Veterinarian

[renniepooh]

Hi there,
I am just wondering if anyone near the Seattle, Washington area has a vet that they really like who seems very good at regulating their dog's diabetes?

We had a specialist for my dog, but she retired in January and we're starting over again. Plus we are switching off Vetsulin to NPH following poor regulation and several seizures, so in this transition period, I want to find another vet we really love, but one who knows what to do :)

Any suggestions out there?

Thank you,
Renee

owned by Gretchen, 12yo female mini-schnauzer, diabetic >2 years.

[Noodle]

Hi Renee

I don't live anywhere near Washington, so I'm not any help on the vet front. Just wanted to welcome you & Gretchen to the board. Sounds like Gretchen has had a rough time on the Vetsulin. If it's any consolation, many members here have had a smooth transition to NPH and are doing great. It's also less expensive, so that's a big plus as well. :)

[Patty]

Hi Renee and welcome!

I can't think of anyone in WA right now. There is a website you can use to search for specialists in the US if you haven't tried it already: http://www.acvim.org/websites/acvim/index.php?p=3

As Daisy said, we've had quite a few people switch from Vetsulin to NPH here and can offer help if you want.

Natalie listened to a web seminar last fall on changing insulins with Dr. Nelson an endocrinologist from U of California. "His recommendation for a starting dose when switching to NPH is to cut the dose "a few units" - from the examples he gave, he would reduce the dose about 20%" http://k9diabetes.com/forum/showthread.php?t=1490

It would depend on the range of blood glucose (bgs) you are currently getting how far you'd want to cut back. Sounds like Gretchen has had some lows on Vetsulin?

We'd love to know more about you and Gretchen :)
Again welcome,
Patty

[Soaphie & Sydney's Mom]

WELCOME! You have come to the right place! So much knowledge here - I'm sure someone will help you find a vet in your locale....

Good luck!

Tami & Soapher

[renniepooh]

Thank you, everyone, for welcoming us to the forum. I am glad to talk to other diabetic-dog-parents :)

I have a couple of basic questions:
1) Why don't vets have us check glucose daily, as we do in humans? I feel negligent knowing nothing all day long.
2) Why do we wait a whole week after a dose adjustment to check glucose curve?
3) Why aren't there any correction instructions (sliding scale insulins: fast acting/short duration) given to help the dog when the glucose is so high like >600? In humans we treat the highs with additional regular/aspart/lispro insulins.

We have had a couple of rough months starting in December when Gretchen suddenly lost her eyesight to cataracts.

As her pet "Mom", I feel really guilty about all this and wonder if I haven't been doing right by her :( I've always wondered why we are instructed by the vets (even the internal medicine specialist) not to check glucose daily ("spot test values don't tell you anything," they've told me and when the curve is okay I can "recheck in 6 months...") So when she bumped smack dab into her first wall (it wasn't a new wall by the way..it had always been there) we found her glucose numbers were in the 500's. We ran a curve the very next day, called the internist and ophthalmologist and got things moving. She had been on 7units Vetsulin in the am and pm for many months but after the Dec curve result the Vet increased her to 8units am/pm. Also, in the meantime, the ophthalmologist found her cataracts to be hypermature and we had them removed late December.

So there were four glucose curves we did, the one in Dec when she was on 7u BID, then one in January to check 8u BID, then the MD had us still do 8 units but give the dose 45 min before eating and repeat curve, then she reduced it to 8 units am and 6 units pm. The results of the last one on Jan 31st when she was on 8 units am and 6 units pm were as follows:

7:15am 526
8:15am 452
9:15am 274
10:15am 162
11:15am 116
12:15pm 81
1:15pm 49 (I fed 1/4 cup food because that scared me!)
2:25pm 94
3:35pm 84
4:24pm 94
6:10pm 243
7:00pm 491

So the internist said to change her dose back to 7 units in the am and 7u pm, recheck curve in 6 months and do a fructosamine test in 2-3 weeks.

