Managing the crises — the night too low, and the days too short of insulin

Daily diabetic care is peaceful — meals, injections (or the liquid), the occasional ear prick. But this disease holds two crises that can break the peace at once, and they point in opposite directions: the crisis of too much insulin (hypoglycemia) moves in minutes; the crisis of too little (ketoacidosis) builds over days.

The good news: both have signals, fixed response sequences, and are largely preventable. This is the complete manual for both — and the time to read it is now, before either arrives.

1. The map of the two crises — accidents in opposite directions

2. The night of low sugar — the order in which a spoon of honey saves a life

The complete version of the drill chapter 01 made you memorise. When glucose falls in a cat on insulin, the brain's fuel line is cut — so the signs are neurological, and the progression is fast.

The ladder of signs — urgency grows downward:

• Early — sudden hunger, restlessness, unusual crying, unfocused eyes
• Moderate — wobbling gait, drooling, trembling, head tilting, blank to their name
• Severe — seizures, collapse, loss of consciousness

The response sequence — exactly this, top to bottom:

1. Rub honey (or syrup) on the gums and inner cheek with a finger — never pour (a clouded cat can inhale liquid). The gums absorb it; this works even in an unconscious cat
2. No response in 5–10 minutes: once more — and by now you should already be moving toward the hospital
3. When she comes around, feed a meal — honey is a spark, not firewood. The low-carb rule takes its one exception here
4. Call the clinic — even after recovery — insulin is still on board and glucose can fall again, and the cause (dose? a missed remission signal?) must be found to prevent a repeat
5. Hold the next insulin until the vet says otherwise — no same-day insulin without veterinary confirmation

3. Ketoacidosis (DKA) — when the short days pile up

The alarm light from the numbers chapter. Starved of insulin for long enough, cells cannot use sugar, the body burns fat, and the exhaust (ketones) turns the blood acidic — this disease's most dangerous emergency and its only crisis that cannot be fixed at home (treatment is admission: fluids, short-acting insulin, electrolyte correction).

• The signal combination — not eating + vomiting + flat is the core trio; added clues: a sweet acetone smell on the breath, fast breathing, dehydration (tacky gums)
• High-risk situations — long-uncontrolled periods, another illness on top (infection and pancreatitis lead), steroid courses, and the undiagnosed cat first found in DKA (the emergency form of first diagnosis)
• The action rule — trio present → check ketones first (urine strip or blood BHB — 2.4 mmol/L and above strongly signals DKA). Positive ketones + an unwell cat = the hospital that day; at night, the 24-hour one. No way to test? The trio alone is enough to go
• Do not — "it's an insulin shortage, so inject more" is forbidden. DKA-state insulin and fluids are entangled with electrolytes — hospital work. Home's job is recognition and transport, nothing more

4. The SGLT2 special alarm — DKA at normal glucose

A dedicated section for households on velagliflozin-class drugs. The drug lowers glucose by discarding it in urine — but it does not fix the insulin deficit itself. So the body can slide into insulin famine while the meter reads fine: euglycemic DKA (euDKA), the crisis that advances while the glucometer says all-clear.

• Timing — the first two weeks are the peak window, though it remains possible at any time; hence the early ketone routine (home days 1–3, clinic days 7 and 14, per the prescription schedule)
• The iron rule of these households — if she won't eat or vomits: withhold the drug, check ketones, call the clinic. "Glucose is normal, so it must be fine" is this drug's trap sentence
• The switch signal — repeated positive ketones, or an actual DKA, ends the drug and moves the cat to insulin — not a failure but the safety mechanism working as designed

5. Sick-day rules — the table that disarms both crises in advance

The common root of both crises is "an unusual day handled with the usual rules." Filling this table with your vet and posting it on the fridge is this chapter's single best prevention.

And assemble the crisis kit while you are at it: honey + ketone strips (or a blood ketone meter) + the glucometer + two 24-hour hospital numbers + a summary card (diagnosis, drug, dose, clinic contact). One basket, one spot the whole family knows.

6. After the crisis — autopsy the event, absolve the person

• Reconstruct the cause — a low: was the dose heavy, the stomach empty, the diet newly changed, or was a remission signal missed (a falling requirement met with an unchanged dose — chapter 04)? A DKA: was a hidden illness brewing, was control quietly slipping? The product of the review is usually one added rule
• Dose reset — the days after a crisis are the vet's conservative re-titration period. Do not push for "back to normal, quickly"
• The guilt — this series' principle, unchanged: accidents are prevented by systems, not by blame. A caregiver who builds the sick-day table, stocks the kit and keeps the log already is that system

7. What to ask your vet

• "Please fill in the sick-day table of section 5 together — with this cat's numbers"
• "After a hypoglycemic event, when and at what dose does insulin resume?"
• "For home ketones — urine strips or a blood meter, and at what value do we come in?"
• "(On SGLT2) please write out the early ketone schedule and the stop criteria"
• "Which 24-hour hospital near us handles diabetic emergencies (DKA admissions)?"

8. Related

• Reading the numbers — how to use the alarm light called ketones
• Insulin in practice — the injection rules that keep crises from being manufactured
• Measuring glucose at home — the context of "measurement never outranks treatment"
• The Diabetes Bible — contents