Update and Quesetion re: Relapse after three year remission

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Amy and Hershel

Amy and Hershel

Member Since 2017
Hi everyone, I joined this forum in 2017 when Hershel was first diagnosed. It was a scary time and I was so grateful for all the support I received. He has been off insulin for almost three years (he only was on 1u of Lantus for a week before he began to regulate himself), and I now only check his levels intermittently while monitoring any changes in behaviour. He exclusively eats Friskies pate. Yesterday, he vomited up his food in the morning, and then pooped outside the litter box, and possibly peed outside it too, though that may have been my other cat's doing. He threw up some bile around 2pm, and then began acting lethargic. I was about to head out of town for 4 days, and my boys have a way of expressing their displeasure when they sense I'm about to leave, so I wasn't too concerned until I checked his BG at 6:30PM and it was 21.4mmol/L! He hadn't eaten since breakfast and I was shocked. I hadn't seen numbers that high since his diagnosis. I took him to the emergency vet and canceled my trip.

The EV kept him overnight and put him on an IV. They got his blood sugar down to 11mmol/L by this morning, and they are keeping him for the rest of the day to do a BG curve, urinalysis, and full bloodwork panel. They said I will hopefully be able to pick him up later this evening, but they might want to keep him overnight again. I've asked them to discharge him as soon as possible, because I know he is terrified there, and I would feel more comfortable doing the curves myself at home. I wanted to transfer him to my regular vet this morning, but they didn't have the capacity to monitor him as frequently as the ER would so I agreed to keep him there.

I'm so scared and am wondering how common a relapse after this much time is, and if it's possible he'll just need another short course of insulin before his diabetes can be managed with diet only again. I feel confident I can manage his diabetes at home with insulin even if it's for the long-term, I guess it's just a matter of waiting for the vet to tell me what dose they are going to start him back on and see how he reacts to it. I also am wondering if if it's reasonable that the EV wants to keep him there for 1.5-2.5 days to monitor him, or if once the urine and blood tests are complete I should feel confident in bringing him home.

Thank you so much for any insight and support you can provide.
 
HI Amy,

Sorry to hear Hershel's feeling poorly at the moment.

I second the suggestions above about checking for dental issues, etc., and for any other possible infectious or inflammatory issues.

The only other things that I can suggest checking out are ketone issues or pancreatitis (what was blood test result for ketones, and did they run either a Snap fPL or Spec fPL test?).

Might also be an idea to ask the EV to prescribe BOTH anti-nausea and appetite stimulant meds for you to take home with you as a precautionary measure. Hopefully they won't be needed but, given Hershel has been throwing up and he may have to go back on insulin again, the last thing either of you need would be feeding difficulty. It's much better to be in a position to respond quickly to any nausea issues immediately so the kitty can keep eating enough. It can be much harder trying to get a completely inappetant cat to start eating again.


Mogs
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I just brought Hershel home from the vet - his bloodwork and urinalysis came back normal - they are still waiting on the results of the urine culture. Last night he'd been showing trace ketones but those are gone today. They gave me these discharge instructions:

If BG <15 and Hershel does not eat - do not give insulin
If BG <15 and Hershel does eat - give half dose - 0.25IU
If BG >15 and Hershel does eat - Give 0.5IU insulin
If BG >15 and Hershel does not eat - give half dose - 0.25IU

The last time they administered insulin to him was this morning 7:40AM and they skipped the evening shot because he wouldn't eat. It's now 11:30PM and his BG was at 16.2 when I tested him an hour ago. He isn't touching his wet food and I'm unsure if I should give him a half dose tonight and monitor BG every 2 hours, or wait until the morning, check BG then and reassess insulin at that time. I'm going to take this query over to the Lantus board, but if anyone has any insight here it would be much appreciated, thank you!
 
For info:

Nausea and Inappetance - Symptoms and Treatments

Try seeing if Hershel will eat if you raise his bowl up a few inches so he doesn't have to lower his head to eat. Also perhaps try warming his food to check whether he can smell it properly.

Also, was Hershel pooping regularly before all this or is there any chance he might be constipated? (I know you mentioned diarrhoea upthread but sometimes more liquid faeces can be squeezed around a hard stool and expelled from the body.)

Just throwing out ideas here.


Mogs
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Critter Mom said:
For info:

Nausea and Inappetance - Symptoms and Treatments

Try seeing if Hershel will eat if you raise his bowl up a few inches so he doesn't have to lower his head to eat. Also perhaps try warming his food to check whether he can smell it properly.

Also, was Hershel pooping regularly before all this or is there any chance he might be constipated? (I know you mentioned diarrhoea upthread but sometimes more liquid faeces can be squeezed around a hard stool and expelled from the body.)