So with that, I was sooo nervous about the 49, instead I started dosing at 6units q12 hours. I probably should have rechecked her curve after a week, because that seems logical, but since the vet told me we were good for another 6 months I trusted that. Anyway, what happened next was that on Monday, March 8th in the morning she didn't seem normal, just in that she couldn't find her food bowl so we thought there was something wrong with her eyes again.

We called the ophthalmologist for next-day appt, and later that morning and afternoon found that she was walking a little bit in a circle. We then thought maybe this isn't a vision problem.... After work, she was still walking a little bit in circles, so we took her to the ER vet. They kept her overnight, did fluids, xray, and found her right sided reflexes lacking. Referred her to a neurologist who was too busy to see her until Thursday. So we watched her all day, I begged for an earlier appt with the neurologist, got one for Wed, she ate but drank little, still circled to the left, and then Tuesday night had her first seizure (that we know of) just after she had her dinner meal. It was about an hour after her supper so I don't think this one was hypoglycemia, but we rubbed Karo on the gums anyway. The BG was 181 when we got to the ER.

They kept her 2 days. She had 2 more seizures (one right after her morning food and insulin, the other 5 hours later), she was started on anticonvulsants and prednisone. We opted not to do an MRI for her because we were afraid of the risk of anesthesia if her intracranial pressure was increased. After she came home and a few days passed, she started to improve. Finding her way around, walking more in a straight line. Barking again. :) Interacting with the other dogs. Then last weekend she had another seizure just 50 minutes after her food/insulin. (this one was less severe.)

I accidentally stumbled across the information about Vetsulin's product alert 2 days ago (which was put out in November), and was worried that my dog might be affected since her glucose hasn't been well controlled lately and has now been having seizures. I contacted the manufacturer of Vetsulin and they said she should be transitioned off it as soon as possible. Their vet looked over her medical records and feels her insulin dose was too high. She did say they consider all lots affected by the product alert, but never said that the affected product contributed to my dogs incident. I am not surprised by that but I guess we can not know for sure.

So here we are, Gretchen is converting over to the NPH, starting at the most conservative dose since it is suspected her previous dose Vetsulin was too high. Her weight is 9 kg, so 9 x 0.25units/kg=2.25 units, the vet said to round down to 2 units twice daily. We just started this today with the morning dose. Since I am home, I've checked her glucose but they are all still very high. I'll do a real curve in about a week.

In the meantime, she's off the prednisone finally so I hope that will calm some of the really high bg readings. She's gone 4 days without a seizure, and we have a follow up appointment with the neurologist next week. She's circling somewhat, but still much improved, although she lost her eyesight in the right eye March 9th and it's not returned (yet : maybe it will?!).

Now that she's better, do you think we would benefit from an MRI? The neurologist said it may reveal a stroke had happened but they can't do anything about it, or it may reveal a brain tumor (and I don't think treatment options are good or that we will do treatment for that).

Any other thoughts?

When we came home from the neurologist's with her anti-seizure med, I looked it up on the internet and found dosing information for dogs. The recommended dose in dogs is 10mg/kg twice daily x her weight of 9 kg, should be about 90 mg. He sent Gretchen home on a 200mg dose twice daily. We called back up to their office, staff called the neurologist at home, and called us back to say they were sorry for the error but the dose had been miscalculated and she should only be on 100mg twice daily. She had already had 3 doses of the 200mg. (She was so sleepy those first two days, by the way, and I'm guessing it could have been from the double dose of anticonvulsant medication.) I guess I just start to worry about everything and fear that I have to be so informed to prevent and help my pet.

I guess I have a trust issue?

Well maybe some of you can help me be a better informed diabetic-dog-Mom. I have to be her advocate because she can't say anything for herself! And believe me, she is one of the sweetest little dogs I want to do right by her :)

Thank you, for listening, at the very least!

Renee and Gretchen:)

[AlisonandMia]

Just a few quick questions (I've just got to go out):

What dose of prednisone was she on and how long since that finished? Was it tapered down (gradually reducing dose) or not?

