Noodle

[Noodle]

Hello

First, I wanted to thank Natalie for providing such an amazing combination of information and support for owners of diabetic dogs. I have been reading here for quite a while and the information has been invaluable! I wanted to start a thread for Noodle and I'm going to pack it with info. My apologies if you fall asleep before you reach the end.

Noodle was diagnosed about a year ago. He is currently on 30 units of NPH (2x day) and also takes Thyroxine (2x day) for low thyroid. He doesn't suffer from any other known illnesses. We test his BG at home (the lip method) pre-meal, pre-walks or other activity & excitement (because they cause him to drop quite a bit), spot checks when needed, and curves. Our meter has been compared to the vets AlphaTRAK and the lab values and is within 15 points (tends to run lower). We initially had a heck of time regulating him, but things improved rapidly once his dose entered the 20's and the Thyroxine was added. He eats Newman's Own Organics Advanced. He also has a reverse curve, so his lowest numbers are always at meal time.

He's been well regulated for many months with BG numbers generally 90 to the upper 100s, with some short trips to the 200+ range when his meals kick in. Depends on the day, activity level, who knows...phase of the moon?

He was originally a little overweight, but his weight resolved itself with the necessary tighter meal routine and elimination of the types of treats he enjoyed prior to the diabetes. Now it's more of an issue maintaining his weight while trying to balance the amount of food to insulin. So of course I had to go and muck everything up by trying to increase his food slightly, and therefore his insulin as well.

We increased his food from his previous 1 1/2 cups each meal to 1 3/4 cups. This of course caused the anticipated giant leap in numbers, so we increased the insulin by 1 unit each injection. I really thought that was a reasonable amount considering he was already on 30U each injection. Initially his BG readings were good and we thought we were on the right track. But then he started to throw us a strange range of numbers. He would have a day or 2 where even his pre-meal readings were up in the 200 range and his later numbers would jump to the 300 & 400's. But then the next day or so we would be fighting lows much of the day, particularly in the few hours before meals.

He does not show any signs of illness or infection and his activity, playfulness, and appetite have consistently been normal. His water consumption goes up a bit when he is running high for long periods, but nothing extreme. We would have never known his BG was so screwy if it had not been for home testing. He had a few infections back before he was regulated (ear & bladder). From those experiences we know his BG goes up and stays there when he is ill and/or on antibiotics.

I decided to curve him and a typical curve with BG tests every 2 hours wasn't giving us enough information since the swings were so great from one day to the next. With the weird wide ranges we were seeing I was starting to suspect we had overshot the increase and he was repeatedly rebounding. So Noodle and I have been very sleepy the last several days as we test around the clock looking for precipitous drops/increases...and I think we found them. I have since pulled back to his original 30 units per shot while maintaining the increase in food. His highs have dropped but we are still seeing lows too far in advance of his meals. I'm hoping that resolves in the next few days.

Here are his latest curves:

Sat 2/6 (31 units)
6am - 257
8am - 260
10am - 222 (then food & insulin)
12pm - 309
2pm - 275
4pm - 377
5pm - 302 (walk after)
6pm - 276 (unusual for him - usually drops further with activity)
8pm - 154
10pm - 132 (then food & insulin)
12am - 267
2am - 347

Sun 2/7 (31 units)
4am - 392 (husband spot checked him when he was up)
8am - 114 (the big drop made me check him more before his meal)
8:30am - 99
9am - 58 (Yikes! Gave him glucose tab & biscuit)
9:15am - 104
9:30am - 114
10am - 119 (then food & insulin)
12pm - 155
3pm - 138
5pm - 135
7pm - 87 (Too low 3 hours before next meal - glucose tab & biscuit)
10pm - 93 (then food & insulin)
12am - 168
2am - 214

Mon 2/8 (31 units)
6am - 228
8am - 203
10am - 148 (then food & insulin)
12pm - 259
4:30pm - 461! (followed by walk)
5:30pm - 473! (NOT the norm - usually drops quite a bit after walk)
7pm - 344
10pm - 205 (then food & insulin)
12am - 421!

