Glucose above 400 - Need advice

[ro-ray]

I'm looking for advice/guidance/feedback on adjusting insulin dose. I'm very concerned that my dog is going to slip back into ketoacidosis. I've been quickly (see attached charts) increasing her dose (now at 16 units, 2X/day). Ketoacidosis vs hypoglycemia. I know she almost recently died from ketoacidosis. Am I increasing her dose to quickly? Should I keep increasing? Same rate? I'm hoping someone has some valuable experience and knowledge to share.

I'll try to pack in as much info as I have.

Dog: Female Lab/Collie mix, ~11 years old, 47 lbs
Diagnosed with diabetes August 1, 2018.

Symptoms included clear sticky residue where she slept, constant thirst/drinking, large increase in appetite and decrease in body weight over the course of of couple weeks or so (was at ~50 lbs)

Went to Emergency hospital 4 days after diagnosis because she went into ketoacidosis. She was throwing up (yellow foam-ish) for over a day and when she started throwing up water after drinking (she couldn't even keep water down), I took her in. She was on IV with antibiotics and short/quick-acting insulin for the 2.5 days.

On August 6, 2018 I started managing (or at least trying to) her diabetes.

Monitor: Alpha-Track 2

Test sites: calluses on elbows

Meals (2x/Day, every 12 hours): ~0.15 lbs Merrick Beef and Sweet Potato (dry), 0.2 lbs Newman's Own Organic Beef (wet), ~.3 lbs 85% lean beef with fat most drained after cooking (Costco) - handful of baby spinach chopped up and mixed in.

Insulin dose: I started out at 5 units 2X/day on Aug 6, and I'm now at 16 units 2X/day on Aug 25.

I've attached images showing a graph of glucose readings and insulin dosing, in addition to meal size and exercise. A full-size, normal meal will show as a value of 300 in the charts, along with a typical full activity/exercise period (which she hasn't had since diagnosis). Insulin dose values use the second/right side y axis.

The nutshell of the charts is that the first week of treatment may have been a bit of a "honeymoon" period, or effects from antibiotics, etc from here hospital visit. 5 Units seemed to be having an effect but very shortly after her glucose shot back up around 400 and the Novolin-N didn't seem to be having an effect so I've been continuing to increase her dose by 1 unit every day or two until I consistently get readings below 300.

The first chart is for Aug 6 to Aug 18, the seconds is for Aug 19 to Aug 25 (now).

Ah, dooh, can't seem to upload images. Sorry for the inconvenience. Table data from excel in following message...

[ro-ray]

Re: Glucose above 400 - Need advice

Unfortunately, I wasn't able to paste in the excel data so that it was readable. I have approximately 100 readings from Aug 6 to Aug 25.

Here's the last two days

Glucose Insulin
12AM 388
10AM 514 15
11AM 438
2PM 378
5PM 357
7PM 349
9PM 446 15
11PM 398

9AM 421 16
Noon 303
2PM 257
4:30PM 376

[MikeMurphy]

Re: Glucose above 400 - Need advice

Hi and welcome to the forum.

A conservative starting dose of Novolin N for a 50lb dog would be 50 x .20 = 10 units twice daily.

The protocol that we like to follow to get to regulation is:

- stay on the current dose for 5 to 7 days.
- do a 12 hour Blood Glucose curve, starting at fasting and then every 2 hours until the next meal.
- evaluate the results
- if necessary, raise insulin in .5 to 1 unit increments, based on the lowest BG reading
- keep repeating this process until BG readings range from 150 to 250 for most of the day.

Based on your current readings, it looks like you can continue to increase. However, it’s really important to let the insulin settle in for 5 to 7 days, so your dog’s body can adjust properly.

Good job testing. Just make sure you follow the proper protocol.

What’s your dog’s name?

[ro-ray]

Re: Glucose above 400 - Need advice

Thanks very much for the quick reply.

