Trace Ketones - Should I treat?

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Kara & Ember

Kara & Ember

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Hello,
Since I haven't been able to get my bio updated, please see my intro post for additional info on my gal: https://felinediabetes.com/FDMB/threads/introduction-new-member.292486/

I also have not had a chance to get my spreadsheet setup, so I've included screenshots of her Libre data.

Basically, decided to test ketones Just Cause (and she's been running a bit high the past couple days, been having some issues with shooting) so figured I would just check. I THINK it showed as trace (but colors are hard and of course the negative and trace are similar, but it looked closer to trace than negative). She doesn't have any other symptoms that I can tell - she is eating normally, no vomiting, (edit: checked her breath, did not notice an acetone scent), etc. She's been a Heavy Drinker since the onset of her diabetes, so it's hard to say whether she's drinking more but she has been more vocal about ASKING for water (she has a water fountain and a bowl of water always, but she likes me to hold the bowl of water and also to drink out of the tub, and she's been very insistent/loud and frequent in asking for those two things).

Since I can't quite tell whether she got her full dose of insulin, I'm basically wondering if I should be trying to treat this by giving her more since her sugars are still high? She's currently on 2 units of Lantus, she ate 2 hours ago (~4pm EDT). Her dinner was ~25g dry Hill's M/D and 50g wet. I'm not sure how this insulin works entirely, so I don't know if I should be giving her more without also giving her more food? Or if I should just be keeping an eye on her and if she develops symptoms bring her in to the Emergency Vet? She has an appointment on Weds for her Trilo recheck.

Other info: she does have a small wound on her side near where her libre is - I'm not sure what happened, she possibly was overgrooming or something about the skin-tac caused an issue? It's difficult for me to get a look at because her fur seems to have grown over it or at least covers it (so I also don't know how long it's been there without my noticing), but I checked it out this morning (when I noticed it) and it doesn't seem infected or anything, but giving as much info as possible. I planned to have the vet take a look on Weds.

Let me know if there's additional information I can provide. Screenshots of each day of her current libre are in this google doc, today at the top and then from 7/16-7/26: https://docs.google.com/document/d/1bEsNxTCzexUjj-_nYs7A6ZL4hogiiNT_A6M9d-nYrCE/edit?usp=sharing

Edit - Libre Readings (times in EDT):
6:06pm = 441
6:35pm = 399
7:13pm = 340
7:30pm = 342

Edit: I'm heading to bed soon, but any info/etc. would be appreciated! Should I increase her dose tomorrow morning to 2.5?
 
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Can you get your spreadsheet set up please? If you are having trouble I will ask @Bandit's Mom to help you. It’s very important we see BG data if we are to help you with dosing. I can see you have provided screen shots of the libre but we are used to using the spreadsheets.
You may have gone to bed by now. Can you get another urine test done for ketones and take a photo of it so we can see please against the colours on the side of the bottle?. It will need to be 15 seconds after taking it to be accurate.
Make sure Ember is eating well. If she becomes lethargic, vomits or has diarrhoea or won’t eat take her to the ER. Otherwise we will wait foe the next ketone urine test.
 
Alright, I think I have the spreadsheet updated now. It's difficult to judge timing and numbers with the libre (and she goes up and down between the hours), so all but yesterday's data I only put in numbers when I actually scanned. I filled in yesterday's as best I could estimate.

I will work on getting another test done. I did a second one yesterday and had the same issue - when I compared it between the two (as in, put the strip in the middle of the two) it seemed to most closely match "trace", but when I compared to each individually, it seemed like it matched both.

Eating / Behavior are still normal. Gave her normal dose of 2 units this morning. Will keep the spreadsheet updated as I can, and will update with image of ketone test when I can get that.
 
With the urine ketone test strips, the colour in the strip will go darker after 15 seconds.
Have you chosen a dosing method yet? I think you could increase the dose to 2.25 units.
 
thank you both! I took a look at the Lantus dosing - I'm kind of at a loss of what to do right now because she's not "normal" yet, so I'm worried about adjusting doses or following a protocol and what not when she isn't where she is going to typically be (i.e., we haven't confirmed her Trilostane dosage yet, and I haven't switched her to a low carb canned food). Her cortisol recheck is Weds this week - assuming that shows she should maintain her Trilostane dose, I'd be looking to transition her food (she just transitioned 2 weeks ago, so I'm also not sure fully about even do that so soon? It seems like some people just feed their cats something different every time with no issue, but I'm very anxious about that with her GI flareups).

I've seen in other posts that her current diet is simply not allowed for the TR protocol, which is likely what I would want to do. So should I even be trying to use TR if she isn't on an allowed diet for it?

