regulation on NPH

[delilah]

Hi,
My 10 year old dog, Delilah, was recently diagnosed with diabetes, but it is not straightforward. In addition to having VERY high blood sugar (in the 600s), she had a bunch of other symptoms that caused many vets to be perplexed. She has ulcers in her mouth and throat, infections on her elbows, and crusty paws. Also elevated liver levels. After taking her to an internist and dermatologist (who worked together) they gave her a preliminary diagnosis of a glucagonoma which is a malignant tumor, in her case on her pancreas, that causes both the diabetes and the other lesions that are not characteristic of typical diabetes. We didn't confirm this diagnosis because the only way to do this for sure is a biopsy which we opted not to do because it is very expensive and if it is positive the prognosis is very bad. She was really sick, lost 25 pounds, and we really thought that she was going to die.

We decided to treat the diabetes and see if it would help. Since then, her behavior is markedly improved. She is acting like herself and gaining weight slowly. Also, her mouth ulcers are gone. I am wondering if she really has the glucagonoma. The perplexing thing is that her blood sugar is still very high (in the 300s and 400s), even though she is acting fine. We were warned that if she does have the glucagonoma, she would be very hard to regulate. She has had multiple curves at the vet and is now up to 18 units of vetsulin twice a day. He thinks that that she may be stressed at the vet which is making it higher, so we are going to take a break from curves for 2 weeks and he is going to do a blood test where you can get an average of their blood sugar for the past 2 weeks (I can't remember what it is called). We both work full time and have 2 young children, so I just don't think it is realitic that we would be able to do home monitoring on a regular basis. We feed her wellness simple solutions and are trying to switch to wellness core (high protein, low carb) to see if that helps to regulate her bs.

I asked the vet about switching to NPH after reading about it here. He said that in his experience, NPH doesn't work as well with dogs who are large breed and hard to regulate, and that it would be like taking 2 steps backwards, but that he would be willing to try if we wanted. I like our vet for the most part and he is not trying to get money from us- in fact he has deeply discounted the insulin curves for us.

So my questions are:
1. Has anyone had experience with a glucagonoma?
2. What has been your experience with NPH and large breed, hard to regulate dogs?
3. Any other thoughts?

Thanks for reading this and any advice- sorry it is so long!!!

[k9diabetes]

Re: Introduction and questions- complicated case

Hi!

Never apologize for a long post!! We love details!!

I am not familiar with this as it is apparently very very rare:
http://www.vetlearn.com/Media/Public...V_25_01_56.pdf

I was interested to see, though, that the tumor may be associated with the islet cells, which typically die in a dog with diabetes.

I take it Cushing's disease was ruled out?

Was an ultrasound done to actually look at the pancreas?

What breed is Delilah and how much does she weigh?

It sounds like she is quite large, in which case 18 units twice a day would not be a lot of insulin and the dose could definitely go higher. If she weighs 80 pounds, 40 units per injection would be a fairly common dose.

I actually prefer NPH for large dogs just due to the volume of liquid you have to inject with Vetsulin, which is a U40 insulin. Plus NPH is a LOT less expensive, which makes a big difference when you're using a fairly large dose.

I know of many dogs in the 60-80 pound range that have used NPH very successfully.

Our dog weighed 60 pounds and his regulation was good with NPH. He was, unfortunately, allergic to it so eventually we had to go back to Regular insulin.

But if Delilah's BG is always in the 300s to 400s, I'd look to raising her dose of insulin first (unless the money and volume injected are a big deal) and see what the Fructosamine test shows - that's the one that gives an average of the blood sugar over the past couple of weeks.

I think far from finding home testing too difficult you would find home testing a time and money saver. Once you know how to do it, it takes literally seconds to test and you get good results in Delilah's home environment.

You can use home testing however much you want or only for curves or even just to check if you're worried about her levels.

Have you seen the video of me testing Chris on the lip?

www.k9diabetes.com/bgtestvideos.html (big file so give it time to download)

If Delilah has any leg callouses, these are also great places to test. Usually you use a lancet by hand there rather than a clicker.

Just something to consider.

I think you've made some great progress already and can probably get still better regulation.

