Curves definitely are not "old school"

[k9diabetes]

I promised to provide some documentation that blood glucose curves are once again the standard of care for monitoring a dog's blood sugar. So I thought maybe it would be wise to set up a thread on this so we have it for future reference.

It is true that a few years ago - maybe 2005 - vet teaching hospitals like UC Davis were dismissing curves and often suggesting using fructosamine tests only. And for whatever reason, it seems like vets really jumped on that bandwagon. But I personally think that was always a mistake. We just don't see a lot of dogs whose vet stress alters their curves.

The fructosamine test is particularly useless when you already know the dog's blood sugar is high, as in a newly diagnosed diabetic.

So following will be references to recent materials providing guidance for monitoring a newly diagnosed diabetic dog that supports the use of blood glucose curves.

Unfortunately, some of the very best support is in the form of webcasts and other audio media. I'll put up those links but think it will be difficult to get a vet to take the time to sit down and listen to something like that.

But there are lots of resources in print too.

Natalie

[k9diabetes]

2010 AAHA Guidelines for Managing Diabetes in Dogs and Cats

This is a nice presentation because it's brand new - issued in 2010 - and available as a PDF. The AAHA is the American Animal Hospital Association.

2010 AAHA Guidelines for Managing Diabetes in Dogs and Cats

http://www.aahanet.org/PublicDocumen...Guidelines.pdf

p. 221 (starts on page 215 of some larger volume)

Initiating insulin therapy

Outline of initial approach

• Administer the first insulin dose (0.25U/kg) and feed in the morning.

• Perform BGC [blood glucose curve] with samples every 2 hours for at least 8 and preferably 12 hours, or until the nadir can be deter-mined.

• If BG remains >150mg/dL, send dog home and repeat BGC in 1 week.

• If BG becomes <150mg/dL, decrease the next dose by 10% to 25% rounded to the nearest unit based on dog body weight and severity of glucose nadir. Ifpossible, hospitalize dog to monitor response to the lower dose.

• Repeat BGC in 1 week (or sooner if concerns for hypoglycemia exist based on results of initial BGC).

Ongoing Monitoring and Treatment of the Dog

During first month after initiating insulin

• Weekly (every 7 to 10 days):

° Recheck examination and BGC.

° Adjust insulin (as listed under Interpretation of the Glucose Curve).

° Continue until clinical signs are controlled, body weight is trending toward optimal, and results of BG testing suggest control (see section on BGCs).

Long-term monitoring

• Tailor monitoring to the dog. Focus on weight, history, physical examination, and client observations regarding thirst, urine output, energy level, and behavior. Treat the dog, not the BG results. Always repeat the BGC 2 weeks after any insulin dose adjustment.

One Caveat... my posting of any guideline here doesn't mean I agree with every step listed or every detail of the approach. My dog, for example, gave no clinical signs - no excess thirst and urination - until his blood sugar was sustained at about 450 or higher so clinical signs were pretty useless to us and we used blood glucose monitoring daily.

But it's clear from these guidelines that Blood Glucose Curves are considered the standard of care for establishing dose and monitoring regulation.

Natalie

[k9diabetes]

Re: Curves definitely are not &quot;old school&quot;

Dr. Audrey Cook has been leading a campaign for tighter regulation of diabetic cats and dogs and has made some excellent presentations in recent years. This article is an ePublication, Veterinary Medicine magazine, and was published in 2007.

September 2007, Veterinary Medicine Magazine

The Latest Management Recommendations for Cats and Dogs with Nonketotic Diabetes Mellitus

Audrey Cook

http://www.nxtbook.com/nxtbooks/adva...hp?startid=600

This is a guide for treating both cats and dogs who have diabetes. On page 608, there is a flowchart that outlines the process of starting a newly diagnosed dog on insulin and monitoring the effect of that insulin with curves.

Page 610:

In-Clinic Monitoring

Serial glucose assays provide the most detailed evaluation of a patient’s response to insulin.