She's been stuck at 2u because 2.5u was causing her to drop low (from 400 down to <100), fast (+5), and then spike back up just as fast (registering HI, 500+, at +11) prior to getting on Trilo. Her numbers have been much tighter the past week on Trilo, though, so I'll increase her dosage by .25u tonight.

She's currently also only getting 2 meals per day - I've gotten the recommendation to feed her snacks and such, but since she's not on a low-carb yet, I'm worried what that will do to her sugars. If someone can point me to some resources or help me understand the "why" behind that recommendation, I'd greatly appreciate it! I've really only found stuff online (and from my vets) saying to meal feed 2x per day at the time of the shot. Vet's direction was feed, make sure she's going to eat her full meal and not vomit it back up, and then shot, within 15-30 mins of eating (adjusting dosage based on how much of her meal she eats). She has always been very food motivated, and I've not had any need to adjust down her dosage due to an unfinished meal. I have adjusted this slightly since I've also increased her wet food % (it used to be just a small amount so she could get her miralax).

Current process for her shots are:
dry food (which she is a bit slow about; roughly half her meal calories)
trilostane and insulin (usually about 15-20 mins after she first starts eating because it takes that long for her to eat)
wet food (another half of her meal calories)
 
Also, regarding her food - she's currently getting about 300 calories per day (because she was losing weight when getting about 220, and her new food is more calorie dense). She's been maintaining her weight at this, but I'm sure it should be reduced once she is actually regulated (Dr. Lisa's site mentions 15 cal per lb, she's currently at 11lbs), but is it possible I should look at reducing now and that might help her get regulated faster?
 
Is there a reason you want to stick with feeding Ember the M/D food? If you were told this is prescription "diabetic" food, your vet is not up to speed on feline nutrition. The pet food manufacturers lost a class action suit for calling their food "prescription." If you look over the ingredients, there is nothing in the food that is a drug or drug-related. These are the non-supplements in the M/D chicken flavor dry food: Chicken By-Product Meal, Corn Protein Meal, Chicken, Chicken Fat, Wheat Gluten, Potato Protein, Powdered Cellulose, Pork Protein Isolate, Corn Starch, Sweet Potatoes, Chicken Liver Flavor, Flaxseed. The protein comes from animal by-products (not muscle meat), gluten, and carbs. It also includes my favorite ingredient -- powdered cellulose which is another name for sawdust. It's also very high in carbs. And, to make matters worse, the canned food is 13% carb which is not low carb either.

You cannot follow Tight Regulation if your cat is eating dry food. You can, however use Start Low Go Slow (SLGS) for dosing guidance.

I would discourage you from rigidly holding to calorie ranges. Rather, keep an eye on Ember's weight. Cats are like people -- some have faster metabolisms than others so the number of calories they may need can be more or less than what's recommended. If Ember is back to a good weight, gradually reduce the calories. It also sounds like you have Dr. Lisa's website information. There are a ton of canned foods on her nutrition chart. You can pick any low carb food for Ember. We consider low carb as less than 10% although most people feed their cats a food that's in the neighborhood of 5%.

The number of calories has nothing to do with getting your cat regulated. It's the carbohydrates that will help with regulation. The higher the number of carbs in your cat's food, the more insulin that is required. It's possible to regulate a cat that needs large doses of insulin. We've had cats with acromegaly that are regulated. However, they are on low carb diets. It helps to keep in mind that cats are obligate carnivores. Their bodies can't process carbs.
 
Sienne and Gabby (GA) said:
Is there a reason you want to stick with feeding Ember the M/D food?
Click to expand...

As I mentioned, I actually do not want to stick with it long term. But I also have been making a lot of changes (including taking her off of z/d onto the m/d just 2 weeks ago 7/16, and starting her on Trilostane) and I do not know if I should be changing her food again so soon. Open to suggestions on that front, I just am terrified of GI flareups so thus wanting to "fix" one thing at a time. I am well aware of the issues with this food, yes I was recommended a prescription diet by my vet, yes I understand this is not ideal. I've read Dr. Lisa's whole write up on dry food in general, and have done a good deal of research on "rx" diets, etc., but introducing "real" protein after 4 years of hydrolyzed only, and having not done the research before making that initial swap, I am simply trying not to overload her system with changes and make sure she gets through these (plus the stress of several vet visits, including long-distance ones and a full 9-hour day plus 2 hours travel) without having a flareup before I try making even more. (below from my above post)

Kara & Ember said:
Her cortisol recheck is Weds this week - assuming that shows she should maintain her Trilostane dose, I'd be looking to transition her food (she just transitioned 2 weeks ago, so I'm also not sure fully about even do that so soon? It seems like some people just feed their cats something different every time with no issue, but I'm very anxious about that with her GI flareups).
Click to expand...

