Update:Ketoacidosis (Relapse) 7/5/14

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Allison and Tillman

Member Since 2014
Hey everyone! My guy Tillman was diagnosed diabetic, and I have been lurking on the board since then. We have had trouble getting him regulated. I work at a low-cost spay/neuter clinic. So I took him in to work when he seemed to be losing weight. After his blood work returned, he was diagnosed, and had ketones present in his urine. He was also seen by another private veterinarian since we are limited at our office in what we can do. That vet prescribed PZI 2.0 units, and DRY Hill's W/D. The vet I work with suggested he actually go on canned M/D. However, I have had him on Friskies Classic Pate instead after visiting the board, due to finances. Niether vets mentioned home testing. After I did a ton of research on here, I spoke with the vet I work for who was shocked he tolerated the home testing so well and suggested I continue with it.

When I first started the 2.0 U of PZI a week later, I got this curve:

AMPS 402 +2 310 +4 178 +6 156 +8 418 PMPS 401 +2 166

This spike made the vet think it was somogyi effect, so she suggested we gradually take him down to 1.0 unit. I did 1.0 unit for about 3 weeks, while spot checking. Then I did a full curve, and got this:

AMPS 332 +2 274 +4 245 +6 298 +8 300 PMPS 235 +2 225 +4 280 +6 247

She was not pleased with these numbers, and suggested we take him back up gradually. He ended up back up at 2.0U.
We were spot checking throughout the week, and doing a full curve on the weekend. He was consistenly in the 230's these past three weeks. So, I took him in for a cysto, and we ran a Urinalysis and C&S, Thursday. It came back negative for infection,but with trace ketones in the urine. Friday, he began vomitting. At first I thought he was simply eating too fast. He has never had a problem eating, and is a beggar. He scarfs most of the time. However, I woke up Saturday, and Sunday to more vomit. However, each time he would eat normally at meal-time, and was testing in the 200's, so was still getting insulin. I gave him some Pepcid AC Sunday to see if it was acid. The vomit is liquid with wet food mixed in. However, this morning I woke up to vomit again, and he has absolutely no interest in eating. I have encouraged him to drink, and he has drank a fair amount, and eating a few small bites of plain boiled chicken. He has been seating in the Sphinx position (sometimes over the water bowl), lethargic, droopy-eyed- and skin turgor is positive for dehydration, Temp 101.4 degrees F. He is not at all himself, and I can tell he is painful. He has finally eaten a small amount of Tuna this afternoon.

I'm thinking Pancreatitis. However, I don't think we can run the SNAP pancreatic lipase at my office, and I really have not been trusting of the vet that prescribed his insulin. I feel like he does not have much experience with diabetic cats, and I have learned more information from this board than him. I guess I can call and ask if they do the SNAP fPL?

I guess I'm asking suggestions until I take him in tomorrow, and if this sounds like pancreatitis? Anyone in the Upstate,SC area with a suggestion for a veterinarian with diabetic cat experience would be helpful, as well. Just very concerned at this point.
 
Re: Possible Pancreatitis?

I noticed you said he had ketones at vet - have you tested for ketones at home? Urine ketone test strips are available just about anywhere that carries diabetic supplies. If he's ketonic, the higher the ketone concentration, the more fluids he needs to help flush those. One of my sugarboyz went ketonic about a month ago - lots of those same reactions from him. I did lactated ringers at home for 5 days along with syringe feeding for 3 days until he started eating by himself again.

If he's nauseated, Pepcid won't help - that's for excess stomach acid. Ondansetron (Zofran) can be used to help with that...needs rx from vet.

Hugs and headbutts!
 
Re: Possible Pancreatitis?

Thanks Squeaky and KT,
He is licking the tuna juice, and from time to time eating a few bites. He did have trace ketones in his urinalysis done via cysto on Thursday, but I haven't done a home test. The vet didn't mention doing any fluid therapy at that time, but we were getting elevated BG levels (almost a straight line, no curve of 230's on 2 units bid) which prompted the urinalysis and culture (thinking possible UTI), but he was eating fine at that time. I am going to take him to work with me tomorrow, and can definetely do some LRS. I read that for pancreatitis the treatment is usually LRS, Buprinex, and Ondansetron, so that may be beneficial as the treatment route either way? When your guy had ketones, were you seeing a change in his response to insulin? Thanks for the response!
 
