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Old 03-30-2010, 02:26 PM
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icaru icaru is offline
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Default My Gigi - 5+ years, end stages?

Hi,

On March 5, 2010, our nearly-9-yr-old Maltese dog, Gigi, was diagnosed with diabetes and mitral insufficiency. She was exhaustively tested for Cushings -- negative. However, she is on heart meds: Fortikor and furosemide.

We live in Europe, vets in Europe use Caninsulin (Vetinsulin) almost exclusively (widely available here, no warning issued). The vets I have contacted (6 of them) have little or no experience with Humulin formulations.

Gigi weighs 9 pounds. She was started on 5 units of Caninsulin once daily. Within a few days it became apparent that she was rapidly metabolizing this insulin and the effect was gone after about 6 hours. The vet then reduced the dose and began twice daily injections, one every 12 hours with a meal.

At first the curve looked promising but once again, after a few days we saw wild swings in the space of 6-7 hrs: from 120 to 400+. After 4pm (7 hrs after injection), her BG value was/is always over 350 until the next injection takes effect.

We decided to try Humulin N. Our vet agreed to try it but admitted that he has never had experience treating a dog with human insulin.

After a week of 'start low, go slow' we again reached 4 IU twice daily = 8 units of insulin for a 9-pound dog. It's a lot! But alas, same problem. From about 4pm until the second injection takes effect around 11pm, her BG values are in the 300 - 400s. IOW, she quickly metabolizes whatever insulin she receives, and the effect is gone. We are unable to extend the duration.

We tried increasing the dosage - at first with Caninsulin, later with Humulin. Both times we got the Somogyi effect. Her BG went down to 40 then shot up about 100 mg/DL per hour until it leveled off above 500.

The vet tells me he has never had a dog as difficult to regulate as ours. The dog has now been in and out of the vet hospital for over 10 days trying to find a smooth curve but so far no luck.

We've two questions:

1) Has anyone else had a similarly difficult experience in regulating their dog, and if so, what worked? Should I try a mixture of N and L? I read that L is not very effective for dogs.

2) Although we have a glucometer, we have let the vet do the glucose curves because we are only able to draw blood from Gigi's upper lip. To get 7 readings in a day we have to prick her lip(s) an average of 10 times during the day. We tried unsuccessfully to draw blood from the pinna of her ear but only once we got enough blood for a reading. Even warming the ear with hot water and rubbing it doesn't work. The vein is tiny, collapses and it clearly hurts her when lanced. So we've given up on the ear. I read that some people draw blood from the base of the tail. Our vet told me not to do this for fear of infection.

What have people with very small dogs found to be an effective technique to get enough blood for a glucometer?

Any experiences you have to share in regulating an insulin resistent dog and / or successfully drawing blood from elsewhere than the lip will be greatly appreciated.

Carole
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Old 03-30-2010, 03:37 PM
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Default Re: Insulin resistance - unable to regulate

Hi Carole and welcome!

Can you tell us what food Gigi is eating? Has she always been on this food?

Sometimes tweaking the diet can help with altering the shape of the curve and extending the duration of insulin. Other times it truly is the way the body is handling the insulin.

I think Natalie's experience resonates closely with your story and I'm sure she'll be along to help as well. Have you read the case study of her dog Chris? http://www.k9diabetes.com/storychrisk.html

Humulin L is no longer in production. I know some of the insulins have different names in Europe. There are some people that use Humulin R (called Humulin S, for "soluble," over there) http://petdiabetes.wikia.com/wiki/Humulin_S to bring down post meal spikes or to cover a short period of time where the longer acting insulin has faded. But you'd definitely want to be able to do a lot of testing.

Another option is to give the NPH 3x a day to cover the gap where blood sugar is rising.

As I said Natalie has some experience with this so I'll let her address those options with you.

There are some people that test the base of the tail with great success as well as the carpal pad. I think Heidi is one of those that have used these places on her dog. I'll see if she can comment.

Take care,
Patty
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Old 03-30-2010, 04:24 PM
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Default Re: Insulin resistance - unable to regulate

Hi Carole,

Please post the results of curves you have had done in addition to telling us more about her food.

I'm not concerned about her dose - 1/2 a unit per pound per injection is fairly common.

The main tools you have to improve regulation are the content of the diet, how often you give food, and how often you give insulin. If someone is home with Gigi most of the time, you have the most options because you can give more meals and/or more injections.

So if we can take a look at her curves, we can see what might work to improve them and talk about what's possible for you given your schedule.

I think the back at the base of the tail would be an excellent place to test Gigi. I know many people who have used this spot for years. The carpal pad is another possibility.

Natalie
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Old 03-30-2010, 07:09 PM
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Default Re: Insulin resistance - unable to regulate

Carole,

Hi and welcome. Don't worry about the insulin dose, it's still in an average range. My Buddy was just over 5kg (around 11 lbs) and he got 4iu twice a day. The specialist said that all the diabetic dogs he was treating at the time were all getting their weight in kg in insulin units!