Her name is Elee (aka's: The ferocious One, The Colossal One, Beast, Dog, Dog who never shuts up while on the boat).

In re the 5 to 7 days. Thanks, I hold to that and hope it continues to drop.

Her glucose just (last night) started dropping below 300 when I increased her dose to 16 units after 1.5 days at 15 (and previously 2 days at 13). In 2 weeks I've went from 7.5 (last prescribed 2 weeks ago) to 16. I increased so fast because because her lowest glucose for the day was 350 or so (for weeks), and she was averaging over 400. Additionally, she started getting dandruff, which was a precursor to her going into ketoacidosis (I have urine test strips, and so far she's OK), so I kept increasing every day or so until she got under 300.

Just to confirm, are the guidelines to stay at the dose for 5 to 7 days even if all of her glucose stays above 400, with exception of one or two in 350'ish range?

I'm not trying to put anyone on the spot, I just don't have access to knowledge and experience (my last 3 vets didn't have any idea about the AAHA guidelines for NPH/Novolin-N and they started me at 5 units for the first 2 weeks).

[jesse girl]

Re: Glucose above 400 - Need advice

Yes 5 to 7 days is the normal settling time for a dose

If your dog is a larger breed with numbers above 400 in a complete curve you may have been able to give more than one unit and up to as much as 2 units

Now upping the dose by one unit after a couple days may not be a problem if your dog is a large breed but once you see anything in the 200s your going to have to give that week to settle and if you suddenly see things in the lower hundreds or lower you may have to lower the dose just to be sure you did not pass what is needed

When resistance is broken sometimes the dose could be to much but you are testing sugar at home so you should catch any lower trends

[MikeMurphy]

Re: Glucose above 400 - Need advice

Right. Stay on the current dose for 5 to 7 days and then do a 12 hour curve. She’ll need that amount of time for her body to adjust. Some dogs can take even longer to adjust. You don’t want to go past her proper dose. This can cause rebound(big swings in blood glucose). Getting Elee close to being regulated is more of a marathon than a sprint. It takes a lot of patience

It’s ok to test a couple times a day, maybe at fasting, before her next curve.

Thanks jesse girl. You and I were both typing at the same time

[CraigM]

Re: Glucose above 400 - Need advice

Welcome to the forum!

You said you are using Novolin-N, just want to be sure you get / know about Novolin-N from Walmart. It’s $25 for the standard 10ml bottle. Syringes are very affordable there as well.

Craig

[CraigM]

Re: Glucose above 400 - Need advice

One other suggestion is to make the meals as repeatable as possible. I don’t know if you are estimating the weight of the ingredients, or actually weighing them on a scale? I used a kitchen scale for my Annie.

You didn’t mention anything about snacks / treats. Is Elee getting anything between the two meals? Annie enjoyed a tiny piece of chicken, or piece of cheese that should be diabetic friendly.

Craig

[ro-ray]

Re: Glucose above 400 - Need advice

Elee - 11 yrs old - 47lbs - lab/collie - diagnosed 1 Aug 2018 - now on 16 units Novolin-N 2x/day
----------------------------------------------------------------------

Everyone, Thanks very much for the valuable and quick feedback. After getting 2 consecutive readings below 300 today, Elee is noticeably more her typical self, but still not fully back to her normal energy level.

Consensus is for me to hold at 16 units for at least 5 days. Thanks for the confirmation and piece of mind. That's our plan.

In re Novolin-N and Walmart, yes, thanks. That's a great tip. Fortunately my pharmacist at Costco didn't fill my first prescription and told me the same thing, so I saved $100's just by having a great pharmacist.