Natalie

[delilah]

Re: Introduction and questions- complicated case

Thanks, Natalie. I forgot to say that Delilah is a lab. When healthy (and a bit chubby) she was close to 70 lbs, but went down to 44! She is now about 50. We did have an ultrasound but it was originally to look at her liver because that was one of the problems suspected early on. The pancreas could not be seen on the ultrasound. We opted not to do a repeat ultrasound at this time because we are trying to keep the costs down and the dr. said that it is VERY hard to see the glucagonoma on the pancreas because it is so small. What would we look for if we were looking for cushings? It never came up with any of the vets, and I can't imagine it wasn't considered, but you never know. Money is a major factor here which is why I was asking the vet about NPH, but we are leaning towards trying to get her better regulated first and then considering switching. Any tips on keeping costs down with Vetsulin? I figured out that if I buy in bulk online (10 bottles) I can save about $10 per bottle.

Thanks for the link and info- I'll check them out.
Martha

[Ricksma]

Re: Introduction and questions- complicated case

Just want to welcome you to the board, and tell you that even though it might be daunting at first, there is really nothing to the blood testing...and with a larger dog, you have more options of testing sites. If you decide to try it, the folks here will give you all the information you will need to be successful with it. It gives you a real feeling of confidence if you are able to actually find out at any time what your dog's bg reading is...confidence that I sorely need from time to time. Welcome, and here's hoping Delilah continues to feel better.

Teresa and Ricky

[Patty]

Re: Introduction and questions- complicated case

Hi Martha and welcome!
I just wanted to say my golden is on NPH. She was 51 pounds at diagnosis and went down to 45. She's now back up to 48 lbs and holding steady.

Early on I fed her Wellness Simple solutions but she stopped eating it after diagnosis and I went searching for another food. I found the reduced fat CORE (has higher fiber content than the regular) and started her on that. I had some beautiful curves on this food with NPH as long as I gave a biscuit at 3-4 evenly spaced times throughout the day. This kept her blood sugar from dipping too low. I no longer feed it because Ali's ears got really red on it (she's my allergy girl)

I have heard many others say that their dog doesn't get a rise from this food or rises much later in the day from it. I would be wary of matching this food alone to vetsulin. Just know that you may have to add something to it to offset the fast acting portion of vesulin especially.

I wouldn't discount the NPH just because of a large breed dog. I know many that it works very well for.

One very simple screening tool for Cushings would be to have a urine creatinine to cortisol ratio (UCCR) test done. This test is very sensitive to stress so ideally you would want to catch the first urine of the day while at home (you can pick up a sterile container from your vet) in a less stressful environment. Refrigerate it until you leave for the vet's office. If the test is negative, most likely the dog does not have typical cushings disease or Hyperadrenocorticism. If positive, further testing will need to be done. There are more extensive tests that can help identify cushings but this would be a low cost place to start.

If you decide you want to do some home testing, even if it is spot checks on the weekends or to check low points, there's a link on here to a couple of free meters: http://k9diabetes.com/forum/showthread.php?t=881

Hope that helps some!
Patty

[janspack]

Re: Introduction and questions- complicated case

Hi Martha,

Welcome to the forum.

I agree with others who have suggested that home testing might not be as difficult as you think. It certainly does cut down the costs considerably as there are not so many vet visits to pay for! I normally only test once a day and as Kathy said, it only takes a couple of minutes to do. Must take you a lot longer than that to take her to the vet. I don't always do the tests every day either - most days but not every day - so missing the odd one wouldn't be the end of the world. If you don't want to blood test, then you could always monitor things at home with urine testing.

I have just looked glucagonoma up on Wikipedia and it says there that in people at least, the glucagon levels are astronomically high - I wonder if it's possible to measure those levels in a dog?? That might give you the answer as to whether she does have the tumour or not perhaps? Apparently, this is one of the diagnostic tests they use for people with this disease.

I'm sure you've done all the research but just thought I'd put this link in for you to look at if you haven't seen it already.

http://en.wikipedia.org/wiki/Glucagonoma

There seems to be things that can be done to help in humans so maybe some or all can be done for dogs.

My diabetic dog is somewhat insulin resistant and has been very difficult to stabilise (still isn't there yet after 4 months) and has had very high glucose readings for most of that time. This forum has played a big part in preventing me from going mad! so hopefully we can all do the same for you.