Re: Possible Pancreatitis?

He is ketonic and severely dehydrated. Ultrasound showed no abnormalities. I'm losing it with worry. Please pray for recovery as he is hospitalized on fluids for the next couple days.
 
Re: Possible Pancreatitis?

Prayers for Tillman to recover and get through this. Fight Tillman. Keep thinking positive that he will make it.
Imagine him eating and feeling himself again. Every time you think of him or start to worry, think of him getting better.
 
Re: Possible Pancreatitis?

Sending hugs and healing thoughts as I just went through this with my cat Maui last weekend. (He is home now and doing well, thankfully.) What made the biggest difference for Maui was 1) fluids 2) better anti nausea control than we originally got with Cerenia, which did little for him and 3) an appetite stimulant.

Hope Tillman recovers quickly! Hang in there!
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

Thanks! That makes me feel better that Maui is home now. I'm trying to stay positive...vet said ketones were +2 (not sure the levels). She also started him on anti-naseau and IV antibiotics because she did get blood in urine and thinking bladder infection. I'm just not sure why that didn't show up on the urinalysis done Thursday. Also, kidney and liver levels looked good so that was a definitely a positive. Potassium was terrible, so obviously that was contributing to the weakness and dehydration. They were going to try to get him to eat tonight and shoot his insulin,too. Thanks again for the well wishes!
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

love, light and purrs to you and your kitty
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

I'm sorry I didn't get back with you after you posted...thank Heaven others also stepped in and commented. :oops:

Dakota, our ketonic kitty in early May, is doing great now so recovery from this just takes time and lots of fluids. I'm sure the IV fluids also contain potassium to help raise that level. Potassium is directly tied to blood glucose as well as other things. Low potassium will make him feel weak and tired. Dakota was at +4 of 4 ketones so at 2+, you're well on the way to getting rid of them.

Thoughts and prayers continue for both Annabella AND you too! Breathe!

HUGS!
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

Thanks so much! Yes, his potassium is very low. Vet said he looked "slightly" better today, but about where she expected. However, when I went to visit he seemed worse to me and so pitiful. He couldn't even open his eyes today, and was SO weak. She said he would not eat, and was being syringe fed today. The tech said he showed a little interest in eating, but was too weak and she syringe fed him. I offered him some food and water while I was there too, he still is acting like he wishes he could eat, but it just too weak to actually do it himself. I was told that the potassium has to be given slowly to build it back up, so tomorrow is when they are really hoping for much improvement and for him to eat. He is on a anti-naseau but they have said nothing about a stimulant. I'm going to ask about that in the morning. Thanks for the encouragement, noone quite understands like you all that have been through similar situations.
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

Hang in there. When J.D. had DKA he was very weak, but got better and better slowly, each day.
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

Just wanted to post good thoughts to you and Tillman from someone who has been there FOUR times
and we are doing fantastic!

My Payne was DX and immediately went into DKA! I had to learn quickly and with these people here,
we finally figured her out. But today she is fat and healthy and running the show! Almost five years
later .....

Keep posting and it will all fall into place, good luck!
Nancy and Payne
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

Thanks so much for the encouragement! The vet said he was were she expected, but it really has just scared me how weak he looked. Also, I trust this veterinarian and staff (which is a new one from my original post, btw), but the fear that that they are not doing enough to make him eat worries me. But, I know that is just me feeling helpless. :YMSIGH:
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

He does need to eat. Hopefully they are feeding him by syringe or tube or IV drip or something. My guy was hospitalized for 8 and 1/2 days and wouldn't eat for them. They kept saying as soon as he eats on his own he can come home. So, I guess they were feeding him some how. They finally gave in and put a feeding tube in and released him and he ate fine once he got home.

