Help with a blood glucose curve please

RE: Help with a blood glucose curve please

grumpyoldman — Thu, 12 Nov 2015 18:36:17 GMT

[quote user="Martin Atkinson"]I'm struggling to know why he needs 2ml, as you say a fraction of a drop is all that is required.[/quote]

I don't all surgeries have glucometers ,but not everyone does .

RE: Help with a blood glucose curve please

Martin Atkinson — Wed, 11 Nov 2015 12:41:46 GMT

[quote user="Neil Wheadon"]I struggle to get 2ml out of a cat once, let alone 6 times a drop suffices??[/quote]Hmmm...I'm struggling to know why he needs 2ml, as you say a fraction of a drop is all that is required.

RE: Help with a blood glucose curve please

Neil Wheadon — Wed, 11 Nov 2015 11:50:18 GMT

[quote user="grumpyoldman"]each 6-8 points 2ml a sample = 40-50ml[/quote]

I struggle to get 2ml out of a cat once, let alone 6 times a drop suffices??

Neil

RE: Help with a blood glucose curve please

grumpyoldman — Wed, 11 Nov 2015 11:27:30 GMT

something I have seen a couple of times in the recent past are 3.5kg cats with "anaemia of chronic sampling " ,3 curves within a week , each 6-8 points 2ml a sample = 40-50ml of blood in a cat that started with 200-250ml , not surprisingly remained unstable getting 5iu bid and no one stopped to look for acromegaly.

RE: Help with a blood glucose curve please

Martin Atkinson — Wed, 11 Nov 2015 09:30:35 GMT

[quote user="Kate Richardson"] they didn't find the reported good control of hyperglycaemia with glargine,[/quote] I still like to use Glargine as my insulin of choice in cats and in cases where I can trust the owner (not many) the control has been better with a much flatter curve. I think the key is being certain the client can be trusted. Where not then they are probably better with Caninsulin as it is cheaper and they are more likely to consistently get the dose right as there is less margin for error with the 40iu/ml presentation.

That said I have managed to 'cure' one diabetic cat, albeit it was a very odd presentation at 5 months following a suspected bout of acute pancreatitis. For a while I though it was going to be the first recorded case of type 1 DM in a cat!

RE: Help with a blood glucose curve please

Kate Richardson — Tue, 10 Nov 2015 21:33:03 GMT

[quote user="grumpyoldman"]

It was a study JFMS 17 11 Nov 2015 p967-969 Management of Diabetic cats in primary care practices: ABVP roundtable report.

The best indicators are weight stability urine output and fluid intake , specific gravity. I think once things are stable endless glucose curves reveal little and contribute little if anything to the long term outcomes while adding considerable expense for less committed clients who are more likely to think stuff this and opt for euthanasia.

[/quote]

Interesting article- I think a few things to bear in mind- it was a round table discussion in the US, all Board certified feline practitioners, working in primary care, and all data collected was from US cats. Things I found interesting were that they didn't find the reported good control of hyperglycaemia with glargine, there was also quite a big disconnect between pre-insulin BG levels and clinical signs, and pre insulin BG could vary from one week to another quite dramatically in the same cat. The practice with the looser control (ie more emphasis on clinical signs than BG) had as good or better results in all the categories monitored - they used PZI insulin. Also very interesting that 'hypoglycaemic crises occurred with alarming frequency' with tight BG control- 50% less frequently in this practice with looser control than the other practices.

For me this ties in with the thinking in cats to think about glucose levels on a weekly basis rather than daily- with such variations in day to day glucose levels then it could be far too easy to tweak the dose based on a single 12-24 hr curve in a clinically stable cat and derail it. If its not clinically stable then BG monitoring if of course useful. But I agree with Mr Grumpy, on rechecks, if it ain't broke, don't try to fix it. Just my thoughts

RE: Help with a blood glucose curve please

Melanie Illingworth — Tue, 10 Nov 2015 19:50:23 GMT

I for one am quite surprised by the number of diabetic pets who turn out to have a diabetic owner... (Or in the case of one dog, both owners!)

RE: Help with a blood glucose curve please

Martin Atkinson — Tue, 10 Nov 2015 19:12:22 GMT

[quote user="Hannah Wynne Richards"] Those owners actually paid more during that 6 months than the others insurence company did for a whole year - simply because they kept bringing me a criticallly ill cat that needed intensive care![/quote]We have a client who had 2 diabetic Min Schnauzers who was just like your second client. Couldn't afford/didn't want to pay for monitoring, did glucose curves once in a blue moon at home but they were unreliable so I couldn't make decisions on changing dose. We went through the DKA routine a couple of times which of course cost more and they were both euthanased within a few weeks of each other because their body condition became so poor. She was obese and diabetic herself. Speaks volumes really, why cant these people see the light?

