A troublesome diabetic canine.... what am I missing?

RE: A troublesome diabetic canine.... what am I missing?

Hannah Wynne Richards — Mon, 28 Dec 2015 10:13:19 GMT

My sympathy. When you do your best, and still fail, it's soul-destroying - and some patients reallly do get to you.

Wynne

RE: A troublesome diabetic canine.... what am I missing?

Andrew Kent — Thu, 24 Dec 2015 17:37:32 GMT

Sorry to hear that Emily, sounds like he was always going to be a tricky case but never an easy call.

Andy

RE: A troublesome diabetic canine.... what am I missing?

Emily Rainbow — Thu, 24 Dec 2015 14:53:42 GMT

Unfortunately he deteriorated overnight and his owners elected for euthanasia as he has also struggled with his deteriorating sight.

Very sad morning as we'd all got quite attached to him!

RE: A troublesome diabetic canine.... what am I missing?

Richard Carter — Thu, 24 Dec 2015 11:50:51 GMT

type 2 diabetes? Rare I know but now that the liver is probably working again, a low dose extra long acting insulin and strict food?

RE: A troublesome diabetic canine.... what am I missing?

Kate Richardson — Wed, 23 Dec 2015 20:45:08 GMT

Do you think he could have been having somorgi over swings and then troughs? Maybe a very low dose of insulin for a few days to keep on top of the keto acidosis? with some iv fluids on board and antibiotics in case of a lingering undetected infection??

RE: A troublesome diabetic canine.... what am I missing?

Emily Rainbow — Wed, 23 Dec 2015 19:34:27 GMT

This evening he is back up to 37.7... I think this dog is going to see me go prematurely grey!

RE: A troublesome diabetic canine.... what am I missing?

Christopher Saul — Wed, 23 Dec 2015 18:51:08 GMT

[quote user="Andrew Kent"]I think this is largely a matter of opinion but personally I wouldn't look for hyperadrenocorticism in this case (or in general early on in the treatment of diabetes) because ALP elevations can easily be explained by diabetes and interpreting the results of adrenal function testing is very difficult in this context. Also, whether or not the dog responds well to insulin makes me more or less suspicious of HAC - so if I can stabilise it on lowish doses of insulin then HAC is unlikely.[/quote]

RE: A troublesome diabetic canine.... what am I missing?

Emily Rainbow — Wed, 23 Dec 2015 09:55:27 GMT

I will look into that Thomas, thanks. Unfortunately things have taken a bit of a twist with this little guy.... He has been managed by a few of my colleagues over the weekend too hence a few inconsistencies.

18/12/15 - day of next glucose curve (prev on 10iu BID Caninsulin).

-He had been violently sick overnight before, very lethargic, and was moderately dehydrated on admission. He was admitted for IVFT and monitoring of his glucose levels etc incase of DKA. No diarrhoea and good appetite. Urine = USG 1.032, Blood +, Protein ++, Glucose ++++, Ketones +++, pH 5.

BG 26.6 before feeding/insulin
2hrs = 20.6
5hrs = 20.8
6hrs = 16.8
7.5hrs = 12.3
9.5hrs = 10.1
11,5hrs = 9.4
14hrs = 18.8. Given 7iu and fed at 10.30pm.

19/12/15

8 am = 5.3 fed, no insulin.
9.30am = 10.6
10.30am = 27.4. Given 5iu insulin.
Much brighter in self, eating well, no further V+. Sent home with glucometer for O' to monitor BG before insulin doses.

20/12/15

7.30am = 18, adv give 8iu.
7pm = 12, adv give 6iu.

21/12/15

-Was wobbly and shaky when owners got up so given food and honey on gums. BG 37.7 shortly after.
8.30am = 29.9, adv give 10iu and check nadir.
5 hours later = 24.
7pm = 16.4, adv give 6iu.

22/12/15

7.30am = 10, adv give no insulin.
7pm = 8.6, adv give no insulin.

23/12/15

7.30am = 7.7. Some regurg/V+ of food after eating. But very BAR, normal motions this am. Adv no insulin and recheck this evening.

He is still very PU/PD, still losing weight (now 9kg). Has bilateral cataracts. I asked another of my colleagues to go through his file with me with all his charts etc as I was questioning the diabetic diagnosis! But he has never been azotaemic, his alb/glob/TP on his bloods have been within our ref ranges (UPC was slightly elevated?), and he has always had glucose/ketones of varying levels in his urine? I was suggesting to his owners that we change him onto once daily dosing in case he is over swinging or maybe even start a new insulin but the fact he has stayed 'normal' since suggesting it has confused me even further? He's such a nice dog with really nice owners - I'm really frustrated for them!