*Decided to drop him back to the original 30 units but maintain the food increase (1 3/4 cups each meal). *

Tues 2/9 (30 units)
4am - 465!
6am - 157 (308 point drop in 2 hours!)
7am - 122
8am - 92
9am - 104
10am - 82 (then food & insulin)
11am - 161
12pm - 243
3pm - 238
6pm - 68 (UGH! Glucose tab & biscuit)
6:30pm - 114
7pm - 120
8pm - 102
9pm - 103
10pm - 72 (Another glucose tab to stop the drop, then food & insulin)
11pm - 127
12am - 239
2am - 236

Today, Wed 2/10 (30 units)
4am - 236
6am - 118
7am - 85 (too low 3 hours before meal - glucose tab & biscuit)
8am - 98
9am - 83 (glucose tab to stop the drop)
10am - 101 (then food & insulin)
12pm - 204
2pm - 241
5pm - 267

So that's where we are so far. Since the drop back to 30 units we have not seen the extreme highs, but we are still fighting the lows and his afternoon numbers today are still higher than his previous norm. Do the extreme variances of highs and lows from one day to the next, and/or the very rapid drops, look like Somogyi rebound...all from a one unit per injection increase?

I'm encouraged that his upper numbers have come down and I'm hoping the lows will come up as the increase leaves his body. In the past he has taken about 3 days to settle into a new dose and this is day 2.

On a side note: I know the amount of testing looks extreme. This is absolutely not the norm, but the lows made me feel like I had to monitor him very closely. He never has symptoms when he runs low, so the only way to catch it is to test. The lip testing doesn't bother Noodle a bit - he can literally sleep through it when he's tired. When he's awake, he comes right over and lays his head in my lap with his nose pointed up. He is the most easy going diabetic dog...we are very fortunate.

Did anyone make it to the end of this post without a break for a nap?

[CarolW]

Re: Noodle

Despite my propensity for falling asleep at the keyboard, your information was excellent, and kept me awake throughout. The details of your report are extremely useful. I wish everyone would be as detailed.

I have some thoughts here, but others are more expert at this, by far, than I am.

First, you MIGHT need to drop the insulin dose below 30 units, to re-establish something like normal responses to the insulin. Which would likely cause some higher BGs for a few days; on the OTHER hand, you might well avoid those scary lows!

The goal would be to stop having to give glucose tablets and extra snacks, as they likely continue to confuse the issue.

My guess is, you'd want to hold Noodle steady for several days, on a lower dose; maybe 29 units? During this period, I would not change the food; I'd continue with the increased amount, unless you see something really weird when you test.

Normally, I don't like all that testing, but I think you are absolutely right to be doing it.

Please keep us closely posted. Cheering you on! Now, please pay attention to what those who know more than I do have to say; there are a number who will probably reply to your thread.

Wed, 10 Feb 2010 17:08:23 (PST)

[Patty]

Re: Noodle

So that's where we are so far. Since the drop back to 30 units we have not seen the extreme highs, but we are still fighting the lows and his afternoon numbers today are still higher than his previous norm. Do the extreme variances of highs and lows from one day to the next, and/or the very rapid drops, look like Somogyi rebound...all from a one unit per injection increase?

Hi and Welcome!

Your information is great! I'd like to be able to sit down and look at your numbers some more later but I don't see obvious rebound going on. I think you could have seen it Tuesday morning with such a fast drop but it didn't happen.

I too hope the lows come up as the residual increase leaves the body. You may need to back off a little more even to get a true picture of what's going on. I'd back off to a point where you don't have any lows even if you have highs for a little bit. You know a unit increase is too much, so if you take a look at the curve without the lows maybe there's some other tweaking that can happen to balance the food/insulin a little better or even increasing in smaller 1/4 - 1/2 unit increments.

Other thoughts:
Infection (though I know you said he usually runs consistently high during infection)
When was his last blood draw for therapeutic thyroid level?
How many days are you on for this insulin bottle?
It may be too that the insulin increase helped bring down his initial numbers but as he settled in it became too strong for him, especially later once his food is gone creating the lows and even overlap on some days.

