Annie & Craig - Getting too smart!

[CraigM]

Our Annie has been diabetic for about a year and I've reading this forum for about two months. Thought it was time to join and share our experiences.

Pets name: Annie
Breed: Lhasa Apso
Age: 8
Weight: 16 pounds
Diabetic since: June 2008
Insulin: Vetsulin - usually 6 units, twice a day
BG meter: AlphaTrak
Food: currently mix of 2 tablespoons of NATURE's RECIPE (Venison & rice) and 1.5 ounces (use a scale) of NATURE's RECIPE (Venison & Rice) dry. Have tried homemade and other commercial brands.

I'll add more info after I see if this post makes it.

Craig, Annie's dad

[CraigM]

Re: Annie needs help

OK, looks I know how to make a post, so I'll continue.

We check Annie's BG, feed and inject twice a day at 8AM & 8PM. There are periods of 4 - 5 days where she stays in what I consider a good range of 100 - 225 (TELL ME IF THIS ISN'T A GOOD GOAL!). Then there are days like yesterday and today!

9-26-09 8AM = 68
9-26-09 8PM = 465
9-27-09 8AM = 61
9-27-09 8pm = 414

I was VERY surprised with the AM readings, but she was active and seemed to be doing OK. The PM readings were about 200 higher than I expected, but again she looked to be doing fine.

As I mentioned in my earlier post, I measure her food fairly closely. We don't THINK she has been finding food on her own, but would eating a little grass (she has access to the back yard) possibly cause the PM readings?

Craig

[k9diabetes]

Re: Annie needs help

That looks like rebound to me. You may not have caught the lowest her blood sugar has been going. And blood sugar in the 60s would be enough to set off the counterregulatory response. I get extremely shaky when my blood sugar drops that low.

So I would reduce her insulin right away and see if that settles it all.

With such a small amount of insulin, dropping 1 unit may be enough to get all blood sugars back into a safe range.

Natalie

[k9diabetes]

Re: Annie needs help

Your goal is good but I do think it likely that she wobbles and somedays that regulation is too tight. You'd want her blood sugar to never go below about 90 and she has definitely dropped lower than that.

And welcome!!! She's adorable!

Natalie

[k9diabetes]

Re: Annie needs help

One more thing... those lows are in the morning. Have you ever had them in the evening? It could be only the night time dose is too high or it could be both.

[CarolW]

Re: Annie needs help

Craig - welcome to you and Annie. I'm glad you joined us.

Indeed, I think those numbers you show suggest the possibility of rebound, as Natalie suggested.

I notice you take readings at fasting-time - just before feeding. What about BG curves? - taking readings every couple of hours, for at least 12 hours (some do 24-hours, but I don't bother, as my dog, Kumbi, seems okay overnight).

Does your vet, or do you, at times, take curves?

I have a bunch of charts on my web site, some of which show rebound, or rebound-like, effects. If you start here, you can go through various charts by using the NEXT buttons above the main pictures on each page.

http://www.coherentdog.org/vek/bgcharts1.php

There are other charts on the web, also.

I think charts help to show what's going on, especially for visually-oriented humans! (me, for instance; haha!)

Another thought I had, though this would really take some work, is that, Annie, being fairly small at 16 pounds, might do well on NPH insulin, which has only one peak (time of most-intense working), rather than the two that Vetsulin has. The first, and heaviest, Vetsulin peak occurs so-many-hours (perhaps 4 to 6) after injection; it's the faster-acting component of Vetsuilin that does that; then a second peak comes along maybe, say, 11 to 14 hours after injection. This second peak would be a gentler one than the first. (My indication of timing is from memory, and may not be perfectly accurate; also, timing of the peaks varies with individual dogs.)

But without curve data, we can't really see anything about how BG levels are varying throughout the day (nor, of course, the night).

If you or your vet does curves fairly regularly, perhaps you could post some curve-numbers? And if not, I would certainly do a curve as soon as you conveniently can. If you do it, of course, you'd need to be home to do it! A curve, though, would help reveal whether rebound is in fact occurring.

Changing insulins is a job and a half, not to be undertaken lightly, and I wouldn't even raise the issue if Annie were going along really smoothly.

But if you think you might like to change, the aim would be to flatten the response to the insulin, between injections. Once a dog is well-stabilized on NPH insulin, too, the need for constant testing seems to be reduced, as long as there aren't other underlying conditions besides diabetes.

I always defer to the observations of Natalie and Kathy on this forum, so I'd certainly attend to what either has to say about Annie.

