The vomiting diabetic patient

Re: The vomiting diabetic patient

Ian Battersby — Wed, 07 Jul 2010 13:52:35 GMT

Hi,

Briefly - appreciate there are always ifs and buts in hypothetical cases.

First important point about ketones body formation is that it is insulin activity that prevents the development of ketones by the liver from FFA. So metabolic changes to switch the liver metabolism to the production of ketones will start if insulin activity is absent.

So i prefer to have some background insulin in my diabetic pateints. I normally instruct owners that if a dog doesn't eat first thing in a morning. Firstly do a urine keto stick if negative give half the dose and then contact a vet for advice. Obviously if keto positive this is a different story.

Certainly a concurrent disease process could increase insulin requirements, but this depends on the diseae process as to how significant this may be, so i am reluctent to advise normal dosages unless the patient is hopsitalised so that glucose monitoring and supplementation can be done etc.

If keto negative and the pateint only just started vomiting it may settle as may just be gastritis, and the owner can resume routne as normal at next insulin injection. But warn them that PUPD is liikely for a day or two as the routine has been disrupted things will need a few days to settle.

But i do agree with the other posts that in this hypothetical case If a diabetic has been vomiting for 48 hours ) then it needs to be assessed more throughly and i wouldn't advise the dog is assessed. To be honest i would say 24 hour would be my limit - but i guess this depnds on frequency of vomting, demeanours conccurent diarrohea. Again as hypothetical lots of variables on this one.

I wouldn't prescribe antibosis unless a- i can confirmed infection e.g. evidence of a UTI which is the first place i look in Diabetics or b- Ketoacidotic and i am concerned insulin resistance caused destabilisation ie.suspicious a concurrent infection is causing insulin resistance. with the thoughts best to treat for infection whilsts awaiting cultures of urine etc as will make dog more responsive to insulin.

Been as brief as i can and hope that helps

Ian

Re: The vomiting diabetic patient

Kate Richardson — Tue, 06 Jul 2010 23:34:01 GMT

[quote user="sophia guymer"]Just a little anecdote on that note:[/quote]

Another little anecdote- I have a diabetic friend who started experiencing confused episodes and couldn't remember where she was when she woke up in the morning- the doctor told her that she was just tired and gave her sleeping tablets- turns out she was having severe hypoglycaemic episodes at night, BG down to 1.7- imagine what could have happened if she had actually followed the doctors advice and taken the sleeping pills.......

Re: The vomiting diabetic patient

sophia guymer — Tue, 06 Jul 2010 19:59:33 GMT

[quote user="Kate Richardson"]they need prompt treatment of even simple illnesses to prevent complications and destabilisation.[/quote]

I think we can all agree to that, yes?? Just a little anecdote on that note: my friends elderly mum is diabetic and started vomiting, went to gp,who said he was going to refer her: by sending a referral letter! So a week later, still vomiting everything up!! she went back, ditto, a week later again she finally saw a locum, by now she was very ill, weak, lost loads of weight, cant even keep smallest amount in, the locum actually phoned the hospital and got her in 'straight away' : it was still nearly a week later before she had the necessary tests done!! advanced ovarian cancer.

I can only imagine what owners would have to say if we treated their dog like that!

Re: The vomiting diabetic patient

Kate Richardson — Mon, 05 Jul 2010 15:08:58 GMT

[quote user="Martin Atkinson"]I would want to be certain that ketoacidosis wasn't the cause of the vomiting[/quote]

I agree, especially if the animal was unwell in itself and if the owners don't want to bring the dog in they could at least drop a urine sample in for you to check first. 1 or 2 vomits in a stable diabetic dog that was bright and waggy tailed otherwise- I would probably reduce the dose until it was eating normally and vomiting had resolved, but 2 days of vomiting, I'd want to see the dog. But it also depends on how well you know the case in question eg how stable is the dog's diabetes. Every diabetic is an individual but they need prompt treatment of even simple illnesses to prevent complications and destabilisation.

Re: The vomiting diabetic patient

Martin Atkinson — Sat, 03 Jul 2010 10:30:30 GMT

I would want to be certain that ketoacidosis wasn't the cause of the vomiting ( are you doing regular fructosamine tests and checking for ketoenuria?). That established, the advice given on investigating the cause and treating the vomiting is pretty standard, I wouldn't have considered any issues for or against with giving antibiotics related to a stabilised diabetic, but I would be a bit more hesitant in a blanket policy of halving the insulin dose. For sure your patient is more likely to die overnight from hyop as opposed to hyper-glycaemia but I've struggled to get a patient stable again where another vet has followed that policy. I would try and measure serum glucose levels more frequently and adjust the dose accordingly if at all practical.

Re: The vomiting diabetic patient

emerald — Sat, 03 Jul 2010 00:13:32 GMT

Depending on Hx and CE, I may want to perform bloods inc checking for pancreatitis.

If the patient is eating normally I probably would give normal amount of insulin, if not eating as well then half dose of insulin.

Assess whether needs IVFT support too.

Re: The vomiting diabetic patient

Michael Woodhouse — Fri, 02 Jul 2010 23:35:38 GMT

If the animal is not eating or is vomiting then I tell owners not to give the insulin.

Simply - a day or two of hyperglycaemia won't do any significant harm, a bout of hypoglycaemia might!

Re: The vomiting diabetic patient

Vikki Halliday LLB — Fri, 02 Jul 2010 22:18:53 GMT

Interesting one, in practical terms I would tend to feed small amounts of very bland food, and half the insulin dose at the normal times.

I would also be prescribing some ranitidine or cimetidine, possibly an anti-emetic such as Cerenia, a NSAID, and perhaps antibiosis if I felt that a bacterial cause was likely.

In any event ,( having ruled out major surgical conditions), the aim is to keep glucose levels stable whilst allowing the GI tract and in particular the stomach, to heal and deal with the inflammation.

Once the vomiting has ceased, and the animal is keeping down larger quantities of bland food, I would return the insulin dose to normal

But I know there are many conflicting aspects to this query!

(Awaiting brickbats from medicine gurus............)