home monitoring of diabetes

Re: home monitoring of diabetes

Rob Davis — Fri, 20 Dec 2013 16:39:22 GMT

[quote user="Hanna Bennett"]o is measuring 8 hours post so should be hitting nadir or not far off[/quote]

I find the timing of the nadir very variable between different dogs. I have one or two where it appears to be only 3-4 hours post insulin. As others have said, I think a curve is essential at least to ensure you are not missing the nadir.

Re: home monitoring of diabetes

Michael Woodhouse — Thu, 19 Dec 2013 19:33:11 GMT

[quote user="Andrew Kent"]Humans use very different insulin types with short duration of action so we can tinker with doses. The point with our patients is that we try to make every day the same.[/quote]

I'd say that depends. We had a working sheepdog that was diabetic. Took about 4 months to get things 'right' but by adjusting intake and insulin you could get her to work well one day and very little the next. Lived maybe 6 years on insulin.

If my dog was diabetic there is no way on earth I could make every day the same. On a wet miserable winters evening neither us want a long walk - in summer with a nice evening or a weekend off call then I want to go for a good walk. We take the dog on holiday and do loads of walking.

It's about managing owner expectation, even with the so called longer acting insulin I'm not sure it's having much effect the next day.

You can, relatively successfully, manage dogs doing what you want with them.

Re: home monitoring of diabetes

Hanna Bennett — Thu, 19 Dec 2013 18:38:54 GMT

oh and she is a total stress head so trying to avoid in hospital glucose curves!

Re: home monitoring of diabetes

Hanna Bennett — Thu, 19 Dec 2013 18:38:17 GMT

thanks for all the thoughts! She is on twice daily caninsulin, fed first then given insulin straight after. o is measuring 8 hours post so should be hitting nadir or not far off. thanks for the info about suprelorin Rory - wasn't aware of that - they are not that keen on the implant either so this may help me sway them to neutering. she has a history of UTIs but current urine samples have an inactive sediment though i guess in a diabetic it probably is worth culturing it anyway. and yes, she has been cushings tested and i am as sure (as you ever can be in a diabetic dog) that she is negative!

will see if owners can do me a glucose curve this weekend. lovely people so sure they'll give it a go.

Re: home monitoring of diabetes

Rory Bell — Thu, 19 Dec 2013 12:23:57 GMT

HI Hanna

Some excellent replies on here already. My 2p worth:

I'd run a 2hourly blood glucose curve, mainly to ensure you are not missing an occult hypoglycaemia, and also potentially to spot any insulin-induced hyperglycaemia. The reason I suspect that there may be an occult hypoglycemia is that I'd not expect, as someone above has already pointed out, a fairly minor adjustment in insulin dose to make a stable diabetic have a catastrophic hypoglycemic episode provided nothing else had changed in the dog's management.

I'd strongly advise getting this dog neutered. Alterations in growth hormone and IGF-1 concentrations induced by fluxes in progesterone may will alter this dog's requirement for insulin over time and make the diabetes difficult to stabilise. If the owners do not want to neuter her, or if neutering does not result in improved stabilisation, then I'd screen this dog very carefully to some underlying disease (occult UTI, occult pancreatitis etc) that may be causing alterations in insulin requirements. If the dog is showing any other signs of disease, then investigate that as a priority ahead of neutering.

Neutering may well decrease insulin requirements so it may be wise to pre-empt this by decreasing the insulin dose ahead of this.

Don't use suprelorin. It does, as you mention, have the potential to cause a surge in oestrogen shortly following application. The surge in progesterone during oestrus / dioestrus will induce an increase in GH, which can antagonise insulin. Once GH falls, so to will the requirement for insulin, and in an already unstable diabetic, this won't help matters!

Hope this helps

cheers

rory

Re: home monitoring of diabetes

Suzanne Kelly — Wed, 18 Dec 2013 22:55:12 GMT

Is the dog on once or twice daily injections? Also do you know when the nadir is likely to be based on one of your curves? I'd be a little worried that with your "pre" blood test being high that you may be in a somogyi overswing. I have almost all my diabetics on twice daily insulin. If funds are low I do an initial curve to figure out how many hours post injection the nadir is and try and time their appointments around the nadir so I can run a blood glucose when they're in for a check up and fructosamine. With a dog like this I'd be inclined to reduce the insulin dose a bit more and get her into hospital for a glucose curve.

Re: home monitoring of diabetes

Glenn Hodgson — Wed, 18 Dec 2013 20:58:17 GMT

IMO spaying these dogs is a HUGE help. Not sure about suprelilin but i find getting rid og the hormones is a cornerstone of treatmwnt.

i have several with curves dropping to 4mmol/l and have been stable with good fructosaminr values.

I eyeball 10 and 15 as a bit high. but hypos are not good.

spay her :-) soon!

also did you checlkfor cushings? sure you will have

Re: home monitoring of diabetes

Andrew Kent — Wed, 18 Dec 2013 20:55:33 GMT

[quote user="Francisco Gomez"]

I have done home glucose curves in a few of my patients. I would suggest to your client to keep on the same dose for a few days (at least 4-5), and then perform a home glucose curve. I.e. take a glucose measurement every couple of hours: from (and including) from before the first insulin injection up to (and including) a couple of measurements after the last insulin injection of the day.