Keep thinking positive thoughts. Keep imagining him feeling better. And keep visiting him and take him something that smells like you (an unwashed T-Shirt or pajamas or pillow case) to remind him of home and your love and to comfort him a little. Keep visiting him and loving him and encouraging him.
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

They did say they syringe-fed today, and I am going to ask about the appetite stimulant in the morning, I'm definitely willing for them to insert the NG tube if it becomes necessary. He normally sleeps by my head on my pillow, so I am going to take the pillowcase tomorrow. I hope that brings him some comfort. Also, his "sister" kitty, Riggs is having some seperation anxiety, she keeps searching for him, so we are crying together. :cry: Thanks again!
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

A NG tube is very limited as to what you can feed and tend to irritate the cat. How well does Tillman tolerate syringe feeding? I have been syringe feeding most of my Patches food for over a year. My civi Joey who is in liver failure has not been eating for about two months and I syringe feed him.
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

I think he is tolerating this syringe feeding well. He is having no trouble swallowing. I guess today the vet hopes he is stronger and can eat more on his own today
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

{{HUGS}} to you both! :YMHUG: How is he doing now? Have you had a chance to visit him today?
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

Sure hope Tillman is doing better today. Sending lots of hugs and get better vines to Tillman.
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

Hi everyone! Just wanted to give an update. After a crazy, crazy week last week. First a recap--as I mentioned, I work at a low-cost spay/neuter clinic, and we are very limited in what we can do at our clinic. I work with two veterinarians who I respect greatly, and think are fabulous doctors. They are excellent surgeons, but both were very experienced private practitioners at one point, and still do relief work. On Tuesday when I brought Tillman to work with me, they immediately agreed I needed to seek treatment for him (at a clinic which could handle the case). I mentioned before the vet that prescribed his ProZinc initially in January, I was not completely pleased with. Therefore, one of the vets suggested a fellow doctor she had worked with a couple years ago in the area (who I will refer to as Dr.X), and whom she thought could handle the case appropriately.

Monday, Tillman had stopped eating. When I took him to Dr.X she ran the labs. He was showing ketones +2, and electrolytes were very imbalanced. We had been having trouble regulating him on the ProZinc, and the prior 3 weeks he was running in the 230s throughout the entire day, without much of a curve. Her course of action was to begin him on Potassium Chloride, intravenously, and see how he responded. Ultrasound was performed and was "negative for abnormalities"

Wednesday--She had not seen improvement, but he was "as she expected", after 24 hours on the fluids. He still had not eaten, was being syringe fed by techs but "was not tolerating it that well". She expected to see more improvement on Thursday, but "really needed him to eat". Meanwhile, I'm obviously discussing the case with my the veterinarians I work with, and they both had some questions on the treatment plan, but I was being patient for the day. She was still giving the ProZinc. He bottomed out BG of 24. They gave him Nutri-Cal.

Thursday--Dr.X had run the electrolyte blood panel to find he is worse. Also, bilirubin was elevated, and he was showing jaundice, and was depressed. Concerns for hepatic lipidosis were surfacing now. Still no interest in food, and she would like to refer me to an Internal Medicine Internist to consider my options for a feeding tube insertion. She consulted with the specialist, who suggested another ultrasound, and possible feeding tube options. When I picked him up he was MUCH better looking than Wednesday, but was definitely happy to be with me and my husband. Went to the specialist. She was FANTASTIC. Suggested we were not being aggressive enough with electrolyte therapy. (Find out that Dr.X was only running him at 20mEQ of Potassium Chloride which is MAINTENANCE! :?:) Also, NEEDS to be on REGULAR insulin to get under control. Also Dr.X has not checked for ketones since TUESDAY because "he bottomed out to 24 last night so she was not really concerned about ketones" Specialist says would give him a couple more days before trying the feeding tube, but was concerned about hepatic lipidosis occurring and would also be more aggressive with the syringe feeding first. However, after her consultation we find out it would be $5000 to proceed...my breakdown ensues because we can't do it...we ask our other options. She suggests we take him back to the regular vet and that she give us some information about her suggestions for treatment. Return to Dr.X and present said information. She "agrees" to follow the specialist suggestions to run him at 60mEQ Thursday night, give REGULAR insulin, but wants us to make a decision about esophageal feeding tube insertion. Dangers of anesthetizing him in this condition are huge.


