least remained steady. Her ketone level is back to normal. Those are 2 of the 3 critical parameters. The 3rd being the BG level, which is kind of all over the place. Returned her to Lantus but at the previous dose of 6 units brought her down to 40 mg/dL. Tried at 3 units which reduced BG to 90 mg/dL but then a half hour later was up over 400. Again considering Somogyi effect. This had been mentioned back during the October incident when a 60 mg/dL result was scattered among several in the 200s, but considered at the time more likely a fluke with the meter. There was no sign of infection in the last lab work. Realizing that Mojito can't stay at the emergency vet forever, she is coming home today with a feeding tube, potassium and phosphorus supplements and other medications. Fingers crossed that she rallies herself to better health at home.
 
That’s great news Mojito is coming home.
If you don’t think you can collect urines for ketone testing then I would suggest buying a ketone blood meter and you test like you do for the blood glucose. It is really important you keep testing every day at the moment for ketones as any sign of them needs addressing quickly which you can do at home to hopefully prevent a return to the ER.
I’m pleased to see she has a feeding tube in. That will make it easier. Did they send her home with anti nausea drugs?
The most important things now is she is getting enough food ( higher calorie food is good ) enough insulin, enough fluids and she is free of infection. Was she treated with an antibiotic at the ER?
I used levemir and it’s a great insulin and worth looking at later. At the moment I would stick with the Lantus until Mojito has fully recovered.
If you would like us to help you with her recovery I would suggest you set up a spreadsheet that we use and put in all the blood glucose levels. It will show you at a glance how she is going. I’ll send you the link. Please keep us posted with her progress.
http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/
 
Hi all, Thank you for your helpful suggestions. I just wanted to give a quick update: Mojito is doing much better. Her feeding tube was removed yesterday, primarily because she broke it at the end and scratched it through all the bandages until the suture came out. But they were able to remove instead of fix or replace because she has been eating on her own. (Eating a lot actually, gained 3 oz in this last week). The spot where the feeding tube was is gross to look at and we struggle a bit to get her to leave it alone. When the doctor who removed it told us the hole would close up on its own, I was a little surprised that they don't close the hole.

In any case, We're on our 2nd at home BG curve, taking readings every hour due to concerns about somogyi effect. Numbers are always high (typically 400+, we're at 4 units currently, she had previously been as high as 6). The emergency vet keeps wanting us to bring her there for an in hospital curve. I'm not super comfortable with this. We've been doing at home curves for one animal or another for almost four years. The 1 time we dropped her off to let them do it, she went in seemingly fine and eating, came out mopey and not eating and that lead right into her 3rd DKA. Whether that was coincidence or not, I have no idea, but point was that something was obviously happening to her there and nobody noticed. Does anyone have a preference for at home or at vet BG curves? See a benefit to at vet curves? Thanks again for your help!.
 
I’m glad Mojito is home and doing better. I think if you can handle a curve at home she will be more relaxed and I’m sure you are watching her like a hawk. Even at the best intentioned vet they can get distracted and busy, they won’t hand feed and open 15 different types of cat food until they find one she’ll sniff . The only thing I will suggest is that if you haven’t already, consider getting a ketone meter so you can keep an eye on that as well. Wishing you and Mojito all the very best.
 
I’m so glad to hear Mojito is eating on her own again!

So for the most part I never see anyone here recommend a curve at the vet if you can just do one at home. Save the money, test at home, use it to spoil your cat or donate it to other sugar cats in need!!! Reason not to besides the cost is that blood glucose levels may rise due to the stress of the visit and travel, and therefore a curve may not be entirely helpful. I think if you are doing it on your own, then you just don’t need the vet to do it. Same goes with fructosamine tests.

Now, if you had no clue what was going on or how to test or anything, it would be a better option than not doing one at all, of course.......

When you have new questions, it may help you to get more responses by making a new post on the main health forum with just that one question and update, too. :)
 
Good to hear an update. I agree with the others. An at home curve is more accurate and less stressful for kitty and your pocket!
Would you like to set up a spreadsheet? We have a great one here. If we can see the numbers we could help you more. Here is the link. If you have any trouble setting it up someone can help you.
http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/
 
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