Vet says "Do NOT increase Lantus dose"

Bill Robinson

Bill Robinson

Member Since 2019
Requested consent to increase Lantus .5U d 12 hrs as BG is remaining very high after 5 days. Doobie is on .5U d 24 hrs.

Internist are out of the hospital until Monday. Ketoacidosis is a big concern for Doobie and very costly for us. Sent spreadsheet to hospital this morning for regular emergency doctors to review in lieu of Internal Med Dr.
Response, "do NOT increase Lantus dosing without clear direction from Internist". The hospital left the same message on 3 phones. Very important that we not consider any changes until the hospital runs their own curve on Tuesday.

Another hospital stay, Doobie under stress in a very loud emergency hospital. BG results in that setting have been all over the place. Not to mention it is $1300/day (we are already well over $10,000 in expense)

Doobie's Ketones are likely to rise again tonight due to 12 hours in the high 300s and low 400's. At what point do we insist the hospital work with us more closely or go elsewhere? I get the "Go Slow" method and the "depot" effect of Lantus.

After 2 DKA emergency interventions (8 days in the Hospital) in the first couple weeks, we feel we need to get his BG numbers down consistently and watch him closely for any signs of Hypo and lower his obvious risk of another DKA emergency.
 
Bill Robinson said:
Requested consent to increase Lantus .5U d 12 hrs as BG is remaining very high after 5 days. Doobie is on .5U d 24 hrs.

Internist are out of the hospital until Monday. Ketoacidosis is a big concern for Doobie and very costly for us. Sent spreadsheet to hospital this morning for regular emergency doctors to review in lieu of Internal Med Dr.
Response, "do NOT increase Lantus dosing without clear direction from Internist". The hospital left the same message on 3 phones. Very important that we not consider any changes until the hospital runs their own curve on Tuesday.

Another hospital stay, Doobie under stress in a very loud emergency hospital. BG results in that setting have been all over the place. Not to mention it is $1300/day (we are already well over $10,000 in expense)

Doobie's Ketones are likely to rise again tonight due to 12 hours in the high 300s and low 400's. At what point do we insist the hospital work with us more closely or go elsewhere? I get the "Go Slow" method and the "depot" effect of Lantus.

After 2 DKA emergency interventions (8 days in the Hospital) in the first couple weeks, we feel we need to get his BG numbers down consistently and watch him closely for any signs of Hypo and lower his obvious risk of another DKA emergency.
Click to expand...

Personally from looking at his SS, you already know what the curve numbers are about. You may want to wait for some of the experts here to chime in, but if it were me - I'd go for the .25 increase - test and watch closely. Have you recently changed Doobie's diet from higher carb (dry) to low carb foods? In that case you will want to be diligent in your watchfulness...I can't tell from looking which protocol you're following? SLGS or TR? You may want to review the stickies at the top of the forum; http://www.felinediabetes.com/FDMB/...-low-go-slow-slgs-tight-regulation-tr.210110/

Many people here, myself included have opted not to listen to our vets and have come to depend on the information you can learn from this forum (as for me my vet told me over 1.5 years ago that if it were his cat, 'he'd put her down' - so much for his advice, huh? Try to read as much as you can here and make a decision based on that information - vets don't always have the best advice for feline diabetics. Best of luck to you!
 
Most vets don't know what they're talking about when it comes to insulin dosing. Or managing any of the diabetes related issues. So don't be too worried about not trusting what they have to say.

Have you gotten Doobie any sub-q fluids, either at home or at the hospital? Sebastian has a history of DKA also and with his recent issues with digestion and appetite, I've found that giving him a bubble of sub-q was very effective in keeping the ketones in check while we dealt with the underlying issues. It can also lower the BG a bit. It's pretty easy to do at home and the whole kit with the bag, line, and needles costs me a little less than $30.

What are his bowel movements looking like? Nice and solid or not? If he's not having good BMs he might be having issues absorbing the food he's taking in, which can lead to the increased ketones. Some pumpkin, S.Boulardii+MOS probiotic, and/or slipper elm bark can help with any loose stool or vomiting issues, assuming he's not B12 deficient.

Do you have a blood ketone meter? Urine ketone test strips are like 8 hours behind what's happening in the blood at that moment, so if you're just going off of urine you'll be behind the ball if you need to react fast, which it sounds like you need to if Doobie is having frequent and fast changes in ketones. Keto Mojo test kit is what I use, runs about $60 off Amazon.

And, if he's not eating much, do you have oral syringes you can feed him with? Making sure he's getting a full load of food, whether he wants to eat it on his own or not, is also crucial for managing ketones.

As far as your dose, I don't really want to weigh in on it. I see you've got a 50 about a week ago on .5, but then lowest since then is the 167 last night, probably a little bit lower towards the middle of the cycle. With hospital stress, appetite issues, and if he's got any underlying issues like pain or inflammation that's artificially raising the BG, it could be easy to overshoot and then see him drop real fast, and if his appetite isn't great right now it could be hard to steer him back up. So I'll leave the dosing advice to those more experienced but some of the other things I mentioned might help you get things a bit more under control.
 
