Diabetic problem

Re: Diabetic problem

Kate Richardson — Wed, 10 Jun 2015 22:17:48 GMT

No I haven't had one crash on day 1 but it might be day 2-7 that it crashes and could have been avoided if the super sensitivity had been spotted early. I'd rather not have that happen but accept I might be being a bit over cautious.

Re: Diabetic problem

Martin Atkinson — Wed, 10 Jun 2015 17:27:28 GMT

[quote user="Kate Richardson"]Does that make more sense?[/quote] It made sense it was just in conflict with :'it sometimes takes a few days for the glucose level to settle'.

I was also told somewhere, sometime that you should hospitalise dogs for a curve on day one but never found a problem so don't bother any more. Its obviously a good policy but getting clients to comply with any sort of monitoring is sometimes a battle without adding to the costs seemingly unnecessarily. I just wonder if you've ever had one that did crash on day one?

Re: Diabetic problem

Kate Richardson — Wed, 10 Jun 2015 17:03:42 GMT

[quote user="Martin Atkinson"]

[quote user="Kate Richardson"]

I would add I do a glucose curve on day 1 of insulin as well, to check the animal is not super sensitive to insulin and it's nadir isn't too low.

.....as it sometimes takes a few days for the glucose levels to settle,

[/quote]The two are slightly in conflict Kate. I used to have them in on day one for a curve but never found it changed anything if I start with a cautious dose, so now your second statement I've extracted is more relevant.

[/quote]

I acept that in most animals the day 1 gluc curve may not show much response to the insulin, but occasionally (and this may be a theoretical problem I have read somewhere that has stuck in my mind!) occasionally an animal can show an extreme response to very small doses of insulin, so my aim is to detect these (if they exist!) and thus avopid sending them home on what for them is potentially a fatal overdose on insulin. Does that make more sense?

Re: Diabetic problem

Martin Atkinson — Wed, 10 Jun 2015 15:01:04 GMT

[quote user="Kate Richardson"]

I would add I do a glucose curve on day 1 of insulin as well, to check the animal is not super sensitive to insulin and it's nadir isn't too low.

.....as it sometimes takes a few days for the glucose levels to settle,

Re: Diabetic problem

Martin Atkinson — Wed, 10 Jun 2015 14:55:32 GMT

[quote user="Anthony Dennison"]

There's an In Practice article which I think Martin has taken these values from (apologies if it's your own formula Martin) that is very good.

What Martin has said is pretty much what I do, except I don't think I could ever get the compliance that he does with monthly fructosamine. I'd be lucky if I get that every 3 months!

[/quote]No but it was plagiarised from some lecture notes by the goddess of endocrinology Krista Visser 't Hooft.

And what I recommend is not what I get hence the comment: 'I can't get every client to comply with this protocol but those that do are the ones whose dogs don't have crises and have a normal life expectancy'!

Re: Diabetic problem

Kate Richardson — Wed, 10 Jun 2015 12:12:35 GMT

There was a recent thread discussing this I think, haven't got time to find a link to it though right now

Re: Diabetic problem

Andrew Mellor — Wed, 10 Jun 2015 12:10:56 GMT

moving on to cats another different locum ( please don't think I have a issue with locums! I have some superb colleagues that have worked for me ) told 2 separate cat diabetic clients that their cats should be on glargine as there is an 80% cure rate with that insulin. he had apparently been taught this at uni. any thoughts? I really like glargine in cats but with the cascade I will start on caninsulin and if thr cat does not stabilise I then go to glargine.

Re: Diabetic problem

Anthony Dennison — Wed, 10 Jun 2015 12:07:26 GMT

Or get clients to come in for expected nadir samples over the first couple of days if they don't want to do a curve on day 1?

Re: Diabetic problem

Kate Richardson — Wed, 10 Jun 2015 12:02:32 GMT

I would add I do a glucose curve on day 1 of insulin as well, to check the animal is not super sensitive to insulin and it's nadir isn't too low. As long as not too low and there is some response, I tend to send owners home with that dose (0.25-.5units/kg bid) for 5-7 days before repeating another curve. I don't worry if the dose isn't right on day 1, as it sometimes takes a few days for the glucose levels to settle, and I would rather the owners get used to the routine and trauma of injecting their dog twice daily without them having to worry about hypos as well, obviously I tell them what to look out for, but I like to take the slowly softly approach. I warn them their animal will likely still show pupd during this period, but things will improve. After a week or so when they are comfortable with the injecting routine and we repeat a curve, I then start changing dose accordingly.

