Dog with DM and atopy

Re: Dog with DM and atopy

Martin Atkinson — Thu, 21 Jul 2011 16:02:06 GMT

[quote user="Rob Davis"]

[quote user="Martin Atkinson"]What time did the dog get its insulin[/quote]

7.30am

All good points and worth following up. As I mentioned previously, the owner is diabetic herself and I have generally assumed (quite possibly mistakenly) that her injection technique should be good as she's used to giving them to herself.

[/quote]

On that dosing time, expecting the nadir to occur between 4-6 hrs post dose, earlier rather than later in an overswing, it does look like your nadir was around 2pm. However, I'd do 1hr glucose tests in that period in case you miss an overswing rebound. The curve up to that point IMO fits a relative underdose but why did it shoot up afterwards to nearly double the starting point (maybe more as you could only measure up to 32)? That shouts to me that the client dosed correctly the night before but underdosed in the morning. I'd definitely review her technique before changing the dose.

On the point about the owner being diabetic, read my earlier post on that, my diabetic client with a diabetic dog is one of my worst offenders for controlling the dog, it also has chronic/acute pancreatitis and is overweight, it is a Schnauzer, but that still says something about the diet, although things are now better I've convinced her to do 24 hour curves at home.

Re: Dog with DM and atopy

Rob Davis — Thu, 21 Jul 2011 12:40:05 GMT

[quote user="Martin Atkinson"]What time did the dog get its insulin[/quote]

7.30am

[quote user="Martin Atkinson"]What happened between 8 & 10 am or between 10 and 12 or 12 and 2 for that matter? It could have plummeted and shot back up during those times - I prefer a 1 hour test period from 2 hours - 6hrs post dose. (What was interesting in your curve I thought was an overswing, was that she didn't reach her nadir until at least 8 hrs post dose IME it is usually around 4-5 hrs). How sure are you the owner gave the insulin? - could be a partially missed dose curve. Have you watched the owner give a dose recently? They could be fully dosing some days and missing others it is surprising the number of ways they can contrive to cock it up when you assume they're doing it correctly and they won't admit it. Are they injecting into the same site every day or a fresh one? The former can lead to irregular absorption of the insulin.[/quote]

[quote user="Julian Earl"]With any unstable or poor-to-control diabetic you must deal with infection - have you got a pyoderma that is partially masked by the steroids? Also, just on principle, check the urine for evidence of infection, and the teeth. Those are the big three sites for complicating diabetic control.[/quote]

There is no sign of pyoderma or periodontal disease, though I have not checked a urine sample recently and it would be sensible to do so.

Thanks for all the replies so far. I'll keep you posted with any progress. Any further suggestions or criticisms gratefully received!

Re: Dog with DM and atopy

Mark Hedberg — Wed, 20 Jul 2011 19:59:09 GMT

[quote user="Martin Atkinson"]

[quote user="Mark Hedberg"]

I'd agree with a suggestion for Lente; more gradual, solid glucose control. It's worth a try, anyway. Do need to give it a few days, as with all new insulin. Works a treat if the owner's compliant and reasonable with injection times.

[/quote]

The OP's case is on Caninsulin Mark which is a lente insulin - did you mean Lantus? If so he has already said cost is an issue. I still think he needs to address the queries I've posted first, I've had clients who I have trained and observed dosing only for them to have been shown to have changed their technique for the worse whilst I assumed they were doing it correctly. My unstable dog in my previous post is a case in point even though I'd instructed the owners how to inject in a different site every day and they swore they did when asked to demonstrate where they showed me 4 injection sites they do in rotation all within a couple of cm of each other.

[/quote]

Did it again, didn't I? Yes, I meant Lantus. Sorry! :)

Re: Dog with DM and atopy

Julian Earl — Wed, 20 Jul 2011 18:46:11 GMT

With any unstable or poor-to-control diabetic you must deal with infection - have you got a pyoderma that is partially masked by the steroids? Also, just on principle, check the urine for evidence of infection, and the teeth. Those are the big three sites for complicating diabetic control.

