weird results from the "curve"

[pronouncedeyen]

Our little poodle mix (about 25 pounds) was diagnosed with diabetes Thanksgiving Day. I'm diabetic so blood testing and insulin use was already familiar to me. After 4 days of numbers all over the place the vet finally brought his numbers down by giving him Humilin R every hour for a whole day.

Since then, we've been doing an every 2 hour curve at home. He's been getting Humilin N twice a day - at breakfast and dinner. His numbers immediately start coming down after the injection but they never go back up! For example, yesterday he woke up with BG at 296. We gave him the insulin and over the course of the next 10 hours, he consistently came down every 2 hours so that he was at at 150 at dinnertime.

As instructed by the Vet, we gave him a smaller dose of Humilin N (2 units) at dinnertime - he ate his whole dinner. His numbers kept going down until at 10:00pm he was at 49! We gave him 2 teaspoons of Karo syrup - what choice did we have? So guess what - he woke up this morning at 390!

The same thing happened the night before, his numbers went so low after dinner that we gave him Karo and he woke up very high.

Any ideas? I was thinking about just not giving him the dinnertime shot and seeing what happens. Is he waking up high because of the Karo or is it just his normal cycle? Is it possible that the duration of his Humilin N could be longer than 12 hours?

Thanks everybody.

[k9diabetes]

Re: weird results from the "curve"

Well, definitely less insulin is called for.

I would say that the high morning numbers are possibly a combination of the karo syrup and rebound: http://www.caninediabetes.org/pdorg/somogyi.htm

The most important thing you can do right now is to get his blood sugar completely out of low territory so he can stabilize.

It is possible that the duration is more than 12 hours but you have seen this dose drive his blood sugar down sharply so it may simply be that it is too much or that there is a bad balance of food and insulin.

Another possibility is "honeymooning" - that once you brought the blood sugar down, that gave the pancreas a rest and it was able to once again produce some insulin (generally always a temporary condition). Our dog honeymooned for a full six months, although it was not as dramatic in terms of low blood sugar as your dog has experienced. So it's hard to say if that is involved but it is a possibility.

I agree with skipping the insulin tonight if his blood sugar is decent and seeing what that does to his blood sugar. If his blood sugar stays high tonight, I would cut the dose down to 1 unit and see if that works better.

If you wind up giving insulin, I would give 1/2 to 1 unit only and assess that level after he has been out of hypoglycemic territory for two full days.

The main thing is that you have to get away from the low blood sugar. The hormone response of rebound can play havoc with their blood sugar for a full 48 hours after a low so you have to keep his blood sugar at a good level for at least 48 hours before you can even begin to assess whether he needs insulin and how much.

Glad you're testing! It is scary to think what would have happened without it.

What diet is he on?

Natalie

[pronouncedeyen]

Re: weird results from the "curve"

Natalie,

Thanks for your advice. We did cut his insulin to one unit tonight, and gave it only after his bg went over 300, which was 2 hours after his dinner. An hour after the injection it was down 30 points. We'll keep monitoring him tonight, to make sure he doesn't get too low. I don't know how anyone does this without checking bg levels at home!
In answer to your question, he eats Wellness, a combo of wet and dry. Any suggestions on something that you think would be better for him over the long haul would be appreciated, though i would probably wait to introduce a new foods to him until after we get his glucose levels regulated.

[k9diabetes]

Re: weird results from the "curve"

Once you're sure you have gotten rid of the low blood sugar, wait a couple of days and then do a curve and post the numbers so we can see how well his Wellness food is matching up with his insulin.

Every dog is different... could be the Wellness works just fine when he's not getting too much insulin. Or the insulin could be running ahead of the food and causing a very steep drop, which might be improved with a food change.

The classic diabetic diet is low fat high fiber. And fiber does seem at least in some dogs to slow the digestion of the food, spreading it out so that it doesn't overwhelm or lag behind the insulin.

Once you have a stable curve, we can use that to see if there is a problem with the diet and how it might be resolved.