At minimum I would split the 0.5u daily dose into a dose of 0.25u twice a day. You're not technically 'raising' the dose at that point.

Most cats really do need BID dosing.

I'd also really push food and fluids. Doobie needs hydration and nutrition, in addition to insulin, to stave off the dastardly ketones. Syringe food and water into him if you have to since it sounds like you haven't been prescribed subQ fluids at home.
 
Wanted to add ...
The person you spoke to at the hospital might have HAD to say "don't change anything" due to procedural or legal liability issues. We as caregivers are all about the cats and helping them NOW but sometimes there are other business-y things at play when dealing with vet hospitals.

As to when to go elsewhere ... that's a tough call. Feline diabetes is generally a home-managed disease and most often curves run at the vet clinic are skewed and the data non-representative of a "normal" at home cycle due to stress, noise, change in eating patterns, and so on. In other words, a waste of time and money. And it doesn't usually give you solid data upon which to make a dosing change. Diabetes isn't at all like "my car is a quart low on oil" so I need to add a quart and we're good to go. It's much more nuanced than that.

My advice is to find a vet who is a "partner" in Doobie's care. You will need a vet to prescribe insulin and antibiotics, run blood work and other tests, and help diagnosis any concurrent health issues. What you DON'T need is someone to run curves or micromanage his daily care or put obstacles in your path. Sometimes it takes awhile to find the right vet who understands that you "get it" and develop trust in each other, but it's invaluable once you do.When after speaking to a vet and feeling them out, if I still get the impression that their attitude is "locked down" and "my way or the highway" then I politely exit and take the highway.

From the vet's perspective, you'd be surprised by how many clients they encounter who nod their heads but don't really understand the gravity of a situation or simply want an easy answer. Sometimes clueless owners even have a cavalier attitude, and it puts an animal's life at risk. As a result, I think vets sometimes are guarded and cautious and even have a bias against proactive and engaged owners until they can develop a level of trust with you. Frustrating but understandable.

You've already shown attention to detail and a desire to do what's needed. Hopefully you will find a vet who can see that and will work closely with you.
 
I agree with @JL and Chip
I would split the 0.5. Units and do 0.25 units twice a day at the very least.
The problem with only giving the insulin once a day is that for 12 out of the 24 hours Doobie is not getting any insulin at all and that leaves the door open for ketones to start developing. To heal, Doobies body needs enough insulin in his body all the time, not just for12 hours, enough food and not have an infection or inflammation and also enough fluids.
You can see looking at his SS how the BSLs are rising during the 12 hours he gets no insulin.
It does make me wonder just how much these vets at the ER know about FD and managing ketones.
You are testing frequently and doing a great job looking after Doobie, but you have one arm tied behind your back with having to only give the insulin once a day.
 
If your vet is dosing lantus once every 24 hours I would be looking for a new vet. Perhaps it’s because the vet doesn’t think you can dose less than .5 but that’s just wrong. I used digital calipers and increased/decreased in less than .25 increments at times. Most cats Ned dosing every 12 hours. If you don’t want to increase which I would do, try dividing the dose into .25 every 12 hours as others have suggested.
 
@JL and Chip provided cogent guidance. I would be concerned that a vet is telling you to dose Lantus once a day. It suggests the vet has not done much reading on diabetes or doesn't have that much experience with diabetes management. The American Animal Hospital Assn's guidelines for diabetes management in cats and dogs clearly states that Lantus should be given every 12 hours. That you're being told otherwise, especially in a cat with ketones, is concerning.

FWIW, the ER vets will defer to your IM vet if only because the IM vet has actually examined your cat.
 
I just got off a plane and am exhausted, but wanted to get this out there before I crash...

Please read Doobie's profile: http://www.felinediabetes.com/FDMB/members/bill-robinson.27180/.

Excerpt from profile: "His first visit on 4/6/19 revealed serious blood abnormalities, including blood glucose reading of 395, among other classic indicators of FD. Also indications of heart abnormalities."

I mention this because of concerns with administering squids when there's a suspicion of heart problems.

A little more history which might be helpful: DKA Emergency - Conflicting Info
 
Agree with what @Jill & Alex (GA) said regarding subq fluids and heart issues. It's been mentioned before but bears repeating ... one has to be VERY careful giving subq fluids at home if the cat has heart issues. Even vets have mistakenly overloaded a cardiac kitty and triggered a problem.

@Bill Robinson ... As of mid May, Doobie was on Orbax, Clavamox, and potassium supplements. Is he still on all of those? Is he on any other meds or supplements?

Did Doobie ever have an echocardiogram to confirm a heart issue? Or is it perhaps the theory that aggressive fluid therapy to combat the DKA caused transient cardiac impact. Just curious.

Also, potassium supplements can cause upset stomach in some cats, which can then lead to inappetance. I always gave it in a pill pocket and with some food (syringe fed if necessary) to ensure my kitty had food on board.

Edited to add: did the vet mention any liver issues? That can also reduce a cat's appetite. Hepatic Lipidosis (fatty liver) is a real concern when a cat isn't eating or isn't eating enough. I glanced at the Lab tab of your spreadsheet and the ALT and bilirubin make me wonder (though there's no alk phos value).
 
