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  #71  
Old 04-14-2010, 04:58 PM
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Default Re: Jessie, Min schnauzer just dx-ed

Quote:
Originally Posted by k9diabetes View Post
Take a blood sugar readings:

- before food and insulin
- 1 hour after
- 2 hours after
- 4 hours after
- 6 hours after
- 8 hours after
- 10 hours after
- before next food and insulin
- 1 hour after
- 2 hours after

That's a long curve and a few more readings than absolutely necessary but I'd like to see what her blood sugar does in some detail in that first two hours after food and insulin.
Oh Kim,
I do understand the struggle. You do what you can do.

Maybe if they can make it to the next curve, they can get more detailed readings, closer to what Natalie posted even if not the whole time span...and a photocopy That will at least give a snapshot picture of what's going on.

Please keep us posted.
I know you have your hands full with your own pups.
Take care,
Patty
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  #72  
Old 04-14-2010, 06:09 PM
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Default Re: Jessie, Min schnauzer just dx-ed

Kim... frankly, I'm worried about Jessie's future. Can you call the vet and talk to him about the possibility of rebound?

Seems like he knows you well enough to put some faith in your concerns.

Natalie
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  #73  
Old 04-14-2010, 06:27 PM
frijole frijole is offline
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Default Re: Jessie, Min schnauzer just dx-ed

I am hesitant to continue to be involved because I feel to push any harder I am undermining my stepfather. I cannot tell you how hard I argued the case. I am shocked he took the easy out.

The vet will most likely say he is comfortable with the dosing amount. Since I am not the owner I can only make suggestions - What could I suggest? A 12 hr curve? Remember my ability to have an intelligent conversation on the topic of diabetes is still somewhat limited.

I am open to ideas... I have to mull this over because I am really really in the middle here. Thanks, Kim
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  #74  
Old 04-14-2010, 07:20 PM
frijole frijole is offline
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Default Re: Jessie, Min schnauzer just dx-ed

I just emailed my mom and sent your message to her. I asked for permission to talk to the vet. Told them to have the Karo handy and to look for the symptoms. Hopefully I will get the go ahead and will call tomorrow. I am out of town Friday and Saturday.

Here is what I am thinking I should bring up:

While Jessie was not controlled at 6 units at least her readings went down after the insulin.

At 8 units her readings all went up.

The measurement is not a complete curve and I am concerned about the lows that are possibly not measured.

I am concerned about a 60+% increase in 2 weeks time. I would like as close to a 12 hr curve done as I can get and the ketones checked asap.

-----------
What did I miss? Is anything incorrect or unclear?

Thanks
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  #75  
Old 04-14-2010, 08:49 PM
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Default Re: Jessie, Min schnauzer just dx-ed

I suggest printing up information on rebound and mention that you are concerned that the now higher readings on more insulin could be somogyi rebound. Mention that the blood sugar dipped into the 300s on 6 units and now Jessie is being given much much more than that.

I'm going to quote here some information from a manual put out by Intervet, which makes Vetsulin insulin. You can print off the entire PDF if you would rather. http://www.vetsulin.com/PDF/20585.pdf

Dose Adjustment

In dogs, dose adjustment should be managed in steps of 10 percent. Following adjustment, evaluation should not take place before the new
dose has been given for a period of at least five to seven days.

The most accurate way to assess response to treatment is by generating a blood glucose curve. Ideally, the first sample should be taken just prior to insulin administration. Alternatively, after the dog has been given its first meal followed by the insulin injection in the morning, the first blood sample should be taken as soon as possible.

Thereafter, blood samples should be taken approximately every two hours throughout the day (12–24 hours). Prior to the insulin injection, the blood glucose is usually elevated. Following injection and absorption of Vetsulin, the blood glucose is expected to fall; at some point the glucose should plateau at its lowest blood concentration (the glucose nadir) after which it climbs again to approximately pre-injection levels. Blood glucose curves at the clinic only approximate how the diabetic dog
responds to insulin at home. Feeding and exercise patterns are different and stress can markedly alter the glycemic response. Some clinicians teach their clients to perform blood glucose curves at home using blood from the pinna and portable glucometers.

Somogyi Effect

An insulin dose that is slightly too high may bring about the Somogyi effect, otherwise known as rebound hyperglycemia. This is a chain of reactions through which the body attempts to counteract the decline in the blood glucose concentration. If the blood glucose concentration falls to less than 65 mg/dl (3.6 mmol/L), or if the blood glucose decreases rapidly regardless of the glucose nadir following injection of insulin, the dog may become hungry and restless or lethargic. In response to a declining glucose level in the CNS, epinephrine, cortisol, glucagon and growth hormone are released.

These hormones bring about an increase in the blood glucose concentration through gluconeogenesis, release of glucose from hepatic glycogen and increased peripheral resistance to insulin.

Polyuria and polydipsia are seen, and this can easily be misinterpreted. If the morning polyuria is thought to be the result of an insufficient insulin dose and a higher dose is given, the problem will be aggravated. An even more pronounced Somogyi effect will follow and, sooner or later, this may result in severe hypoglycemia when the counter-regulatory mechanisms are exhausted.