I have on extremely rare occasions seen a dog... just one that I can think of... that apparently regulated on one injection of NPH a day and certainly it's possible that it's overlapping.

It's always challenging when you're dealing with so few units. At 2 units, a half unit change is a 25% change in the dose. That's a lot.

I used to adjust my dog's 7-8 units of insulin per injection by quarter units using syringes with half unit marks. If you're not already using syringes with half-unit marks, you might consider switching to those so you can do finer adjustments more easily.

Natalie

[pronouncedeyen]

Re: weird results from the "curve"

Natalie,

All great advice - thanks. We've kept him above 100 for 3 days now but his numbers are still crazy. I don't have his log in front of me but it seems like his numbers are wild. Wednesday he woke up above 300, got 2 units at breakfast and dinner and woke up yesterday at 400. Yesterday we gave him 2 units at breakfast and dinner but was still around 400 so we gave him another 2 later. This morning he was at 300.

My diabetes is easy to control compared to him! If I eat more, my numbers go up. If I exercise or take insulin they go down. He's all over the place.

What's strange to me is that on Tuesday and Thursday he woke with very high bg and had the same amount of food, the same amount of insulin and no exercise except running to the door to bark at other dogs. Yet Tuesday his numbers kept going down all day until he was at 49 but yesterday he hovered around 400 all day.

I have a prescription for smaller syringes - I'll try that next.

Thanks,

- Ian

[k9diabetes]

Re: weird results from the "curve"

So did he get 6 units yesterday?

When you have access to his readings for the past few days, could you post all of the readings here?

I'm still concerned that the blood sugar may be dipping low and just not being caught with occasional tests. Especially yesterday when he stayed in the 400s. If he's going down close to 100 most days, a wobble could send him very low and you might not catch it. A true low could generate the kind of blood sugar you saw on Thursday.

Natalie

[CarolW]

Re: weird results from the "curve"

Natalie,

All great advice - thanks. We've kept him above 100 for 3 days now but his numbers are still crazy. I don't have his log in front of me but it seems like his numbers are wild. Wednesday he woke up above 300, got 2 units at breakfast and dinner and woke up yesterday at 400. Yesterday we gave him 2 units at breakfast and dinner but was still around 400 so we gave him another 2 later. This morning he was at 300.

My diabetes is easy to control compared to him! If I eat more, my numbers go up. If I exercise or take insulin they go down. He's all over the place.

What's strange to me is that on Tuesday and Thursday he woke with very high bg and had the same amount of food, the same amount of insulin and no exercise except running to the door to bark at other dogs. Yet Tuesday his numbers kept going down all day until he was at 49 but yesterday he hovered around 400 all day.

I have a prescription for smaller syringes - I'll try that next.

Thanks,

- Ian

Ian - don't underestimate the activity of running to the door to bark at other dogs! This is a high-excitement activity! It likely affects BG levels considerably.

Dogs in a fairly constant, or frequent, state of excitement, typically have high cortisol levels. It takes days for these to subside on their own - days without any particular excitement to set them off again.

People who study dog-behavior learn this sort of thing - or, SOME of them do; others never do learn.

So, I'd certainly keep records on how much of this run-to-door-and-bark is going on; that should help you evaluate what is going on with BG levels.

Fri, 4 Dec 2009 20:35:24 (PST)

[pronouncedeyen]

Re: weird results from the "curve"

Hi, again. These are Asa's readings for the past few days, up until about 5:30 p.m. tonight, Dec. 7. (i'm ian's wife, meredith -- i was gone over the weekend so the blood checks aren't as regular/frequent as i would have liked, but here it is: (oh, and insulin is humulin n, unless noted)

12/4

7:09 am 443.....had breakfast and 2 units
7:25 pm 233....dinner and 2 units
1:35 am 342...2 units

12/5
11:51 am 170....2 units
1:58 p.m. 118
3:30 p.m. 296
6:55 p.m. 448....2 units humulin r
2 units n
1:03 a.m. 401.....2 units n