What anticonvulsant is she on?

Was her BG checked when she had the seizures (as close in time as possible to the seizure)? Low BG can trigger seizures and confused behavior - and this is probably more likely if the BG has dropped very rapidly.

Alison

[renniepooh]

Hi Alison,

Those are good questions.

Her prednisone was 10mg BID on day 1, then 5mg BID for 3 days, then because of the high BG's, we were told to cut the dose in half, so 2.5mg BID x 3 days, then 2.5mg daily x 2 days, then 2.5 qod, and now off.

Her anticonvulsant is zonisamide (Zonegran).

The BG following the first seizure was checked as soon as we arrived at the ER vet (took about 25 minutes to drive there) and we had already rubbed the Karo syrup on her gums before we left the house. BG was 181. About an hour later it was 167.

Second seizure happed at the vet hospital. They checked her BG, reading was "HI" at 6am, seizure occurred around 7:30am just after the food/insulin administered.

Third seizure happened at vet hospital, too at 12noon the same day. No BG recorded.

The fourth seizure happened 10 days later at home. We administered rectal valium and checked her BG which was "HI". On my meter, "HI" is >600. This happened about 50 minutes after her evening meal/insulin.

Thanks for asking, and let me know what you think of this.

Renee

[AlisonandMia]

Does sound like the seizures probably aren't BG related (though some could have been I guess).

The drug she is on is, from what I can see, pretty new in dogs, not very often used and often used as second-line therapy often as an add-on when other meds are not fully effective. Did the treating vet tell you why he/she chose that particular med?

Here's a link to a good canine epilepsy site: http://www.canine-epilepsy-guardian-angels.com/

and zonisamide is mentioned at the bottom of this page: http://www.canine-epilepsy-guardian-angels.com/OtherMeds.htm

Alison

PS: When was his last dose of pred?

[renniepooh]

Thank you for the links. Yes, the zonisamide was a surprise to us. In the consultation, the neurologist told us he was going to put Gretchen on phenobarbital, starting with a loading dose. I only found out later that day from the technician that he put her on zonisamide instead, so it was not explained to me why he switched. I have an appt with him on April 1 and I will ask that question.

Her last dose of pred was 3/23.

One more thing, on her blood workup, her triglycerides were 1863. I know this is really high, and I was trying to find information on k9diabetes on the treatments and risks of this. I asked the internist about how we can lower the TG and she said medications don't work in miniature schnauzers. I wonder how her high TG plays into all this...

Renee (with a snoring Gretchen at my feet...)

[AlisonandMia]

Maybe you should ask a bit earlier. Do you think it is possible that it was a mistake of some sort, and could that be related to the dosing mix up, I wonder??

I believe high blood lipids can make BG control difficult. There are a lot of mini-shcnauzers on this list so no doubt you will hear from their people soon.

Alison

[k9diabetes]

Hi Renee,

Gosh, you all have really been through a ringer lately!

I am not a vet of course but the various behaviors you describe regarding the seizures and especially the circling sounds more like a seizure or vestibular or other type of brain problem unrelated to her blood sugar.

I am really glad that you are transitioning over to NPH, not only because of the Vetsulin supply problem (it's not clear to us yet whether there is actually any problem with the function of the insulin and it's really the lack of supply that's making it critical to go to another insulin) but because Gretchen has such a long deep drop in her blood sugar on Vetsulin.

That January 31 curve goes from over 500 down to 49 in 6 hours - that is far from optimal. Our dog did something like that and our solution was to change insulins - www.k9diabetes.com/k9diabetes.pdf (http://www.k9diabetes.com/k9diabetes.pdf).

It's possible that her blood sugar will be more level on NPH, allowing you to better regulate her. That would be a good thing.

I will write you more separately on your questions as my answers will be somewhat long! :)

The switch to NPH is a great opportunity to change how you've been monitoring her diabetes and possibly to get better regulation so this could be a good thing.

Natalie

[k9diabetes]

You ask some great questions about diabetes in dogs...

