Toby's consistantly high readings

[Susan and Toby]

If Toby's high numbers were a result from bouncing, why would he have days like today
and yesterday where he remains high all day? It is fortunate that there are no ketones present. I can tell he doesn't feel well. His energy and appetite are low and he is more isolate. It is good to see days where he has a string of yellow readings but the AMPS and the PMPS and he is bright and interactive.
The days always end up in the red and black boxes though. How long can a kitty survive with readings like this? I love him so much
and I am afraid.
His vet says that he is the most challenging case of diabetes that she has ever seen. She is discouraged stating that his diabetes isn't being controlled. (nor has it ever been) They want to rule out if is there is an underlying cause and have scheduled an ultrasound. He went through this before in the last few months and nothing was found. His vets also want him to have 3.5 units. Do you still feel that this is not a good idea?

 

[Bron and Sheba (GA)]

Here is your last thread https://www.felinediabetes.com/FDMB/threads/ketones.295975/#post-3227995
Hi Susan, is Toby still getting zofran for nausea? I am concerned he is not eating well at the moment and seems to have no energy.
If he is not getting any dry food at the moment I would swap to the TR (tight regulation) dosing protocol as that will get him into better numbers quicker.

His vet says that he is the most challenging case of diabetes that she has ever seen. She is discouraged stating that his diabetes isn't being controlled. (nor has it ever been) They want to rule out if is there is an underlying cause and have scheduled an ultrasound

Until you find the best dose for Toby his numbers are not going to be normal. He has not been a diabetic for long and he has had DKA and it often takes months for a cat to go down into more normal numbers.
Instead of doing another ultrasound, if he has already had one in the last few months, I would ask for a pancreatic blood test if he is not eating well and is not active and his ketones are ok at the moment. The test you need to ask for is a fPLspec, or a fPL snap.

vets also want him to have 3.5 units. Do you still feel that this is not a good idea

Did we say he should not go to 3.5 units? Maybe it was because he was seeing blue BGs for the first time on the dose, although he did have a blue BG back on 12/6, and when they first see blue BG with a new dose you need to hold that dose the same for 10 cycles before increasing the dose.
A lot of the BGs being high is because Toby is bouncing which is normal for newly diagnosed cats.
Because of the DKA at diagnosis and ketones I think you could go up in dose to 3.5 units. But I would like to ask @Wendy&Neko her opinion first. Hopefully she will be around later today.

 

[Wendy&Neko]

Susan, I think you are OK to go to 3.5 units now. It's been a long time since he's seen anything under 100 on this dose.

I agree with Bron. I'm not sure what the point of another ultrasound would be. It's only been 4 months since his diagnosis. Feline diabetes is a marathon, not a sprint. My Neko spent many months in those high numbers, but I still eventually got her to be fairly well regulated. It took a year since she stopped bouncing to the reds.

 

[Susan and Toby]

Hi Bron-
Tonight he wouldn't even eat baby food. Just a few bites of Epigen 90. I am now feeding him this exclusively when he won't eat FF pate. I have been giving him Zofran at the AMPS and around 4 hours before his PMPS. When I get up around 3 or 4 am to check his BG I have been giving him another at that time. What do you recommend for Zofran dosing?
I asked the vet about pancreatitis. I think she said that she ruled this out before but was planning to recheck. Would this be the same as the tests you recommend?
If not, I will mention this to her.
You did say before to keep him at 3.25.
I hope that 3.5 is correct at this time.
I need to read up on TR dosing method again.
Thank you.

 

[Susan and Toby]

Susan, I think you are OK to go to 3.5 units now. It's been a long time since he's seen anything under 100 on this dose.

I agree with Bron. I'm not sure what the point of another ultrasound would be. It's only been 4 months since his diagnosis. Feline diabetes is a marathon, not a sprint. My Neko spent many months in those high numbers, but I still eventually got her to be fairly well regulated. It took a year since she stopped bouncing to the reds.

I wondered what would have changed from the last ultrasound. This was included with a thorough
work up with an internist to determine why his diabetes was not being controlled with insulin.
Maybe she thinks she might discover something new.

 

[Bron and Sheba (GA)]

I would double check your vet did the fPL spec test for pancreatitis. It is not included in the routine blood tests.
How much zofran are you giving Toby? Is he still 10lbs?. I would give it routinely 3 times a day if he is not eating well.
If he is not eating for you, offer him whatever he will eat. It is very important he eats and eats well.
Do you also have an appetite stimulant for him?