Re: Dog with DM and atopy

Martin Atkinson — Wed, 20 Jul 2011 09:04:24 GMT

[quote user="Mark Hedberg"]

[/quote]

Re: Dog with DM and atopy

Mark Hedberg — Tue, 19 Jul 2011 20:05:28 GMT

Re: Dog with DM and atopy

Anthony Todd — Tue, 19 Jul 2011 19:13:45 GMT

[quote user="Rob Davis"]My thinking was that we need to use pred to manage pruritis (already on immunotherapy as well), and that keeping the level as constant as possible was likely to have a more even day to day influence on the DM (I am happy to be corrected on this if my assumption is wrong).[/quote]

Er, yes, I didn't think of that TBH...

Don't worry the slurry will descend in due course, or just an accusatory silence, which is worse.

Perhaps someone can comment on prednisolone and diabetes please vis a vis dose of pred and influence on blood glucose.

Re: Dog with DM and atopy

Martin Atkinson — Tue, 19 Jul 2011 17:25:06 GMT

What time did the dog get its insulin? What happened between 8 & 10 am or between 10 and 12 or 12 and 2 for that matter? It could have plummeted and shot back up during those times - I prefer a 1 hour test period from 2 hours - 6hrs post dose. (What was interesting in your curve I thought was an overswing, was that she didn't reach her nadir until at least 8 hrs post dose IME it is usually around 4-5 hrs). How sure are you the owner gave the insulin? - could be a partially missed dose curve. Have you watched the owner give a dose recently? They could be fully dosing some days and missing others it is surprising the number of ways they can contrive to cock it up when you assume they're doing it correctly and they won't admit it. Are they injecting into the same site every day or a fresh one? The former can lead to irregular absorption of the insulin.

By coincidence my unstable diabetic dog I mentioned in my last post is in again today with a very flat curve (staying around 20-24mmol/l. She doesn't have the large fluctuations yours does so I will gradually increase the dose again, I know from past experience she will remain persistantly hyperglycaemic until I get up to the original dose, she will be as stable as she ever is for several weeks then go hypo again. I also have a diabetic cat in thats been on the same dose for years and has a periodic glucose curve he's gone hypo today and had to have glucose. It isn't easy - but there's the challenge.

Re: Dog with DM and atopy

Rob Davis — Tue, 19 Jul 2011 16:58:53 GMT

Following the last odd curve, I suggested reducing the insulin from 15IU to 13IU BID. Since then the dog has been PUPD and lethargic and the owner did another curve at the weekend as follows:

8am 19.5mmol/l

10am 27.1mmol/l

12pm 22.4mmol/l

2pm 21.3mmol/l

4pm 29.7mmol/l

6pm >32mmol/l

8pm >32mmol/l

Do you still think this looks like Somogyi?!

I'm struggling with this one

Re: Dog with DM and atopy

Rob Davis — Tue, 19 Jul 2011 16:53:24 GMT

[quote user="SteveOwen"]Sounds an ideal case for Cortavance to me.[/quote]

How do you use it for generalised pruritis in a hairy dog?

Re: Dog with DM and atopy

Rob Davis — Tue, 19 Jul 2011 16:48:27 GMT

[quote user="Anthony Todd"]Would it not be better to give a higher dose of pred., enough to control symptoms as necessary, rather than a continuous low dose?[/quote]

My thinking was that we need to use pred to manage pruritis (already on immunotherapy as well), and that keeping the level as constant as possible was likely to have a more even day to day influence on the DM (I am happy to be corrected on this if my assumption is wrong).

Re: Dog with DM and atopy

SteveOwen — Sat, 16 Jul 2011 18:12:41 GMT

Why?? Why not Cortavance. As effective, safer....and not much dearer.

Re: Dog with DM and atopy

Anthony Todd — Sat, 16 Jul 2011 11:38:50 GMT

[quote user="Rob Davis"] 5mg SID prednisolone[/quote]

Would it not be better to give a higher dose of pred., enough to control symptoms as necessary, rather than a continuous low dose?

Does a high intermittent dose have a similar/same effect on the adrenals?

