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Jessie, Min schnauzer just dx-ed

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  • #61
    Re: Jessie, Min schnauzer just dx-ed

    I think he is doing it the easiest way for him: 6 then 8 then 10. While he has many positive traits.
    I wonder if he's ever stopped to think what 6 - 8 - 10 is in terms of percentage increase!

    Alison

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    • #62
      Re: Jessie, Min schnauzer just dx-ed

      Yeah... it really does help with small dogs to think in terms of percentages instead of units. Raising a dose of 25 units to 27 is no big deal - an 8% increase. Raising a dose from 6 to 10 is a 66% increase!

      In a dog whose blood sugar got down into the 300s on 6 units... Yikes!

      Comment


      • #63
        Re: Jessie, Min schnauzer just dx-ed

        Don't laugh but I have no idea what any of these levels mean. I asked him to find out what we are shooting for. What is "normal"? Where do we want jessie to be? I have no clue.

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        • #64
          Re: Jessie, Min schnauzer just dx-ed

          Ideal regulation in a diabetic dog, which is actually rarely achieved, would be for blood sugar to fall between 100 and 150.

          Slightly more reasonable but also not always manageable is 100-180.

          Generally I'd say aim to have blood sugar throughout the day between 100 and 250 with as much below 200 as possible.

          Makes no difference to me what the curve looks like - some are valleys with lowest blood sugar mid-day, some are mountains with lowest blood sugar at meal times, some are even like a double humped camel!

          The thing to aim for is the flatest range of levels possible.

          Lowest blood sugar always controls how much insulin you can give.

          If the blood sugar starts at 250, drops to 100, and then rises back to 250, great! No more insulin needed.

          If the blood sugar starts at 500, drops to 100, and then rises back to 500, NOT so great... but you can't give any more insulin because more insulin will drop that 100 lower still.

          That's why you want the curve to be as flat as possible and you decide how much insulin to give based on the lowest average blood sugar.

          There is variation day to day, which is why we aim to keep it around 100 for a low. So on days when it goes lower than average, there is some room for it drop safely.

          Blood sugar down into the 60s is hypoglycemia and anything significantly lower than that, 40s, 30s, 20s, can result in seizures, coma, and brain damage.

          I get low blood sugar and I feel pretty awful when my blood sugar hits the low 60s and high 50s.

          Keeping the blood sugar under 180 prevents blood sugar from spilling into the urine.

          Natalie

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          • #65
            Re: Jessie, Min schnauzer just dx-ed

            Nat, Pat, Peggy, Alison - thank you. I drafted a book and sent it. I am going to go see if I can sleep now. You are all angels. Thank you.

            PS Thru all of this Jessie acts totally normal. Other than the urination she is happy go lucky and clueless that we are all worried about her.

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            • #66
              Re: Jessie, Min schnauzer just dx-ed

              Well, that's a good thing!

              We live in an urban area with dozens of vets and a vet school and in the end we still had to work things out ourselves for Chris. You will get it worked out too.

              Natalie

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              • #67
                Re: Jessie, Min schnauzer just dx-ed

                Hi Kim

                How is Jessie today?
                Forbin, miss you every day. See you at the bridge Buddy.

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                • #68
                  Re: Jessie, Min schnauzer just dx-ed

                  Hi Kim,

                  Also checking to see how Jessie is doing today. Hugs
                  Luv,

                  Lynne and Angel Lady 7/98-3/09 Forever in my heart

                  Comment


                  • #69
                    Re: Jessie, Min schnauzer just dx-ed

                    I am at work. Did not hear from mom or stepdad this morning so I don't know what they decided to do. I have nervously checked my emails all day. I will keep you posted.

                    Comment


                    • #70
                      Re: Jessie, Min schnauzer just dx-ed

                      Sorry for not getting back to all of you who were so helpful the other night as I struggled to grasp the basics and pass them along to my parents. I was afraid that I failed when there was no update yesterday.

                      This a.m. I emailed my mom to ask about Jess and what they decided regarding reducing the dosage from the vets recommended 10 units to 6.5 as you suggested. She replied that he decided to go with the vet's instructions. He feels if he's doctoring with this vet he needs to follow his instructions....She said she reminded him that doctors aren't always right.

                      And that was it. So at this point I pushed it as far as I feel I can. I think it will take a major scare to prove a point and there isn't anything more I can do about it. I just pray Jess can handle the increase. If she can't, I pray she lives thru it. I am sick.

                      Thanks to everyone who helped. Kim

                      Comment


                      • #71
                        Re: Jessie, Min schnauzer just dx-ed

                        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
                        Patty and Ali 13.5yrs 47lbs diagnosed May '08 Ali earned her wings October 27, 2012, 4 months after diagnosis of a meningioma ~ Time is precious ~

                        Comment


                        • #72
                          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

                          Comment


                          • #73
                            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

                            Comment


                            • #74
                              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

                              Comment


                              • #75
                                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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