Silkie's Ultrasound results....

[silkiegal]

Re: Having to stop insulin for 5 days!

I did try Natalies food suggestions, and his numbers stayed within the same range. All over the place. No ketones in his urine, had that tested last week. They are wanting to give him 1 unit to start of Levimeer, 2x day. Ultrasound is Wed. That will be able to tell us if he has large adrednal glands and Cushings, or it can be stress related. Silkie gets VERY stressed out easliy as vet. Panting, etc.
I told the specialist internist that 5 days does not sound good to me. He says, 1 day off NPH is enough. Thank God. My reg vet was being overly cautious, and she has never had a patient on Levimeer.I will take all these questions from you and NAtalie to the specialist Wed. I will post then. Thank you a million times over!!!!

Silkiegal

I was reading back through Silkie's thread and found this post from Natalie. I'm not sure that switching to Levemir is going to solve the issue. I think you're going to still wind up working on a complex food/insulin balance.


I'm wondering if you tried this and what his numbers were like?

As far as ketones, they are something that can show up with persistent high blood sugar and should be check often in this situation. I would have some ketostix or ketodiastix on hand for checking him.

Silkie is 18 lbs and currently on 8u NPH. It looks like they are wanting to start with about half his current dose since Levemir is 4x's stronger in dogs. 1u Levemir is equivalent to 4u active insulin, though it has a different peaking action.


It seems like there's a lot going on at once. When are they wanting to do the ultrasound?


The overlap could potentially come from the Levemir lasting longer than 12 hours. So you are looking at possible overlap occuring from the first dose into the next one. This shouldn't impact the switch from NPH to Levemir. So, waiting 5 days doesn't make a lot of sense.

I'm sure Natalie will have a great deal of insight as well.
These are the things running through my mind and questions I would ask IF you decide to make the switch...

- I would not wait 5 days without insulin. This is very dangerous in a dog that is not producing any insulin. Silkie is obviously rising before his next shot, so any residual NPH in his system will have minimal impact on the Levemir. And, the dose of Levemir is significantly less than his NPH dose.

- I would monitor closely and test for ketones.

- Are they planning to dose him 1u every 12 hours or waiting to see if the Levemir lasts longer?

- Are you currently using syringes with 1/2u markings to make dosing the Levemir easier? (I think you are but wasn't sure)

- Because Levemir is essentially a peakless insulin (a much flatter profile than NPH), will they consider adding a faster acting insulin to help with meal spikes if needed?

Maybe you've discussed these things with your vet already, but they are questions I would want touched on before switching.

I think the decision is being made too quickly though. I think you have a lot going on with Cushings testing and more might be done with his food/insulin balance. I would put him back on NPH tonight and work through the questions and possibilities yet.

Patty

[Patty]

Re: Update: Silkie Insulin, spoke to specialist...

So, I will not give Humulin on Tuesday, and see him Wed for the ultrasound, then Silk will go on Levimeer.

I still am not a fan of this approach.

1. I agree with Natalie in that there is no reason to rush into the Levemir.

2. If Silkie is rising into his next shot, I don't see any reason for a "wash out" day. This just causes very high blood sugar. You can see my reasons for this in my last post.

3. I would go for the ultrasound Wed and wait for the results. Discuss possibilities with your vet based on those results. Tackle one issue at a time instead of switching insulins and proceeding with the ultrasound at once.

Take a look at the questions I posed regarding switching to Levemir previously. I would also discuss all these possibilities before making a switch.

The internet can be confusing with so many people giving advice and your vet telling you something else. But I can say my dog would not have the life she does now had it not been for the people on these forums. I sought help from a local vet, an Internal Med Specialist, and 2 heads of Endocrinology at major universities. The IMS told me there was no way to test my dog without a venous blood draw, and all of them said that curves were useless before I found a vet with enough knowledge to help me with her first curve.

All I'm saying is there's truly a lack of information being taught when it comes to diabetes. That's not to say that a vet isn't highly knowledgeable in other areas or compassionate. But, the information with regard to managing balances with insulin and food and how some of these "newer" insulin work is just now evolving. People didn't used to manage canine diabetes as closely as we are now. You really have to be an advocate for research.

Levemir is not just a "longer acting" insulin but it is used as a basal insulin. It does not have the peak that NPH does. The strength of it can also be an issue for dogs. So, while it may work great, more likely you will need to work a bit harder to match its action profile.

My 2 cents worth...
Patty

[Soaphie & Sydney's Mom]

Re: Update: Silkie Insulin, spoke to specialist...

How many units of NPH are you giving currently?

I know there is someone on this board that uses Levemir and I believe gives a very low dose per KG. I think I calculated it for my dog, Soaphie (who weighs 64.9 pounds) and it equaled 2.9 units. I think you would want to go lower than 1 unit of Levemir as it is VERY potent.

