diabetus mielitus?

Re: diabetus mielitus?

Kate Richardson — Mon, 16 May 2011 09:07:47 GMT

[quote user="Ruta"]

The latest news from me. I talk with the owner and she understood all risk and agreed to start treatment. I will start as soon as I will get Canininsulin, possibly from Tuesday.

I will try to stabilize the bitch and then spay her. Maybe someone has the special anesthesia monitoring form for diabetic's dogs?

[/quote]

Excellent!

Get her started on insulin, but don't worry about getting her perfectly stable prior to the spay- you will probably struggle to get her stable until she is spayed anyway. Just make sure she is bright, eating and drinking, and especially that she has no ketones in her urine. I would probably aim for 1 week on insulin prior to spaying so her metabolism has a chance to start normalising.

On the day of the spay, give her a half dose of insulin, obviously no food that morning, and do the op as early in the day as you can so you have all day to monitor her. IV fluids would be a good idea. Many diabetics are low in potassium, so if you can check that pre-op it may be helpful and supplement in iv fluids if necessary, but if you don't have the ability to check electrolytes in house, I would just go with a balanced fluid such as hartmans. (I can send you info on how much potassium to supplement in fluids if you need it)

In terms of anaesthetic, I would use your normal protocol for premed/induction/maintenance- use what you are familiar with, and do the spay. Check her blood glucose intermittently, you will probably find it remains high. The actual surgery will be no different to any other spay you do. In recovery, just monitor glucose intermittently, and get her eating asap and then continue with her insulin when due in the evening. If you can keep in her overnight, this will probably give you peace of mind, if you are able to monitor her overnight, but if you don't have the facilities to do this, then she is probably best at home where mum and dad will be watching her like a hawk!

Depending on what dose of insulin you have her on prior to surgery, you will need to assess her needs over the next few weeks after spaying due to the fact you have removed the insulin resistance factor.

It might be worth teaching the owners how to check a blood glucose at home and getting them to buy a glucometer, so they can do glucose curves at home? This will help you a lot in deciding what insulin doses to use.

If you have any worries about infection, especially urinary tract infection, then some broad spectrum antibiotics amy be a good idea as well. Whilst I don't advocate use of antibiotics unnecessarily, as funds will limit you sending urine samples for C&S, it is unlikely to do any harm to have some amoxyclav on board.

Re: diabetus mielitus?

Rach — Sun, 15 May 2011 19:38:10 GMT

[quote user="jose targa"]

all right...i must change pathognomonic for characteristic ...

...maybe you must change "glomerular" for tubular diseases??

Regards

[/quote]

oops yes, no offence meant by the way,

Rach

Re: diabetus mielitus?

Ruta — Sun, 15 May 2011 15:58:36 GMT

The latest news from me. I talk with the owner and she understood all risk and agreed to start treatment. I will start as soon as I will get Canininsulin, possibly from Tuesday.

I will try to stabilize the bitch and then spay her. Maybe someone has the special anesthesia monitoring form for diabetic's dogs?

I would appreciate it.

Ruta

Re: diabetus mielitus?

Kate Richardson — Thu, 12 May 2011 13:17:16 GMT

You'll be fine, give it a go as long as they work with you and accept the limitations. Then you will have experience!

Re: diabetus mielitus?

Ruta — Thu, 12 May 2011 13:09:26 GMT

Thank you, Kate, for all support and very useful information. I know it is not easy case, but I must start from somewhere, especially when it is one vet practice. I will talk with the owner tomorrow about all possibilities, included biggest practice with more experience vets. But I don't think that she will be happy with that.

So, however, if I will try, the most important for me will be to control hypoglycemia if it will occur.

I am so happy that I have you on this forum. You are really fantastic. Thanks a lot.

I will let you know how it's goes after my conversation.

I really appreciate your help.

Ruta

Re: diabetus mielitus?

Kate Richardson — Thu, 12 May 2011 12:05:34 GMT

Oh and diet wise, yes there are specific diets that will be beneficial but will cost more, so probably not going to be an option for you. We often use Chappie as an alternative but I don't know what diets you have access to. I would probably look at what the dog is currently eating and work out a fixed ration for her, divided into 2 daily meals before her insulin injections. And figure in some weight loss into those amounts and regularly weight and adjust diet as needed until she reaches her target weight, aiming for slow steady weight loss.

Re: diabetus mielitus?

Kate Richardson — Thu, 12 May 2011 12:01:13 GMT

As far as I am aware, caninsulin should be BID in all diabetics now? Please correct me if I am wrong. And as far as I know caninsulin only comes in 1 strength of 40iu/ml.