1) Why don't vets have us check glucose daily, as we do in humans? I feel negligent knowing nothing all day long.


You can check your dog's blood sugar as often as you want to and she happily tolerates it. Some dogs tolerate it better than others.

Generally, diabetic dogs get a simplified version of what human diabetics do. In part because we can feed them the same amount/content of food every day so there isn't as much variability as people experience.

Partly because a lot of people wouldn't be willing to do for a pet's diabetes what they would do for their own. Some people (fortunately not many) won't even give insulin, let alone home test. And there is a learning curve that human diabetics go through to do that so owners of diabetic dogs must educate themselves first.

Partly because dogs generally tolerate diabetes pretty well and can thrive without perfect regulation.

So there's no reason you can't test more than the vet wants you to.

I would just say that you want to make sure you're getting useful information from your tests, not checking just to check it. It is possible to get too obsessed with numbers and wind up treating a dog like a pin cushion. And create more worry, not less, in the process.

Here we have the full spectrum - members who don't test their dogs' blood sugar to members who test it every day and everything in between. A lot depends on your dog's particular food/insulin balance and amount of blood sugar variability. Some dogs settle into a routine and don't require much testing. Other dogs are what I call "wobblers" and they benefit from testing daily to compensate for those wobbles.

Chris got four injections a day and we tested a minimum of three times a day and I did vary his insulin dose periodically in response to tests. We were using Regular faster acting insulin and the variations in dose were small - usually 1/4 to 1/2 a unit with his dose range rarely going beyond 7-8 units per injection.

That wasn't the vet's recommendation but it was what worked best for us with Chris' particular style of diabetes.

If you take Gretchen's curve, a premeal test every day really wouldn't tell you very much about her blood sugar later so might not be very useful. But more frequent curves and then changes to better regulate her would be very helpful.

Some dogs have curves shaped like mountains so the premeal reading is the lowest and they don't have to worry about lower blood sugar between meals.

In Gretchen's case, I'm not too worried about going with the extremely conservative starting dose but I wouldn't want her to stay with that for very long if it clearly isn't nearly enough insulin. With small doses, you do have to raise it in small increments.

In every case we have seen so far, the NPH dose wound up being very similar to the prior Vetsulin dose.

Oh and Gretchen is the perfect example of a dog for whom a fructosamine test is going to be a waste of time and money. Since the fructosamine test is an average of the blood sugar for the past two to three weeks, given her curve on January 8, she would probably come in on the fruc test looking like she has decent blood sugar of about 250 when in fact she is swinging through very large highs and lows that average to a decent number. So a fructosamine wouldn't really tell you anything at all about how well regulated she is or whether her dose is good. I'd pass on the fructosamine test altogether - it doesn't give you half as much information as home testing and curves and is, thankfully, falling out of favor for dogs.

Natalie

[k9diabetes]

2) Why do we wait a whole week after a dose adjustment to check glucose curve?

Especially when first starting to regulate a diabetic dog, it can take time for the full effect of a dose adjustment to show up. Also, early on (or later if regulation isn't good), having had high blood sugar can create some temporary intolerance to insulin and it takes time to "break" that insulin resistance. That makes it easy to overshoot the right dose.

Later on, when you're at a good dose that needs a minor tweak, I think the one-week wait is less important for SOME dogs. There are dogs who always need time to settle into a long-term response and there are some who seem to respond right away.

But as a general rule, I'm in favor of giving dosage changes at least 3-5 days to settle in before evaluating them for any sizable dose change.

3) Why aren't there any correction instructions (sliding scale insulins: fast acting/short duration) given to help the dog when the glucose is so high like >600? In humans we treat the highs with additional regular/aspart/lispro insulins.

Some people do make adjustments with faster acting insulin. However, it's an advanced technique that people must learn to do as diabetics themselves and you would have to learn to do for your dog. And there has to be a problem you are trying to solve for which faster acting insulin is the solution.