I definitely want to get her transitioned as soon as safely possible, but safely is the keyword there and I just don't have a good enough understanding of her flareups etc. to know whether she would respond poorly to a change.


Sienne and Gabby (GA) said:
The number of calories has nothing to do with getting your cat regulated. It's the carbohydrates that will help with regulation. The higher the number of carbs in your cat's food, the more insulin that is required. It's possible to regulate a cat that needs large doses of insulin. We've had cats with acromegaly that are regulated. However, they are on low carb diets. It helps to keep in mind that cats are obligate carnivores. Their bodies can't process carbs.
Click to expand...

I do understand the obligate carnivores/etc., and I apologize for not being more clear - I do know that calories are not the relevant number, but mentioned that number since it's what I'm using to measure and then extrapolating that fewer calories would mean fewer carbs, and thus helping with regulation in that regard.
 
It sounds like you're on top of things. I don't disagree with making small, strategic changes so you know what's going on if Ember's system isn't happy with the changes.
 
@Bron and Sheba (GA) finally got another ketone test (got an actual sample this time so i can retest if needed).

here is the picture at 15 seconds (I took a video so I can also try to find a way to send that if that is more helpful)
sorry if the image is massive lol if there's a better way to do that let me know
IMG_9206.png
 
Bron and Sheba (GA) said:
Yes that looks like a trace. I’m glad you increased the dose of insulin. Can you increase the amount of food?
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I can probably try, but I need to get her next Libre on (going to work on that today). Once I've got that, I'm going to swap her fully to wet food (m/d for now, but going to go look at foods today to see what I can find to transition her to). Mainly worried about a hypo even though the m/d wet isn't low carb, it's still lower carb than the dry and I get antsy when I don't know the impact lol. She's currently getting about 140 cals per meal and I'm going to look at adding some snacks (again, wanting the libre so I can track the impact). Hopefully can find some good treats for her while I'm out today as well. She was kind of interested in the chicken thighs, but not as much as I would have liked. I'm hoping once she gets regulated and swapped to a low-carb, she'll be able to maintain her weight on fewer cals (as long as the ketones are gone, too).

I've also updated her spreadsheet with her recent labs.
 
@Bron and Sheba (GA) alright, new libre is working, and she's fully on wet food as of today. She was a little high at +.5 and +1 (389, 359) and has come down to 257 at +2. I checked ketones again around 2pm ET, and they were still somewhere in that in between "don't really match either color", but I brought the sample to the vet as I asked them to do a preventive care panel (with the blood specks see below, and the ketones and the food changes, I just want to make sure everything is kosher, and they were already taking blood for her Trilostane cortisol recheck).

I am looking at swapping her to Weruva chicken frick a zee (https://www.chewy.com/weruva-cats-in-kitchen-chicken-frick/dp/43940) - I picked up a can to see if she'll be interested in it. Also picked up some duck liver bites from vital essentials (she loves those lol) as this variety of food doesn't have liver. Going to offer some of the new food with breakfast tomorrow.

Does anyone know if offering a food that is being transitioned to as a snack is counter-intuitive? I assume the idea is that the body is digesting both foods at once, majority being the current food, and then the body can slowly adapt to the new food?

I did talk to both of my vets (internist and my primary vet) today as she threw up this morning (not food, just white foam) but there were specks of blood. Neither were overly concerned (and neither was I, I think she was chewing on the plastic tag on my AC unit, which I've removed). Primary vet has a concern with swapping foods again so soon due to pancreatitis concerns, internist does not have any concerns there but "highly recommends a prescription diabetic diet". I tried to (nicely) ask why these diets are recommended. (When I originally mentioned wanting to swap, I noted that I wanted to switch to low carb, species appropriate and to stop feeding my cat sawdust - the internist came back vehemently that there is "no sawdust in any of these foods"). I am curious of the response I'll get on why it's recommended (hill's m/d wet specifically is somewhere between 13-20% carbs, has powdered cellulose, carrageenan, veggie starches, and absolutely NO muscle meat - only pork liver (as the first ingredient, big no from Dr. Lisa), pork by-product, and chicken fat. They mentioned they recommend everything except for the Purina DM dry (wet is ok, Royal canin glycobalance wet/dry are ok, and hills m/d wet/dry are ok). this is my first time going against a vet's recommendation, so I am a little nervous about how they'll respond (and of course, the continuous self-doubt of my own decision making abilities)
 
I know it’s hard going against vets advice but remember they are taught about nutrition by the big cat food manufacturers who promote their prescription foods.
Trust your gut. I feed my cats a home made diet and it is just meat, meat and meat and is nutritionally balanced. When I feed them it looks like food. I’m not saying feed a home made diet but cats need muscle meat not all the added stuff they add and call ur prescription.
Just tell the vet Ember won’t eat the prescription food. Thru can’t argue with that.