RE: Help with a blood glucose curve please

Hannah Wynne Richards — Tue, 10 Nov 2015 18:00:57 GMT

Owner commitment is certainly important.

I once diagnosed 2 diabetic cats in one week.

Cat 1 was insured, and had devoted owners who brought it in at the polydipsic stage. They agreed to everything I suggested, allowed me to properly stabilise it, and also monitor it. It lived for years.

Cat 2 was uninsured, and had owners who didn't like spending money. It was brought in in a keto-acidotic crisis. I pulled it through, started stabilising, got it 1/2 stabilised, and they missed an appointment, just carried on with the amount of insulin it was on then. It had another keto-acidotic crisis, I pulled it through etc. Eventually it had a crisis during which it was euthanased as it wasn't responding. I only kept that one going for about 6 months, and thought I'd done exceptionally well to manage that!. Those owners actually paid more during that 6 months than the others insurence company did for a whole year - simply because they kept bringing me a criticallly ill cat that needed intensive care!

By the way, I'm always a twice daily person with caninsulin.

Wynne

RE: Help with a blood glucose curve please

grumpyoldman — Tue, 10 Nov 2015 13:50:17 GMT

[quote user="Martin Atkinson"]]I totally disagree with this. Not only can owners not be trusted to perform reliable glucose curves at home or even give the correct dose of insulin their interpretation of symptoms is unreliable.[/quote]

Depends upon the owner . less committed owners will often elect for euthanasia because its peeing in the house ,scavenging, the commitment is damaging their lifestyle etc those are one ones that do not last long and that has the square root of bugger all to do with how many glucose curves its had.

Once or twice daily dosing and frequency of monitoring has much less influence on time to cataract surgery ,than breed.

RE: Help with a blood glucose curve please

Martin Atkinson — Mon, 09 Nov 2015 09:12:36 GMT

[quote user="grumpyoldman"] I think once things are stable endless glucose curves reveal little and contribute little if anything to the long term outcomes [/quote]I totally disagree with this. Not only can owners not be trusted to perform reliable glucose curves at home or even give the correct dose of insulin their interpretation of symptoms is unreliable. My experience with diabetics where there is minimal monitoring is that they rarely live for more than 2 years. Those where the owner is committed to close monitoring once stable i.e. glucose curves at least every 3 months, have a normal life expectancy. It never ceases to amaze me how many ways owners find ways to confuse me by not doing things correctly, never more so than with diabetics.

RE: Help with a blood glucose curve please

Neil Wheadon — Sun, 08 Nov 2015 23:25:11 GMT

Thankyou

Neil

RE: Help with a blood glucose curve please

grumpyoldman — Sun, 08 Nov 2015 20:57:40 GMT

It was a study JFMS 17 11 Nov 2015 p967-969 Management of Diabetic cats in primary care practices: ABVP roundtable report.

RE: Help with a blood glucose curve please

Neil Wheadon — Sun, 08 Nov 2015 14:34:51 GMT

[quote user="grumpyoldman"]Recent feline journal ,which quoted % of cats going into remission was highest with a minimalist approach. [/quote]

Any more detail on this? Weight loss would be a good idea.

Neil

RE: Help with a blood glucose curve please

grumpyoldman — Sun, 08 Nov 2015 14:02:09 GMT

[quote user="Martin Atkinson"]the variation in different sites is not significant[/quote]

I would agree to differ on that , also once daily is better IME , ref Recent feline journal ,which quoted % of cats going into remission was highest with a minimalist approach.

RE: Help with a blood glucose curve please

Tricia Goulden — Sun, 08 Nov 2015 10:53:13 GMT

MSD are very helpful with advice regarding glucose curves. Their websites www.pet-diabetes.co.uk and www.caninsulin.co.uk are helpful too.

I use an Alphatrak and I like it. I feel more comfortable using a device developed for the species I treat and they operate on a very small amount of capillary blood making them ideal for owners to use at home. If an owner is comfortable with using a glucometer I believe they should be encouraged to invest in one. Not just for glucose curves but for reassurance if their diabetic animal is off colour, is off their food or maybe has exercised more or less than normal. As you would in a human diabetic. I think their role should be discussed when managing a diabetic animal.