In re her meals, I don't weigh them but I'll check Amzn for something inexpensive. That will help remove one questionable variable. Thanks. As for snacks, the last 3 days I've been giving her about 0.15lbs (~6 small pieces) of BBQ steak (a lean cut) between her 9 am meal and 9 pm meal, usually between 3 and 6 pm. I stopped all her other snacks when she was diagnosed and only give her protein (like bbq steak, no seasoning or marinade). She's thrown up 2 or 3 times since she got out of the hospital (Aug 6) and it was yellow foam and one time had some grass (I try to keep her from eating it). My guess was that her belly was really empty and she's been inhaling every meals so figured low/no glycemic snack might help. Forgot to mention that the throwing up also added to the urgency and my decision to increase the dose at a faster rate.

After doing a lot of reading here, I realize it's a marathon, but watching her go through a weekend at the hospital with ketoacidosis has made the race to under 300 feel like a life or death sprint. The information on this site is providing the best guidance I've received thus far. Thank you all very much.

btw - is there a way to upload pics. I have 3 weeks of data, with 4 to 6 glucose readings every day (along with meal relative size and relative exercise). The data provided by other users has been very helpful. I hope I can provide helpful data in return.

[ro-ray]

Re: Glucose above 400 - Need advice

Alas, I found out how to upload and link pics (hiopefully). Here's Elee's glucose readings with insulin dosages (right y axis). The values for exercise and meal size are just relative numbers, with 300 being a full meal size and normal high intensity exercise.

Aug 6, 2018 to Aug 18, 2018 (left y axis goes to 600, hard to read, most values are under 500)
http://k9diabetes.com/forum/picture....pictureid=3353





Aug 19, 2018 to Aug 25,2018 (today) (left y axis goes to 600, hard to read, most values are under 500)
http://k9diabetes.com/forum/picture....pictureid=3354

[bichons9]

Re: Glucose above 400 - Need advice

Right. Stay on the current dose for 5 to 7 days and then do a 12 hour curve. She’ll need that amount of time for her body to adjust. Some dogs can take even longer to adjust. You don’t want to go past her proper dose. This can cause rebound(big swings in blood glucose). Getting Elee close to being regulated is more of a marathon than a sprint. It takes a lot of patience

It’s ok to test a couple times a day, maybe at fasting, before her next curve.

Thanks jesse girl. You and I were both typing at the same time

Hi, I have a little different issue and wonder how others would handle this: I accidentally closed Suzie in the room where I found her near the open bag of cat food. And of course, her BG spiked to 495 @ 12 am and in AM 565. Because the BG (using Vetsulin) tends to increase at around 1:30-2am and then reduces somewhat by AM, would you all allow nature to take its course OR knowing that by 1-2 am the glucose spikes even more...Does anyone intervene with a touch of R? I do not keep R but worried that had her BG reached 600+, should I have had R available to counteract the spike?However, i would not know how much to give in that situation. Also, with all of the concerns over vast BG changes expressed, I found some studie/articles that examines the variables that can influence the BG in humans,e.g..the need for a "normal" hematocrit, brain size is greater in children having greater glucose concentration that may lead to hypoglycemia in capillary blood. I could not find info on a dog that suggests the best perfusion site to test the BG. I use the front upper foot pad that is getting "tough" and the not often, the because she hates it. I can't imagine her tolerating the inner lip...Have a great day everyone!!! P.S...Interesting!!!
Canine Diabetes Mellitus
Richard W. Nelson, in Canine and Feline Endocrinology (Fourth Edition), 2015
Continuous Glucose Monitoring Systems

[jesse girl]