Gretchen is the perfect example of how dangerous that technique can be if used improperly. Let's say you did that premeal test from your last curve, saw the blood sugar was 526, and decided to add some faster acting insulin.

Without having done multiple curves over time, you wouldn't know that her blood sugar was going to drop all the way down to 49 from that starting point of 526. Giving extra faster acting insulin to Gretchen given the curve you posted would be a disaster - it would likely plunge her blood sugar very very low with potentially fatal conseqences.

Dogs, as Gretchen demonstrates with her curve, do not necessarily get a rise in blood sugar from eating. Their bodies process intermediate insulins differently than people's bodies do. A single intermediate insulin actually works really well for a lot of dogs and some can't tolerate the rapid action of Regular or Humalog.

So if my dog suddenly has blood sugar in the 500s or 600s when he's normally well regulated, it's important to ask why it's suddenly so high and look at solving whatever problems are causing it so I can get him back to a regulated state.

Natalie

[Patty]

Renee,
What type of food is Gretchen eating?

I think getting her triglycerides lower will be on the list of important things to address to lower her risk for stroke/further strokes if that's what's happening and to help control her blood sugar as well. High triglycerides seem to be more common in mini schnauzers and several people here have struggled with this issue as well.

Patty

[pgcor]

Well, I don't post here often because frankly - not much to offer. But, I wanted to say that Natalie's last two posts are so critical to understanding diabetes that I posted them to my office wall!

Lots of good information that I keep forgetting....THANK YOU NATALIE!!!

and God bless all struggling with this illness.

Pam

[k9diabetes]

NOTE:

Above I said we were using Regular insulin. Just to clarify, Chris got ONLY Regular insulin. We didn't use any other insulins with him.

So we did not add a faster acting insulin to something like NPH. We just made minor adjustments to how much Regular he got. He got 7-8 units of Regular with each meal and whether it was 7.0, 7.25, 7.5... depended on his premeal blood sugar reading.

This was a system we used after doing numerous curves demonstrating his typical food/insulin pattern. So I knew what time of day his blood sugar was lowest and highest and about how much it would generally rise and fall.

Natalie

[renniepooh]

Wow, I just read all the great input here, and I'm glad to have your help!

Thank you for all that great information. I read Natalie's case study on Chris's history with insulin, and it was very helpfull information. I hope that I can get to a point with Gretchen where I understand her so well with how she responds to her insulin.

About the fructosamine test, our previous internal medicine vet (the one that just retired) told us that it wouldn't be a very useful test for managing diabetes or adjusting the dose, and she didn't use it. Then when the new internist became involved, she wanted the fructosamine test done. I guess there is both opinions out there, but I agreed with the first internist, too, and didn't think the fructosamine was going to give us valuable information. With the amount of tests and money we go through anyway, I don't really want to waste any on the fructosamine if it won't help.

What Natalie said makes alot of sense about the daily testing. So what do people generally do? How often do you test and how often do you recheck curves?

It appears the shape of the curves are generally the same, with the highest level around mealtime and the lowest at the nadir. Would it be helpful, if once the approximate time of her nadir is established, to test just before her morning meal and then again at least near her suspected nadir? That way if her glucose control is starting to become poor, I'll know about it sooner than later. Maybe not on a daily basis, but at least once a week? The reason I ask this is because the recommendations from the internist have been, "recheck curve in 6 months." It just seem like so long to go without knowing!

Gretchen's food is Hill's WD. It is high fiber and low fat. She has been on the dry food for 2 years, but lately with her seizures, sometimes she doesn't want to eat and we offer her the canned WD. That entices her to eat then, I think she likes the canned well.

I understand how using two different types of the insulin (N and R) can be dangerous, too, since there will be overlap of the actions. Hopefully we can get her regulated on the NPH. She's started on 2 units BID and will check her curve after one week. I am sure it will need to be adjusted up though.

So what do other owners do for their dogs to help reduce their triglycerides?

She had another seizure last night and one this morning. Hopefully no more for a while. We have a re-check with the neurologist on Thursday.

Renee