Friday--I bring all the paperwork with his labs to work on Friday, since I had received copies to take to the specialist. I discuss all this with my co-worker veterinarians who are VERY disappointed in the previous treatment given by Dr.X, and don't understand why she is running him on maintenance and why in the world he hasn't been on regular insulin. [My co-worker vets said they would have been running him at 40mEQ before the specialist suggestion] So--I decide the feeding tube is too risky, because he is still syringe feeding. Thursday, I syringe fed him some and although he wasn't super happy about it, he was definitely tolerating it well considering, unlike they said. So we decide, to just bring him home. He would be better off home with us, even if he was going to go, at least he was happier at home. I speak with the Dr.X who agrees for me to take him home, syringe feed and "see". I ask for regular insulin, since I home test. She agrees. I go to pick him up and she HAS NOT BEEN RUNNING HIM AT 60mEQ, BUT 40mEQ, HAS NOT GIVEN THE REGULAR INSULIN, BUT HUMULIN-N, AND SENDS ME WITH THAT. UGH. Also, have him on anti-microbial, and anti-naseau. I'm an experienced veterinary assistant, with a BS in Animal and Veterinary Sciences. So my co-worker veterinarians do everything in the power to help me get what I need for him through the weekend. I get the regular insulin at the pharmacy, we put in a catheter, and I give him 60mEQ potassium chloride, test test test (he was ALL over the place up down up down) and regular insulin, throughout the weekend. Saturday he was still testing with ketones. I syringe fed Gerber Ham and Gravy baby food, and he liked it alot better than the pureed canned food. I gave him 10cc EVERY hour, and slept hardly a wink.

SUNDAY NIGHT- He is so weak and jaundice, and I'm getting desperate. I buy some dry food just to see what happens. He was a all dry food cat before diagnosis. He had been on 9Lives and Friskies Pate before the crash. He ATE THE DRY FOOD. It was a significant step in the right direction. I continued the syringe feedings, and he grazed on the dry throughout the day. Monday we ran blood work. HIS POTASSIUM LEVELS WERE NORMAL. NO KETONES. His liver values were SIGNIFICANTLY improved. It was a miracle. My co-workers are thinking there was a possible low-grade pancreatitis that threw this in motion. He's been on sub-q fluids this week...and we are working on the task of getting his blood glucose under control, and transition back to the appropriate food. So we have started Hill's m/d dry ( I KNOW, I KNOW)...but I don't want to back track on him not eating. So hopefully I can transition him back to the wet food. We tried Humulin-N for the last 3 days and it is just not at all enough control. He has been as low at 101, and as high as 600 (partly due to the dry food, and partly to the humulin). So today I got Lantus (man...more $$$ :YMSIGH: ). He started on one unit for tonight's stick (after testing at 600! again)...and I have been testing like crazy all week. He was 600 at 7pm, and I gave him one unit of Lantus to start it out. Just tested him at 10 and he is 601! UGHHH! I know Lantus peaks at 5hr, but I would hope we would have already started going down by now (+3). I'm trying to be cautious with the Lantus as I'm transitioning from dry food to, Hill's m/d...back to the wet food. But I am determined to get him under control, because man it was terrifying almost losing him last week.

I can not thank you all enough for the kind words and support through this very close call. Any suggestions on moving forward with Lantus, and transitioning back to wet food I would gladly hear. We do bloodwork again tomorrow, please continue to pray for continued improvement! Thanks again!!!
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

Lantus peaks/hits nadir anywhere between +5 to +7 hours after the shot, on the average.

The effects are cumulative; if you follow a Tight Regulation protocol, this means you need to stick with a dose for 5-7 days on the initial dose and 3-5 days on subsequent changes, to allow it to stabilize. There are more details in the written protocol and some options to increase the dose more rapidly if certain test criteria are met.

The formula to determine the initial dose:
What is his current weight?
What is his ideal weight?
Take the lower weight.
If in pounds, convert to kilos (pounds / 2.2).
Multiply by 0.25.
Round down to nearest quarter unit for safety.
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

Thanks for the response! After all his weight loss over the past week he is 8.5lbs, ideal 10lbs. So that would put him at 0.97. So- I guess I will be hanging on to see the response in the next few days. Just kind of scary him being this high, of course...so I guess that means trying to transition to the wet again more quickly!
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

Wow! What a week you have had! So glad that Tillman is a bit better and is back home. Sounds like Tillman is another DKA (diabetic ketoacidosis) survivor. Way to go Tillman! Sending get better prayers and healing vines to you both.