RE: Help with a blood glucose curve please

Francisco Gomez — Sun, 08 Nov 2015 09:12:56 GMT

[quote user="John Flynn"]

[quote user="Francisco Gomez"]That's why we use the Alphatrak device, it is designed for cats and dogs. The human ones might give a higher margin of error.[/quote]

I've looked and not convinced yet that there's any reason to think that a more expensive device marketed for cats and dogs out-performs on reliability versus a well-chosen medical unit at a quarter of the price?

[/quote]

I confess I don't know, but the device comes with two different settings: one for cats and another for dogs. So it might be that there's a difference besides the price...

RE: Help with a blood glucose curve please

John Flynn — Sun, 08 Nov 2015 07:50:57 GMT

[quote user="Francisco Gomez"]That's why we use the Alphatrak device, it is designed for cats and dogs. The human ones might give a higher margin of error.[/quote]

RE: Help with a blood glucose curve please

Martin Atkinson — Sat, 07 Nov 2015 18:29:31 GMT

[quote user="Neil Wheadon"]I had a run of glucose curves recently in a day practice, all tested between 0930 and 1700, some no nadir, so ordered a home tester that cost £62. Some practices hire these out, less stress to the animal too in a competent owners hands[/quote]The key word is competent! Sadly I've found pet owners to be universally incompetent and I would not rely on the results. I would rather interpret a possible stress affected curve in house than rely on owner's results. And the worst offenders are those who are diabetic themselves. The only time I would want a home curve or at least a few tests to compare is with a second 12 hour curve.

Back to the OP I would start over with minimum dose bid and do a curve in 7-10 days or so and get as many tests in every hour as you can in working hours. I would get the owner to dose at 7 am and bring in at 8.30 when we open, there should have been little budge from baseline in less than 2 hrs, then test hourly until 7 pm. Then review. Until you've done that you can't make any decisions.

RE: Help with a blood glucose curve please

Glenn Hodgson — Sat, 07 Nov 2015 18:16:32 GMT

I also go for bid doseing when possible.

This looks more like insulin activity tailing off in the 24 hours rathethan smogi. I think the latter has a faster increase in blood glucose after the nadir than this

RE: Help with a blood glucose curve please

Francisco Gomez — Sat, 07 Nov 2015 13:35:09 GMT

[quote user="Emma Middleton"]

I've spoken to the owner and as her husband is diabetic they are going to try and check the BG at home before giving the 2nd insulin injection.

[/quote]

Just one thing though - since you're mentioning about monitoring at home where a diabetic person lives - it is true that there is some margin of error with hand-held devices. That's why we use the Alphatrak device, it is designed for cats and dogs. The human ones might give a higher margin of error.

In our practice, we even have a in-house Alphatrak and one that we rent out!

RE: Help with a blood glucose curve please

Neil Wheadon — Sat, 07 Nov 2015 13:29:59 GMT

[quote user="grumpyoldman"]I often use them with ATE cats, if unsure the BG in the back foot is always a lot lower than the front.[/quote]

Going sideways but a lactate monitor is handy for these

Neil

RE: Help with a blood glucose curve please

Neil Wheadon — Sat, 07 Nov 2015 13:28:33 GMT

Nice article in vet cpd this month about home sampling in cats.

Home monitoring suggested by pricking the skin just next to the pads then gently squeezing. I haven't tried this in dogs.

I had a run of glucose curves recently in a day practice, all tested between 0930 and 1700, some no nadir, so ordered a home tester that cost £62. Some practices hire these out, less stress to the animal too in a competent owners hands

Neil

RE: Help with a blood glucose curve please

Emma Middleton — Sat, 07 Nov 2015 12:46:53 GMT

[quote user="Martin Atkinson"]Why haven't any samples been taken after 4.40 pm - you can't make any decisions unless you've got the best part of a 12 hour curve.[/quote]

Quite right Martin. It's an inherited case that was booked in for me to do the curve after my colleague started once daily dosing and no instructions given to owner about what to do on the morning of the curve, so I cracked on and did the best I could. Maybe I should have sent them away and then done it properly another day, but it's done now.

The dog was a bit stressed for some of the samples so in hindsight it could well have been that.

Thank you all for your input, it's really helpful. So now I don't think I need to worry about the little blip. I've spoken to the owner and as her husband is diabetic they are going to try and check the BG at home before giving the 2nd insulin injection.

RE: Help with a blood glucose curve please

Rob Loxley — Sat, 07 Nov 2015 12:41:09 GMT

+1 for BID dosing, re what dose to give going from your 13iu SID then I'd speak to MSD - their advisors are usually pretty helpful

occult UTI might be worth investigating if PUPD persists