diabetic help!

Re: diabetic help!

Christopher Saul — Thu, 21 Oct 2010 21:15:16 GMT

Thinking on, I suppose it's possible that the hypurin bovine insulins may get prioritised to human use so we may have to mange with hypurin porcine PZI and hypurin porcine neutral, but only time will tell I suppose.....

Re: diabetic help!

michelle greaves — Thu, 21 Oct 2010 19:07:57 GMT

Thankyou christopher! thats really helpful, i will look into seeing if we can get it, i know its not ideal, but i think starting again with this case would put about 6 months hard work to waste!

michelle

Re: diabetic help!

Christopher Saul — Thu, 21 Oct 2010 17:35:17 GMT

Hi All,

I know this is going off at a slight tangent but regarding Michelle's original question of using PZI..... I had a quiet afternoon and did some phoning around.......

As far as I can work out the situation is this: It is Pfizer's (i.e. insuvet) production which is interrupted (and may or may not return). This means that the insuvet range may soon be unavailable if wholsalers run out. However, the production of hypurin ( by a company called wockhardt)- a rival product range to Pfizer's human insulin range - is unaffected.

The hypurin range includes both bovine and porcine - PZI, lente and neutral being available in both types.

My own feeling is that, under the cascade, all animals needing lente should if possible be converted to caninsulin.. we cannot justify using hypurin lente where there is a licensed alternative.

However for those patients needing PZI, for DKAs requiring neutral, (or for those rare patients where porcine insulin doesnt work) - I see no problem using hypurin.

I hope that helps

Re: diabetic help!

Mark Holmes — Thu, 21 Oct 2010 14:34:34 GMT

Spayed the diabetic today, all fine. Interesting discussion with virbac re Alizin who have suggested may be useful in antagonising progesterone and improving glycaemic control in these dogs. They suggest it is given d1 d2 and d7. They also suggest spaying ASAP but Alizin can help in the early stages (anecdotal evidence) and immediately post neutering.

Re: diabetic help!

Martin Atkinson — Thu, 21 Oct 2010 13:58:30 GMT

[quote user="Michael Woodhouse"]

I have found fructosamine rather disappointing in these cases. In my experience if we are getting somogyi overswing the fructosamine can still be high.

[/quote]

If fructosamine is in the 'good recent control' range then the patient is stabilised, if it is high then this won't differentiate between a somogyi effect and an underdosed patient but it at least draws your atention to do something. Equally if its in the lower end of 'excellent control' there is a danger of hypoglycaemia so more carefull monitoring is needed.

Re: diabetic help!

Christopher Saul — Thu, 21 Oct 2010 13:06:03 GMT

I would agree Michael that this is not an ideal case for fructosamine monitoring, just that it may add some information. I would normally use fructosamine for monitoring of clinically stable diabetics

Re: diabetic help!

Michael Woodhouse — Wed, 20 Oct 2010 23:53:37 GMT

[quote user="Christopher Saul"]With regards to the question of how to monitor the case fructosamine can be useful.[/quote]

I have found fructosamine rather disappointing in these cases. In my experience if we are getting somogyi overswing the fructosamine can still be high.

Re: diabetic help!

nikki — Wed, 20 Oct 2010 22:07:08 GMT

[quote user="Mark Holmes"]

I have just had a dog present newly diabetic 6 weeks post season, in the highly insulin resistant stage. Borderline ketoacidotic. Need to spay it but reluctant to do so when unstable, particularly with KA on the horizion but having difficulty treating the KA and stablising the diabetes dt progesterone. I did consider progesterone antagonists but Virbac are not confident it will work. Any suggestions. I wonder whether I just need to bite the bullet and get it spayed but does anybody have the 1/2 life of progesterone handy for some idea of how quickly her insulin sensitivity will return to normal?

[/quote]

we had a similar case last year - had it in the hospital for a couple of days, stabilised it as best as poss and then spayed it. diabetes disappeared within a week or so if i remember rightly.

Re: diabetic help!

Christopher Saul — Wed, 20 Oct 2010 18:50:34 GMT

Hi Michelle this sounds a difficult case and I sympathise. With poor owner compliance diabetes is always a headache.

With regards to your question of using human insulin, I'm afraid I have no experience with this so can't help you. It may be worth talking to the Pfizer techincal support to see what they recommend.

With regards to the question of how to monitor the case; do you think the owners may be amenable to doing a home glucose curve (pinprick of ear/handheld glucometer)? I have had some success with owners doing this. Also fructosamine can be useful. Ultimately however I feel that you can never really control a case without having your owners on-side.

What dose of PZI is he on? 2.2IU/Kg seems like a massive dose. I'm guessing you've already quizzed the owners on things like storage/injection technique etc.

Re: diabetic help!

Christopher Saul — Wed, 20 Oct 2010 18:11:42 GMT

Hi Mark

Though I don't know the T1/2 of insulin, as far as I am aware, insulin effectiveness takes approximately 7 days to return to normal following withdrawl of progesterone - i.e about a week after the end of dioestrus. I am not not a reproductive expert but I believe that the luteal phase wanes gradually in the non-pregnant bitch (unlike pregnant bitches) and so progesterone levels decline gradually over a period of time.... so it is difficult to put a time on it.

It would be interesting if anyone can say how many days the progesterone dependant phase typically lasts in the bitch, I cannot remember off the top of my head. Is she 6 weeks after the onset of season or the end?

My approach would be to stabisise the ketoacidosis with agressive therapy (IV fluids, soluble insulin etc); after all true DKA is a medical emergency... and then spay as soon as she's stable.

Hope this helps

Chris

Re: diabetic help!

Michael Woodhouse — Wed, 20 Oct 2010 17:35:49 GMT

[quote user="Mark Holmes"] I wonder whether I just need to bite the bullet and get it spayed but does anybody have the 1/2 life of progesterone handy for some idea of how quickly her insulin sensitivity will return to normal?[/quote]

According to a very reliable peer-reviewed source (wikipedia) the half life is 25-50 hours!

If it's fairly stable and urine not full of ketones I would get on and spay it myself.

Re: diabetic help!

Mark Holmes — Wed, 20 Oct 2010 17:20:38 GMT

Re: diabetic help!

Martin Atkinson — Wed, 20 Oct 2010 10:15:53 GMT

Same reply as for the Insuvet post regarding the information on insulin in the BSAVA formulary. Regarding monitoring: are you using fructosamine as a monitoring test? If that is normal then you're OK if its high it could be an overswing or underdosing so you need a curve. Maybe you should give the owner a stark choice: leave the dog for a glucose curve or let you dog die. Sadly I had one who chose the latter but worse: after we got the dog beautifully stabilised in-clinic (twice) if kept becoming unstable until I found the owner wasn't giving the insulin, 'because the dog didn't like injections', (oh so it prefers to feel ill and die then) and they had it PTS.