Since your kitty had the electrolyte imbalance and presence of ketones, we strongly suggest you get those urine ketone tests at home on a regular basis, at least once a day. Better to catch it early if it happens again, when it might be just a trace of ketones and you can help by getting more fluids into your kitty. Kitties that have had ketones in the past seem to be more prone to developing them again.
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

What a rough week.

As others said it takes a week for the initial dose of lantus to settle so expect some wonkiness. Meanwhile check his blood , and his urine for ketones whenever he is over 340.

Also I usually recommend 3-4 blood tests a day

- always before the shot - this is mandatory as you don't want to shoot when too low. As a newbie this too low number is 200 but is reduced over time once you have the data to know if its safe.
- mid cycle - 5-7 hours after morning shot depending on your schedule. This is to see how low the cat’s blood sugar is going. The low point "nadir" is what you base dose changes on since you don't want the cat dropping too low (under 50).
- before bed (2-3hours after Pm shot) to get an idea of what the cat's overnight plans are. If this number is less than the pre shot test number you may want to set the alarm for a test a few hours later as this implies an active cycle.

Also you might want to set up a spreadsheet to track results and trends.. http://www.felinediabetes.com/FDMB/viewtopic.php?f=6&t=18207


Wendy
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

Thanks for the responses! Bloodwork shows continued improvement today, but elevated WBC. So obvious infection somewhere, vet thinks possibly bile duct which may have initiated the pancreatitis theory or kidney infection. Started on antibiotic today. Hopefully can get infection under control so glucose management can follow.
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

Glad he's doing better and hope the antibiotics kick in soon
x
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

Hope Tillman is improving! I just sent you a message to your inbox in regards to Vets in the UpState area and my phone number for you to call if you just need to talk. The best advice I can give you is listen to the members on this board. They are so knowledgable and are the reason I was able to get Monet OTJ!
 
Re: Update:ketonic, not Pancreatitis, hospitalized.

Thanks again everyone! The bloodwork this week showed no ketones, liver and kidney values normalizing, and WBC decreasing. This is all good news. Still have some wonkiness with the sugar this week, though. I'm working with the vets at my office to get this regulated, and they are being great. However, the vet keeps changing the dosage based on the numbers we are getting throughout the day. He seems to be better regulated on 2 units, but she fears him dropping too low on that dosage as the WBC decreases. So I am testing often! We have gotten as low as 190, but as high as 530 and hardly any control some days this past week. But that has been shooting anywhere from 1.0 to 1.5 to 2.0 units. With the Lantus, I almost wonder if we should be more consistent with the dosage starting out? I'll try to post some numbers later this weekend so you all can get an idea. He is still on the dry m/d, and I don't know if I should wait to transition back to wet food until the infection is under control? Thanks again so much for the support...hope everyone is having a great 4th!
 
Re: Update:ketonic, hospitalized.

Lantus (and Levemir) are depot insulins. That is the insulin builds up in the body and thus you need a consistent if possible. It would not be possible if yo get a very low preshot BG. If you do then either give a lower dose or no dose at all.
 
Re: Update:ketonic, hospitalized.

Your signature says you are using Prozinc. If you have switched to using Lantus, it would be very helpful to us if you would update your signature.

Have you seen the STICKY: LANTUS & LEVEMIR - TIGHT REGULATION PROTOCOL? It's from over in the Insulin Support Group (ISG) Lantus(Glargine) Tight Regulation forum here. Also called the TR forum. This protocol was originally developed by the researchers at the University of Queensland and was published in the vet journals. Our version puts it in more easily understandable layman terms and has added a lot of insights and notes from our practical experience helping out hundreds of cats. It's worth a look see. BJM pointed it out to you once, but you might want to look at it again and even give a link or hardcopy to your vet.
 
Re: Update:ketonic, hospitalized.