 

[Sienne and Gabby (GA)]

The one question I would have for the vet is if there's anything going on with Toby's teeth. If there's any kind of dental issue, it may be a reason Toby isn't eating. If there's no medical reason for Toby to not be eating, some cats do better with a combination of Zofran and Cerenia to control nausea. Has the vet suggested an appetite stimulant like mirtazepine?

What you're seeing with the bouncing is pretty normal. Toby hasn't gotten used to being back in more normal numbers. Until his liver and pancreas stop overreacting, you're likely to see bounces.

 

[Susan and Toby]

His vet talked about teeth. Toby only has 4 teeth.
They are in front and not an issue. I give him Zofran
4 hours before eating. He is also on Mirtazepine and Cerenia. He was doing so well with eating.
Today he won't eat. I force fed him before AMPS.
He hates this. Vets discourage this. What else can I do?
So upsetting.

 

[Wendy&Neko]

Try giving Zofran an hour before eating, it doesn't take 4 hours to take effect.

Did you give insulin last night? The spreadsheet shows blank for units given.

 

[Susan and Toby]

Here is your last thread https://www.felinediabetes.com/FDMB/threads/ketones.295975/#post-3227995
Hi Susan, is Toby still getting zofran for nausea? I am concerned he is not eating well at the moment and seems to have no energy.
If he is not getting any dry food at the moment I would swap to the TR (tight regulation) dosing protocol as that will get him into better numbers quicker.

Until you find the best dose for Toby his numbers are not going to be normal. He has not been a diabetic for long and he has had DKA and it often takes months for a cat to go down into more normal numbers.
Instead of doing another ultrasound, if he has already had one in the last few months, I would ask for a pancreatic blood test if he is not eating well and is not active and his ketones are ok at the moment. The test you need to ask for is a fPLspec, or a fPL snap.

Did we say he should not go to 3.5 units? Maybe it was because he was seeing blue BGs for the first time on the dose, although he did have a blue BG back on 12/6, and when they first see blue BG with a new dose you need to hold that dose the same for 10 cycles before increasing the dose.
A lot of the BGs being high is because Toby is bouncing which is normal for newly diagnosed cats.
Because of the DKA at diagnosis and ketones I think you could go up in dose to 3.5 units. But I would like to ask @Wendy&Neko her opinion first. Hopefully she will be around later today.

Hi Bron
I asked the nurse to check his last bloodwork for fPL
and he said that he did not see this. I made an appointment tomorrow for him to have this test.
I recall that his vet said that his potassium levels were normal. Does this rule out issues with his pancreas?

 

[Larry and Kitties]

What dose of Zofran (0ndanastran) are you giving? For a normal size cat (~10 pls) 4 mg orally every 6-8 hours is given since the duration of action of ondansetron is only 1-3 hours. SuvbQ administration has significantly duration of action and it is a lot better.

 

[Bron and Sheba (GA)]

Hi Bron
I asked the nurse to check his last bloodwork for fPL
and he said that he did not see this. I made an appointment tomorrow for him to have this test.
I recall that his vet said that his potassium levels were normal. Does this rule out issues with his pancreas?

Potassium levels and pancreatitis are two different issues. I’m glad you are getting the FPL test done.
How’s his appetite today? Did you change when you give the zofran as Wendy suggested.

 

[Susan and Toby]

What dose of Zofran (0ndanastran) are you giving? For a normal size cat (~10 pls) 4 mg orally every 6-8 hours is given since the duration of action of ondansetron is only 1-3 hours. SuvbQ administration has significantly duration of action and it is a lot better.

Hi Larry-
I give Toby .5mls of liquid compound odansetron.
I don't know how that translates into 4mg of a pill.
Doesn't make much sense to give at bedtime which I have been doing. I requested a bag and a line from vet
yesterday. I gave him 50 units as directed by vet.
Only ate baby food later. Is it suppose to help with appetite?

 

[Wendy&Neko]

If he is nauseous, which can cause him to lose his appetite, then ondansetron will help. But give the doses closer to his meal times.

 

[Susan and Toby]

Potassium levels and pancreatitis are two different issues. I’m glad you are getting the FPL test done.
How’s his appetite today? Did you change when you give the zofran as Wendy suggested.

They should have the results back by Tuesday.
Christmas might delay this. I'll post as soon as I find out the results.
Yes! Wendy's suggestion worked out well! I gave it to
him as she recommended this morning and he eat ate a whole can of FF! Hopefully I will have the same results this evening.

