Starting diabetes treatment

Re: Starting diabetes treatement

emerald — Mon, 12 Dec 2011 22:06:11 GMT

Isn't a glucose curve needed to know the rough nadir?

Re: Starting diabetes treatement

Braden Collins — Tue, 06 Dec 2011 07:27:56 GMT

The other thing I find helps owners with insulin injections initially is to clip patches of hair at the injection sites. This helps their confidence with injectino as they know they are injection in the correct location and they can see the needle is in. By the time the hair grows back they are confident enough to inject through the fur.

Re: Starting diabetes treatement

Bob Russell — Mon, 05 Dec 2011 12:33:11 GMT

The post was 'starting diabetes treatment'. I warn owners that cats can go into remission and may not need injections for life. For most owners tightly monitoring glucose levels can be very daunting but once they (and the cat) are settled on a regimen we will discuss how we continue to monitor.

Some refuse to do much more than fructosamine, observation of drinking and cat. I suspect many of these have relatively high glucose levels so not ideal. We work with the owners rather than dictate. Touch wood our diabetic cats are doing well at the moment!

The chip would be wonderful if it could be properly and permanently implanted. The one I have seen stays in for about a week and costs about £400!

Re: Starting diabetes treatement

katie mountford — Sat, 03 Dec 2011 15:49:12 GMT

[quote user="David Mills"]

Martin: complete overkill with glucose curves every month.

It is, I believe, only ever useful when a truly unstable diabetic is presented, and even then I find a good reason not to. The effects of hospitalisation and the high, high (unacceptable in my view) variability makes it an exercise in being seen to be doing something.

Why not use urinalysis at home combined with fructosamine? Far more likely to give you an accurate answer

[/quote]

This approach has a risk of missing those cases that you get such good control of that they can go into diabetic remssion. I do out of hours work and I had seen at least 3 cases in the last year of cats that have been hypoglycaemic (2 of which presented post seizure and 1 was comatose) because, according to the owners, they were monitored on fructosamine +-urinalysis and not had glucose curves done. Those cases appear very well controlled ie stable weight, drinking/urinating normally because their glucose has been trending downwards until they develop into a hypoglycaemic crisis. In cats in particular the early signs of a hypo can be very subtle and easy for owners to miss, leading to the life-threatening complication (although these are nice cases if we get them in time as they have a 'miraculous' recovery following glucose administration if given in time). As Martin says-if we are aiming for diabetic remission then closer monitoring is indicated. Glucose curves are not ideal but probably the best we have and good owners are often happy to do it at home (and it can keep their costs down too). Has anyone had any experience of the glucometer 'chip' that could be implanted sc? I read about it a while ago but not heard much about it since

Re: Starting diabetes treatement

Martin Atkinson — Sat, 03 Dec 2011 11:42:42 GMT

[quote user="Bob Russell"]

The closer the monitoring the longer the cat should live!

[/quote]

I gave you 5 stars for that line alone Bob.

Re: Starting diabetes treatement

Bob Russell — Fri, 02 Dec 2011 17:55:34 GMT

We start insulin at the lowest data sheet dose, once a day to get the owners used to the idea of dealing with a diabetic cat. We do glucometer tests daily for the first few days.

Owners are given set tasks each day. Starting with handling syringes, loading them and injecting (into oranges!). The owner goes home with syringes, sharps containers and a bottle of water for injection. They can practice as long as the want until they are happy. Day 2 is usually for questions and a step by step guide to injecting. Day 3 they have a go themselves. This is when I will adjust the dose unless there have been problems.

Owners are in charge and we help as long as they need. Within a few days the owners generally take over and I split the dose in two.

First glucose curve if all is going Ok is after about 10 days to give me an idea of how the insulin is behaving.

This seems to be pretty well in line with the data sheets and works well for us. I warn owners that it is costly to start with but then gets a lot less! We don't recommend reusing but I would not lose sleep if owners decided to do so.

How close the cat is monitored is up to the owner. The closer the monitoring the longer the cat should live!

Re: Starting diabetes treatement

David Mills — Fri, 02 Dec 2011 17:28:01 GMT

[quote user="Hannah Wynne Richards"]

David I would give more weight to your comments on the variability of curves if you hadn't previously suggested re using syringes (unhygienic ) and using bottles for more than 28 days (illegal ) As it is I tend to dismiss your views as "any excuse to avoid charging -regardless of the welfare of the patient "

Wynne

[/quote]

Ms Richards:

1. I suggest you read a little more about the science behind glucose curves, as others have pointed towards. I'll even give you my science direct log in if you like to help you with this.

2. Have you any figures regarding whether reusing syringes is this woolly 'unhygienic' - certainly at our hospital we have never seen an injection site reaction/abscess/infection for, I dunno, 5 years, of using at most one syringe a day.

3. Insulin - what can I say, people think it's expensive. It is. If they don't come back for a repeat for 3 months, what is there to do?

