diabetes case

Re: diabetes case

ilanit — Thu, 05 Feb 2015 08:42:08 GMT

Dog is now on 26 units twice daily and is very stable on this! :)

Re: diabetes case

Martin Atkinson — Wed, 24 Dec 2014 16:49:01 GMT

[quote user="ilanit"]I have checked on injection technique..[/quote]Are they injecting it into exactly the same place which can lead to fibrosis or varying the site?

I have found that clients have limitless ways to confound you when you assume they are injecting properly and they often lie about whether they missed or not. I never take anything for granted on that. Even when I've seen them practice in front to me they come back a while later and they are doing it wrong.

Re: diabetes case

ilanit — Wed, 24 Dec 2014 16:42:28 GMT

Dog is neutered.

I have checked on injection technique... is storing properly, not shaking it etc.

Re: diabetes case

ilanit — Wed, 24 Dec 2014 16:41:14 GMT

Caninsulin is not available at my end. I have been using insulatard for a long time and it generally works well. We have glargine for cats.

Owner now agreed on twice daily. Managed to get him to do 8am and 7pm... still don't get why he doesn't want to do 8pm to have 12 hours in between, but that's as far as I got. He did insist he cannot change food, he tried them all.. I gave up on that end. Started 10 units BID.. probably need to go up quite a bit, but prefer to be conservatively.

Re: diabetes case

Martin Atkinson — Wed, 24 Dec 2014 13:50:51 GMT

[quote user="Robin Grimmer"]Maybe the owner doesn't really want to treat and is looking for euthanasia.[/quote]I've certainly been there before and I very much second the rest of what Robin said about client technique/compliance - been there before too!

I've got a case at the moment with an obese PD/PU dog with obese owners. They are always making comments about the fees and I actually posed the quandary that it may not be worth even paying for the investigations if they were' t going to be committed to the treatment and they said they'd only be able to inject it once a day. It turned out it isn't diabetic but despite the above I feel that if the importance of the correct treatment was forced on them they would have accepted it.

Re: diabetes case

Robin Grimmer — Wed, 24 Dec 2014 13:22:07 GMT

Check that the owner is giving the injection correctly, and handling the insulin properly. Also is it an entire female? If so will need spaying. You need to take charge of the case - difficult withsome owners I know. Start on bid caninsulin as Andrew says. Have a serious talk and say this is how we need to treat it. Maybe the owner doesn't really want to treat and is looking for euthanasia.

Re: diabetes case

Andrew Kent — Wed, 24 Dec 2014 12:18:24 GMT

The problem with NPH is that the duration of action is reported to be anywhere from 6-24 hours so its probably no more likely to be suitable for once daily administration and indeed many people would advocate using it twice daily from the beginning. It is also an insulin that is infrequently used (we could get into a long discussion about whether you can justify not using the licensed product because the owner doesn't want to :-p) which means that people have less experience with how it behaves.

Some dogs will be controlled on any insulin and some are much more tricky, but in the tricky cases using an unusual insulin makes it harder to decide what to do.

My preference would be to abandon NPH and use lente insulin (Caninsulin) as you will find it much easier to work out what is going on. Clearly this needs to be combined with a discussion with the owner about compliance and whether they really want to treat the disease - if they do they have to follow something close to the plan you give them.

Good luck!

Andy

Re: diabetes case

Bob Russell — Wed, 24 Dec 2014 12:04:58 GMT

Seems quite a low dose and a bit quick for somogyi effect but another one not familiar with insulatard. If this is a difficult client then it is difficult to be sure they are doing things right anyway!

A cooperative client is key to successful control of diabetes so I would be another to suggest you don't lose any sleep over this case.

If you are heading up in doses but not getting control then Martin is probably right that Cushings or hypothyroidism may be complicating things.

Re: diabetes case

Martin Atkinson — Wed, 24 Dec 2014 10:29:33 GMT

What other investigations have you done?: might be worth looking for HAC and hypothyroidism if indicated if you haven't already.

However, I would not lose too much sleep over this, you can't do much if the client won't work with you.

Re: diabetes case

ilanit — Tue, 23 Dec 2014 19:53:56 GMT

owner is incredibly difficult to work with. He insists the dog has to be fed at 5pm!

When trying to convince him to give twice daily he insisted on giving at 9am and 5pm.

When I finally got him te agreeing on 8am and 8pm he changed his mind after 2 days and went back to sid... would love to send him flying!

Anyway... I did start on 10 units (left it out to keep it shorter). glucose 24 mmol 5 hours after insulin. then 15 units, 30 mmol 5 hours after. Then 20 units... see above.

Re: diabetes case

Martin Atkinson — Tue, 23 Dec 2014 19:10:53 GMT

[quote user="ilanit"]

Hi,

I am a bit confused about this diabetic case.

40kg lab, newly diagnosed with diabetes mellitus (uncomplicated)

glucose prior to treatment: 25mmol

Started on 20 IU of insulatard once daily (owner does not want to give twice daily).

Following samples after 1 week:

4pm: glucose 19mmol

5pm: fed and 20IU insulin given

6pm: 19 mmol

7pm: 32 mmol

10pm: 33 mmol

11 am (so next morning): 22 mmol

I know it's not a full curve, but I don't understand why the glucose goes up after insulin treatment. Could I have missed a somogyi effect here? But I took sample one hour after insulin and 2 hours after, so I should have caught that?! Also dose is still quite low (0.5IU/kg), so should not give somogyi.

Could the increase purely be postprandial? He's feeding some rubbish pedigree diet.. owner keeps insisting that's all he eats and he tried all other diets we suggested. But 5 hours after eating it's still 33!

I am confused! Should I increase?

Thanks and happy Christmas :)

[/quote]

It looks like it could be a Somogyi effect but as you say you should have spotted the drop if you're doing it every hour however even in aweek it could have gone chronic. I would be inclined to stop and re-start at 0.25mg/kg - I'm going the other way and I think your starting dose is too high.

Have you done a fructosamine?

I would have a serious word with this owner and tell him that he is compromising your ability to treat the dog not wanting to give twice daily injections and insisting on feeding it a crap diet and quite honestly I would hope he cleared off somewhere else although sadly I realise you may not have that luxury.

Re: diabetes case

Rob Davis — Tue, 23 Dec 2014 19:06:08 GMT

I'm no expert but...

I think you need to be increasing the dose, and ideally doing a full curve (I know you know that!). Is there any particular reason the insulin is being given at 5pm? It would seem easier to be giving it first thing in the morning to fascilitate doing a curve.

I'm not familiar with insulatard - I assume it's a lente formulation?