 

[Susan and Toby]

Guess I spoke too soon. Toby had such a good day.
Now he looks unwell again and would not eat PM meal. Maybe fluids before breakfast and AM dose will reverse this.

 

[Larry and Kitties]

.5mls of liquid compound odansetron.

The bottle should give the concentration in X mg/ml or similar wording. What is written on the bottle or other paperwork that came with the bottle?

 

[Susan and Toby]

They should have the results back by Tuesday.
Christmas might delay this. I'll post as soon as I find out the results.
Yes! Wendy's suggestion worked out well! I gave it to
him as she recommended this morning and he eat ate a whole can of FF! Hopefully I will have the same results this evening.

His vet thought that the fPL test was a good idea according to her nurse. Makes me wonder why she didn't do this sooner. I imagine though when he had the extensive work up with the internist he checked this out. It appears that she is repeating all the tests including an ultrasound that he did. All is to determine if there is an underlying issue to explain why he is not responding to insulin properly. He found nothing. She also ordered a IGF-1 test for him. Google says it is to check for acromegaly. Does this make sense?

Also I have questions about assist feeding. Looks like Toby might be starting a stretch of not eating.
The last couple of days I have been carefully swiping wet food in his mouth. As you know vets discourage this. How do you feel about this? Also I am confused
about dosing him when he won't eat or eats a tiny bit.
I've read a couple of different opinions.

 

[Susan and Toby]

The bottle should give the concentration in X mg/ml or similar wording. What is written on the bottle or other paperwork that came with the bottle?

Hi Larry-
I couldn't find anything on the bottle and I threw away the paperwork that it came with.
Regarding SubQ fluids- vets instructions are to give 50 units everyday for three days. That's all she wrote.
That doesn't make sense to me. What do you recommend?

 

[Wendy&Neko]

Fluids are usually given based on cat weight, but there are also other considerations. If a cat has any heart issues, fluids are not a good idea. Ask me how I found out about Neko's heart problems - from starting fluids. What is the "units" for fluids?

Has Toby been on insulin since August 28th?

If they are doing an IGF-1 test for Toby, and they have enough blood, I'd toss in a test for IAA as well. The blood goes to the same place for testing and is a cheap add on. Some cats have one or the other conditions, or both, like my Neko. One in about 4 diabetic cats has acromegaly, so it's not an unreasonable test to do.

He needs food, assist feeding can help. Some suggestions in here:

• Syringe/Assisted Feeding (Video and Tips)

 

[Susan and Toby]

Fluids are usually given based on cat weight, but there are also other considerations. If a cat has any heart issues, fluids are not a good idea. Ask me how I found out about Neko's heart problems - from starting fluids. What is the "units" for fluids?

Has Toby been on insulin since August 28th?

If they are doing an IGF-1 test for Toby, and they have enough blood, I'd toss in a test for IAA as well. The blood goes to the same place for testing and is a cheap add on. Some cats have one or the other conditions, or both, like my Neko. One in about 4 diabetic cats has acromegaly, so it's not an unreasonable test to do.

He needs food, assist feeding can help. Some suggestions in here:

• Syringe/Assisted Feeding (Video and Tips)

Vet ordered 50 units of fluids for 2 to 3 days.
She also wrote to pay attention to his breathing.
I would be inclined to give fluids after the three days are up. Maybe once a week or whatever you think.
He does drink a lot of water though.
Yes he has been on insulin since August 28th.
It was too late to include the IAA test but I'll mention this to his vet. Rather than use a syringe I swipe feed
small amounts of wet food at a time. It's easy with him because he only has front teeth. Is this not recommended?

 

[Susan and Toby]

Susan, I think you are OK to go to 3.5 units now. It's been a long time since he's seen anything under 100 on this dose.

I agree with Bron. I'm not sure what the point of another ultrasound would be. It's only been 4 months since his diagnosis. Feline diabetes is a marathon, not a sprint. My Neko spent many months in those high numbers, but I still eventually got her to be fairly well regulated. It took a year since she stopped bouncing to the reds.

I am sorry to be harping on this. It is reassuring to read that Neko and other kitties can spend so much time in
high numbers and become more regulated. None the less it is upsetting to see his BG over 600 and 700 for
so many hours. My questions are- even if his ketones
are not alarming is there any other harmful effects of this? How does it make him feel? I know he seem brighter and more animated on the rare occasions
when he has a stretch of numbers in the yellow zone.