Jenny

PS 9lb is 4.08kg
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Old 03-30-2010, 09:09 PM
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Arrow Re: Insulin resistance - unable to regulate

To Carole from Carol - a big, fat welcome to you and Gigi! I LOVE Maltese!

You said Gigi was diagnosed on 5 March - well, that's only a few weeks back; it can take time to work out how to regulate a dog on insulin, especially when you have the other (here, heart) complications as well. And food makes a big difference, too - adjusting that really can help.

I DO like the human insulins for dogs; my Kumbi is on Novolin-NPH, which I think is like the whatever-it-is-Humulin you have over there in Europe.

Kumbi has been on this from the start, well over three years ago, and it took us more than a year to get him regulated. He was okay in the meantime, just had his numbers jumping around a lot - but he never got into rebound, nor had a hypo.

I trust if you changed to human insulin, you also changed the syringes you use, from Caninsulin ones to human ones, right? You'd have to, to get the doses right.

I see you're getting all kinds of really useful help here; why am I not surprised? I'm looking forward to seeing Gigi's curve numbers.

Oh - about prick-site for testing - I use Kumbi's "lip" I alternate sides, usually, and by the time a curve-day is over, his mouth has lots of holes in it. He's probably somewhat bigger than Gigi, almost twice her size, but I think i'd be able to find room for those 10 to 12 pricks in a day, without really wrecking the "lip." You can prick fairly close to a previous prick, I think. I love the lip as a prick-site, because it doesn't hurt the dog, and I think it's very efficient; tends to bleed easily (Kumbi doesn't, though, so I warm the area first, by folding his lip down over a very-warm wet paper towel.)

I have pictures and descriptions here:

http://www.coherentdog.org/vek/bgtest.php

I did consider trying other prick sites for Kumbi, but prefer the lip. It heals up fairly quickly. So maybe you'd want to try that again, after all. I wonder about the base-of-tail - is your vet aware that's done on the BACK, not to the side, nor under the tail? I too would worry about possible infection in such a situation. I'd think on the back would be safe, though.

Tue, 30 Mar 2010 20:07:36 (PDT)
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Old 03-31-2010, 03:20 AM
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icaru icaru is offline
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Default Re: Insulin resistance - unable to regulate

Thanks to all of you who have answered my post about Gigi. Re food and curves ...

By the time Gigi got the final diagnosis (Cushings or diabetes), she had lost 25% of her body weight and was a little bag of bones. On March 5 when we received the definitive diagnosis of diabetes, she got her 1st insulin injection of 5 IU of Caninsulin.

She had a very bad reaction 15 hours later. It started at half past midnight. Not knowing what was happening -- I thought maybe a hypoglycemic reaction -- I gave her Nutrigel. This might have been a big mistake. We both went through a night of hell.

She arrived at the vet clinic at 9 am in a ketotic state, nearly dead. By a miracle, she survived. We still don't know what happened that night. I suspect a delayed reaction to a high first dose of insulin but the vet thinks it was probably a heart problem. Whatever, it totally changed her food habits.

Before she was eating Royal Canin Sensitivity Control (has allergies, this was the only food she could eat and not scratch. Cannot eat foods with beets, beef, lamb or wheat).

Following the start of insulin injections, for a week she lived only on Virbac Nutrigel (soya paste). When she started to eat by herself again, she refused everything except ... scrambled eggs ! She even refused her most favorite thing, steamed chicken breast. We have tried every kind of diabetic food, she won't touch any of them. Won't even eat what she used to eat, RC Sensitivity Control.

After about 1 week she began eating a little but only scrambled eggs and tuna fish. Slowly that is changing. After 3 days of that, she refused tuna and we went back to chicken, cooked oatmeal, brown rice and scrambled eggs (no oil, salt or anything, just egg). Then she refused to eat if oatmeal was mixed in.

Now I am trying to reintroduce kibble. She likes RC Weight Control which is also glucose regulating. Here is what she currently eats twice daily (2 meals, 2 injections, each 4 IU Humulin N):

50 grams chicken breast cooked in a bag, i.e., like steamed.
70 grams scrambled egg & kibble omelet. 200-230 grams/day of food (I weigh and record everything she eats).

Prior to her diabetes she was eating 120 g kibble daily. She is now eating much more, probably due to the severe weight loss following her diabetic onset.

I grind up the kibble and add it to the eggs while cooking to make a kibble omelet. Sometimes I add a bit of cooked brown rice which has a low glycemic index (white is high, brown is low).

She will not eat anything else for now except sea biscuits as a treat, 2 / day (dried codfish skins, made into cubes. 85% protein).

Re curves, we have only done 1 curve as pricking her lip 10 times that day was excruciating for us, more than for her. The vet has done all of the curves (vets much less expensive here than in the US).