12/6
8:52 a.m. 323...breakfast, 3 units
1:53 p.m. 142
4:01 p.m. 211
6:27 p.m. 266....dinner 3 units
10:44 248.....1 unit

12/7
6:40 a.m. 288...breakfast, 3 units
4:27 p.m. 297
5:20 p.m. 353...dinner 4 units

These are obviously less than perfect days, but if you can give me any advice it would be appreciated. it seems like i'm not giving him enough, but i have to be at work from 7:30 until until 3:30 every day -- i'm terrified of giving him too much insulin before i leave in the am. -- or before i go to sleep! ...also, i'm not sure why ian gave him the r and the n that one day (i guess just to bring that high number down quickly, and hopefully keep it down with the longer acting stuff) and i'm worried about mixing and matching insulins.
i could do a better curve this weekend -- and i do have a couple from the first days he came home from the vet, if you want to see those, too.

thanks!
meredith (asa's mom)

[CarolW]

Re: weird results from the "curve"

Hi, again. These are Asa's readings for the past few days, up until about 5:30 p.m. tonight, Dec. 7. (i'm ian's wife, meredith -- i was gone over the weekend so the blood checks aren't as regular/frequent as i would have liked, but here it is: (oh, and insulin is humulin n, unless noted)

12/4

7:09 am 443.....had breakfast and 2 units
7:25 pm 233....dinner and 2 units
1:35 am 342...2 units

12/5
11:51 am 170....2 units
1:58 p.m. 118
3:30 p.m. 296
6:55 p.m. 448....2 units humulin r
2 units n
1:03 a.m. 401.....2 units n

12/6
8:52 a.m. 323...breakfast, 3 units
1:53 p.m. 142
4:01 p.m. 211
6:27 p.m. 266....dinner 3 units
10:44 248.....1 unit

12/7
6:40 a.m. 288...breakfast, 3 units
4:27 p.m. 297
5:20 p.m. 353...dinner 4 units

These are obviously less than perfect days, but if you can give me any advice it would be appreciated. it seems like i'm not giving him enough, but i have to be at work from 7:30 until until 3:30 every day -- i'm terrified of giving him too much insulin before i leave in the am. -- or before i go to sleep! ...also, i'm not sure why ian gave him the r and the n that one day (i guess just to bring that high number down quickly, and hopefully keep it down with the longer acting stuff) and i'm worried about mixing and matching insulins.
i could do a better curve this weekend -- and i do have a couple from the first days he came home from the vet, if you want to see those, too.

thanks!
meredith (asa's mom)

Hi Meredith and Ian,

Yes; please post any curves you have from the vet.

Acknowledging that you have to be at work between 7:30 a.m. and 3:30 p.m. - this means you can't be doing readings during that time. So I guess we wait till the weekend (as you suggest) for a full BG curve.

I do have a comment. I would be TERRIFIED to be using Humulin-R on my Kumbi. Also, is that a double-dose - Humulin-R AND Humulin-N, on this entry:

12/5

11:51 am 170....2 units
1:58 p.m. 118
3:30 p.m. 296
6:55 p.m. 448....2 units humulin r
2 units n
1:03 a.m. 401.....2 units n

I'm talking about the 6:55 p.m. entry.

Then, I notice your next reading is about six hours later. It's quite high; not quite as high as the 6:55 p.m. reading. But who knows what happened to Asa's BGs in the interim? Any possibility they dropped sharply and then shot back up? I'd think there would be that possibility.

If you haven't already read this article; let me suggest you read it:

http://www.k9diabetes.com/insulinfood.html

Also, I have a friend, elsewhere, who used Humulin-R, and found (with regular testing) that its duration in the body seemed to be irregular. She changed to using Humalog, and remarked that that insulin was more predictable.

On the other hand, at this stage with Asa, I don't think I'd be using any type of fast-acting insulin, unless my vet were a specialist and I were doing it in close consultation with the vet.