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tiffmaxee said:
If your vet is dosing lantus once every 24 hours I would be looking for a new vet. Perhaps it’s because the vet doesn’t think you can dose less than .5 but that’s just wrong. I used digital calipers and increased/decreased in less than .25 increments at times. Most cats Ned dosing every 12 hours. If you don’t want to increase which I would do, try dividing the dose into .25 every 12 hours as others have suggested.
Click to expand...

I like the idea of splitting the dose into two 12 hr doses. I have digital calipers, but i found using my fly tying table-mounted magnifying glass with built-in light worked really well. I will keep the total dosing the same. That seems to makes sense to me based on the "depot" action of Lantus.
thanks,
Bill
 
JL and Chip said:
Agree with what @Jill & Alex (GA) said regarding subq fluids and heart issues. It's been mentioned before but bears repeating ... one has to be VERY careful giving subq fluids at home if the cat has heart issues. Even vets have mistakenly overloaded a cardiac kitty and triggered a problem.

@Bill Robinson ... As of mid May, Doobie was on Orbax, Clavamox, and potassium supplements. Is he still on all of those? Is he on any other meds or supplements?

Did Doobie ever have an echocardiogram to confirm a heart issue? Or is it perhaps the theory that aggressive fluid therapy to combat the DKA caused transient cardiac impact. Just curious.

Also, potassium supplements can cause upset stomach in some cats, which can then lead to in appearance. I always gave it in a pill pocket and with some food (syringe fed if necessary) to ensure my kitty had food on board.

Edited to add: did the vet mention any liver issues? That can also reduce a cat's appetite. Hepatic Lipidosis (fatty liver) is a real concern when a cat isn't eating or isn't eating enough. I glanced at the Lab tab of your spreadsheet and the ALT and bilirubin make me wonder (though there's no alk phos value).
Click to expand...

They do suspect a mild heart issue, but aren't sure. He has had two echocardiograms. DKA fluids have complicated a firm diagnosis. Doobie is off all meds now. Until today, he had a great appetite and was getting plenty of water (added to every meal + bowl of water). Today he has acted hungry, but doesn't eat much. His Urine Ketones start to climb every evening before his shot, then trail off overnight back to NEG. We get up and test every time we hear him in his box. Not getting much sleep these days.
Liver is also a question, but they ruled out Hepatic Lipidosis. They keep saying there is no obvious underlying health issues. BG is top issue to get under control so the rest of the functions can stabilize.
 
Sue and Luci said:
Personally from looking at his SS, you already know what the curve numbers are about. You may want to wait for some of the experts here to chime in, but if it were me - I'd go for the .25 increase - test and watch closely. Have you recently changed Doobie's diet from higher carb (dry) to low carb foods? In that case you will want to be diligent in your watchfulness...I can't tell from looking which protocol you're following? SLGS or TR? You may want to review the stickies at the top of the forum; http://www.felinediabetes.com/FDMB/...-low-go-slow-slgs-tight-regulation-tr.210110/

Many people here, myself included have opted not to listen to our vets and have come to depend on the information you can learn from this forum (as for me my vet told me over 1.5 years ago that if it were his cat, 'he'd put her down' - so much for his advice, huh? Try to read as much as you can here and make a decision based on that information - vets don't always have the best advice for feline diabetics. Best of luck to you!
Click to expand...

Doobie has been on a reduced carb diet since his early April diagnosis. Fancy Feast and Friskies wet food mostly. about 9 to 11 oz per day. He also gets an ounce of cooked pork chop meat to chew on once a day. He loooves his lean pork.

I like the idea mentioned below to split his dose to .25U d 12 hours. Not increasing the dose yet, just splitting it. Once things stabilize and smooth out, increasing the dose to maintain tight control of BG.
Thanks for the reply!
 
Can't thank you all enough for the great info and taking the time to help those of us who are new to all this!
Thank you, Thank you, Thank you All!
We are going to split his daily dose into .25U d 12 hrs and see if that levels off his curve. If it does, then we will tackle the right dose base on the numbers. That step feels like a no-brainer to me.

We fed Doobie with a syringe to be sure he got a few more ounces in him. That did NOT go too well. What a mess. You'd think we were killing him. He shook his head after every mouthful and splattered food all over the kitchen cabinets, floor, even the ceiling got some. Funny...sort of, if you find the Keystone Cops humorous.
The lengths we go to for our animals...
 
You are being great parents to Doobie. He is lucky to have you. I’m sure the syringe feeding is no fun but you have to do what you have to do. :bighug:
 
I think he might be nauseous. I’d ask your vet about getting some cerenia or ondansetron. All the stress might have caused pancreatitis and inappetence is a classic symptom.
 
Bill --

The food is important in managing ketones. If a kitty isn't getting enough calories, the cat starts metabolizing stored fat which then produces ketone bodies. As Elise noted in the post above, it's possible that Doobie is nauseous. If he acts like he's hungry, takes a lick or two of food and then walks away, nausea is a possibility. Cerenia or ondansetron can help with nausea. Since both are prescription drugs, you'll need to talk to your vet.
 
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