Re monitoring, we are moving more and more to home testing and am finding owners surprisingly compliant, not least because it is significantly cheaper (BIG incentive). Maybe it's being in a rural area, more owners are comfortable with injecting their pets and thus glucose testing? Some are happy to do this from day 1. Otherwise I prefer a glucose curve in the hosp, on bid insulin a 12 hour period is usually enough, but I am lucky that we have facilities for 24hr monitoring if nec. I must admit I don't tend to use fructosamine a lot, and I do go on clinical signs a lot as well. But its often a case of using a combination of methods, and finding what suits each animal and owner. I tend to be a bit stricter on monitoring in cats especially early on as there is so much potential for remission compared to dogs, and this is often another incentive for cat owners to be more compliant with regular monitoring.

Re: Diabetic problem

Anthony Dennison — Wed, 10 Jun 2015 11:34:55 GMT

[quote user="Martin Atkinson"]

Following up on the previous post based on the glucose curves:

If pre-insulin BG* is >20mmol/l and nadir is >10 dose of insulin is increased 10-25%

If pre-insulin BG is 15-20 and the nadir 5-10 the dose is maintained

If pre-insulin BG is 10-15 and or the nadir is 3.5-5 the dose is decreased by 25-30%

If pre-insulin BG is <10 and the nadir is <3.5% I might stop insulin for 24 hrs then resume with a 50% reduction in dose

[/quote]

There's an In Practice article which I think Martin has taken these values from (apologies if it's your own formula Martin) that is very good.

What Martin has said is pretty much what I do, except I don't think I could ever get the compliance that he does with monthly fructosamine. I'd be lucky if I get that every 3 months!

Re: Diabetic problem

Martin Atkinson — Wed, 10 Jun 2015 11:18:45 GMT

Following up on the previous post based on the glucose curves:

If pre-insulin BG* is >20mmol/l and nadir is >10 dose of insulin is increased 10-25%

If pre-insulin BG is 15-20 and the nadir 5-10 the dose is maintained

If pre-insulin BG is 10-15 and or the nadir is 3.5-5 the dose is decreased by 25-30%

If pre-insulin BG is <10 and the nadir is <3.5% I might stop insulin for 24 hrs then resume with a 50% reduction in dose

* given it is not always possible to measure BG before dosing given that glucose levels with lente insulin will not fall for 2 hrs I would assume that the test taken < 2hrs after dosing is pretty representative of that at the time it was given.

Hope that helps.

Re: Diabetic problem

Martin Atkinson — Wed, 10 Jun 2015 11:10:09 GMT

[quote user="Andrew Mellor"]

D o you start on insulin , then have in for curve ?

do you have in for curve day one and give first dose etc ?

do you start immediately on diabetic food ?

[/quote]Full blood profile and haematology, fructosamine and urine exam to start.

I would then start on insulin bid 0.25-0.5 iu/kg depending how diabetic it was then perform a 12 hour glucose curve after a week to let it stabilise a bit but with a warning for the owner to look for signs of a hypo and always have some glucose water in the fridge. If the curve was showing good control I would repeat it after a month or once a week if the dose needed adjusting until it was stable. After that I'd advise a fructosamine every month and a curve every three months. I can't get every client to comply with this protocol but those that do are the ones whose dogs don't have crises and have a normal life expectancy. Some will perform a curve at home but as said before (although it may have been harsh) I don't trust them from bitter experience.

I'm not a fan of diabetic food (especially cats) and so long as they are not feeding it total crap I think it is more important that the animal is fed what it is used to but keeping quantities and timing constant.

Re: Diabetic problem

Andrew Mellor — Wed, 10 Jun 2015 09:57:20 GMT

This is all very useful for a surgeon like myself, I am not bright enough to be a medic.

if you are presented with a newly diagnosed diabetic, lets say dog because they tend to be more straight forward what is your protocol from that point, lets say dog is nocturic and polydipsic , possibly loosing weight , presumably everyone starts with routine bloods?

D o you start on insulin , then have in for curve ?

do you have in for curve day one and give first dose etc ?

do you start immediately on diabetic food ?

Re: Diabetic problem

Kate Richardson — Wed, 10 Jun 2015 09:22:22 GMT

[quote user="Andrew Mellor"]

if you stop altogether are you not more likely to cause ketoacidotic crisis though?

[/quote] Rarely in my experience, but sensible to check urine 1-2 times daily for ketones and step in with insulin if they appear. And as long as dog is eating and bright.

Re: Diabetic problem

Anthony Dennison — Wed, 10 Jun 2015 09:12:32 GMT

[quote user="Martin Atkinson"]Secondly owners are universally useless as performing curves at home, especially overnight not surprisingly as we all like to go to bed, and leave large gaps between testing so anything could have happened and you may miss Somogyi overswings. IME If its going to be worthwhile testing needs to be every 2 hrs at least, preferably hourly for the first 4-6 hours post dosing.[/quote]

Bit of a sweeping statement Martin. I know clients with a diabetic cat that drop off a 12 hour curve every month for the vet to check over.