What type of dog is Noodle? How much does he weigh now? What do you consider his ideal weight since I know you are trying to put some weight on him?

Again, welcome. There are a lot people here to bounce ideas off of.
Take care,
Patty

[Noodle]

Re: Noodle

Thank you for the welcome, thoughts, and questions. Let me answer the questions first...

Noodle is a Lab mix and was about 65 pounds at diagnosis. The vet said he wasn't obese but if the new routine helped him drop a little, that would be great and that 60 was probably ideal for him. He easily achieved that but since then has gone slowly up and down from a low end of 53 to a higher end of 58 or so. The vet has seen him as low as 55 and thought he looked fine.

There just seems to be something about that last couple of pounds when they drop. Once he hits 55 or less, you can see his ribs too easily and he just doesn't look healthy to me. I was also concerned because his activity level will increase in the Spring as the weather warms up, with longer walks and playing with his neighborhood buddies - there are a LOT of dogs in our neighborhood. I was hoping to stabilize his weight before I had extra calorie burning to add to the equation. I would say the weight he looks healthiest is about 58lbs but I would settle for always maintaining above 55. But honestly, I wish I hadn't messed with things since his regulation was so good!

Funny you should ask about the insulin vial. I just called in a refill last night and began the new vial tonight. His screwy numbers do coincide with the duration of his last vial of insulin. I don't think anything at home could have compromised the vial in any way. I keep a refrigerator thermometer next to the insulin and the temperature is always fine. Because of his large dose, a vial only lasts us a little over 2 weeks - the expiration date is fine and we've only had it for 2 weeks. We purchase it from Walgreen's and haven't had any problems in the past. It hasn't been dropped or shaken and the appearance is the same as always. Can the strength of the insulin vary enough from vial to vial to cause problems?

He goes to the vet next week for his blood draw to check the thyroid levels. I was already wondering if the Thyroxine was contributing to the constant slow weight lose. He is on the minimum dose, but it should be interesting to see the results of the blood work. Can a dog who previously needed the Thyroxine to regulate suddenly not need it anymore?

If we don't have his numbers resolved by next weeks appt, I already planned on having them check his urine and give him the once over (particularly his ears) for signs of infection or anything else I may be missing. It just seemed too coincidental that his numbers flaked out after I messed around with the food/insulin. Last summer he did fall out of regulation (his numbers were very high) and the vet couldn't find anything wrong with him. But they agreed to try a round of antibiotics and his numbers went back down to normal, so we figured he had a low grade infection somewhere.

We may be seeing a light at the end of the tunnel though. He did hit another low end number tonight (76), but not until 1 hour before meal time which is an improvement. I stuck with the 30 units again tonight. I'm going to stay up and test him until I'm sure he is maintaining high enough numbers. We will check him again at 4 & 6am to see if he is dropping too low again, too early. If he is, I'm going to drop him another unit (to 29) at breakfast until we get rid of these early low numbers. As much as I hate highs, the worry and lack of sleep is getting to me - I can't keep testing him around the clock much longer. We will just have to let him flip to the higher end for a bit and then work down from there. But it makes me a wreck since his eye sight has not been effected and I'm always fearful that he will lose his sight if he has highs for too long. Which brings me to my next question...

We previously used the U-100, 31g, short needle syringes that held 30 units. Since he eventually went up to the 30 unit mark, the vet switched us to the syringes that hold 50 units. It's really hard to judge half units or less on these things but I'm not finding the larger unit syringes with half unit markings. Is that only available on the smaller 30 unit syringes? I found some other combos on websites, but none with the magic combo of 31 gauge and holding more than 30 units. I'm not sure if the needle gauge would make a big difference to him or not - he's extremely easy to inject, so he might not mind a bit larger gauge.

Thank you for letting me bounce things around. It's so nice to have a place to think out loud with others who understand the situation - not to mention people who I don't have to justify why I BG test at home or continually aim for good regulation. Sometimes it feels like you're banging your head against the wall.