[Margaret Boyle]

Re: Introduction and questions- complicated case

Thanks, Natalie. I forgot to say that Delilah is a lab. When healthy (and a bit chubby) she was close to 70 lbs, but went down to 44! She is now about 50. We did have an ultrasound but it was originally to look at her liver because that was one of the problems suspected early on. The pancreas could not be seen on the ultrasound. We opted not to do a repeat ultrasound at this time because we are trying to keep the costs down and the dr. said that it is VERY hard to see the glucagonoma on the pancreas because it is so small. What would we look for if we were looking for cushings? It never came up with any of the vets, and I can't imagine it wasn't considered, but you never know. Money is a major factor here which is why I was asking the vet about NPH, but we are leaning towards trying to get her better regulated first and then considering switching. Any tips on keeping costs down with Vetsulin? I figured out that if I buy in bulk online (10 bottles) I can save about $10 per bottle.

Thanks for the link and info- I'll check them out.
Martha

Welcome Martha, I cannot offer you any advice except go for the home blood testing and you will manage it fine it is frightening at first but you will soon get the hang of it. There are plenty people here who will help you.
Look at Natalie's video of her testing Chris and she makes it look so easy and
it is once you get the first few over and you feel comfortable.
We make a lot of mistakes to begin with and there was nobody more nervous than me now it only takes a couple of minutes. Good luck and welcome.

LOL

[delilah]

Re: Introduction and questions- complicated case

Thanks to everyone for your thoughtful responses. In response to a few- when I took Delilah to the specialist he called around and said that there are no labs that test for glucagon- one in Michigan used to but doesn't anymore because it is so rare than anyone would want a test for it.

In terms of the home testing, I meant that we're not home all day to test throughout the day. I would be too worried to test in the am, determine that she didn't need insulin, and then go to work for the rest of the day. I'm open to testing it once daily or if I'm concerned. I will look into it.

[delilah]

previous message cont'd

oops- i sent my last message accidentally without finishing it.

Patty- I'm not sure what you mean about the wellness core- why would you be wary about feeding it alone? I'm not sure what you mean about the fast acting aspect of Vetsulin (I'm new to all of this). Actually, we mix in some turkey and pumpkin for extra fiber. I can't give her something every 3-4 hours because I'm gone for about 8 hours or so to work.

Thanks!
Martha

[Patty]

Re: previous message cont'd

Patty- I'm not sure what you mean about the wellness core- why would you be wary about feeding it alone? I'm not sure what you mean about the fast acting aspect of Vetsulin (I'm new to all of this). Actually, we mix in some turkey and pumpkin for extra fiber. I can't give her something every 3-4 hours because I'm gone for about 8 hours or so to work.

Martha,
Vetsulin "is a lente product, and contains 30% "fast" insulin (semilente) and 70% "slow" insulin (ultralente)." http://www.caninediabetes.org/cdinsulin.html
Take a look at the vetsulin graph on this page. The red line indicates when the insulin is typically strongest and blood sugar is lowest. Hopefully Kathy will add to this...she knows all the good links!

The reduced fat CORE dry food has not caused a rise in blood sugar levels in 3 dogs that I know of and caused a late afternoon rise in another. The turkey and pumpkin are good but I'm not sure they will match the "fast acting" portion of the insulin which drops blood sugar fairly quickly. You may need something that gets into the system quicker like unenriched white rice.

This is also where even weekend home testing can help figure out what the food is doing and give you the results you want.

I think reduced fat CORE is a decent food if you're looking at dry foods but I would caution against using it alone as I think you may have some unexpected lows.

You might take a look through Soaphie's thread: http://k9diabetes.com/forum/showthread.php?t=400 Soaphie is on Vetsulin and eats the Wellness venison and rice formula.

You also mentioned worrying about finding a low in the morning and not giving insulin. If you do test and get a low, the insulin can be reduced or a snack given to offset this.

I know it's a lot to take in, but this board is great at helping to answer any questions you have.

Take care,
Patty

[We Hope]

Re: Introduction and questions- complicated case

Lente insulin is a combination of 30% fast acting semilente insulin and 70% slow acting ultralente insulin. When you put these two insulins together, you come out with an intermediate-acting insulin.