Kara & Ember said:
Does anyone know if offering a food that is being transitioned to as a snack is counter-intuitive? I
Click to expand...
That’s fine.
Don’t worry about Snacks during the cycle affecting the BGs. Ember needs to eat well and the insulin dose is adjusted accordingly. The only time you need to withhold food is for the 2 hours Preshot as we don’t want that test to be affected by food. Does that make sense.
 
Ok got it!

Less worried about it affecting her BGs, but moreso wondering if feeding the NEW food as a snack (before she's fully transitioned) would be counter-intuitive to the "transition slowly to avoid GI upset" methodology. (I guess I do worry about it affecting her BGs since the new food is low carb, so wanting to feed that as the snack versus her hills) but I have been feeding her before bed (about now, +4 pm) plus a couple snacks (+4, +8) during the day. Just like 10g of her wet food. She also got some chicken tonight. I need to pick up some non-liver treats for her (it's weird having her be allowed treats lol she's been restricted for so long).

When should I be looking to test her ketones again (and expecting them to be back down to neg)?
 
I would continue to test ketones daily if you can just while there is the question of possible ketones. I know from experience it can be hard to tell the difference between negative and trace sometimes.
Re the food transition, just make sure the overall amount of food during the day, either meals or snacks is done slowly to avoid tummy upsets.
Do you have an automatic timed feeder to use? We find them invaluable for diabetic cats. You could then leave a later snack during the night. If you are in the US petsafe have some feeders to look at.
For snacks, a teaspoon or two of normal low carb food is fine
 
well... the good news is she likes the weruva... the bad news is she maybe likes it a bit TOO much and is now pretty uninterested in the m/d lol going to have to get her to eat the m/d first I guess. I hope this doesnt become an issue with the transition. She ate a bit more when I mixed them, but yeah...
 
Well it’s great she likes the Weruva. Offer the md first when she’s hungry. The transition shouldn’t take too long. I am wondering why you are giving 2.25 U in the am cycle and 2 units in pm? Lantus works best when you stay with the same dose.
I see you got some lovely greens in the pm cycle.
 
Bron and Sheba (GA) said:
Well it’s great she likes the Weruva. Offer the md first when she’s hungry. The transition shouldn’t take too long. I am wondering why you are giving 2.25 U in the am cycle and 2 units in pm? Lantus works best when you stay with the same dose.
I see you got some lovely greens in the pm cycle.
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Ah ok, I was concerned about it being the first time she was on the wet food only. the 2's I listed (also what I gave her this morning) were "Fat 2's", so not a full .25 reduction (probably closer to 2.1 or 2.2)

Those greens are still "spooky" numbers to me at the moment with how she likes to dip drastically (her libre reading from last night looks like a V lol). I know they are the goal, but they make me nervous still

upload_2024-8-1_10-2-38.png



Also heard back from the vet this morning - her urinalysis came back and they are showing she is negative for Ketones.


Also, a question for home testing - I saw on Dr. Lisa's site she was practicing on her kitties and was poking them from behind (on the back of the ear) - is that a possible way to do it? I thought it would need to be in the front of the ear. I'm not sure I could do it still, since it probably pokes through and that would make it so I couldn't do her transdermal meds, but if I could figure something else out for those meds, back of the ear would be way easier. I would love to be able to use a meter instead of needing to rely on a libre (which can quit at any time).
 

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Great it was negative ketones! I would still test a couple of times a week.
With testing you test on the fur side. If it’s poking right through you might have to adjust the depth on the lancet device. Are you holding a cotton ball behind the ear when testing?
Are you feeding a snack at around +2 and +4? This will help stop any sharp drops.
I think you could start posting over on the Lantus forum now when everyone uses Lantus or levemir.
I’ll tag @Bandit's Mom and @tiffmaxee to keep an eye out for you. I’ll link a post about posting on the Lantus page below
 
Bron and Sheba (GA) said:
Great it was negative ketones! I would still test a couple of times a week.
With testing you test on the fur side. If it’s poking right through you might have to adjust the depth on the lancet device. Are you holding a cotton ball behind the ear when testing?
Are you feeding a snack at around +2 and +4? This will help stop any sharp drops.
I think you could start posting over on the Lantus forum now when everyone uses Lantus or levemir.
I’ll tag @Bandit's Mom and @tiffmaxee to keep an eye out for you. I’ll link a post about posting on the Lantus page below
Click to expand...

I havent tried poking, its always seemed very daunting and i assumed it would cause irritation on her inner ear (which i cant give her transdermals if thats the case). I will work on posting over there assuming i can get her transitioned to a better food (i have another post because we are currently at the ER)
 
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