Just throwing out ideas here.


Mogs
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Thank you for all these suggestions, Mogs. The EV did not give me anti-nausea meds to take home but they did give him some while he was there. I tried all sorts of things to get him to eat his wet food, sprinkled some parmesan on top, mixed it with warm water, different locations and positions, but he won't go for it, or even his brother's dry food which he is always trying to steal. He is such a sensitive kitty and I naively thought his appetite would come back once the terror of being at the EV was over and he was back home. He was pooping regularly before this and when I brought him home from the EV last night he peed and pooped in the litter box right away. His BG when I brought him home last night was 16.2mmol/L and this morning it was 14.6mmol/L but I have not given any insulin since he hasn't eaten since 7:00am yesterday, when he had his last insulin shot. I don't have a syringe to try assist feeding so I decided to bring him to his regular vet this morning. They are keeping him for the day and want to redo all of the bloodwork, including for pancreatitis, which I'm not sure if the EV did or not but am assuming they did since they said "full bloodwork panel." This is because apparently the EV cannot (will not?) send over the results of the tests for 24-48 hours. I'm so frustrated - I spent $1860 at the EV - can't they just read my vet the results over the phone?! My vet said they will try and obtain the results so that they don't have to redo all of them, I think they felt sorry for me because I was crying on the phone. I really can't afford any of this, but don't have much of a choice at this point. :(
 
Amy and Hershel said:
The EV did not give me anti-nausea meds to take home [...] He is such a sensitive kitty and I naively thought his appetite would come back once the terror of being at the EV was over and he was back home.
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This is what I was worrying about, hence the suggestion to ask for the supportive meds. They might never be needed but it's so helpful to have them there just in case. Hopefully your own vet will give you some going forward. Tip: If nausea is an issue then Cerenia AND ondansetron can both help. They have different modes of action and if required they can be used in tandem. An appy stimulant is also advisable to ask for when kitties need a bit of help to start eating again. Mirtazapine is probably the more common med prescribed but thee is also cyproheptadine. Cypro is milder in action than mirtz but because it has a shorter half-life you can give it more frequently if needed, and that can give more control over dosing.

I'm so frustrated - I spent $1860 at the EV - can't they just read my vet the results over the phone?!
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I'd be frustrated too, Amy. It's ridiculous that they can't call out the results to you. :mad:

At least Hershel is at your vets right now and hopefully they'll be able to do the necessary to help him start eating again, get some insulin into him, fluids if he needs them, and also keep an eye on ketones, etc.

Keeping fingers and paws crossed here that Hershel will be feeling and eating better very soon. I know how hard this must be on you so saying some prayers for both of you. Be sure to let us know as soon as you have some news.

:bighug: (((Amy and Hershel))) :bighug:


Mogs
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Critter Mom said:
This is what I was worrying about, hence the suggestion to ask for the supportive meds. They might never be needed but it's so helpful to have them there just in case. Hopefully your own vet will give you some going forward. Tip: If nausea is an issue then Cerenia AND ondansetron can both help. They have different modes of action and if required they can be used in tandem. An appy stimulant is also advisable to ask for when kitties need a bit of help to start eating again. Mirtazapine is probably the more common med prescribed but thee is also cyproheptadine. Cypro is milder in action than mirtz but because it has a shorter half-life you can give it more frequently if needed, and that can give more control over dosing.



I'd be frustrated too, Amy. It's ridiculous that they can't call out the results to you. :mad:

At least Hershel is at your vets right now and hopefully they'll be able to do the necessary to help him start eating again, get some insulin into him, fluids if he needs them, and also keep an eye on ketones, etc.

Keeping fingers and paws crossed here that Hershel will be feeling and eating better very soon. I know how hard this must be on you so saying some prayers for both of you. Be sure to let us know as soon as you have some news.

:bighug: (((Amy and Hershel))) :bighug:


Mogs
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They did end up sending the results to my vet, after I called them and gave them an earful. They didn't do the pancreatitis test (why?!) but my vet did that today - haven't gotten the results yet. She said that even with a negative test result, pancreatitis might still be an issue. She hasn't given him any insulin since he won't eat and he is holding steady around 14mmol/L. So I am picking him up in half an hour, and she is giving me an appetite stimulant cream and anti-nausea pills (cerenia) and we are going to try a bunch of different diabetes-friendly wet foods. It's promising that all the other bloodwork and urinalysis was normal, but if he's still not eating by tomorrow, she would like to do an abdominal ultrasound to look at his pancreas and check for cancer, and potentially put him on a feeding tube. I've been a wreck since this began, but I'm trying my best to stay calm and positive for Hershel. Your prayers are so appreciated, thank you. :bighug:
 
I just brought him home from the vet and although still not quite back to his usual self he is way more energetic than he was this morning, AND he went straight to his food bowl and ate some of his usual Friskies pate! He didn't eat a ton of it, but I'm so glad he finally got some food in him, and he keeps going back to nibble. I have the anti-nausea meds and appetite stimulant should I need them. I'm really starting to think that he must have had a terrible experience at emerg and that was what was at least partially responsible for his low appetite.
 