This can be done easily if you manage to do it on a day that the owner would be at home. I.e. a Sunday. As long as they don't alter the dog's routine.

You will have a much more detailed case of how the dog does during the day after you do a couple (at least) of these curves. Having only two measurements is not sufficient because you don't know what the glucose is doing in between measurements, particularly in complicated cases like this.

[/quote]

I would second this - I think you need to know what is happening through the day before you can advise on what to do with dosing or timing of insulin. How are you currently timing insulin compared to food?

Re: home monitoring of diabetes

Hannah Wynne Richards — Wed, 18 Dec 2013 20:55:16 GMT

Try being the operative word!

Wynne

Re: home monitoring of diabetes

Andrew Kent — Wed, 18 Dec 2013 20:52:48 GMT

[quote user="Michael Woodhouse"]

[quote user="Hanna Bennett"]

and she takes at least two weeks to settle to any dose change - fascinating to see, backs up what I've always said about not changing doses too quickly!

[/quote]

And yet human diabetics change their dose as often as twice daily based on what they have eaten their activity level and the glucose reading. There is zero evidence that the dog requires any time to settle on a new dose and I am not convinced that 1iu extra can take you from stable to hypo.(see the link suggesting the person increases their next dose 6iu!)

http://www.diabetes.co.uk/blood-glucose-meters/abbott-freestyle-insulinx.html

I think one of the biggest mistakes we make with the animal diabetics is expecting that every day is the same.

[/quote]

Humans use very different insulin types with short duration of action so we can tinker with doses. The point with our patients is that we try to make every day the same.

Re: home monitoring of diabetes

Hannah Wynne Richards — Wed, 18 Dec 2013 20:48:03 GMT

I agree with the" expecting every day to be the same" point, but doctors can be bolder as their patients quickly learn the signs of an impending hypo, and can do saomething about it. Ours can't.

Wynne

Re: home monitoring of diabetes

Michael Woodhouse — Wed, 18 Dec 2013 20:40:26 GMT

[quote user="Hanna Bennett"]

and she takes at least two weeks to settle to any dose change - fascinating to see, backs up what I've always said about not changing doses too quickly!

[/quote]

http://www.diabetes.co.uk/blood-glucose-meters/abbott-freestyle-insulinx.html

I think one of the biggest mistakes we make with the animal diabetics is expecting that every day is the same.

Re: home monitoring of diabetes

Hannah Wynne Richards — Wed, 18 Dec 2013 20:11:49 GMT

If in doubt, I'm inclined to prefer a mild diabetic to risking a hypo.

Good luck-sounds a tricky one.

Wynne

Re: home monitoring of diabetes

Francisco Gomez — Wed, 18 Dec 2013 20:02:33 GMT

hmm quite a tricky one, I see...

Re: home monitoring of diabetes

Hanna Bennett — Wed, 18 Dec 2013 20:00:05 GMT

same routine that day, had eaten. hypoglycaemia was not 'normal' hypo - I've seen those before and they usually stop fitting after iv glucose, at which point you can get them to eat and bob's your father's brother. this dog's glucose wouldn't go above 2 for hours even with glucose cri. didn't think she was going to make it, and if it happens again I think her owners would just opt for pts as they were very distressed by it all, so really important to avoid.

Re: home monitoring of diabetes

Francisco Gomez — Wed, 18 Dec 2013 19:53:51 GMT

The day she presented with hypoglycemic signs, had she eaten? was the same usual person giving the insulin? I know it sounds like obvious questions but I had a couple of clients whose dogs are VERY fussy with food, so I advice them to give 1/2 insulin first and only give the other half if they eat their breakfast/dinner. I have also encountered the 'brother in law' or 'cousin' who didn't know exactly was '10iu' was while real O was on holidays...

Re: home monitoring of diabetes

Hanna Bennett — Wed, 18 Dec 2013 19:50:16 GMT

and she takes at least two weeks to settle to any dose change - fascinating to see, backs up what I've always said about not changing doses too quickly!

Re: home monitoring of diabetes

Hanna Bennett — Wed, 18 Dec 2013 19:48:29 GMT

thanks for the replies! the clinical signs were starting to spiral again at 10iu, pupd and very hungry. I am a big believer in clinical signs over numbers but this dog has us worried so a bit more cautious than I would usually be.

Re: home monitoring of diabetes

Andrew Kent — Wed, 18 Dec 2013 19:43:17 GMT

Are the clinical signs controlled? In my view in dogs control of clinical signs is one of the most important aspects.

Andy

Re: home monitoring of diabetes

Francisco Gomez — Wed, 18 Dec 2013 19:36:44 GMT

Btw, I don't think pre=15mmol/l and post=10mmol/l are too low

Re: home monitoring of diabetes

Francisco Gomez — Wed, 18 Dec 2013 19:34:32 GMT

This can be done easily if you manage to do it on a day that the owner would be at home. I.e. a Sunday. As long as they don't alter the dog's routine.