He gets everything from smooth in the beginning to Somogyi effect yesterday. The only curve we did at home clearly shows a Somogyi-like effect. That was done on the day I tried to raise her Caninsulin shot from 3.3 to nearly 4 IU. .

In addition to this curve, I have kept a detailed record of food eaten, meds given, insulin injected, urine glucose and a smattering of BG readings taken when we suspected hypoglycemia. In fact, once we found her BG at 40, we gave her Nutrigel and some honey, it then went to 506 !

Those of you who do or did daily curves, how many times per day did you prick your dog's lip? This is the main reason we have asked the vet to do the curves as they draw blood directly from the jugular vein.

He told me last night he has never had a dog so difficult to regulate. Tomorrow we bring her home for good. After that we are on our own to continue testing and trying to regulate her.

So we welcome all suggestions ! Greatly appreciated.
PS. Yes we are using 100uL syringes with Humulin, 40uL for Caninsulin. Lilly says Humulin does not need to be refrigerated but we are doing it anyway.

Also, Humulin L (lente) still exists on the market.

Last edited by icaru; 03-31-2010 at 03:41 AM. Reason: Humulin L
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Old 03-31-2010, 06:01 AM
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Default Re: Insulin resistance - unable to regulate

Hi Carole,
Just a quick note...I'm wondering if we're talking about the same insulin when it comes to Humulin L?

Humulin L[2] was a U100 r-DNA/GE/GM intermediate-acting, lente insulin[3][4][5]. Novo Nordisk also made similar insulins, calling them Novolin L[6] and Monotard[7][8].
"L" came to an end when Eli Lilly announced in July, 2005 that it would no longer be produced[9][10]. The UK & Euro production of Humulin L stopped a year prior to this, in July 2004[11][12]. http://petdiabetes.wikia.com/wiki/Humulin_L

INDIANAPOLIS, July 6, 2005 - Eli Lilly and Company (NYSE: LLY) today announced that it is discontinuing production of Iletin® II Pork Insulin (Regular and NPH®formulations), and Humulin®U Ultralente® and Humulin®L Lente®(Humulin U and Humulin L) insulin products. Given current inventories and patient demand, these products should be available in pharmacies through the end of 2005. http://newsroom.lilly.com/ReleaseDet...leaseID=168048

Patty
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Old 03-31-2010, 07:59 AM
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Default Re: Insulin resistance - unable to regulate

Hi Carole,

I would like to help you but I feel others here are way more able to do so. To me however, the severe BG drop over the first 4 hours looks like Gigi is metabolizing the insulin too quickly, resulting in rebound. I wonder if it would help to back off the insulin from 3 units to 2 1/2, to see if you get a better response. That would be my thought, but I would wait until you hear from others to see what they think.

Regarding home testing, there are several sites where you could test Gigi if you're concerned about always pricking the lip. Ozzi refuses to let me take blood from his lip, not that it hurts, he just doesn't want anyone in his face! I use his elbow callus. Others use the area just above the tail, or the paw pad. You can get many ideas from the videos and resources here. So you are not limited to the lip. Having said that, from what I have read, the lip has fewer nerve endings so apparently it's not so painful, even though WE think it is!! Personally, I think it's the best location, and wish I could do that, so you might be okay taking it from her lip each time, especially if you are successful doing so.

Regarding the number of times to test when doing a curve, it's best to take the first morning (pre-feeding, pre-insulin) blood test, and then test every 2 hours as you did, over a 12 hour period. It's nice to get a 24 hour curve if that is possible, but most people seem to do 12 hour curves to get an idea of how their dog is metabolizing insulin.

Good luck and keep us updated!
Kevin
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Old 03-31-2010, 08:41 AM
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icaru icaru is offline
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Default Re: Insulin resistance - unable to regulate

Patty, you are of course correct about Humulin L. I was reading an old page from Lilly but in fact, it is no longer on the market in Spain either.
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Old 03-31-2010, 10:03 AM
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Default Re: Insulin resistance - unable to regulate

Hi there Carole!

First off, welcome to this group. There are lots of great people here to help you.

I wanted to tell you that I test on the carpal pad of my Westie, Chloe. I tried the lip, but she would not have it. I did use the base of the tail, but to be honest, I really felt I was hurting Chloe every time because I had to use a very heavy gauge lancet in order to penetrate the thick skin that she has in that area. The carpal pad was the answer for us. It is almost painless. My girl is standing up on a table when I take the sample, but there is a video on photobucket where the dog is lying down. Either way works. Another good tip that I found works to get the blood flowing is to put a heat pack on the area for about 10 or 15 seconds, then gently massage the leg. Chloe loves that part, LOL. I will try to find the link to the video and post it.

Anyway, for us this is the way to go. Every dog is different in what they will tolerate, so you just have to try alternate sites until you find what works for you and your dog.

I hope this helps in some way, but I know you can do it!

Hugs,
Heidi and Chloe
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