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Please make sure you are testing every day for ketones while he is unwell, not eating much and you are skipping insulin doses. All these things can contribute to ketones and if any appear you need to act quickly to get rid of them.
Encourage small snacks often. As long as he eats, it really doesn’t matter what food it is. The most important thing is he does eat.
 
Welcome home, little fella. (((Hershel)))

It is indeed good news to hear he's having some grub. It's much easier to keep a queasy cat eating with a little support than trying to completely kick start the appetite.

I echo Bron's advice about vigilance on ketones.

C'mon, li'l Hershel. Eat your fudz for your mama.

(((Amy)))


Mogs
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Thanks for checking in, Mogs. He ate a tiny bit this morning and has had a few treats. I'm giving him Mirtazipine and Cerenia in 30 minutes and 1 hour, respectively, and hoping it helps. I gave him 0.5u of insulin last night and this morning but it seems to be having no effect on his BG. I'm thinking the dose is too small but am afraid to increase it given how little he's eating. When he was first diagnosed three years ago, he was getting 1u and it worked immediately and he only needed it for about a week. I'm waiting for the vet to call me today with the pancreatitis blood test results. He's walking around a little but his energy is low, he must be so hungry. And the strangest thing is his big brother keeps hissing and growling at him and then walking away when he gets no response. :(
 
So it turns out he does have pancreatitis. I'm somewhat relieved to finally have a diagnosis, devastated thinking of how much pain Hershel must be in, and so annoyed that the emergency vet didn't catch this. He's going on Bupenorphrine twice daily. Hoping this will bring his appetite back and lift his spirits.
 
At last! At least you know what you're dealing with now, Amy, and how to treat it, to whit:

IDEXX Pancreatitis Treatment Guidelines

The above has everything you need to know - and ask for! - about pain relief, nausea control, appetite stimulation.

Tip: Do take note of the IDEXX recommendation about starting a course of B12 injections ASAP: it can give a kitty a bit of a boost and it helps improve appetite (certainly did for Saoirse :) ).

See earlier in this thread for the link to the nausea and appetite info at Tanya's Site. Very helpful.

I found that the key to helping Saoirse keep eating was addressing the nausea. Per the info in the IDEXX guide, Cerenia and ondansetron can both be used to treat nausea in cats. I found that ondansetron worked significantly better for Saoirse. Note that Cerenia and ondansetron can be used in concert if required (they work on different pathways in the body). Appy stimulants don't tend to help much on their own in a nauseated cat. You could well need both.

Assuming that Hershel's eating wet food, you can add a little water to each feed to help keep him hydrated. That will make him feel better too.

Another simple tip is to raise Hershel's food and water bowls up a couple of inches. It should be more comfortable for him to eat and drink if he doesn't have to lower his head to the bowls.

There's also a useful link on getting the right pancreatitis treatments (references UK in particular but the overall principles are universal in application) in the following post from the FDMB FAQs:

https://www.felinediabetes.com/FDMB/threads/article-on-pancreatitis-for-uk-residents.194915/

Hope some of that helps, Amy. Sorry I can't do more but I'm exhausted.

Sending healing vibes to your little one. So glad you got the bupe for him. I think he will very likely need anti-nausea meds and probably appy stimulants too to help him keep eating.

:bighug::bighug::bighug:


Mogs
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Critter Mom said:
At last! At least you know what you're dealing with now, Amy, and how to treat it, to whit:

IDEXX Pancreatitis Treatment Guidelines

The above has everything you need to know - and ask for! - about pain relief, nausea control, appetite stimulation.

Tip: Do take note of the IDEXX recommendation about starting a course of B12 injections ASAP: it can give a kitty a bit of a boost and it helps improve appetite (certainly did for Saoirse :) ).

See earlier in this thread for the link to the nausea and appetite info at Tanya's Site. Very helpful.

I found that the key to helping Saoirse keep eating was addressing the nausea. Per the info in the IDEXX guide, Cerenia and ondansetron can both be used to treat nausea in cats. I found that ondansetron worked significantly better for Saoirse. Note that Cerenia and ondansetron can be used in concert if required (they work on different pathways in the body). Appy stimulants on their own don't tend to help much on their own in a nauseated cat. You could well need both.