RE: A troublesome diabetic canine.... what am I missing?

Thomas Johnson — Tue, 22 Dec 2015 12:34:29 GMT

[quote user="Emily Rainbow"]

Whats the name of the bovine one? Did you test for insulin antibodies or just change it?

I regularly use Glargine in cats but my understanding was that it's not so reliable in dogs?

[/quote]

I've got a couple of animals on Hypurin Bovine PZI, and it's available through our usual wholesaler (Henry Schein).

RE: A troublesome diabetic canine.... what am I missing?

Emily Rainbow — Tue, 15 Dec 2015 08:17:55 GMT

Whats the name of the bovine one? Did you test for insulin antibodies or just change it?

I regularly use Glargine in cats but my understanding was that it's not so reliable in dogs?

RE: A troublesome diabetic canine.... what am I missing?

Martin Atkinson — Mon, 14 Dec 2015 16:54:39 GMT

[quote user="Richard Carter"]we had one spaniel that wouldn't stabilise on caninsulin without almost using a bottle at a time but is doing fine on the bovine one - just more tricky to get hold of[/quote]On that basis could try Lantus Glargine.

RE: A troublesome diabetic canine.... what am I missing?

Richard Carter — Mon, 14 Dec 2015 11:51:07 GMT

we had one spaniel that wouldn't stabilise on caninsulin without almost using a bottle at a time but is doing fine on the bovine one - just more tricky to get hold of - owner gets script filled through tescos

RE: A troublesome diabetic canine.... what am I missing?

Emily Rainbow — Sat, 12 Dec 2015 15:06:41 GMT

He's not clinically stable, still pu/pd to point of overflow incontinence overnight and still loosing weight.

We do have to wake him up sometimes to take his glucose measurement but will sound out how his owners feel about doing the next curve at home.

RE: A troublesome diabetic canine.... what am I missing?

Kate Richardson — Sat, 12 Dec 2015 10:40:17 GMT

[quote user="elspeth riley"]Just a thought but have you tried changing how you perform your glucose curve? I have one dog who I keep in cat ward. She doesn't seem stressed but I never get a good curve is she's in the dog ward, even if there's no other dog. In the cat ward, perfect.[/quote]

Definitely something to consider, especially in an apparently clinically stable animal- one where I would be probably using fructosamine to help assess. I think this case is still unstable though so glucose levels are likely true.

RE: A troublesome diabetic canine.... what am I missing?

elspeth riley — Sat, 12 Dec 2015 07:55:52 GMT

Just a thought but have you tried changing how you perform your glucose curve? I have one dog who I keep in cat ward. She doesn't seem stressed but I never get a good curve is she's in the dog ward, even if there's no other dog. In the cat ward, perfect.

RE: A troublesome diabetic canine.... what am I missing?

Andrew Kent — Fri, 11 Dec 2015 19:03:07 GMT

Ok, so we can forget the triglycerides based on that level.

lets see what happens on the higher insulin dose!

Andy

RE: A troublesome diabetic canine.... what am I missing?

Emily Rainbow — Fri, 11 Dec 2015 14:54:18 GMT

[quote user="Andrew Kent"]

Hi Emily,

Measuring a fasting triglycerides would be useful on this dog, a significant number of miniature schnauzers have idiopathic hypertriglyceridaemia which, if severe, can induce an insulin resistance (and indeed may have contributed to the cause through chronic pancreatitis etc).

Depending on that result I would be looking at an ultra-low fat diet if elevated, so Hills I/D low fat or RC GI low fat.

Do let us know how you get on

Andy

[/quote]

Triglycerides 1.99 (0.34-1.97). Lab comments this is most likely related to the diabetes, choke stasis, pancreatitis, hypothyroidism or cushings.

He's curved the best he has so far but still pretty pants! Currently on 9IU BID, I have increased to 10 units.

0 hours = HIGH

1 hour post insulin = 38.2

3 hours = 28.5

4.5 hours = 25.3

5.5 hours = HIGH

RE: A troublesome diabetic canine.... what am I missing?