Just my two cents....

[Patty]

Re: Update: Silkie Insulin, spoke to specialist...

I did try Natalies food suggestions, and his numbers stayed within the same range. All over the place.

Can you post the results of these trials? Sometimes another set of eyes can help see something someone else might miss in a trend.

Sometimes the case is one particular food not working, like the rice, and another needs to be used that has a higher or lower glycemic index.

No ketones in his urine, had that tested last week.

If his blood sugar remains high, this is something you'll need to do frequently at home.

[Patty]

Re: Update: Silkie Insulin, spoke to specialist...

How many units of NPH are you giving currently?

I know there is someone on this board that uses Levemir and I believe gives a very low dose per KG. I think I calculated it for my dog, Soaphie (who weighs 64.9 pounds) and it equaled 2.9 units. I think you would want to go lower than 1 unit of Levemir as it is VERY potent.

Just my two cents....

I knew you were working through possibilities of Levemir with Soaphie if you can't get her Caninsulin, Tami.

Silkie is on 8u per shot. Vet wants to start her on 1u which is equivalent to 4u per shot I believe.

[k9diabetes]

Re: Update: Silkie Insulin, spoke to specialist...

I wasn't sure if you meant the ultrasound or the insulin test. I would NOT do the insulin test but think an ultrasound is always a good idea.

If Silkie was my dog, I would keep him on NPH for now. I would do the ultrasound because more information is always better.

Then I would take all of the test results in hard copies and all of his blood sugar results from your home tests and let someone with a lot of experience here working with curves take a look at what's been done so far.

I'm not sure the experiments with food timing, etc. were extensive enough to prove whether they were working or not. Describing blood sugar as all over the place can mean a lot of things and someone with significant experience with curves and adjusting those curves with diet and exercise could probably get a lot more information from them by looking at the actual data.

It's understandable that you are feeling overwhelmed by all this. I didn't learn how to adjust a curve with diet overnight. As I mentioned before, even if an experiment fails, how it fails can be informative.

So take advantage of the years of experience here and put the data you have where folks can see it. You can email it to me if you want. k9diabetes@gmail.com.

If we take a look and we can't help, no loss to you or Silkie. But maybe we can help - even if it's only to say that a particular attempt wasn't long enough to determine the results. Or that the failure of it told us something about how the food and insulin work for him.

Natalie

[diggydog]

Re: Update: Silkie Insulin, spoke to specialist...

I wouldn't rush into switching your dog to Levemir and would try to stick with the NPH and work a diet to better balance out with the insulin.

I switched Alfie to levemir last year and its not been an easy insulin to deal with and to be totally honest if I could turn back the clock and opt not to put him on levemir I would.

You dont need to stop the current insulin your on either. I gave Alfie his usual insulin (think we were on isuvet at the time) shot at night and then started him on levemir.
Its an extremely potent insulin and you need to tread carefully with all dose adjustments if you do decide to go down that road.
Any increase you make has to be done in tiny amounts as 1 unit of levemir is like giving 4units of NPH so even a 1/4 unit increase of levemir is a like 1 unit of NPH and can have a massive impact on bg's.
Its also worth mentioning that levemir is meant to be a peakless this is not always the case. Its meant to last 24hours and Alfie did neither of these things with it.

I am not trying to put you off trying it but had I known how difficult it was going to be putting Alfie on it then I wouldn't have bothered!

[silkiegal]

Re: Update: Silkie Insulin, spoke to specialist...

Thank you. Is Alfie doing well on Leminer though? If not, why not switching back to NPH? Do I just ignore the two vets who suggest I switch?I want to get him regulated asap, so he can have cataract surgery one day. Dont know what to do?

Thanks

I wouldn't rush into switching your dog to Levemir and would try to stick with the NPH and work a diet to better balance out with the insulin.

I switched Alfie to levemir last year and its not been an easy insulin to deal with and to be totally honest if I could turn back the clock and opt not to put him on levemir I would.

You dont need to stop the current insulin your on either. I gave Alfie his usual insulin (think we were on isuvet at the time) shot at night and then started him on levemir.
Its an extremely potent insulin and you need to tread carefully with all dose adjustments if you do decide to go down that road.
Any increase you make has to be done in tiny amounts as 1 unit of levemir is like giving 4units of NPH so even a 1/4 unit increase of levemir is a like 1 unit of NPH and can have a massive impact on bg's.
Its also worth mentioning that levemir is meant to be a peakless this is not always the case. Its meant to last 24hours and Alfie did neither of these things with it.

I am not trying to put you off trying it but had I known how difficult it was going to be putting Alfie on it then I wouldn't have bothered!

[silkiegal]

Re: Update: Silkie Insulin, spoke to specialist...