Assuming that Hershell's eating wet food, you can add a little water to each feed to help keep him hydrated. That will make him feel better too.

Another simple tip is to raise Hershell's food and water bowls up a couple of inches. It should be more comfortable for him to eat and drink if he doesn't have to lower his head to the bowls.

There's also a useful link on getting the right pancreatitis treatments (references UK in particular but the overall principles are universal in application) in the following post from the FDMB FAQs:

https://www.felinediabetes.com/FDMB/threads/article-on-pancreatitis-for-uk-residents.194915/

Hope some of that helps, Amy. Sorry I can't do more but I'm exhausted.

Sending healing vibes to your little one. So glad you got the bupe for him. I think he will very likely need anti-nausea meds and probably appy stimulants too to help him keep eating.

:bighug::bighug::bighug:


Mogs
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You've been so incredibly helpful, Mogs, thank you!! He's on quite a cocktail right now with the Bupe, Cerenia, Mirtazapine, and insulin, but I feel hopeful and so comforted by all the wisdom and support offered in this community. :bighug:
 
Amy and Hershel said:
You've been so incredibly helpful, Mogs, thank you!!
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Just paying it forward, Amy. Elise and another member (Helen IIRC) helped me when Saoirse had a massive pancreatitis flare not long after she started insulin treatment.
They helped to save my girl's life, for which I will be eternally grateful to them. Saoirse had been struggling to eat for weeks but they introduced me to ondansetron. I'd never have known about it otherwise. I had to specifically request it from my vet. It completely turned things around for my girl. It helped her to eat a little bit more almost straight away and within a few days she was able to eat regularly under her own steam.

FYI, there's a pancreatitis primer in the FDMB FAQs section.

I'm gone. Eyes are out on stalks. :rolleyes:

:bighug:


Mogs
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Update and question crossposted to Lantus forum:

Hershel's mood, energy and appetite returned to normal after three days on the Bupe, Cerenia and Mirtazipine. He has no residual symptoms or unusual behaviours, which is amazing, but his blood sugar still looks slightly too high. I use SLGS and an AlphaTrak 2 and I know the protocols here are based on human meters, so I've been conservative with the insulin and sometimes don't know if I should give him his dose based on the pre-shot numbers and nadirs. If anyone could look at his spreadsheet and offer any advice, it would be greatly appreciated. Should I be trying to get him into the greens? Do some cats BG levels just run slightly higher? And again, I want to thank you all for helping us so much.
 
HI Amy,

I am glad to hear that Hershel is feeling better. :)

I've looked at Hershel's spreadsheet and he is running in fairly good numbers but he's in the upper end of the normal range with a few readings creeping above it.

Question: I note from the spreadsheet that you've been giving just the AM doses of Lantus over the past few days. Is it tricky for you to monitor at night?

Lantus is dosed on the nadir BG level. I have an Alphatrak so I understand the issue with trying to determine dose adjustments when the protocol criteria use BG levels on human meters.

If you look in the attached file below, under one of the tables there, they give some suggestions on how to adjust the TR protocol thresholds for use with a pet meter. They also suggest setting the target BG range as the normal reference range for cats. My vet gave me the normal reference range for BG in cats as 3.9-8.3mmol/L as measured on a veterinary glucometer (70-150mg/dL).

I'd suggest maybe printing off the SLGS protocol and the document below, and using them to have a discussion with your vet about which thresholds to use on the Alphatrak when determining dose adjustments. At minimum, please confirm with them the normal reference range you should use.


Mogs
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Thank you, Mogs. I've been skipping the nighttime doses because I spent two nights away over the weekend and didn't feel comfortable having the pet sitter give him his shot without being there to monitor him later, and because of what I wrote above - being unsure about whether or not to dose based on the pre-shot numbers, especially if I haven't tested for nadirs during the day. My vet told me to skip the shot altogether if his pre-shot number is less than 12mmol/L, but as you can see I've generally been giving him a token dose as long as he is above 8mmol/L. You're right, I should probably tell her that I've been using this protocol!
 
I'd have done exactly the same in that situation, Amy. :)

The vast majority of the time Hershel's BG is in the normal range, albeit in the upper reaches thereof. Maybe see how Hershel gets on without insulin for a few days, and watch out for whether his numbers start trending upwards and then have another consult with your vet? If they do drift up, perhaps continuing treatment with a tiny dose of Lantus for a little while to give the pancreas a little more support might be enough to see Hershel fully back into remission (anti-jinx!).

Purely because you're reducing/suspending insulin treatment, maybe as a precaution do the odd check on Hershel's pee for ketones (belt and braces!).


Mogs
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