And I suppose all the obvious allergens are constantly eliminated?

Re: Dog with DM and atopy

SteveOwen — Sat, 16 Jul 2011 11:09:38 GMT

[quote user="Rob Davis"]

Patient is a 7 year old spayed labrador. Diagnosed with atopy a few years ago, on immunotherapy, but still requires 5mg SID prednisolone to keep pruritis under control. Developed diabetes in September 2010. I am currently struggling to control the diabetes, dog is still pupd, polyphagic, losing weight, but also starting to look pot-bellied. She is currently on 18IU caninsulin BID (current weight 22kg). Has anyone seen iatrogenic cushings on this level of prednisolone (<0.25mg/kg SID)? If it is non-iatrogenic cushings, then will running an ACTH stimulation test be significantly affected by the daily dose of prednisolone? I have discussed trying to change from pred to atopica for the atopy, but although the dog is insured, the owner pays 15% excess, so atopica still works out as a signfiicant cost (on top of everything else!). Any thoughts gratefully received.

[/quote]

Sounds an ideal case for Cortavance to me. Safe, and cheap (compared to Atopica, but actually not much more than pred). And actually just good as Atopica according to a study quoted in a Tim Nuttall webinar I watched recently (www.thewebinarvet.com/virbac-webinars, scroll to the bottom). He apparently uses it first line for atopy! Until the webinar I'd only really used it for local lesions (hot spots and the like) but since I watched it I've used it for generalised AD and seems to work really well. No reason why not really, doesn't take too long to spray the whole of a westie!

Re: Dog with DM and atopy

Martin Atkinson — Thu, 14 Jul 2011 16:53:09 GMT

[quote user="robloxley"]

[quote user="Martin Atkinson"]Also you may now need to consider HAC again[/quote]

Would Cushing's not give more of an insulin resistance picture - it seems from the curve that the dog is responding to the insulin?

[/quote]

As it happens I have an unstable diabetic dog in today which is also under therapy for HAC on trilostane. It is usually showing more of a resistance picture but today came in for a spot glucose and it was 2.4, (currently having an afternoon glucose curve). This dog has gone hypo 3 times on roughly the same dose (13iu bid) over a couple of years, we reduce it by 30%, it then goes persistantly hyperglycaemic until we get it back to the original dose, it is OKish for months and then throws another hypo. I think this goes to show that there is no pattern to a dog with DM & HAC so you have to keep your mind open. Just a thought but I wonder if the daily production of cortisol varies in HAC and as you increase the dose of insulin because its resistant you may get a low cortisol day/period and the requirement may suddenly drop which could be the case in the OP's dog.

PS we have had to increase the dose of Trilostane once but the ACTH stim test shows current stability of HAC in this dog.

Re: Dog with DM and atopy

Rob Loxley — Wed, 13 Jul 2011 13:59:18 GMT

[quote user="Martin Atkinson"]Also you may now need to consider HAC again[/quote]

Would Cushing's not give more of an insulin resistance picture - it seems from the curve that the dog is responding to the insulin?

Re: Dog with DM and atopy

Laurence Webb — Wed, 13 Jul 2011 11:13:02 GMT

I'd agree with Martin - the glucose is dropping too low followed by a rebound hyperglycaemia. Drop the insulin by 25-50% and repeat the curve. Hopefully you'll see a normal response to insulin although it's likey you'll need to gradually increase the dose. If the owner is happy to keep doing glucose curves at home that would be preferable to fructosamine as it only indicates the average glucose level and misses the peaks and troughs.

Re: Dog with DM and atopy

Martin Atkinson — Wed, 13 Jul 2011 11:03:58 GMT

It looks like she is overswinging to me so far from increasing insulin I would be reducing the dose by at least 25% with a curve like that otherwise you're in danger of a big hypoglycaemic episode. Fructosamine also becomes unreliable in this situation because the dog is spending more time above theshold than below despite overdosing. If it still remains that unstable you may consider Lantus (Insulin Glargine) which is absorbed at a much more constant rate and avoids the peaks and troughs. I've only tried it in cats without huge success I'll admit, largely because it is100iu/ml and getting the dose right was difficult, this shouldn't be such a problem in a dog but cost may be an issue. Also you may now need to consider HAC again.