I would go for twice daily caninsulin injections, starting at 0.5iu per kg. I would start with this dose as if money is tight you want to try to get the dog on a stable dose as soon as possible but I would really try hard to get them to leave the dog with you for the day for the first dose so you can be certain it isnt over sensitive to the insulin- stress to the owners the seriousness of hypoglycaemia ie it might die! You can probably get away with a blood glucose prior to giving the insulin and then 2 or 3 gluc checks over the first 12hours ie not strictly every 1-2 hours, plus monitoring for any signs of low blood sugar plus a blood glucose just before it is due for its second dose of insulin so you can be more sure it definitely needs twice daily dosing.. As long as you are happy that the dog is not going to become hypoglycaemic then the dog can go home with the owners injecting. Don't worry if there is little change in the blood glucose following the first dose, better to get the dog home with the owners injecting on a dose that is too low to start with so they don't have to worry about hypoglycaemia initially and just have to cope with actually giving the injections. Depends a bit on how intelligent your owners are though! Give them a week to get used to the regime and then if the dog is still pupd get them to increase the dose by 1iu but not more frequently than every 4-5 days.

Urine dipsticks are useful but use it in conjunction with the clinical signs. Eg if the dog is clinically stable but urine glucose +++ don't worry too much, but if the dog is clinically stable but urine glucose is persistently trace or negative, I would be looking to check blood glucose levels and potentially reduce the insulin dose.

It is going to be harder for you (but not impossible) if you don't have experience with diabetics to make decisions based on clinical signs only if the owners really won't spend any money (although we are all here to help you); are they aware of the ongoing costs of treatment? Make sure they are aware of your inexperience with this disease and how difficult it may be to control the dogs diabetes without monitoring and that they accept any risks of not testing and monitoring as they should. Can they afford to have the dog spayed? Cos if not you may never get any kind of control in this dog in which case it may be kinder to think about euthansia...?

Re: diabetus mielitus?

Ruta — Thu, 12 May 2011 09:37:32 GMT

First of all thank you very much for all your help. I know it will be challenging for me, but I think I will make it.

As far as I saw in Canininsulin data sheet is written that dosage for dogs 25kg is 10IU once daily. My patient weight is 30kg. So, it would be 12IU once daily? Canininsulin is recommended twice daily just for cats and small dogs (still from data sheet). Should I start with twice daily? Christopher mentioned 0,3-0,4 IU/kg twice daily. What do you think? And which concentration Caninininsuline should I use? 40IU/ml?

Are there any specific diets for diabetics dogs? What I should know about exercise? Should I recommend low or high activity?

Thank you, Michael, for very nice idea about urine dipstick test, I think I will try. Because the owner doesn't have money for insulin-glucose-response curve.

I appreciate all your help. Thanks a lot!

Ruta

Re: diabetus mielitus?

Kate Richardson — Thu, 12 May 2011 07:39:39 GMT

[quote user="Christopher Saul"]Regarding monitoring 'on the cheap' I would say that the most important factors I use to decide if a diabetic is well controlled are: bodyweight, water intake, general demenour/physical examination. If all of theses are normal (often combined with a good fructosamine for good measure) then I'm happy. A perfect glucose curve would be nice but in my opinion I feel clinical control is more important than perfect glycaemic control.[/quote]

Absolutely. Important to monitor blood glucose when initiating insulin but once happy with the dose, monitoring via clinical signs is perfectly acceptable and much cheaper. Explain that the inital costs may be moderate but ongoing costs may be kept minimal, however as Chris said def warn re possibility of complications. Good luck!

Re: diabetus mielitus?

Christopher Saul — Wed, 11 May 2011 23:45:35 GMT

I agree this dog is diabetic.

Can't add alot that hasn't already been said by the others but I would reinforce the point about neutering; you really must spay her if she's stable enough for anaesthetic.

There are lots of protocols for control of DM, and none is perfect; what is important is that you become comfortable with a regime you know. I usually start with a dose of between 0.25 and 0.5 IU per Kg, (usually about 0.3 or 0.4) twice daily of caninsulin. I divide the daily food intake between 2 equal meals as close as possible to 12 hours apart, and have the owners inject immediately after food.