If it were me, I would be leaning on Natalie's suggestions, and keeping in close touch with your vet as well.

Dogs aren't quite like humans, in this sense: human diabetics know how they feel, and perhaps it makes some sense for them to adjust their own insulin doses, throughout a 24-hour period. I understand that the reason for feeding dogs (typical protocol) twice a day, and injecting insulin, usually, a short time afterwards) is that dogs cannot tell us how they feel, and our ability to estimate something like BG levels is very limited (without constant testing).

I note that Asa's diagnosis was on Thanksgiving Day (U.S. - I'm in Canada) - that's quite recent. I think you can expect it to take some time to achieve something approaching regulation. Natalie mentioned, also, the possibility of honeymooning - that is, that the pancreas might begin to produce some insulin again. That, too, would affect the insulin dose.

The only additional remark I can make that might make some sense would be that I would aim for eventual consistency in feeding and in insulin timing and dose, and, as Natalie said, Asa could be rebounding (Somogyi rebound). So my own first attempt, if I were in your position, would be to stabilize Asa's BGs at a high enough level to prevent rebound from occurring, if possible.

I'll be here watching, and cheering you on.

Mon, 7 Dec 2009 17:39:44 (PST)

[pronouncedeyen]

Re: weird results from the "curve"

carol,

thank you SO much for your post. i haven't read that article but will in the morning -- i appreciate all of your advice, and will definitely warn ian about the humulin r. i'll also put another call into my vet -- she has yet to see the most recent curves, though i have to say i'm less than thrilled with her office thus far. they seem to know far less than the regulars on this site!

asa's blood glucose went down to 65 tonight, about 2 hours after dinner and insulin. i gave him a little snack -- now at about 11 p.m. he's back up to 211. i'm sure he'll be close to 400 if not higher in the am -- why is this insulin peaking so quickly? i know that everyone says it takes some time to get adjusted, but i just can't make sense of his readings from one day to the next, and i'm so afraid of his losing his vision while i try and figure this out. the vet said he's already suffered some renal damage just from the week or so he went undiagnosed!

i will do a 12 hour curve on saturday and sunday, and post those results at the end of the weekend.

thanks again,
meredith

[k9diabetes]

Re: weird results from the "curve"

I will get back to your readings in a second but I wanted to say that the person who was using Humulin R and having problems was trying to use it in a way that wasn't working for her dog or how she wanted it to work.

Chris used only R insulin for his last three years and did beautifully on it.

There is a school of thought that doesn't like the older insulins because they feel they aren't as predictable as the newer analog insulins. It wasn't my experience through three years of daily use, but even if it's true, a LOT depends on what you are using Regular insulin for. And whether your dog's body processes it in the way you want it processed for it to solve the problem you are trying to solve. Sometimes it just isn't going to do what you are trying to do and that's not the fault of the insulin.

True it must be used carefully but Chris got no other insulin but R. I was very surprised when the vet told me this could be done as there seemed to be so much fear around using it. But the vet mainly doesn't often suggest it because not many people are willing to give three to four injections a day. Not because it doesn't work.

In Chris' case, it wasn't metabolized much faster than NPH and aside from giving it more often than we did NPH, there wasn't much noticeable difference.

Before anyone rushes out to start using R...

I would call it an advanced technique and you definitely would have to be home testing and monitoring a lot in the beginning and working with the vet. Not to mention solving a specific problem with it.

It's not often needed to be used for anything but lopping off high post-meal spikes.

Vetsulin has 30% faster acting insulin in it already. Not quite as fast as R maybe but still faster acting.

Still, the profile from NPH is often nice and flat and no faster acting insulin is needed.

Natalie

[k9diabetes]

Re: weird results from the "curve"

Dec 01
AM BG 296
3 units
next 10 hours BG dropped
150 at dinnertime
2 units
BG dropped
10pm BG 49 gave karo
Next am BG 390

Same thing previous night
Shots at about 7am, 7pm

December 4

Breakfast 443, 2 units
Dinner 233, 2 units
1:35am BG 342... 2 more units.