So many dogs (by no means all) do well on the human (NPH) insulins.

Vetsulin, or its counterpart elsewhere, Caninsulin), seems to do a really good job for a lot of dogs - but then, so does Novolin-NPH, or Humulin-NPH (or similar insulins) - for many dogs.

My Kumbi, who weighs about 20 pounds (right now, 19 pounds), does really well on Novolin-NPH, and he's been on that from the time of his diagnosis, 1 September, 2006.

Welcome! I'll be following Annie's story.

Mon, 28 Sep 2009 00:24:34 (PDT)

[We Hope]

Re: Annie needs help

Once a dog is well-stabilized on NPH insulin, too, the need for constant testing seems to be reduced, as long as there aren't other underlying conditions besides diabetes.

I'm not able to see how the use of NPH appears to mean that there's less need for testing. Can you provide any references?

Kathy

[CarolW]

Re: Annie needs help

Hi Kathy,

Thanks for catching that. It's a fairly complex consideration, according to all I read in various places - essentially, two other forums.

I'm not able to see how the use of NPH appears to mean that there's less need for testing. Can you provide any references?

Kathy

Not specifically, but in general. This comes from long series, multiple posts, on other forums; I don't remember seeing such remarks here, though they may exist.

What appears to happen with people who change from Vetsulin (or Caninsulin) to NPH insulin is that, in general, they stop feeling very concerned about that first peak that occurs with the 30% amorphous component of Vetsulin. So, where once, they might have tested halfway through the day (or 4, 6, 8, whatever, hours after injection), people who have changed seem sometimes to omit that midday test.

I notice here, practically everyone seems to learn to test BG levels at home. I think that's a great safety measure, as well as keeping stress levels down for the dog, and it also helps keep costs down.

On the other forums I frequent, or read regularly, there are numbers of people who choose not to learn to test, some who do learn, but avoid testing much, and some who work to maintain tight glycemic control, and so, test at least at fasting-time (usually that's twice a day, before dog-meals), and sometimes "midday" (estimated insulin-peak-time, especially Vetsulin's [Caninsulin's] first peak).

That's all providing there's no particular indication of conditions other than diabetes.

Mon, 28 Sep 2009 07:56:32 (PDT)

[We Hope]

Re: Annie needs help

Like Natalie, I also see some rebound here, which would mean an insulin reduction.

Let's look at Lente insulin, which is what Vetsulin is. Whether it's made from pork, beef or r-DNA, all Lente insulins work the same way.

Marion,

Right now, what you may be seeing is the point where the fast-acting semilente insulin peaks--around 10 AM--and the second peak at about 4 PM is that of the long-acting ultralente.

http://www.ncbi.nlm.nih.gov/pubmed/9...gdbfrom=pubmed

Pharmacokinetics of a porcine insulin zinc suspension in diabetic dogs.
Journal of Small Animal Practice-1997

"Ten dogs with naturally occurring diabetes mellitus were injected with a highly purified porcine insulin zinc suspension at a dose according to their expected requirement. Plasma insulin and glucose concentrations were measured at two-hourly intervals over 24 hours following injection. There were either one or two peaks in plasma insulin concentration: one at about four hours (mean 4.3 +/- 1.3 [SD]) and another at about 11 hours (mean 11 +/- 1.85) after the injection. The second insulin peak was seen in only eight dogs. Persistence of elevated plasma insulin concentrations ranged from 14 to 24 hours (mean 17.4 +/- 3.65). These results compare favourably with those published for other intermediate-acting insulin preparations used to treat canine diabetes mellitus and suggest that this preparation has useful properties for the successful management of many canine diabetics."

Taking this apart a bit, they say that the first peak at about 4 hours after insulin is plus or minus 1.3 hours. That means it could be 1.3 hours sooner or 1.3 hours later. Then you see them talk about the second peak at 11 hours--plus or minus 1.85 hours later. Meaning that it could be close to 2 hours earlier or later than 11 hours.

These numbers are an average of the times noted for the 10 dogs tested, with 8 of the 10 showing evidence of the second, later peak.

All Lente insulins "operate" like this, in the respect that there are two Lente family insulins combined to produce the insulin--30% fast-acting semilente and 70% slow-acting ultralente.

http://diabetesindogs.wikia.com/wiki/Lente

But what's shown as a time activity profile is all of this nicely "smoothed" out:

People who continue to use Lente insulin (beef only now--imported from the UK) and those who formerly used it when it was more widely available would have also had the possibility for the two peaks because no matter what one makes or made the insulin from, it still works in the same fashion.