There is a boxed series of questions she suggests asking before using a fructosamine test to monitor regulation. Any sign at all of a problem and the recommendation is to do a blood glucose curve instead. So basically, she’s saying fructosamine tests are only adequate when things look good.

Page 612 (emphasis is mine):

If the patient is doing clinically well, fructosamine assays can be performed in place of serial glucose measurements (Figure 4). Serum fructosamine reflects average serum glucose concentrations for the previous three weeks. If the fructosamine concentration is elevated, a glucose curve is necessary before dose adjustments are made. It is not safe to arbitrarily increase the insulin dose, as patients receiving too much insulin may have elevated fructosamine concentrations secondary to the Somogyi effect (in which acute hypoglycemia results in severe and often prolonged hyperglycemia).

[BestBuddy]

Re: Curves definitely are not &quot;old school&quot;

I find it a little strange that this is from an American publication and they talk about kg not lbs.

Also .25u/kg seems very low.

Jenny

[k9diabetes]

Re: Curves definitely are not &quot;old school&quot;

The following link goes to a Webcast provide by Dr. David Bruyette, who has been working since last year on presentations sponsored by Abbott, which makes the AlphaTrak blood glucose meter for pets.

While Abbott has an interest in selling the AlphaTrak, I have attended one of these presentations in person and listened to the following Webcast and I consider both to be excellent. The webcast below is really exceptional in my opinion and covers a lot more than communication. It's a good basic primer on treating a diabetic dog.

There is no sales pitch for the AlphaTrak and there is a great deal of support for home blood glucose testing and for curves.

http://www.abbottanimalhealthce.com/...ing_owners.htm

You can call Abbott and ask them for a code to listen to the presentation. And, better yet, if your vet isn't yet a fan of home testing, encourage them to listen to it.

Natalie

[k9diabetes]

Re: Curves definitely are not &quot;old school&quot;

That insulin recommendation is low - it's what AAHA has been using in everything I've seen related to the transition from Vetsulin. It seems like the starting dose recommendations have been dropping.

I think this may also be due in part to the fact that they are lumping cats in with dogs and the tendency for cats to go into remission has driven them to use a lot less insulin in the beginning now that they follow a protocol that is likely to bring about remission. It shouldn't get carried over to dogs but seems like that is why it is happening.

But I also think that may not be a bad thing if it's accompanied by careful monitoring in the beginning. Chris' starting dose was 1/2 mg/kg (1/4 unit per pound) and was too much insulin and it's not all that unusual for a dog to need less than 1/4 of a unit per pound.

The med dosages I've been getting lately from vets are being stated in mg/kg and they just work out the kilogram measurement from the pounds.

Natalie

[BestBuddy]

Re: Curves definitely are not &quot;old school&quot;

I suppose it is good that the dosage is started lower but as long as there is follow up to make sure the dog is getting enough insulin to start getting the BG into better numbers. I worry that dogs are started low without monitoring by the vets, just told to come back in a week or two if things are not improving.

I wonder how I would cope now with a diabetic, it seems live forever ago that Buddy was my patient.

Jenny

[k9diabetes]

Re: Curves definitely are not &quot;old school&quot;

Having just started prednisone with Jack tonight, the same thing has been on my mind. It's hard to believe it's been more than two years since Chris passed away.

Natalie

[CarolW]

Re: Curves definitely are not &quot;old school&quot;

Natalie,

Thanks so much for taking this on. I was very fortunate that my vet, though in general practice, specialized in Internal Medicine. She always fully supported adjusting insulin dose based on BG curves, and also supported and assisted as I learned to do the curves at home.

Let's hope more vets get on board with using BG curves for dose adjustment, and also, that more support and assist their clients in learning to do curves at home.

Mon, 17 Jan 2011 04:56:40 (PST)

[k9diabetes]

Re: Curves definitely are not &quot;old school&quot;

Any time someone home tests blood glucose, my question about a fructosamine test is:

What will a fructosamine test tell you that taking blood glucose measurements at home will not?

My answer would be not one thing, which is why I'm not in favor of them for any dog whose blood sugar is being tested, at the vet or at home.