This shows you when the faster amorphous (semilente) has its peak (is working the hardest), and when the slower crystalline (ultralente) does the same thing. Shown in purple is the effect this point of the insulin's action has on the blood glucose.

Most often though, you see the time activity profiles for Lente shown "smoothed out", without the separate actions of the semilente and ultralente shown.

The Humulin L shown is human Lente insulin which Lilly discontinued in 2005; all Lente insulins have similar activity profiles. Now look at the Humulin 70/30 profile shown. Humulin 70/30 is a combination of intermediate-acting 70% NPH insulin (Humulin N) and 30% faster acting R insulin (Humulin R). You are also seeing the activity profiles separately for both Humulin N and Humulin R. When the two insulins--the intermediate NPH and the fast-acting R are put together, that also makes up yet another intermediate-acting insulin--the Humulin 70/30.

We were talking about this a while ago because you can spot the peak of the semilente and the ultralente in some dogs but not in others:

Marion,

Right now, what you may be seeing is the point where the fast-acting semilente insulin peaks--around 10 AM--and the second peak at about 4 PM is that of the long-acting ultralente.

http://www.ncbi.nlm.nih.gov/pubmed/9...gdbfrom=pubmed

Pharmacokinetics of a porcine insulin zinc suspension in diabetic dogs.
Journal of Small Animal Practice-1997

"Ten dogs with naturally occurring diabetes mellitus were injected with a highly purified porcine insulin zinc suspension at a dose according to their expected requirement. Plasma insulin and glucose concentrations were measured at two-hourly intervals over 24 hours following injection. There were either one or two peaks in plasma insulin concentration: one at about four hours (mean 4.3 +/- 1.3 [SD]) and another at about 11 hours (mean 11 +/- 1.85) after the injection. The second insulin peak was seen in only eight dogs. Persistence of elevated plasma insulin concentrations ranged from 14 to 24 hours (mean 17.4 +/- 3.65). These results compare favourably with those published for other intermediate-acting insulin preparations used to treat canine diabetes mellitus and suggest that this preparation has useful properties for the successful management of many canine diabetics."

Taking this apart a bit, they say that the first peak at about 4 hours after insulin is plus or minus 1.3 hours. That means it could be 1.3 hours sooner or 1.3 hours later. Then you see them talk about the second peak at 11 hours--plus or minus 1.85 hours later. Meaning that it could be close to 2 hours earlier or later than 11 hours.

These numbers are an average of the times noted for the 10 dogs tested, with 8 of the 10 showing evidence of the second, later peak.

All Lente insulins "operate" like this, in the respect that there are two Lente family insulins combined to produce the insulin--30% fast-acting semilente and 70% slow-acting ultralente.

http://petdiabetes.wikia.com/wiki/Lente

But what's shown as a time activity profile is all of this nicely "smoothed" out:

People who continue to use Lente insulin (beef only now--imported from the UK) and those who formerly used it when it was more widely available would have also had the possibility for the two peaks because no matter what one makes or made the insulin from, it still works in the same fashion.

It may be that you will continue to see two peaks from Cara. When her bg's were so high, it would have been difficult to impossible to have seen it.

Lucky did not show two peaks but just the one later in the day, so he was still keeping with his tradition of not going by the book.

Does this help any--sure hope so!

Kathy

If you have copies of the blood glucose readings from the vet curves and would post the times and numbers, in seeing them, we might be able to tell if there is a drop which might be creating a high later on in the day.

Kathy

[delilah]

need advice on getting started with home testing

Hi,

I want to start testing my 10 y.o. yellow lab, Delilah. To recap:

Her bs has been very high at her curves at the vet (in the 300s and 400s), but because she seems to be doing so well- acting like herself, gaining weight, the vet was suspicious that anxiety at the vet is causing the high #s. I also think it was in part to me making a mistake with the insulin (due to instructions that were not detailed enough) which I have corrected. He did a fructosamine test last week and the result was 532 which he said is in the lower end of the fair range (I'm not sure how the fructosamine #s work), so we're making progress. She is now on 18 units of vetsulin 2x/day. He wants to do another fructosamine in a few weeks. I have also recently switched her food (to Wellness Core) which may be helping.