Is this correct, that he got 2 more units at 1:35 am?

December 5

Apparently no breakfast in the am
11:51 am 170....2 units
1:58 p.m. 118
3:30 p.m. 296
6:55 p.m. 448....2 units humulin r 2 units n
1:03 a.m. 401.....2 units n

December 6

8:52 a.m. 323...breakfast, 3 units
1:53 p.m. 142
4:01 p.m. 211
6:27 p.m. 266....dinner 3 units
10:44 248.....1 unit

Today

6:40 a.m. 288...breakfast, 3 units
4:27 p.m. 297
5:20 p.m. 353...dinner 4 units

I have to confess this is very confusing. Insulin is not being given on any kind of predictable schedule or predictable amount, which makes it impossible to know what is and isn't going on with the NPH. Tossing in R at times is making it even more difficult to analyze the situation.

Perhaps his curves from the vet already tell the story but here's what I would do...

First and foremost, settle on a dose of NPH and give the same amount at each meal every 12 hours like clockwork, even if that tight a schedule may not be able to be maintained long term.

Given the low blood sugar he has experienced on 3 units, I think it will have to be 2 units of insulin until enough time has passed to really evaluate how he's doing on that - three to four days preferably. 2.5 units absolutely at most.

Not 3 units because he has already experienced significantly low blood sugar on 3 units. We already know that at least at times that is too much insulin.

Next... Stop trying to correct his blood sugar with R.

R has to be used methodically after you know when his blood sugar on NPH is highest and lowest over some time where you are working with trends instead of chasing individual numbers so that you know there actually is a problem and that R is the right way to solve it. We don't know that at this point.

That means you can't panic when you see blood sugar in the 300s or 400s and rush to fix it. The only way we can know what is working and what isn't and what is likely to fix what isn't working is to watch for a few days without intervening. The R introduces all kinds of variables, overlap... it is just muddying the picture.

Of course, if his blood sugar goes low on 2 units, you need to treat that with syrup and reduce his insulin. But ignore higher numbers for now.

This weekend, after four full days of a regular schedule of NPH, same amount every day at the same times of day and no injection outside those normal ones...

Do a curve and post the results.

There are a lot of possibilities. The curve after a stable regimen will tell us what we need to know.

I can't emphasize strongly enough how important sticking to basics is from now until the curve. I know how hard it is to see higher blood sugar but for a few days we need that higher blood sugar to give us a picture of what's actually happening.

Natalie

[CarolW]

Re: weird results from the "curve"

carol,

thank you SO much for your post. i haven't read that article but will in the morning -- i appreciate all of your advice, and will definitely warn ian about the humulin r. i'll also put another call into my vet -- she has yet to see the most recent curves, though i have to say i'm less than thrilled with her office thus far. they seem to know far less than the regulars on this site!

asa's blood glucose went down to 65 tonight, about 2 hours after dinner and insulin. i gave him a little snack -- now at about 11 p.m. he's back up to 211. i'm sure he'll be close to 400 if not higher in the am -- why is this insulin peaking so quickly? i know that everyone says it takes some time to get adjusted, but i just can't make sense of his readings from one day to the next, and i'm so afraid of his losing his vision while i try and figure this out. the vet said he's already suffered some renal damage just from the week or so he went undiagnosed!

i will do a 12 hour curve on saturday and sunday, and post those results at the end of the weekend.

thanks again,
meredith

Meredith and Ian,

I'm glad if my note to you helped. There's another article you will also want to read; it's here:

http://www.k9diabetes.com/regulated.html

If you read that, and the insulin-and-food article I mentioned earlier, you should gain a kind of basic comprehension that will help you make necessary decisions.

Through all this, it's good to be in contact with your vet, always assuming your vet is quite knowledgeable about diabetes - not all vets are.