It may be that you will continue to see two peaks from Cara. When her bg's were so high, it would have been difficult to impossible to have seen it.

Lucky did not show two peaks but just the one later in the day, so he was still keeping with his tradition of not going by the book.

Does this help any--sure hope so!

Kathy

So it's not a must to have two peaks from Lente; some do and some don't. My Lucky had just one at 6 hours after food and insulin.

Here's a look at the old Time Action Profiles when Lilly was still producing an r-DNA Lente insulin, Humulin L:

Note also there are two non-analog mixed insulins' Time Action profiles shown here-Humulin 70/30 (30% fast acting R insulin and 70% intermediate acting NPH insulin) and Humulin 50/50 (50% fast-acting R insulin and 50% intermediate-acting NPH insulin). Theoretically, there should be two peaks for them also--one for the fast-acting R and one for the slower-acting NPH, but we see a "smoothed out" graph for both of them and also for the Lente insulin, Humulin L.

http://www.vetsulin.com/vet/Monitoring_Somogyi.aspx

"An insulin dose that is too high may bring about the Somogyi effect or rebound hyperglycemia. This is produced because blood glucose concentrations fall too rapidly. The moment that the Somogyi effect is triggered is very individual – it is a life-saving response."

Years ago on another board, we had a dog who was very well-regulated on NPH insulin. However, every time his bg's approached 85 mg/dl, he would have all the symptoms of a hypo. The answer was to slightly reduce his insulin to keep him from nearing the 85 mark.

Lucky on the other hand, would be going along at 85 8-10 hours after his Caninsulin/Vetsulin shot and feeling fine.

Like Natalie, I think Annie needs the insulin reduction because the lows and highs sure look like they're rebound-related.

Kathy

[We Hope]

Re: Annie needs help

Hi Kathy,

Thanks for catching that. It's a fairly complex consideration, according to all I read in various places - essentially, two other forums.



Not specifically, but in general. This comes from long series, multiple posts, on other forums; I don't remember seeing such remarks here, though they may exist.

What appears to happen with people who change from Vetsulin (or Caninsulin) to NPH insulin is that, in general, they stop feeling very concerned about that first peak that occurs with the 30% amorphous component of Vetsulin. So, where once, they might have tested halfway through the day (or 4, 6, 8, whatever, hours after injection), people who have changed seem sometimes to omit that midday test.

I notice here, practically everyone seems to learn to test BG levels at home. I think that's a great safety measure, as well as keeping stress levels down for the dog, and it also helps keep costs down.

On the other forums I frequent, or read regularly, there are numbers of people who choose not to learn to test, some who do learn, but avoid testing much, and some who work to maintain tight glycemic control, and so, test at least at fasting-time (usually that's twice a day, before dog-meals), and sometimes "midday" (estimated insulin-peak-time, especially Vetsulin's [Caninsulin's] first peak).

That's all providing there's no particular indication of conditions other than diabetes.

Mon, 28 Sep 2009 07:56:32 (PDT)

Then this is strictly anecdotal.

Kathy

[k9diabetes]

Re: Annie needs help

From what I'm hearing about Annie's regulation, a large swing in blood sugar is not a problem. On good days she maintains within a nice tight range. But her blood sugar levels have some variability so some days she goes too low on the same dose of insulin. With those wobbles, it won't be possible to maintain such tight regulation - the good days will have to run a bit higher to keep the low days from going so low.

http://www.vetsulin.com/vet/Monitoring_Somogyi.aspx

This looks like classic rebound to me... just the kind of thing that if one didn't catch the 66 and only saw the 485 and might up the insulin still further when actually a decrease is what's needed to prevent the rebound.

Looks like it may be mainly a night problem. I'm anxious to hear more about how often Annie experiences this.

Natalie

[CraigM]

Re: Annie needs help

We don't want you to think we have left this forum, I do read it everyday. Thanks to everyone and from your comments, and what I've read, it does look like Somogyi Rebound / Over-swing. I've REALLY tried to reduce the dose of Vetsulin, but I panic when I see BG readings of 400+, and then break down and give a full "normal" 6 units! Today was typically hard to accept:

4AM = 101
8AM = 414, fed, gave 6 iu (had been the "normal" dosage)
11AM = HI
1PM = 473
3PM = HI
5PM = 422
8PM = 493, fed, gave only 4 iu to "kick" the rebound???

