Ozzi is gone... August 15, 2010

[ozzi]

My dog (Ozzi) is a 13 year old mixed breed..half Dalmatian and half Australian cattle dog. He was diagnosed with diabetes last August, and we are still trying to get him adjusted on insulin, almost 6 months later. We initially started him on Humulin N and because of the cost, we switched him to Novolin N (made by Relion from WalMart). About two weeks after changing him to Novlin N twice/day, he started to deteriorate, and we switched him back to Humulin N. About 2-3 weeks after, he again began to deteriorate. By deteriorate, I mean that his blood sugars rose, he had increased drinking and urination, lethargy and hind leg weakness. Each time we brought him to the vet, insulin was increased. He has lost about 10 pounds and currently weighs 65 pounds. We did a glucose curve that showed the insulin peaks at TWO hours instead of 6-8 hours. Here are the results:

8am 276
10am 114
12pm 147
2pm 190
4pm 282
6pm 310

Since the NPH is essentially working as "regular" insulin on him, we asked about splitting the dosage in three rather than twice a day, which the vet said not to do. About a month ago, Ozzi's symptoms increased again, and were so worrisome that we called our vet who was not available and the covering vet didn't seem to want to get involved! So we were left with dealing with him on our own over the weekend. For some unknown reason, we decided that we would give him Humulin N 23 u in the morning and Novolin N 23 u in the evening. For whatever reason, he has been doing very well on this regimen. Yesterday, I picked up a new vial of Novolin N and this morning it was "separated" with all the residue on the bottom and clear on the top half. Usually it's cloudy, with just a little residue on the bottom. I called Novo Nordisc and they are sending out a new vial of Novolin N, however they advised that i NOT refrigerate the insulin after starting use.

Basically, I want to do the right thing, and I'm completely frustrated. Here are my questions, if anyone has experienced a similar situation:

(1) Has anyone else had a glucose curve like this, and what was done to make it better?
(2) Is anyone else alternating using Humulin N and Novolin N?
(3) Has anyone had their insulin completely separate with all the precipitant on the bottom? Have you used it?
(4) Do you store your insulin in the refrigerator or at room temperature after using it?
(5) Does anyone know if one can get assistance for the cost of insulin? I called Lilly and Relion and their assistance programs don't extend to pets!
(6) I'm concerned about using Novolin N now, however this regimen seems to be the only one that has been working for any length of time, so I'm concerned about going back to Humulin N twice/day.

Thank you for reading this, and I welcome any advice. I love Ozzi dearly and I don't know what to do at this point.

[k9diabetes]

Re: Insulin Frustrations!

I just have a couple of minutes online but...

The good news is that I think you're more worried about this curve than you need to be.

Although there's a generalization that NPH "usually" peaks in about six hours, it's far from a reliable standard. There's so much variability in how any one dog metabolizes an insulin and food that we see everything from curves like this to curves that are "mountains" instead of "valleys."

Ozzie's insulin is lasting close to 12 hours... not sure when his meals are in here... 6am and 6pm?

You can tell it's lasting about 12 hours because the high points at meal time are approximately the same level.

One thing that can help level out a curve like this, actually, is to give something readily digestible with the meal so that the food gets moving as fast as the insulin does.

If you look at www.k9diabetes.com/insulinfood.html, I describe the food/insulin balance essentially was a race. If one outruns the other, you get sharp increases (if the food moves too fast) or decreases (if the insulin moves too fast).

This type of curve is actually the simpler one to try to fix with a food increase because you can't do much about how insulin is metabolized but you definitely can change the content of his food to change how it is metabolized.

If you succeed, you would like bring up all of his blood glucose levels and then increase the amount of insulin to bring them down.

The cycling is a concern and could be from other problems... I would want to stay with the same insulin manufacturer for a few weeks and do several curves and see if his BG is consistent when the type of insulin is consistent. If his BG still bounces back up, then there are potential causes like Cushing's disease or infections.

Plus... these readings really aren't bad. Some folks here would give a lot to have their dog spend that much time with BGs in the 100s. So there's a lot of good news here.

Will check back in later,

Natalie

[ozzi]

Re: Insulin Frustrations!