4. 'Welfare's a funny thing isn't it - an easy word to throw around carelessly without really thinking about how you are using it. How, in this instance, would an animal's welfare - lets say a cat with straightforward DM - be affected by any measure I recommended? I'll start: syringes - no; insulin - fructosamine says no; not doing glucose curves - no. Fascinated to hear your version.

Re: Starting diabetes treatement

Siobhan Westbrook — Fri, 02 Dec 2011 11:28:57 GMT

I think there needs to be a division between best practice for dogs and best practice for cats; I agree that a glucose curve on a cat is less likely to be useful than on a dog, whether performed soon after diagnosis or later on. Cats have a far greater variablitiy day to day than dogs do, due partly to the reserves of pancreatic function (also stress-related hyperglycaemia as already mentioned). Fructosamine is now thought to assess approximately 1-2 weeks, and combined with thorough owner records (appetite, thirst and energy levels) and weight records, this can provide a really good idea of how stable they are. One-off blood glucose measurements or urinalysis in cats are almost totally useless (dipstick useful for ketones only really!), whereas urinalysis in dogs can be very helpful. I'd be much keener to monitor cats in this way, whereas I'd go more with Martin's regime in a dog. Agree with starting lowish in either case (0.5-1iu/kg BID in cats anyway) while the owner gets accustomed to injecting their pet. I also usually tell owners at the beginning that while most diabetics are relatively easy to stabilise, the odd one is a nightmare that takes ages to get right!

Re: Starting diabetes treatement

Hannah Wynne Richards — Fri, 02 Dec 2011 10:54:35 GMT

Amazing how reassuring a chat with another owner who's done it can be. Much better than us professionals

Wynne

Re: Starting diabetes treatement

plantagenet — Fri, 02 Dec 2011 10:17:43 GMT

I am always pleasantly surprised by how well owners take to injecting and doing curves at home. I much prefer this, especially for cats which sulk and don't eat when they are here. We get our experienced 'diababetic owners' to chat to the newly diagnosed and give them confidence. I alter the number of points on the curve depending on how happy I am with the animal clinically.

Re: Starting diabetes treatement

Hannah Wynne Richards — Fri, 02 Dec 2011 09:48:18 GMT

Wynne

Re: Starting diabetes treatement

Martin Atkinson — Fri, 02 Dec 2011 08:51:12 GMT

[quote user="David Mills"]

Martin: complete overkill with glucose curves every month.

Why not use urinalysis at home combined with fructosamine? Far more likely to give you an accurate answer

[/quote]

On this we must agree to differ. Maybe monthly glucose curves are over-kill but I re-iterate: most endocrinologists believe curves are the only reliable way of accurately determining correct insulin dosage, urine and fructosamine are unreliable as they too easily hide a Somogyi effect and should only be used as a guide. If you believe your curves are compromised by stress why not train your clients to perform them at home, they can get a curve on the graveyard shift as well which is often different than the daytime one.

Re: Starting diabetes treatement

David Mills — Fri, 02 Dec 2011 01:42:43 GMT

Martin: complete overkill with glucose curves every month.

Why not use urinalysis at home combined with fructosamine? Far more likely to give you an accurate answer

Re: Starting diabetes treatement

Martin Atkinson — Thu, 01 Dec 2011 19:32:51 GMT

[quote user="Simon Neuhoff"]

Martin the concusion from the study was that glucose curves vary every day and in every patient. What you see today is almost certainly not going to be the case tomorrow. The animals had been hospitalised for four days and continued to show variability - they weren't more responsive as a result of less stress and acclimitisation. So I believe you need to be cautious in reacting to the results of a glucose curve and I consider these in light of the other factors you can monitor.

From my point of view an animal that is eating normally, drinking normally, has a stable weight and a fructosamine that is in the rigth zone and similar to previous levels is a stable animal. i don't believe that a glucose curve will add any significant information.

[/quote]

Well we're damned if we do and damned if we don't aren't we? Despite it's stated limitations, the insulin response curve is still the most useful tool we have until we can attach 24 hr monitors to all our patients for a week at a time.

Re: Starting diabetes treatement

Simon Neuhoff — Thu, 01 Dec 2011 16:07:54 GMT

[quote user="Martin Atkinson"]

[quote user="Simon Neuhoff"]

Personally I NEVER do glucose curves in stable patients.

[/quote]

How do know they're stable if you don't monitor them carefully? A lot of the feedback from clients is subjective and you cannot rely on single glucose tests, urine tests or fructosamine levels as these can all hide a somogyi effect. Glucose curves may not be ideal for every case and they are subject to stress but there is no doubt in my mind that those patients that come for regular curves (or have owners that can be relied on to perform them at home) are more stable and live longer than those that are assumed to be stable because they've not had any hypoglycaemic or DKA episodes. Also, the more you do them the more you can rely on them as the patients get used to coming in regularly, several of ours' (dogs and cats) are allowed to wonder round the (secure part) of the surgery and act like the surgery pets. Not one of my diabetic patients is completely stable they all need periodic micro-adjusting of their doses - usually downwards because a well stabilised patient becomes less insulin dependant and while I know if you're not careful you end up chasing numbers and the most important thing is for the cat to appear normal to it's owner, we can strive for perfection.