I have recommended fructosamine tests in cases where a dog just won't sit for blood sugar testing at home AND gets so freaked out at the vet that the dog's mental health is an issue. I prefer, in those cases, to combine the fructsoamine test with urine testing if possible so there is some sense of the variation in glucose levels during the day, something the fructosamine doesn't address at all.

One way around freak-outs during curves by the vet is a drive-by curve if the vet is reasonably close by and someone can be home to make a trip to the vet multiple times a day - just long enough for a tech to draw a sample and then back home again until the next one is due. This has worked really well for dogs who get very stressed being locked in a kennel all day (which would stress me out).

As a perhaps overly broad generalization, I would say that vets who like the fructosamine test and more or less refuse to do curves don't really care about getting GOOD regulation; their standard has to be that the pet just stops peeing in the house and call that regulated. Because you can't do much more than that with fructosamine tests only.

One last aside... cats' diabetes can go into remission (it's more like Type 2) but that couldn't be discovered until people started to bring their cats' blood sugar down into a good range close to normal. If no one had ever pushed beyond the really low quality of regulation that was the standard for pets 10 years ago, I don't think you would see the remissions in diabetic cats you see today.

Natalie

[BestBuddy]

Re: Curves definitely are not &quot;old school&quot;

I'm still trying to get my head around the difference between fructosamine and hb1ac tests.

I know all the diabetic clients using the centre where I work have to have the hb1ac testing done. I know people are a lot different than dogs but it seems that the diabetic educator thinks the hb1ac is very informative. We have a lot of non compliant diabetics who don't bring in their meters to be downloaded and if you look at their BG record books it looks like they have been testing and doing the right thing but when they have the hb1ac the educator can tell they have been telling "porky pies" (lies).

I do know the hb1ac is tested every 3 months and would be an expensive test if it wasn't covered by medicare. Have you ever know a dog to have one of these?

Jenny

[k9diabetes]

Re: Curves definitely are not &quot;old school&quot;

NAVC - November 2009
NAVC is the North American Veterinary Conference

Consultant on Call

Diabetes Mellitus Part 2: Treatment
By Rebecka S. Hess, DVM, Diplomate ACVIM, University of Pennsylvania
November 10, 2009

http://www.cliniciansbrief.com/colum...rt-2-treatment

You may need a login to view the full article. I'm quoting the relevant passage.

Follow-Up

While 0.5 U/kg is a safe starting dose for insulin, it is usually not the dose that the animal is going to require for long-term treatment. The dose is changed based on clinical signs and glucose curves, which are performed approximately every 2 weeks for 1 to 2 months.

Blood Glucose Curves

• A blood glucose curve is performed by measuring blood glucose concentration every 2 hours for 10 to 12 hours.

• After initial glycemic regulation is achieved (blood glucose should range between 100 and 250 mg/dL for a dog and 100 and 300 mg/dL for a cat), a blood glucose curve is performed every time the owner notices clinical signs consistent with hyperglycemia or hypoglycemia, or when other clinical signs (such as vomiting or signs of lower urinary tract infection) develop.

• If the dog or cat has no clinical problems, a blood glucose curve is performed every 3 to 4 months.

Blood glucose curves and concentrations are always interpreted in view of clinical signs. For example, if a dog is well regulated and has no evidence of polyuria, polydipsia, polyphagia, or weight loss, and blood glucose concentrations range from 180 to 250 mg/dL over a 12-hour period, the dose of insulin does not need to be changed. However, in a dog with the same blood glucose concentrations that has the signs mentioned above, the dose of insulin should be increased.

Serum Fructosamine Concentration

Occasionally cats will not tolerate a glucose curve and blood glucose measurements will not be reliable due to stress hyperglycemia. In this case, serum fructosamine concentration can be used for patient monitoring.

[k9diabetes]

Re: Curves definitely are not &quot;old school&quot;

I have seen discussions of why they use the fructosamine rather than the Hb1AC... I do not recall the reasoning but I think it would be pretty easy to find. I believe the Hb1AC is more expensive and I'm sure that comes into play but my vague recollection is that there was some other reason.

Natalie