[CarolW]

Re: Noodle

Just a few quickie notes here - I believe only the 3/10 cc syringes have half-unit markings; sorry!

The insulin should be just fine, if you're using up a vial in two weeks; my vet has me use a vial for five weeks before discarding. My Kumbi is currently on 7.5 units of Novolin-NPH insulin, twice daily, and I can't use up the full contents of a vial in five weeks. No matter; I keep the vials around for at time, and eventually discard them. I make sure to have one or two fresh vials available, in case I drop one.

Which NPH insulin is Noodle on? Just curious.

About exercise, you are so right; increasing exercise will change insulin requirements. Too bad we can't just allow diabetic dogs to exercise at will, if they tend to overdo things. Once you have good regulation, though, you could feed before an exercise period, or even after, if need be, and try to time exercise so it doesn't occur at the same time the insulin is peaking!

I can't really do that with Kumbi - his insulin tends to peak anywhere from 3 to 6 p.m. - and he needs his afternoon walks, so I usually give him a snack (10 kibbles, at the moment), about 3 p.m. I dare do this because I have lots of curves on Kumbi, so I know what his trends are.

It's only in the beginning, before a dog is reasonably well-regulated, that snacks aren't advised (apart from hypoglycemic episodes - I mention that because we have a newly-diagnosed, hypoglycemic dog on the forum currently).

One thing I'm considering doing, with my poor vision, is using a very fine-tipped permanent marker to mark the barrel of the syringe at Kumbi's current dose, 7.5 units - off to one side of the marking, so I don't obscure the actual marking. I think maybe I'll do that with a red marker. It's a tricky maneuver to make that mark! I think I'll practice on used syringes!

Thu, 11 Feb 2010 01:16:48 (PST)

[Noodle]

Re: Noodle

Which NPH insulin is Noodle on? Just curious.

He is on Humulin N.

Looks like we may be back to normal or close to it. His breakfast number was 101, which is right in his average am pre-meal range before I increased the insulin. I expect to start seeing higher than normal post meal increases though since I kept him on the increased food but he's back to the old insulin dose.

I'm going to leave it at 30 for a while until I'm positive the lows are gone. Unfortunately, he was already at 348 2 hours after his meal last night. I left him alone after that so I'm not sure if it climbed any higher. My husband checked him at 4am and he was down to 257, so hopefully he didn't stay in the 300's very long.

[CarolW]

Re: Noodle

|I wouldn't worry too much, for a few days, if Noodle's BGs get into the mid-300's; he doesn't seem to be staying there long; of course, you can check (when you can!)

I like your plans; hold steady for several days, as it takes that long before the body adjusts.

Please keep your reports coming!

Thu, 11 Feb 2010 09:11:46 (PST)

[k9diabetes]

Re: Noodle

It's not clear to me whether the half cc syringes from Hocks have half unit marks:

http://hocks.com/Merchant5/graphics/...01/4724266.jpg

[k9diabetes]

Re: Noodle

The attached isn't much more help but it does list the various syringes available from BD. See the first page of syringes.

http://www.bd.com/hypodermic/pdf/BD_Hypo_Catalog.pdf

[Patty]

Re: Noodle

Hi,

But honestly, I wish I hadn't messed with things since his regulation was so good!

I do understand that frustration. It's hard to rock the boat when you have a good thing going with numbers.

Funny you should ask about the insulin vial. I just called in a refill last night and began the new vial tonight. His screwy numbers do coincide with the duration of his last vial of insulin.

Your vial should be fine. But any time you get toward the bottom of the vial I think the concentration can change a bit within the fluid that's left, just from the mixing process if nothing else. Human diabetes educators often advise to only use a vial until there a 1/4 left in the bottom and not beyond that for this reason.

Can a dog who previously needed the Thyroxine to regulate suddenly not need it anymore?

I do know depending on the blood draw his needs can fluctuate and he may need a larger or smaller dose.