Hey y'all, Tillman took a turn last night. He vomitted in the middle of the night and is nauseous this morning. Won't eat. Gave him metoclopramide this am and he is testing at 504. He got one unit of Lantus, and tested positive for ketones. He got 150cc of fluids sub q. At this point we can not afford to go much further, and if he doesn't improve today we may have to make a decision. Please keep us in your thoughts and prayers today. The vet thinks something else underlying may be going on since bloodwork was improving so much but we just haven't been able to get regulated. Again I would appreciate our thoughts and prayers as welcome forward. Thanks
 
Re: Update:ketonic, hospitalized.

Lantus can take 3-7 days to stabilize on a dose due to the carryover effect. The first dose level may take 5-7 days; after that it may take 3-5 days. If you change with every shot, it never stabilizes.

Its like a funnel.
Pour in water too rapidly, the funnel fills and overflows.
Pour in water too slowly, the funnel doesn't fill, it just runs right out.
Pour it in a bit quickly, then back off and pour consistently, the funnel fills partway and maintains a near constant level.

Or

Its like walking up the down escalator.
Go too fast, and you're at the top and get off.
Go too slow, and you're dumped back at the bottom.
Go a smidge fast at first, then level of on the rate of step climbing, you stay somewhere in the middle.
 
Re: Update:ketonic, hospitalized.

I'm so sorry! Sending tons of healing vines your way. Lantus does take time to really work like BJ said.
 
Re: Update:ketonic, hospitalized.

He's still reading in the 500s and we started the regular insulin to try to get him back down. He feels awful, and the vet is concerned this is chronic recurrent pancreatitis keeping him high and putting him at risk for ketoacidosis here again. If the at home fluid and insulin therapy does not work this weekend, we have to consider euthanizing. I'm heartbroken.
 
Many hugs coming your way. I am very new to this, still trying to get Kitkat regulated, so I don't have any words of wisdom, just know how you must feel.
 
matag - I just read Tillman's story and my heart breaks for you. He's such a fighter, in fact, you both are. You're amazing in your devotion to get him well.

Tears and lots of healing prayers and good thoughts for sweet Tillman.
 
Thanks so much. I have gotten his glucose down gradually throughout the day, testing and shooting regular insulin every hour. He is now in the 100's so he will get regular insulin every 6 hours now. Also has gotten 300cc of sub-q fluids so far. I started syringe feeding tonight a few hours ago after he kept down the metaclopramide. Will continue the feedings very hour. I'm really hoping the naseau is from the ketones and not pancreatitis. But we will take it hour by hour at this point. Thanks again for the support, it means a lot.
 
It sounds like you're doing the right things. I am sending quick healing vines to Tillman and perseverance vines and hugs to you. I'm sure the feeding every hour is going to wear you out. Hopefully, you can change to every 2 hours soon. You're doing all you can. My J.D. didn't want to eat when he had ketones. Prayers to you and Tillman.
 
matag said:
Thanks so much. I have gotten his glucose down gradually throughout the day, testing and shooting regular insulin every hour. He is now in the 100's so he will get regular insulin every 6 hours now. Also has gotten 300cc of sub-q fluids so far. I started syringe feeding tonight a few hours ago after he kept down the metaclopramide. Will continue the feedings very hour. I'm really hoping the naseau is from the ketones and not pancreatitis. But we will take it hour by hour at this point. Thanks again for the support, it means a lot.
Click to expand...
I just reread this. You were giving regular insulin every hour? Wow. I would go with the every 6 hours. I am so glad you are home testing. Please be as good to yourself as you can.
 
Well---great news! :-D Tillman started eating again yesterday morning, and acted like he felt the best he has since first coming home from being "hospitalized" two weeks ago. (This most likely due to his glucose being in normal range all day). Took him in for bloodwork this morning, and it was "great". Thank you all so much again, for the support!

I did a protocol on the regular insulin suggested by the specialist when we first visited her. This is protocol for ketoacidosis and would be what they would do at most vet's office. (keep in mind he was in the 500-600s, testing positive for ketones, and not eating---normally I would suggest going to your vet for treatment. I am a experienced vet tech, and was at my limit on putting any more funds into his treatment, so we went with this.) He was receiving sub-cutaneous LRS throughout the day, as well.