 

[Wendy&Neko]

I asked Neko's internal medicine vet the same question on spending all that time in high numbers. He said that as long as kitty does see some good numbers, it's not as bad as if they are perpetually in high numbers. All the time high numbers means the insulin dose is way too low. Seeing the odd high number and then bouncing doesn't seem to be as harmful for them, and means you are getting closer to a good insulin dose. Toby has gotten down to 160 on this dose, so that's a good sign. But, he'll likely need more insulin in due course.

However you can get food in him, that is good if he is OK with it. Some people even spoon feed if that works.

 

[Susan and Toby]

Hi Wendy- His vet said that his high numbers means
that he is not responding to insulin so there must be an underlying cause. She sent me to an internist
who did extensive tests only to find a UTI.
As I mentioned, she wants to do another ultrasound
which didn't make sense to you and Bron. I will
question her on this. It seems that she wants to
perhaps redo all of these tests again to find the underlying cause. Would the results be different now than they were a few months ago? Is it futile to repeat this all over again? Should I ask her specifically if she is exploring something new? I will be sending his vet an email with some questions. I would appreciate it if you could direct me on this.
Sounds like you and Neko's internist would report that Toby's BG readings are not indicative to him being insulin resistant. I should be getting the results back soon for the fLP. Maybe at that point he will not need any more diagnostics.
Sorry if I am repeating myself. I can't remember exactly what I shared before.
Thank you very much.

 

[Wendy&Neko]

There are many things that can cause insulin resistance. Inflammation and/or infection are two of them. Getting the fPL test back would tell us one of those possible things which is pancreatitis. Which also causes nausea and lack of appetite. Has he been treated for the UTI and over it now? I'm trying to think of things that would cause him to be off of his food as well. Antibiotics cause destroy the good tummy flora, so a probiotic is a good idea when they are on antibiotics.

There are also some secondary conditions that can cause insulin resistance, such as kidney and heart disease, and possibly some GI conditions, some of which can reduce appetite. The IGF-1 test will check if he has acromegaly, a benign pituitary tumour that sends out excess growth hormone and causes diabetes. Note, most cats with acromegaly have huge appetites due to the excess growth hormone (think growing teenagers).

I think it wouldn't hurt to ask the vet (IM vet or regular vet?) what they might be thinking is happening inside Toby. I'd wait for the fPL and IGF-1 test results first before going ahead with an ultrasound. I'm a fan of using a vet who is a specialist in doing ultrasounds.

 

[Susan and Toby]

Regarding pancreatitis:

please read message from Toby's vet.

"Toby’s FPL pancreatic marker is elevated as expected [ this was elevated when he was at Beacon and the ultrasound he had a few months ago at Bluepearl was also suggestive of pancreatitis ]. This value can remain elevated for some time, though I suspect he still has an active pancreatitis given how he acts. He is already on the treatment regiment for pancreatitis… appetite stimulant and anti-nausea medications, theoretically we could add in pain medications but you mentioned before when we had discussed Gabapentin closer to around the time he was discharged from Blue Pearl that he doesn’t seem to do well on it, we can consider adding it in at a lower dose."

Is this the only treatment for pancreatitis?

 

[Wendy&Neko]

Here is a detailed post on pancreatitis. A Primer On Pancreatitis

You are also giving fluids, which is part of the formula for treatment, but are missing the pain medication. There are alternatives to gabapentin, buprenorphine is what my vet has given me for my cat that has had pancreatitis. I know people who have had pancreatitis, and it is incredibly painful, pain management is important.

 

[Susan and Toby]

Hi Wendy -I am very upset that he wasn't started on pain meds initially. His vet has finally prescribed 0.15 mls of gabapentum now to give to him when he appears to be in pain. I can tell when he doesn't feel well and he shows the symptoms of pain. but the vets direction is too vague. He also has days when he is eating well, is bright and interactive.
Another more experienced knowledgable vet will be
overseeing his care at my request. I will report to her that I've heard that Buprenorphine is more the protocol for pancreatitis. In the meantime, how should I dose him..PRN or standing order? How often?
Is this 0.15 mils enough?
He seems to have a good response to this.
Also regarding fluids. Vet ordered 50 mls.
How often?

On another note- As you can see, his readings have been astronomical! His vet says that without ketones it is alright for him to stay in that zone as long as his clinical signs are generally good. Is that true? How do our kitties feel when the readings are so high?
Thank you.

 

[Wendy&Neko]

The spreadsheet says 0.5 units insulin given this morning? I think you can increase his dose to 3.75 units.

As for how our kitties feel, depends what they are used to, but hard to believe it feels good.