I just saw Natalie's note that Chris was on the Humulin-R - I believe, no other insulin - and, as Natalie said, they could manage that because they were home with Chris, and could test, any time. My friend was using two insulins, same as you - NPH of some kind (Humulin-N or Novolin-N; I don't know which offhand) and added the R, same as you did, but then later, changed the R to Humalog (I believe - or it might have been Novolog - same idea).

The issue here is one of possible overlaps, so that two insulins are working, maybe peaking - at once. That certainly could cause swings in BG levels - even sharp ones.

In general, I would follow Natalie's suggestions, as she is an excellent teacher, and has long experience assisting people with diabetic dogs.

All along, too, I'd be in touch with your vet - if not instantly, within a reasonable time.

Wht you need is a plan for Asa for the rest of the week, to begin with, till you can do a curve on the weekend. And, as Natalie suggested, I would aim at AVOIDING any possible hypoglycemic episodes. I don't know what effect, specifically, ceasing to give the R-insulin will have, except perhaps to reduce the instances of sharp drops in BG levels.

I believe that for a few days, Asa's body will be adjusting, whatever change you make with the insulin, so you won't have a clear picture for a couple of days. In this situation, I wouldn't freak out at an occasional reading in the 400s; if you get a higher one, I'd phone your vet.

It's quite possible that high-ish morning (fasting) readings result from the fact that the dog has been sleeping through most of the night; there's also something called something like "dawn syndrome," which sometimes produces higher readings at morning fasting.

I think if you can steady the insulin dose, skipping the R insulin, and using only the NPH (Humulin-N), and take BG readings when you CAN, and go that way for a few days, you may begin to get better stability in the BG curve. A few days running high could happen - but I think you need stability in the food and in the insulin dose, in order to assess where to go from here.

As time goes on, maybe Asa will turn out like Chris - perhaps doing well on R-insulin only - but that's a fairly rare occurrence. Many dogs on NPH insulins (Humulin-N or Novolin-N) achieve quite decent regulation without ever using an R insulin.

Of course, choice of food makes a difference too. I couldn't myself make a recommendation about food, but only confirm what Natalie said, that a classic diet for a diabetic dog would have restricted fat, be high in fiber, and, of course, meet known standards for being "complete and balanced."

The fiber part of the diet seems to help slow digestion somewhat, which gives the insulin a chance to "catch up" with the food as it's being digested; anyway, that's how I understand it.

Mon, 7 Dec 2009 20:53:06 (PST)

[pronouncedeyen]

Re: weird results from the "curve"

ok, here are the results from asa's curve this past weekend (sat. and sun. 12/12 and 12/13)

12/12/09

7:14 am 290 breakfast and 4 units humulin n

9:16 am 274

11:14 am 156

1:24 pm 176

3:18 pm 321

5:15 pm 405

6:53 pm 374 dinner and 4 units

12/13

7:25 am 344 breakfast and 4 units

10:00 am 325

11:50 am 258

2:18 pm 325

4:15 pm 254

6:11 pm 329 5 units and dinner

9:52 89 (I only did this check to make sure I could go to bed without him crashing, since 5 units was the most i've given him, but 4 didn't seem to be doing much if he ate with bg in the 300s. I gave him a milk-bone type snack since his bg was so low, and he was 374 this morning (Monday, 12/14). So the insulin is peaking at about 4 hours? isn't that kind of short? also, just fyi, on saturday he spent a lot of time outside -- not really exercising, but awake and sniffing around etc. while i raked --- certainly more activity than he gets during the week when i'm at work and he sleeps. sunday was rainy, so he was in mostly.

on the bright side, I gave him 5 units this morning and when i got home tonight he was at 232 -- the lowest dinner time reading all week. (though i don't know what happened all day). He had just 4 units tonight, and i won't be able to do another 12 hour curve till next monday. let me know what you think, and thanks!

meredith

[peggy0]

Re: weird results from the "curve"

My advise would be to raise it only 1/2 unit at a time and let it sit for at least 4 days. 1 unit is a pretty big jump.