Re: Diabetic problem

Martin Atkinson — Wed, 10 Jun 2015 08:57:04 GMT

[quote user="Andrew Mellor"]do people get owners to do 24 hour curves or hospitalise and do themselves or do you assume as I do that if curve is ok during the day that something similar will happen overnight[/quote]Well firstly a 12 hour curve (usually nearer 10 in practice) would show you that the glucose nadir i.e. the point fo maximum effectiveness of the insulin is nearly always 4-6 hours post dose and nearly always glucose has returned to pre-dosing level 12 hours after dosing. This is screaming that the dog needs twice daily dosing and that for the second 12 hours it is way above threshold and is therefore not properly stabilised. You would only need a 24 hr curve if the glucose hasn't reached starting point after 12 hrs and the curve is still rising. Other than that, if its on twice daily dosing, I think it is reasonable to believe the second 12 hours will be similar to the first so long as they are feeding at the same time the dog is dosed but there will be minor difference due to rest/exercise patterns.

Secondly owners are universally useless as performing curves at home, especially overnight not surprisingly as we all like to go to bed, and leave large gaps between testing so anything could have happened and you may miss Somogyi overswings. IME If its going to be worthwhile testing needs to be every 2 hrs at least, preferably hourly for the first 4-6 hours post dosing.

My observation on your question in response to Kate's post is: if the dog has been having hypoglycaemic episodes/overswinging, it is unlikely that you would get a keto-acidotic crisis after a couple of days without insulin but you are likely to kill the dog if you persist with too high a dose and it goes hypo while no-one is around!

Re: Diabetic problem

Andrew Mellor — Wed, 10 Jun 2015 08:40:21 GMT

if you stop altogether are you not more likely to cause ketoacidotic crisis though?

Re: Diabetic problem

Kate Richardson — Tue, 09 Jun 2015 21:51:32 GMT

My first thoughts in a clinically stable dog would be what has upset the balance. OK the dog may not have had perfect glycaemic control, but enough for the owners (and you guys) to be happy. So I would check the insulin first and storage, and admin, check the skin for thickening which may suggest poorer uptake of the insulin, then I would be looking at the urine for a UTI first and any other concurrent problem. Something has changed with dog. I agree with others that bid insulin is IME better, but some animals do ok on sid treatment. But I think an increase in dose and going to twice daily was way extreme, and not surprising the dog crashed, and as others have said, likely somorgi-ing (is that a word?!) all over the shop currently. I like to stop all insulin for 2-3 days to allow the body to settle, then reinstate insulin.

Re: Diabetic problem

Andrew Mellor — Tue, 09 Jun 2015 19:26:11 GMT

clinically stable with no weight loss or gain , no pu/pd and intermittent glucose curves and nadir point checks. but not 24hour glucose curves

do people get owners to do 24 hour curves or hospitalise and do themselves or do you assume as I do that if curve is ok during the day that something similar will happen overnight ?

Re: Diabetic problem

Martin Atkinson — Tue, 09 Jun 2015 17:45:07 GMT

[quote user="Kate Richardson"]You say he was stable over the past 2 years- is this based on clinical stability or BG monitoring/fructosamine or both?[/quote]You and I have the same suspicion here Kate. I questioned this in my first reply, whether the dog had ever been truly stable, but Andrew didn't really address it.

Re: Diabetic problem

Kate Richardson — Tue, 09 Jun 2015 17:33:50 GMT

[quote user="Andrew Mellor"]

Diabetic beagle from 2 + years ago been stable on 22iu caninsulin uid and royal canin diabetic food, came in 1 week ago had lost nearly a kg very rapidly and mid afternoon reading was 25mmol/l,

locum saw him and said it was all wrong he had to be on twice daily insulin , put him on 24iu bid

[/quote]

Did any other tests get performed other than a single blood glucose? Urine sample? Glucose curve? Or did the dose just get increased on the basis of a single BG?

You say he was stable over the past 2 years- is this based on clinical stability or BG monitoring/fructosamine or both?

Re: Diabetic problem

Martin Atkinson — Tue, 09 Jun 2015 13:49:31 GMT

Given the dose the dog was on previously was 2mg/kg by my calculation and I would normally advise a 50% reduction in dose in a dog with a big Somogyi effect then I still think even 0.5mg/kg would over-doing the reduction so I would stick with that as a re-starting point.

Re: Diabetic problem

Robin Grimmer — Mon, 08 Jun 2015 21:06:12 GMT

Martin, I think 0.5mg per Kg bid is too high. I'd go down to 0.25mg per Kg bid.

Re: Diabetic problem

John Flynn — Mon, 08 Jun 2015 20:22:44 GMT

For an alternative, less-informed, opinion: I'd switch to determir and stabilise from scratch with weekly BG curves starting with 1 unit (TOTAL, NOT per kg!) twice daily (using 0.3ml U-100 syringe with decent length of needle) and going up half a unit at a time based on the BG curves.

Re: Diabetic problem

Hannah Wynne Richards — Mon, 08 Jun 2015 17:27:52 GMT

Is the locum still alive?

Wynne