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 after lowering the insulin dose.

If the Somogyi effect is suspected, an alternative approach involves decreasing the dose by 10–25 percent and closely observing the clinical picture. If signs of polyuria or polydipsia become worse following dose adjustment, it is unlikely that a Somogyi effect was the cause of the regulation problems.

Conversely, if the polyuria and polydipsia disappear within two to three days, it is probable that the Somogyi effect was the cause.

What is Somogyi Overswing?

Somogyi overswing is the normal physiological response to hypoglycemia caused by a high insulin dose. It is also called insulin-induced hyperglycemia or Somogyi effect.

Why does it occur?

After the administration of a high dose of insulin, glycemia decreases rapidly [below 65 mg/dl (3.6 mmol/L)]. A chain of reactions which counteract hypoglycemia are initiated:

• Release of epinephrine, ACTH, glucagon and growth hormone

• Stimulation of lipolysis, gluconeogenesis and glucogenolysis

This results in rebound hyperglycemia (with or without ketosis) that cannot be controlled, as a diabetic dog does not secrete sufficient endogenous insulin. Glycemia can reach levels of 400 mg/dl (22 mmol/L)
or greater.



Although the attending veterinary practitioner should be highly suspicious if the dosage of insulin is exceeding 2 IU/kg, a blood glucose curve is the only diagnostic tool that can be used to detect a Somogyi effect. Either of the following blood glucose curves indicates the Somogyi effect:

• Hypoglycaemia (low nadir) followed by rebound hyperglycaemia.

• A rapid decrease in blood glucose with an adequate nadir, followed by rebound hyperglycemia.
__________

It's important to note that the blood sugar can run amok for as much as three to four days after a rebound. So if a curve is done immediately within three or four days of one occurring, you may just see high blood sugar. That does NOT mean that rebound did not occur. It is necessary to reduce the dose of insulin - in this case back to 6.0 or 6.5 units - and then wait probably 5 days and then do a curve to see what the insulin is actually doing.

I'm especially concerned because they cut out the snacks. Cutting them out is good... but if the insulin is already basically an overdose, reducing the amount of food she gets with it could make matters worse!

I know this is a terrible time for you so I especially thank you for trying to go to bat for Jessie because I am quite worried about that insulin dose. If she rebounds all this time, her body will eventually exhaust the glucose reserves and she won't be able to recover.

I have, sadly, seen a dog who was given an absolutely massive overdose due to bad instructions on how to fill the syringe. That dog was given something like 10 times the dose of insulin she should have gotten. She survived three or four days - almost unbelievable given how much insulin was being injected - but eventually she had no glucose reserves left and she lapsed into a coma and died.

Maybe the vet can be appealed to "better safe than sorry" and agree to reduce the dose, back up, and move more slowly.

Natalie
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  #76  
Old 04-15-2010, 05:17 AM
frijole frijole is offline
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Default Re: Jessie, Min schnauzer just dx-ed

Nat, that is what I needed thanks. I just got the OK to phone the vet. That article on the Somogyi Effect helped alot. I am guessing that my stepdad didn't bring up or be specific enough about Jess's increase in thirst and urination. Thanks. Kim
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  #77  
Old 04-15-2010, 10:15 AM
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Default Re: Jessie, Min schnauzer just dx-ed

Kim,
That is so good to hear!! Keep us posted.
Patty
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  #78  
Old 04-15-2010, 11:16 AM
frijole frijole is offline
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Default Re: Jessie, Min schnauzer just dx-ed

Those articles you gave me Natalie really hit home with them. My stepdad all of a sudden saw firsthand that the source of your info and recommendation was coming from medical info and not just internet chatter. (even tho I had said this before)

They were going to review everything and get with the vet themselves. My mom said that my stepdad was not understanding the vet and that as is his style, he was embarrassed to ask questions. I told them that they needed to understand this disease and get over the fear of asking questions because Jess' life is on the line. I also told them to have that meeting today for the same reason.

I just got an email that they are meeting with him at 2:30. My mom is going as well which is a good thing because she is not afraid. I told them not to back down from the 6.5 units number and exactly why. If I worked in the same town I would have gone but I am 30 minutes away and today is the busiest day of the year for me... timing...

Fingers crossed.
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  #79  
Old 04-15-2010, 11:48 AM
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Default Re: Jessie, Min schnauzer just dx-ed

That's great Kim! I hope the vet cooperates.

Natalie
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  #80  
Old 04-15-2010, 11:51 AM
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Default Re: Jessie, Min schnauzer just dx-ed

Tell your stepdad that plenty of vets don't really understand diabetes either and should be asking someone who does!

Nobody who has neither a medical degree nor a veterinary degree should feel embarrassed because they don't understand a medical condition!

Wouldn't it be nice if we all were just born understanding Cushing's and Diabetes!! Think of all the time and money and heartache we would have saved ourselves.

Natalie
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