Anyway, I would like to do some home testing to get a sense of her bs more regularly. I read on this site that you have to take the meter that you get to the vet and test the blood with theirs and yours a few times to see how different they are. I'm wondering how people did this logistically. It seems like a big pain to take her to the vet on several occasions and have them test her blood. And they would probably charge me too. Is this what I have to do or is there another way to do it?

Thanks!!
Martha

[eyelostit]

Re: need advice on getting started with home testing

Hi,

I want to start testing my 10 y.o. yellow lab, Delilah. To recap:

Her bs has been very high at her curves at the vet (in the 300s and 400s), but because she seems to be doing so well- acting like herself, gaining weight, the vet was suspicious that anxiety at the vet is causing the high #s. I also think it was in part to me making a mistake with the insulin (due to instructions that were not detailed enough) which I have corrected. He did a fructosamine test last week and the result was 532 which he said is in the lower end of the fair range (I'm not sure how the fructosamine #s work), so we're making progress. She is now on 18 units of vetsulin 2x/day. He wants to do another fructosamine in a few weeks. I have also recently switched her food (to Wellness Core) which may be helping.

Anyway, I would like to do some home testing to get a sense of her bs more regularly. I read on this site that you have to take the meter that you get to the vet and test the blood with theirs and yours a few times to see how different they are. I'm wondering how people did this logistically. It seems like a big pain to take her to the vet on several occasions and have them test her blood. And they would probably charge me too. Is this what I have to do or is there another way to do it?

Thanks!!
Martha

What I do is take my meter with me to the vet, have them check bg and save me some blood that they have drawn, I then use this blood (they give me some in a syringe) to test my meter, then I test her like I do at home at the vets office to see the difference between the real blood sample and the capillary blood we get from poking there skin. Ask the vet if they are using the pet Alphatrak Meter for testing or if they are using the lab when they do this.

My dog always seemed like herself after dx and using insulin, he bg was really high but she was acting fine, only thing she did was throw up at first from the bg being very high that went away after 1st week.

I'd hold off on the fructosamine test if you are going to home test. I think home testing will ease your mind alot.

If Delilah is eating and acting herself thats great, any urine leakage ? and are you using the keto diastix to check urine?

Dolly

[ravenecw]

Re: need advice on getting started with home testing

What I do is take my meter with me to the vet, have them check bg and save me some blood that they have drawn, I then use this blood (they give me some in a syringe) to test my meter, then I test her like I do at home at the vets office to see the difference between the real blood sample and the capillary blood we get from poking there skin. Ask the vet if they are using the pet Alphatrak Meter for testing or if they are using the lab when they do this.

My dog always seemed like herself after dx and using insulin, he bg was really high but she was acting fine, only thing she did was throw up at first from the bg being very high that went away after 1st week.

I'd hold off on the fructosamine test if you are going to home test. I think home testing will ease your mind alot.

If Delilah is eating and acting herself thats great, any urine leakage ? and are you using the keto diastix to check urine?

Dolly

Taking the meter to the vet is such a good idea, I did that the last time I was there to see the difference (in fact I took 2 meters there, I have 2 incase 1 reads really funny I like to verify- crazy huh? it's just something I do because like everyone else I really like to know where my dog is at, especially at certain times of the day as lately I have been testing 3-4 a day usually unless I feel the need to test more).


I so agree about the Fructo test the more and more I read and hear about it, unfortunately for me my vet is almost making me do it- hopefully I will have that straightened out tomorrow but that is another story. Do what you feel comfortable but home testing is such a help, you will really see how much more you feel like you really know what's up.

[Fishslayer]

Re: need advice on getting started with home testing

My vet insisting on a fructosamine test after I had been home testing for 3 months and providing 2 different curves was the straw that sent me looking for another vet for Lucy's spay.

I don't know what it is with vets and fructosamine tests. The vet who did Lucy's spay said it was pretty much a waste of time with a regulated dog.

I had the vet test my meter when Lucy was spayed. They only tested at one BG level but it was almost exactly where Natalie's chart for the One Touch Ultra II was so I didn't worry too much. I DID get a bit nervous when her BG was getting toward a low.

Rick