Thanks Natalie! That does make me feel better. Ozzi eats at 8am and 8pm, at the same time that he gets insulin, so the 8am glucose on the curve is his fasting glucose. The vet's office closes at 7pm, so we couldn't get an 8pm reading, and have been unsuccessful taking his blood at home even though we have a glucometer! Our vet keeps telling us to go by symptoms and not by his blood glucose readings, but I feel like tighter control will thwart the onset of complications, and he already has a lumbar neuropathy and visual issues.

[Soaphie & Sydney's Mom]

Re: Insulin Frustrations!

I agree with Natalie - many would be envious of those numbers!

What are you feeding Ozzie & how much?

Hang in there!

Tami & Soapher

[ozzi]

Re: Insulin Frustrations!

Thanks Tami. As I have read more and more in the forum, I see how much tougher others have it. I'm used to people with diabetes, all of whom are really well controlled, so I guess I transferred that desire for tight control to my dog. I worry about the complications that bother him more and more every day, causing him to fall frequently. I built a ramp for him to go out, but there still are 5 stairs that he has to navigate to get to the ramp.

In the meantime, prior to his diagnosis, I never "fed" Ozzi at certain times, but rather left kibble out so he could eat whenever he wanted. This worked well for 13 years, but with the diagnosis, I had to make sure he ate with injections. I currently feed him 3.3 ounces of Alpo Chop House after each insulin injection and leave out Science Diet Mature Adult which he nibbles on throughout the day. I give him Milkbone Chewy treats (1/2 now instead of a whole one) when he comes in from outside, and also give him reduced fat american cheese, and a piece of carrot or apple from time to time. Unfortunately, he was used to eating table food after every meal, so I have severely decreased that, but he does get something after we eat. If it's meat, I have no problem with it but if its carbohydrate, he only gets one piece of macaroni for example. I know its not good, but I've had him since he was 2 months, and don't feel that he would understand if I cut it out completely.

PS: My other dog, Abby, is a 13 year-old terrier mix of some sort, who is not diabetic, but LOVES the addition of the Alpo twice a day....since they both insist on getting the same thing!! LOL

Thanks for your comments.
Kevin

[k9diabetes]

Re: Insulin Frustrations!

Hi Kevin,

Finally I have a little time for the forum!

A couple of things I was thinking reading about Ozzie...

One is that, fortunately, dogs generally don't suffer the kinds of organ damage and complications that you see in human diabetics. My understanding is that part of this is lifespan - that living with diabetes for 30-40 years does a lot of the damage. And the other part is that a dog's body actually tolerates higher blood sugar better with the exception of the cataracts. So the good news is that your dog can have a great happy healthy life even if the blood sugar is not extremely tightly controlled.

The other thing I was thinking is that a dog with blood sugar in the range of Ozzie's is most unlikely to have diabetic neuropathy. It does occur in dogs but is it rare and every time I have seen it happen, it has been in a dog whose blood sugar has been very severely elevated for a number of weeks. Like I've seen it commonly in dogs whose blood sugar is staying at 600-700.

So far every dog I've seen who had neuropathy usually entirely or at least mostly recovered from it. So with good blood sugar if you are still seeing hind leg weakness several months after getting the BG mostly 250 or less, it is important to consider other potential causes.

Diabetic dogs who also have as yet undiagnosed Cushing's disease are infamous for seeming to do well on an increased dose of insulin, only to have the blood sugar pop back up again a few weeks later and then repeating that pattern increase after increase. So if staying on one brand of insulin does not prevent that from happening, Cushing's disease is another possibility to consider.

Cushing's becomes especially important to consider if you get the insulin dose up to 1 unit per pound per injection and are still having this problem.

Another rare occurrence is honeymooning. I'm not really sure why it's called that! You may be familiar with it. This is a revival of the pancreas' ability to produce insulin when the injected insulin gives it a rest for a while. It's essentially always temporary and we don't see it often in diabetic dogs.

Our dog did a quite dramatic honeymoon. He went from 14 units twice a day slowly down to 1 unit twice a day in a 60 pound dog! Every time we did a curve his blood sugar was low and we reduced the insulin. Then one day his pancreas gave out producing insulin for good and his blood sugar went high again and we had to up the dose.

I mention this because maybe Ozzie had the ability at first to produce some insulin and has been slowly losing that ability over the past six months, which has caused you then to have to increase the dose. So it would look like the new dose suddenly stops working when in fact it could be that it's the pancreatic function that's slowly degrading.