Regarding monitoring 'on the cheap' I would say that the most important factors I use to decide if a diabetic is well controlled are: bodyweight, water intake, general demenour/physical examination. If all of theses are normal (often combined with a good fructosamine for good measure) then I'm happy. A perfect glucose curve would be nice but in my opinion I feel clinical control is more important than perfect glycaemic control. Whilst I would agree with Michael that urine dipsticks are useful, I would exercise caution with regards to making dosage adjustments on the basis of these alone; whilst it is ideal to have no glucose at all in the urine, many diabetics who are reasonably well controlled will have some degree of glucsuria because they wont be below the renal threshold all the time.

Another important factor is to explain to the owners that diabetes is a difficult and complex disease and that things may go wrong from time to time, especially if they aren't prepared to invest much money; this is not necessarily their fault (or yours)... I find if they're prepared for some complications then they're more understanding whe they do arise. Warn them that there is good possibility ( upt o 75%) that the dog may develop cateracts at some point in the next year.

Hope this helps, I know your first diabetic can be a worry.

Chris

Re: diabetus mielitus?

jose targa — Wed, 11 May 2011 23:08:42 GMT

all right...i must change pathognomonic for characteristic ...

...maybe you must change "glomerular" for tubular diseases??

Regards

Re: diabetus mielitus?

Michael Woodhouse — Wed, 11 May 2011 22:39:51 GMT

[quote user="Rach"]It was my understanding that glucose can be present in the urine with some kidney (glomerular) diseases, despite normoglycaemia, so an increase glucose in blood as well as urine is require to make a diagnosis of DM.[/quote]

Classic example would be pulpy kidney or nephrosis in lambs. Both give you glycosuria yet neither are diabetic! Far from pathognomonic.

As far as the OP - there's enough info there for me to call the dog diabetic. Never seen the point in doing a fructosamine at this point [in a dog, stress induced hyperglycaemia in a cat so I might if glucose was equivocal].

If there's limited money you can titre insulin dose using daily urine monitoring - not as precise but cheap and does work.

Heed the spaying advice.

As an aside - had an owner with a pu/pd dog bring me a urine sample ++++ glucose. Got in in for bloods, normal glucose. Asked for repeat urine ++++. Scratch head a little. Thought hard what to do until I collected a free catch sample that had no glucose in it. Moral of the story 1; don't attach to much significance to urine samples brought in in jam jars. Moral of the story 2; if they are that bad at washing jam jars never accept a cup of coffee........

Re: diabetus mielitus?

Rach — Wed, 11 May 2011 22:19:13 GMT

[quote user="jose targa"]The presence of glucose in urinary sample it´s pathognomonic: remember this! years ago diabetes was diagnosed by its test (yes, drinking a small quantity...).[/quote]

It was my understanding that glucose can be present in the urine with some kidney (glomerular) diseases, despite normoglycaemia, so an increase glucose in blood as well as urine is require to make a diagnosis of DM.

Re: diabetus mielitus?

jose targa — Wed, 11 May 2011 21:30:06 GMT

Hi Ruta!.

Yes, i agree with you, that´s a diabetic patient. Normal levels of glucose in plasma are 70-120 mg/dl (i.e. 3,9-6,1 mmol/L). The presence of glucose in urinary sample it´s pathognomonic: remember this! years ago diabetes was diagnosed by its test (yes, drinking a small quantity...).

If the financial resources are limited, you can offer to the owner start an insuline treatment and make a glucose-curve study. You must keep the dog monitored all day.

Good job! and good luck!

Regards from Spain

Re: diabetus mielitus?

Mark Holmes — Wed, 11 May 2011 21:17:44 GMT

Can I just mention that if the bitch presented with diabetes in the 6 weeks post season they can be almost refractory to insulin. Spay asap and consider antiprogestergens. They are at risk of DKA.

Re: diabetus mielitus?

Mark Hedberg — Wed, 11 May 2011 21:14:43 GMT

Oh, and definitely weight loss - fat dogs tend to be a bit insulin resistant, and insulin injected into fat instead of subcutaneous may not absorb as well.

Re: diabetus mielitus?

Mark Hedberg — Wed, 11 May 2011 21:13:45 GMT

I would say the glucose in the urine is very diagnostic; the glucose in the blood sample is also very diagnostic. I don't see that the white cells are highly elevated - you've got a diabetic patient, so far. :)

Your next step is a glucose curve - Food, insulin, and a series of blood glucose measurements tracking your patient's blood sugar. Ideally you want to maintain blood glucose between 5-10 mmol. Which and how much insulin you use varies per patient.

Once you have the dog stabilized, spay the dog - neutered bitches have a MUCH stabler blood glucose. This will save your owner a LOT of headaches in future.

Good luck!