If we don't have his numbers resolved by next weeks appt, I already planned on having them check his urine and give him the once over (particularly his ears) for signs of infection or anything else I may be missing.

That's a good idea. Just to rule out any extraneous factors.

It just seemed too coincidental that his numbers flaked out after I messed around with the food/insulin.

I agree. It may very well be that you'll have to work with the food/insulin balance.

the worry and lack of sleep is getting to me - I can't keep testing him around the clock much longer. We will just have to let him flip to the higher end for a bit and then work down from there. But it makes me a wreck since his eye sight has not been effected and I'm always fearful that he will lose his sight if he has highs for too long.

I do understand that! Ali frequently throws me for a loop and I'm up trying to figure out our next move. I worry about her eyesight as well. But you do have numbers coming down into the 100s still and are not running him higher for a long period of time. Just long enough to figure out what the pattern is without adding food to keep the bgs up. And I think that will help you the most in finding a long term solution.

It's really hard to judge half units or less on these things but I'm not finding the larger unit syringes with half unit markings. Is that only available on the smaller 30 unit syringes?

I know Carol and Natalie addressed your syringe question. Since you can't get the 1/2 unit markings, can you find a landmark on the syringe to eyeball a 1/2 unit increase if you needed to? When I eyeball 1/4 unit changes in Ali's dose, I try to line up the plunger with a certain line. I'll look at where the top of the black lip is in the barrel - 7 1/4 unit would have the center of the lip on the plunger lined up with the 7 1/2 unit mark for example. That way you can repeat it.

not to mention people who I don't have to justify why I BG test at home or continually aim for good regulation. Sometimes it feels like you're banging your head against the wall.

I agree. The people here are great for bouncing ideas around . Sounds like you have a good understanding of what's going on. It's just hard to find that balance. Feel free to post your curve after Noodle's been on the lower dose for a while.

Take care,
Patty

[Noodle]

Re: Noodle

Thanks, Natalie. I wish they made it easier for everybody and listed the markings for each type. Of course, I also wish all the makers would manufacturer syringes with quarter, or at least half markings, on each syringe size they offer. I guess human diabetics don't necessarily have to deal much in half & quarter units above 30 units, so they must not feel there is enough of a market to make it worth their while.

It would be nice to have a line of diabetic pet specific products...but they would probably just try to overcharge for them anyway.

[Noodle]

Re: Noodle

Patty, that's interesting about the vial potentially changing strength as you near the bottom. Sometimes Noodle's numbers creep up as we approach the last quarter. I call it the bottom of the vial blues, lol. My husband thinks I'm nuts, but if I switch him to a fresh vial, sure enough, they come right back down.

I'm going to take a closer look at the current 50 unit syringes we have and see how close I may be able to eyeball a half or even quarter unit increase, and look for a landmark. If that doesn't work, it may be easier to go back to the 30 unit syringes and just draw beyond the 30 a bit. Since the spacing is bigger its just easier to eyeball then on the 50's.

I'm taking it easy on him today since I know I will have to start checking for lows again early this evening. But I will probably curve him again on Monday, as long as he continues to stay clear of those lows through the weekend...paws crossed.

[Patty]

Re: Noodle

One other thought that might help...they do make syringe magnifiers too that might allow you to see the smaller adjustments a little better. There are several kinds out on the market if you google them.

[Noodle]

Re: Noodle

Oh, I am soooo buying one of those. Looks particularly handy for those of us entering our reading glasses years. *sigh*

[Noodle]

Re: Noodle

I've read the comparison of meters that was performed that put the One Touch Ultra at the top of the list of human meters. Does anyone know if the Mini version of that is comparable? I just received a free one in the mail and tested it against our current meter using the same blood sample.

Current Meter - 309
UltraMini - 253

As much as I like the lower number the Mini gave me, I suspect it is the one father off than my current meter. The last time my vet and I compared my meter to their AlphaTRAK, mine was 14 points lower. Having said that, we haven't tested and compared since sometime last summer. Also, he runs lower at the vet from all the excitement so it may be more accurate in the lower range.