Emily Rainbow — Tue, 08 Dec 2015 14:36:51 GMT

[quote user="Andrew Kent"]

PS I see the dog has also had a specialist abdominal ultrasound, in which case I assume the adrenals will have been measured - do you have the sizes?

Andy

[/quote]

Thanks Andy, haven't got the measurements to hand as today is my day off but they were 'within normal reference range'.

He's coming back in end of this week for triglycerides and his next curve so will report back.

RE: A troublesome diabetic canine.... what am I missing?

Andrew Kent — Tue, 08 Dec 2015 14:18:01 GMT

PS I see the dog has also had a specialist abdominal ultrasound, in which case I assume the adrenals will have been measured - do you have the sizes?

Andy

RE: A troublesome diabetic canine.... what am I missing?

Andrew Kent — Tue, 08 Dec 2015 14:16:37 GMT

I think this is largely a matter of opinion but personally I wouldn't look for hyperadrenocorticism in this case (or in general early on in the treatment of diabetes) because ALP elevations can easily be explained by diabetes and interpreting the results of adrenal function testing is very difficult in this context. Also, whether or not the dog responds well to insulin makes me more or less suspicious of HAC - so if I can stabilise it on lowish doses of insulin then HAC is unlikely.

If I were to screen for Cushing's in a dog with diabetes then ACTH stimulation would be my preference - low dose dex has a lower specificity in many studies meaning it has a higher risk of being impacted by non-adrenal illness.

Just my thoughts :-)

Andy

RE: A troublesome diabetic canine.... what am I missing?

Emily Rainbow — Tue, 08 Dec 2015 10:15:40 GMT

But can i trust the results of a LDDS in an uncontrolled diabetic? Or would an ACTH stim be more suitable?

RE: A troublesome diabetic canine.... what am I missing?

Martin Atkinson — Mon, 07 Dec 2015 18:13:33 GMT

[quote user="Kate Richardson"]would a low dose dex be of more use than an ATH stim? [/quote]I prefer LDDS for Cushings anyway regardless of, but especially with, the current issues with Synacthen. I suspect many are reluctant to do this as it takes all day if you're going to do 8 as well as 3 hr tests.

RE: A troublesome diabetic canine.... what am I missing?

Kate Richardson — Mon, 07 Dec 2015 15:56:24 GMT

[quote user="Emily Rainbow"]

Bloods 25/09/15

-*ALT 158 (10-100)
-*ALP 370 (23-212)
-GGT 7 (0-7)
-*Bilirubin 18 (0-15)
-*Cholesterol 11.05 (2.84-8.27)
-*Amylase 1987 (510-1589)
-*Lipase 5761 (200-1800)
-*Glucose 26.46 (3.89-7.94)

Bloods 24/11/15 (Post scanning)

-*ALT 590 (10-100)
-*ALP 677 (23-212)
-*GGT 10 (0-7)
-Bilirubin 8 (0-15)
-*Cholesterol 12.62 (2.84-8.27)
-Amylase 440 (510-1589)
-Lipase 1181 (200-1800)
-*Glucose 29.15 (3.89-7.94)

-CPLi 100.5 (0-200)

[/quote]

If you look at the ALP level on the second sample it has increased; USG may be artefactually elevated sec to the proteinuria and glucosuria; UPC is elevated. I think Cushings is a strong possibility, but a concurrent hepatopathy needs to be considered with the rising ALT elevation as well, but both could be sec to the diabetes. I don't see any value in a urine creat:cortisol ratio- it's only useful as a rule out and what are the chances of it being negative in this case- I would say virtually nil. Dificulty diagnosing cushings though, cortisols are going to be raised due to stress anyway, would a low dose dex be of more use than an ATH stim? I would be having a chat with my lab (Andy Torrance at TDDS would be a GREAT person to talk to, he's superb on endocrinology in particular)

RE: A troublesome diabetic canine.... what am I missing?

Thomas Johnson — Mon, 07 Dec 2015 14:40:53 GMT

[quote user="Matt Hilary"]

Would be very surprised if Cushingoid with USG of 1.038 - usually far more dilute. Could UCCR as negatives usually reliable.

[/quote]

I would tend to agree, but would be slightly concerned that the amount of glucose in the urine would cause an artificial elevation in the specific gravity.

RE: A troublesome diabetic canine.... what am I missing?

Emily Rainbow — Fri, 04 Dec 2015 19:02:47 GMT

Thanks everyone will run the fasting triglycerides and see what we get.