Our dog honeymooned a full six months and then lost insulin producing ability quickly but I could see it happening more gradually.

That's a long way of saying that the insulin itself might not have been behind what you were seeing. If you can hold with this pattern now for a longer period of time, you should get a chance to see if the insulin is the source of the confusion or whether something else is going on.

As for storage, most people I know have kept the insulin in the refrigerator. The only reason I can see for not storing it there was if there was some concern that the temperature of the refrigerator was damaging the insulin. Otherwise, my understanding has always been that you can use it longer if you keep it refrigerated.

Just be sure it's standing upright so the crystals don't rest on the rubber stopper.

Natalie

[eileen]

Re: Insulin Frustrations!

Kevin,

If per chance Ozzi is suffering from diabetic neuropathy you might want to look into supplementing him with Methyl-B12.

Having had a diabetic cat with this condition (dogs develop cataracts whereas cats, neuropathy) I did alot of research on the supplement. There are studies that show this to improve conditions in cats as well as humans.
At last look there was not any conclusive studies I could find on its use in dogs because it was said that it is rare, but yet does happen.

Several months ago I suggested Methyl B-12 to a woman on another list who had a dog with what appeared to be neuropathy...could barely walk, couldn't raise his leg to pee without falling over.
She reported just this week that after about a month with Methyl B-12 she is seeing dramatic improvements.

Here's a quick link pertaining to cats with neuropathy.

http://www.felinediabetes.com/weak-back-rear-legs.htm

Of course as Natalie pointed out, most often better glucose control does have them recovering from most signs of neuropathy.

Eileen/Mildred

[ozzi]

Re: Insulin Frustrations!

Thanks Natalie and Eileen. The source of Ozzi's neuropathy has been an issue for some time. About three years ago, he started to have days when he couldn't even get up from a sitting or lying position. This occurred about every 3 or 4 months. We had a full workup done, (labs, ultrasound, spinal Xrays, etc.) and nothing showed up (except over 100 bladder stones for which he had a cystotomy!) The vet said it was essentially a lumbar neuropathy of unknown origin. When his symptoms increased and no longer spontaneously resolved within 24 hours, we started him on deramaxx daily, which helped a great deal. When he was initially diagnosed with diabetes, he essentially could not walk at all. His hind leg weakness had increased ten-fold. His initial blood glucose was almost 700. As expected, his leg weakness responded dramatically with lowered blood sugars. While the source of the neuropathy is unknown, it gets worse with high sugars, and responds to better sugars. Here's the weird thing...if we give Ozzi either Humulin N or Novolin N twice/day, his leg weakness increases, but giving him Humulin in the am and Novolin in the pm improves this dramatically. The vet says she doesn't know why this is happening, but feels that if it's working, continue. I really need to get over the fear of taking his blood so I can curve him at home. I realize that would be very helpful.

[k9diabetes]

Re: Insulin Frustrations!

We definitely see dogs with pre-existing leg problems finding those problems much worse with high blood sugar and being seemingly more sensitive to high blood sugar, presumably because they are kind of on the edge already so it doesn't take as much nerve function blunting for them to show signs of neuropathy.

I wish these kinds of spinal problems were easier to diagnose!

We had weakness and easy tiring in our dog and treated him with Metacam (NSAID) and at one point even tried Tramadol - which made him throw up!

We learned later that the really bad times when he did not want to walk were actually caused by allergies, first to NPH and then to a food we tried, apparently from soy as that was the only new ingredient.

It seemed, for him, to generate almost like a polyarthritic reaction - stiffness, soreness. I spoke to someone shortly after we figured it out and she said she gets very tired and sore if she consumes the food that she's allergic to accidentally.

I only figure it out initially because I was researching stiffness online and came across a forum for people suffering from something called "Stiff Man Syndrome". Several diabetic people posted that they thought they had this SMS but then they eliminated NPH and immediately it cleared up. So we took Chris off of NPH and poof - arthritic stiffness and soreness disappeared within 48 hours! Sure surprised me. Later, we found the same thing with the food change.

Natalie

[k9diabetes]

Re: Insulin Frustrations!