The regular insulin therapy is as follows:
Initially 0.2U/kg regular insulin IM

Hourly 0.1U/kg regular insulin IM

Also monitor blood glucose every 30-60 minutes (I did every 60)

If BG is falling at >100 mg/dl/hr---decrease dose to 0.05/U/kg/hr IM
If BG is falling at 50-100 mg/dl/hr--continue at original dose (he was dropping like this--so I did this version)
If BG is falling at <50 mg/dl/hr--increase dose to 0.2/U/kg/hr IM

When blood glucose <300 mg/dl--hourly insulin dose can usually be changed to--Regular insulin SQ (if hydrated) at 0.5U/kg every 6 hours.
(dextrose drip usually started at veterinarian at this time to prevent hypos)

NPH, Lente, or Ultralente insulin started when patient is off IV fluids, is eating and drinking, and has no vomitting or ketoacidosis.

I followed this technique with a high dose IM/SC technique. He was well hydrated because I caught this early, and was doing fluids. So, I did an initial high-dose IM stick (0.2U/kg regular insulin IM), and the concurrent hourly sticks I did SC.

His numbers were as follows:
524 AMPS (Gave 1 unit regular insulin IM)
484 +1 (0.5 unit regular insulin SC)
533 +2 (0.5 unit regular insulin SC)
487 +3 (0.5 unit regular insulin SC)
439 +4 (0.5 unit regular insulin SC)
426 +5 (0.5 unit regular insulin SC)
368 +6 (0.5 unit regular insulin SC)
289 +7 (2 unit regular insulin SC)
233 +8
183 +9 (here I began syringe feeding 20cc at a time of Gerber Ham and Gravy)
186 +10 (fed 20cc)
166 +11 (fed 20cc)
159 +12 (fed 20cc)
164 +13 (this is +6 hours after 2 units--he was below 200 and I would be asleep, so I did not stick here)
183 +17 (got up in the middle of the night for a check)

Even though he has started eating again, he is still on the regular 2 units every 6 hours. I am transitioning him back to the wet. Trying the fancy feast, and sheba pates this time. When he began eating again on Sunday I saw HUGE jumps when he decided to eat the dry food. While today on the wet I saw a minimal jump. Just another thumbs up for the wet food! :)
 
Wow!

Glad he is doing better for you.

How will you do the transition back to the longer acting insulin.
 
We will introduce the long-acting tomorrow. Since the vet was not that familiar with Lantus, I have printed the tight-regulation protocol to take to her tomorrow to see what she thinks. After reading the suggestions here, I think we were not shooting high enough, or consistently enough with the Lantus the last two weeks. She was afraid of a hypo as his WBC was coming down, but in actuality I think he would benefit from starting out with the tight-regulation recommended 1.0 units for his weight (0.25IU/kg), plus an additional 0.5U for history of ketones= 1.5U, and follow this protocol to get a depot going. He was never getting lower than high 100's nadir when she kept adjusting the dose (anywhere for 1 to 2 units) , day by day anyway...so I think she was changing it up to much. PLUS-I think being on the Hill's MD dry along with the infection obviously kept him elevated. His WBC is in normal range now after 2 weeks on Clavamox, and I have started him back on low-carb wet (Sheba and FF) as of today. Any thoughts on trying the tight regulation protocol? First 3 days do you test AMPS, +5, +7, and PMPS?, or do a full curve?
 
Hi. I'd like to invite you to join the tight regulation lantus forum where you can get help with all your lantus questions. We test at at least 4 times a day and more when home. I get a AMPS or PMPS, +1-+3, +5-+7 for each cycle. If you vary the testing times you don't need to do a true curve too often. I'm glad your cat is doing better. You are right that more insulin is likely needed.

Elise
 
You may want to make 1 change at a time, so you know what is having the effect.

If you are going to start with a higher dose than calculated, test often in the +5 to +7 hours after the shot to watch the nadir period for heading too low. It takes 5 to 7 days on the first dose level to stabilize.

It is possible to use a bolus of R with Lantus, however we consider it an advanced technique and it should be posted in one of the specialty Lantus forums where experienced users can give feedback. Also, please add a note to your signature about "custom dosing for your cat only, do not follow".
 
Thanks! We are going with the 1.5 units for the next week, and seeing what sort of results we get. I'll be sure and head over to the Lantus tight reg board, as well. Thanks again everyone!
 
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