Re: Dog with DM and atopy

Rob Davis — Wed, 13 Jul 2011 09:04:39 GMT

I'm looking for a little further advice on this case.... Unfortunately we have had to take the dog off atopica as cost was becoming an issue (although the dog is insured, the owner pays a 20% excess on all claims). She is currently on 2.5mg pred SID and we are unable to reduce this without her becoming significantly pruritic. Her DM has been very difficult to control with large fluctuations in blood glucose levels. Her owner has now managed to start measuring her blood glucose at home, and she produced the following curve for me at the weekend:

8am 26.2
10am 16.5
12 noon 14.1
2pm 5.4
4pm 2.7 - gave her 4 small dog buiscuts and half a carrot
6pm 25.5
8pm 32.2

She is currently on 15IU caninsulin BID. I am considering changing to TID insulin, but I have never done this before. Does anybody have any experience with this? If so what does of insulin would you suggest starting on? Does anybody have any other bright ideas?

Thanks in advance for any suggestions.

Re: Dog with DM and atopy

Rob Davis — Fri, 04 Feb 2011 17:22:28 GMT

[quote user="Richard Fox"]Sorry wasn't being overly critical. BTW I have just found out Dexamethasone does not affect the ACTH stim so if you want to try that a few days /week before the test and then re-introduce pred then that maybe better?[/quote]

No need to apologise - it wasn't taken as being overly critical, and if I wasn't prepared to hear criticism of my work up I wouldn't post! Many thanks for your thoughts.

Re: Dog with DM and atopy

Kate Richardson — Fri, 04 Feb 2011 09:53:49 GMT

[quote user="Martin Atkinson"]

I have one diabetic owner with a diabetic dog which she allowed to go into DKA and continually puts up obstructions to me doing glucose curves and other monitoring on cost grounds. She is grossly overweight and so clearly is not addressing even the most fundamental aspects of her own condition so what hope is there for the dog?!

[/quote]

Shouldn't have, but did have to LOL!!!

Re: Dog with DM and atopy

Martin Atkinson — Fri, 04 Feb 2011 09:38:40 GMT

[quote user="Rob Davis"]

[quote user="Mark Hedberg"]

May be a silly question, but how well is the owner's diabetes stabilized? (Just curious; not all diabetic patients are equally complient.)

[/quote]

Fair question, and I don't know the answer (it would perhaps feel a little intrusive to start quizzing her about her own health...), but perhaps I shouldn't take it for granted that she is competant.

[/quote]

Re: Dog with DM and atopy

Richard Fox — Fri, 04 Feb 2011 09:37:23 GMT

[quote]

I agree, I'm not at all certain of HAC, but am really just trying to establish if an ACTH stimulation test will be useful while it's on pred. It sounds as though we should leave it off for at least 24 hours before performing the test, although I would imagine its effects would last longer than this?

[/quote]

Sorry wasn't being overly critical. BTW I have just found out Dexamethasone does not affect the ACTH stim so if you want to try that a few days /week before the test and then re-introduce pred then that maybe better?

Re: Dog with DM and atopy

Rob Davis — Fri, 04 Feb 2011 08:57:06 GMT

[quote user="Mark Hedberg"]

May be a silly question, but how well is the owner's diabetes stabilized? (Just curious; not all diabetic patients are equally complient.)

[/quote]

Fair question, and I don't know the answer (it would perhaps feel a little intrusive to start quizzing her about her own health...), but perhaps I shouldn't take it for granted that she is competant.

Re: Dog with DM and atopy

Mark Hedberg — Wed, 02 Feb 2011 21:56:58 GMT

[quote user="Rob Davis"]

Her owner is also diabetic, so I'm as confident as I can be that there is no problem with insulin storage etc.

[/quote]

May be a silly question, but how well is the owner's diabetes stabilized? (Just curious; not all diabetic patients are equally complient.)