Cushing's also can cause hind leg weakness, which is why I would keep that in mind if things do not improve with both the insulin and the leg weakness.

Canine Cushing's Forum - our "sister" forum

www.k9cushings.com/forum

Natalie

[ozzi]

Re: Insulin Frustrations!

Thanks Natalie! It's funny because when Ozzi initially started insulin, he dramatically improved, to about the level he was at prior to diagnosis. Then he deteriorated until we switched him to Humulin in the am and Novolin in the pm. He has been doing awesome regarding the weakness, until the past few days. He has a great deal of trouble getting up, and when he's up he's pretty good, although most recently if he stands for more than a couple of minutes, his back legs start to gradually "fall" until he cannot seem to hold his weight, and actually "collapses" to the floor. Being a typical male, he absolutely refuses help from us (lol) and prefers to get up on his own, which makes me crazy, yet, as a male myself, I do understand! Our vet talked about changing his insulin from NPH to a different type of insulin if this continues. She also mentioned testing him for Cushings, but felt this was probably not the underlying issue because his blood sugar does respond to the insulin, and some of his readings 6 hours after insulin have been as low as 70, which she said she has never seen in a Cushing's dog. So, I'll keep having his blood monitored until I start it myself, and see what's next. I just wish I could ask him how he's feeling!!!!!!

[k9diabetes]

Re: Insulin Frustrations!

Do you know how to do a quick nerve test?

You support their weight and then turn over a back paw so the top of the paw is resting on the floor.

If the communication via the nerves is good, they should right it quickly to a normal position.

If the communication via the nerves is not good, as in neuropathy or things like degenerative myelopathy, they can't feel that the paw is turned under and they will leave it that way for a long time or even indefinitely.

It's a quick way to test it that you can do at home.

That might help sort out whether this is a pain/arthritis type problem or a nerve/communication problem.

From http://neuro.vetmed.ufl.edu/neuro/NExam.htm

Conscious proprioception is one of the first tests to perform. This reflex is partially responsible for many of the other postural reflex responses and is a good indicator of spinal cord dysfunction. The test in performed by the turning over of each paw, one at a time, so that the animal is standing upon the dorsum of the foot. This is not a normal position for the foot and the normal animal will almost immediately reposition the foot to the normal position, so that it is once again standing upon the plantar surface.

Natalie

[ozzi]

Re: Insulin Frustrations!

Natalie,
I didn't know the fancy name for that test (lol), but the vet has done it a few times when she examines him. His response is very slow, but he does return his back paws to the plantar surface eventually. This was part of the work up that lead her to conclude that he has a neuropathy.
Kevin

[k9diabetes]

Re: Insulin Frustrations!

I didn't know it had such an impressive name either! Just looked it up last night looking for a better description of it than mine.

Natalie

[ozzi]

Re: Insulin Frustrations!

LOL Natalie! I forgot to mention that Ozzi also has a "foot drag" at times. Sometimes when he's walking, particularly when navigating stairs or even going over a threshold, his hind leg paws will "catch" and the dorsal surface ends up under him causing him to fall. At first we thought it was his vision, but now realize that its most likely the neuropathy causing that, so we are very careful with him on stairs and hold his collar. He does well with this in general. The other thing we have noticed is that if we don't immediately clean up after he poops (which can be a challenge on some wintry New England days!) he will unknowingly walk in it, and he seems to have no idea about it. He doesn't try to get it off because I think he doesn't realize it's there. Also, over the past year, he has had episodes (about once/week) of fecal incontinence, and has no idea whatsoever that he is doing so. I think the neuropathy is causing a fairly great loss of sensation in the lower part of his body. He never has urinary incontinence. As I previously mentioned, his neuropathy work-up with our vet showed no tumors or abnormalities on Xray, ultrasound, etc. The year or two previous to these more dramatic symptoms, Ozzi experienced "episodes" about every 3 or 4 months where he would "collapse" and then walked with a limp, which resolved spontaneously within a day or so. He has been on deramaxx for that for the past 3 years. I think somehow that was the beginning of the neuropathy issue. I'm wondering if there is anything that can be done for him or if taking him to a neurologist would be anything more than academic. Does anyone have any thoughts?? Thanks, I appreciate the advice, and I LOVE the forum!! I don't feel all alone anymore!!