[/quote]

Re: Starting diabetes treatement

Martin Atkinson — Thu, 01 Dec 2011 15:39:53 GMT

[quote user="Simon Neuhoff"]

Personally I NEVER do glucose curves in stable patients.

[/quote]

Re: Starting diabetes treatement

Simon Neuhoff — Thu, 01 Dec 2011 15:08:31 GMT

Personally I NEVER do glucose curves in stable patients. I have a study lurking somewhere which compared glucose curves in hospitalised patients on the same regime (ie food, injections etc) daily for four days which showed that they vary WILDLY from day to day - and these were all well controlled patients. As I see it glucose curves are only a small part of the puzzle and can be useful in trying to work out why an animal is not stable but they need to be interpreted with caution and in light of the overall picture - ie taking in to account appetite, thirst, weight, fructosamine levels.

Re: Starting diabetes treatement

Claire McConnell — Thu, 01 Dec 2011 13:46:14 GMT

[quote user="Martin Atkinson"]Once stable I will insist on a curve every month or when they buy a new bottle of insulin.[/quote]

I agree and work as the others here have suggested with the same initial doses and initial monitoring.

Just wanted to ask Mark if he actually really gets a glucose curve out of his patients monthly even when they seem very stable?

Well done if you do and although I agree that would be "best practice" , at my practice most of our diabetic owners will not usually be happy about coming in monthly for their pet to have a curve done. I think some of our long term stable diabtics only have a fructosamine done 6 monthly and can go longer without curve if fructosamine results are good and c/s in control.

What does anybody else think?

Re: Starting diabetes treatement

Kate Richardson — Wed, 30 Nov 2011 10:03:54 GMT

Yes, I start with the stated doses, and monitor blood glucose on the first day, in case of an animal being highly sensitive to insulin. Admittedly rare, but have seen it in cats especially, and I don't want to risk sending an animal home and it having a hypoglycaemic crisis in the first few days of treatment! Also, I find many owners have enough to worry about with giving the injections, so if they really don't have to worry about hypoglycaemia for the first few days, then they can concentrate on giving the injections correctly initially until they are comfortable with it.

Re: Starting diabetes treatement

Martin Atkinson — Tue, 29 Nov 2011 09:16:32 GMT

I would start dogs at 0.25-5iu/kg bid and cats 0.25iu.kg bid if glucose <20 and 0.5iu/kg if >20, Caninsulin for both. I would perform a fructosamine before I started so you can observe a trend later. Train and observe owners in injection technique, tell them to vary the injection site and check it again after a couple of weeks especially if the patient isn't stable - its amazing how many ways they can find to do it wrong! Discuss diet: high protein kitten food (Purina) for cats and somebody's diabetic control diet for dogs feed equal amounts twice daily but most importantly emphasise: same diet, same amount , same times and feed about the same time as insulin doses except grazing cats. Glucose curve after one week and every 5-7 days after a change of dose, titrate dose accordingly. It is very useful if you can get clients to do glucose curves at home especially for cats and the second 12 hours! Some will require a lower dose in the evening than the morning. Fructosamine after 3 weeks but beware high levels of fructosamine can hide a Somogyi effect, same for urine tests - don't rely on them of make dosing decisions use them only as a guide. Once stable I will insist on a curve every month or when they buy a new bottle of insulin. Use the earliest possible excuse as an opportunity to get cats on Glargine!

Re: Starting diabetes treatement

Richard Carter — Tue, 29 Nov 2011 09:08:55 GMT

Would start low dose for first week. Think the first week is more important to get the owner and patient trained and comfortable than try stabilise the patient.

Re: Starting diabetes treatement

Braden Collins — Tue, 29 Nov 2011 03:26:07 GMT

I tend to follow the package instructions for a start but would tend to do a blood glucose curve after 7 days rather than fructosamine - I could be wrong but I think fructosamine gives a picture over the previous 3 weeks so would still be influenced by the previous hyperglycaemia, and I feel that we can get a better idea of trough levels and duration of action with a blood glucose curve.

Re: Starting diabetes treatement

David Mills — Mon, 28 Nov 2011 21:16:59 GMT

0.5iu/kg cats/small dogs, 1iu/kg for larger dogs, see back in 7-10days for fructosamine and spot blood glucose and urine analysis. Obvious instructions re hypos.

Find your stated doses do little if anything.

Incidentally, fructosamine is interpreted alongside clinical outcome (PUPD, appetite, demeanour), don't chase numbers and lab's 'fair control' is usually good enough.

Also don't throw away vials after 28d or use a fresh syringe each time.