I'm sure you see why I want to give the "normal" 6, or even 7, units when you see readings over 400.

Additional info: My wife and I were on vacation for three weeks last month and Annie was living with our Daughter-in-Law. She is a Vet Tech and reduced Annie's food intake because she thinks Annie is overweight. Annie had been getting one cup of can / dry mixed for each meal. Meals were reduced to about 3/4 cup mixed. That's a 25% decrease in food. I'm now wondering if there is a correlation between food quantity and Vetsulin dosage? Seems like there should be. If this is true, then Annie's "normal" dosage should be reduced, right?

I'll do another test at 10PM and midnight. If this is Somogyi Rebound, should I see BG come down even though I only gave 4 iu at 8PM?

Thanks!
Craig and Annie

[We Hope]

Re: Annie needs help

Craig,

First of all, you're right in that less food usually means less insulin; the doses you're giving take both basal (body's needs without considering food eaten) plus the insulin needed to properly deal with the food.

The thing with rebound is that what's making for the higher numbers are the lows too much insulin's creating.

When the system hits a low, other body hormones known as the counter-regulatory ones, are triggered by that. One of their jobs in the body is to try to protect it from harm if the system senses a low has been reached. So they raise the bg's--sometimes very high--to try to do that.

http://diabetesindogs.wikia.com/wiki/Somogyi_rebound



Somogyi rebound-a theoretical graph of what happens if you ignore the low bg numbers and focus only on the high ones created by the lows. As the insulin dose increases, the lows become lower, causing the counter-regulatory hormones to send the bg's higher in response. The only way to stop the extreme highs is to stop the lows; this means LESS insulin rather than more because it is the lows which are responsible for creating the highs.

And from this theoretical example, you can see how the insulin increases make the lows lower and in response, the high bg's higher. It's something like throwing a ball to the ground--the harder you do that, the higher it bounces back into the air.

These counter-regulatory hormones triggered by the lows, don't just automatically cut off, they "ease" back into normal levels. This can take 2-3 days:

http://diabetesindogs.wikia.com/wiki..._Still_High.3F

"Rebound is a vicious circle, with the body going either at or near hypoglycemia from the effects of too much insulin.

"When the lows occur, the body's "self-defense" mechanisms set to work, producing hormones which are meant to raise blood glucose levels. Of course they do, and the result is hyperglycemia. The systems of living beings do very little abruptly; it's more of an easing into or easing out of a situation or condition.

"It may take a few days after the insulin dose has been adjusted downward for the high blood glucose which follows hypoglycemia to return to normal.

"Just one at or near hypoglycemia incident can release cortisol into the blood, which can keep blood glucose values elevated for up to 3 days."

http://www.vetsulin.com/PDF/20585.pdf

Vetsulin-Page 21

"Hyperglycemia can sometimes persist for as long as three days after a single hypoglycemic episode. As a result, blood glucose concentrations do not always normalize within a few days of lowering the insulin dose."

So sticking to the lower insulin dose should mean you will see Annie's bg's start to gradually reduce over a few days' time.

HTH!

Kathy

[k9diabetes]

Re: Annie needs help

The most important thing to know is that it can take several days with no low blood sugar for things to get back to normal. It's amazing how poor the blood sugar can be for 48 full hours or more after.

So you're just gonna have to promise yourself you are not going to "chase numbers."

Because you will actually cause Annie to have high blood sugar by overdosing the insulin. You have seen how 6 units of insulin can plunge her blood sugar from over 400 down into the 60s. So every time you give her that much insulin, you are sending her blood sugar into freefall.

When you have gone five full days with a reduced dose and NO blood sugar below 100 - because she can be going low at times you're not testing - then, only then, will you know what her body is actually doing with that dose of insulin and have a baseline for future decisions.

At that point, I'd do a curve.

My guess is that Annie "wobbles" in that once or twice a week her blood sugar runs lower than normal. That will have to be taken into account once you get her stabilized and out of rebound in how tight you run her control.

Chris had a couple of ACTH tests for Cushings and they are a lot like a rebound episode - same kind of hormonal surge. His blood sugar run much higher for two full days after.

Natalie

[k9diabetes]

Re: Annie needs help

Something to remember... short of more than trace ketones, there is no damage from blood sugar in the 400s short term. So she will get through having blood sugar in that range for a couple of days when you no longer try to fix it. And then she will stabilize and she won't have to do the 400s anymore!

I would very much like to see a curve once she is stable to see if she returns to that nice narrow range of BGs.

Natalie