Re: Glucose above 400 - Need advice

Hi, I have a little different issue and wonder how others would handle this: I accidentally closed Suzie in the room where I found her near the open bag of cat food. And of course, her BG spiked to 495 @ 12 am and in AM 565. Because the BG (using Vetsulin) tends to increase at around 1:30-2am and then reduces somewhat by AM, would you all allow nature to take its course OR knowing that by 1-2 am the glucose spikes even more...Does anyone intervene with a touch of R? I do not keep R but worried that had her BG reached 600+, should I have had R available to counteract the spike?However, i would not know how much to give in that situation. Also, with all of the concerns over vast BG changes expressed, I found some studie/articles that examines the variables that can influence the BG in humans,e.g..the need for a "normal" hematocrit, brain size is greater in children having greater glucose concentration that may lead to hypoglycemia in capillary blood. I could not find info on a dog that suggests the best perfusion site to test the BG. I use the front upper foot pad that is getting "tough" and the not often, the because she hates it. I can't imagine her tolerating the inner lip...Have a great day everyone!!! P.S...Interesting!!!
Canine Diabetes Mellitus
Richard W. Nelson, in Canine and Feline Endocrinology (Fourth Edition), 2015
Continuous Glucose Monitoring Systems

You cant be sure how the body will react when insulin starts working at a higher range over lower . My jesse is quite different at a higher range over lower and she usually drops but if lower she usually rises . Since you have no real experience with r and how your dog will react i might just leave things alone . Just have plenty of water to drink if necessary

[ro-ray]

Re: Glucose above 400 - Need advice

sorry for typos folks, tired, need to go to bed...

This is just a follow up post in case anyone tracks this thread and could use a conclusion/closure as to how things progressed after 3 months/90 days post diabetes diagnosis.

In a nutshell, Elee's doing pretty well on 15 units immediate post breakfast (~9:30 am) and the same post dinner (~9:30 PM). Using Novolin N and I found the cheapest tester and test strips at Walgreens, it's their generic brand and the strips are ~$15 for 50 strips, by far the least expensive. I compared it with the alpha track 2 and 12 out of 14 readings were 13% to 15% lower, so that if alpha track 2 had a reading of 100, the walgreens meter had a readying of 85 to 88. The percentage difference also held for readings around 400.

For me and Elee, we went pretty aggressive and increasing the dosage, and it took at least 3 weeks at 15 units to feel comfortable with that dose (we tried as high as 17 for a couple days but levels got in the high 40s so i quickly gave some syrup on a bone and then the levels rocketed about 200 in less than 30 minutes). Our aggressive approach was used because acidosis was a really threat, and I work from home so I'm around her 24/7/365, so I could reduce the risk of hypoglycemia.

To reiterate what other threads point out, it was key for use to establish a consistent diet, BOTH quantity and ingredients. Reducing kibble to less than 20% of weight also has a big effect (50 to 100 points). We're able to have a handful midday snack (lean, grilled steak and/or hamburger drained of fat using a spageti strainer).

She will occasional have a reading in the high 300's, and sometimes it correlates back to new treat being introduced or sometimes it seems to be related to her just not feeling 100%, but most of the time she's now between 80 and 200 (using 15 units of Novolin N from walmart). I didn't bother will uploading the data again because numbers were all over the place until we finally started settling in at 15 units for at least 5 days straight. One last, maybe important note. We stopped swimning in the lake for the summer, and that may have also greatly helped because I think the bacteria and algea in the lake was degrading her immune system and she had cronic UTI's. She has been in the lake for months and no UTI, no infection, no more signs of acidosis. If you have a swimmer, you probably want to stop the swimming until you can get on a good/steady dosage.

The long game is definitely the way to approach this. Thanks everyone. Hopefully this is helpful/useful to others.
-------------------------------------------------------------------
Elee is about 11 or 12, ~50 lbs, lab/collie mix, female and still very much full of energy

[jesse girl]

Re: Glucose above 400 - Need advice

Well that is wonderful news

Yeah swimming in a lake could be problematic . I try not to let dogs lick jesses back end

Jesse problems sometimes starts with the ears . She will start shaking here head and itch them and i see her numbers go up . Once the problem is gone the numbers go back down

The UTIs may have been the problem all along with regulation

sometimes you have to be aggressive with regulation and fortunate you were able to be at home to monitor and find the right dose

[k9diabetes]

Re: Glucose above 400 - Need advice

Wonderful news!!! And thank you for letting us know.

Natalie