Yes, will do the ultrasound on Wed. Thank you for all of your info. I will keep him on NPH for now. I wil pick up blood results tomorrow, and post them here. I will let you all know what the specialist says, on Wed. I wont change to Levimeer. And do the white rice with NPH longer, and post curve results. I did not do it more then a week, so I need to do it longer.

My BIGGEST worry with Silk is that is is going blind. I want to get surgery for him when regulated. So that is my goal. I have a while to get there.
Anyway, I will post next week, the results, and what the specialsit says.

What do I say to the specialist about not doing the Levimeer, even if he highly suggests it?

Thanks Natalie,
Silkiegal

I wasn't sure if you meant the ultrasound or the insulin test. I would NOT do the insulin test but think an ultrasound is always a good idea.

If Silkie was my dog, I would keep him on NPH for now. I would do the ultrasound because more information is always better.

Then I would take all of the test results in hard copies and all of his blood sugar results from your home tests and let someone with a lot of experience here working with curves take a look at what's been done so far.

I'm not sure the experiments with food timing, etc. were extensive enough to prove whether they were working or not. Describing blood sugar as all over the place can mean a lot of things and someone with significant experience with curves and adjusting those curves with diet and exercise could probably get a lot more information from them by looking at the actual data.

It's understandable that you are feeling overwhelmed by all this. I didn't learn how to adjust a curve with diet overnight. As I mentioned before, even if an experiment fails, how it fails can be informative.

So take advantage of the years of experience here and put the data you have where folks can see it. You can email it to me if you want. k9diabetes@gmail.com.

If we take a look and we can't help, no loss to you or Silkie. But maybe we can help - even if it's only to say that a particular attempt wasn't long enough to determine the results. Or that the failure of it told us something about how the food and insulin work for him.

Natalie

[silkiegal]

Re: Update: Silkie Insulin, spoke to specialist...

I will do the white rice with food before shot again, and do it more then a week. I will post those numbers next week.

thanks

Can you post the results of these trials? Sometimes another set of eyes can help see something someone else might miss in a trend.

Sometimes the case is one particular food not working, like the rice, and another needs to be used that has a higher or lower glycemic index.


If his blood sugar remains high, this is something you'll need to do frequently at home.

[silkiegal]

Re: Update: Silkie Insulin, spoke to specialist...

Ok, I will wait to see the internist, before switching.I have to think about all this stuff and information. I want to believe that the specialist will not put Silkie on something that could be bad for him. The Levimeer is just another way to try and see if his numbers go down. It is just another approach for his specific situation. We are dealing with him almost being blind as well. Going to the eye specialist next week to get a baseline exam. I am trying to not panic here, and see what happens next week.Thank you, so much Patty. I will post next week with more info. I wont switch to Levimeer till I have more info...

I still am not a fan of this approach.

1. I agree with Natalie in that there is no reason to rush into the Levemir.

2. If Silkie is rising into his next shot, I don't see any reason for a "wash out" day. This just causes very high blood sugar. You can see my reasons for this in my last post.

3. I would go for the ultrasound Wed and wait for the results. Discuss possibilities with your vet based on those results. Tackle one issue at a time instead of switching insulins and proceeding with the ultrasound at once.

Take a look at the questions I posed regarding switching to Levemir previously. I would also discuss all these possibilities before making a switch.

The internet can be confusing with so many people giving advice and your vet telling you something else. But I can say my dog would not have the life she does now had it not been for the people on these forums. I sought help from a local vet, an Internal Med Specialist, and 2 heads of Endocrinology at major universities. The IMS told me there was no way to test my dog without a venous blood draw, and all of them said that curves were useless before I found a vet with enough knowledge to help me with her first curve.

All I'm saying is there's truly a lack of information being taught when it comes to diabetes. That's not to say that a vet isn't highly knowledgeable in other areas or compassionate. But, the information with regard to managing balances with insulin and food and how some of these "newer" insulin work is just now evolving. People didn't used to manage canine diabetes as closely as we are now. You really have to be an advocate for research.

Levemir is not just a "longer acting" insulin but it is used as a basal insulin. It does not have the peak that NPH does. The strength of it can also be an issue for dogs. So, while it may work great, more likely you will need to work a bit harder to match its action profile.

My 2 cents worth...
Patty

[k9diabetes]

Re: Update: Silkie Insulin, spoke to specialist...

It's not that Levemir is "bad" but there are two issues working against it:

- It's new and largely untested in dogs
- It's four times more potent in dogs (not so in people)

In theory, based on how it works in people, Levemir would deliver a long-lasting steady supply of insulin that has fewer peaks and valleys and lasts longer than NPH.

But... and this is a big but... so far in dogs it has not consistently provided either a flat profile or a longer duration.

Lantus was supposed to do the same thing in dogs and it hasn't often worked for them.

Dogs metabolize insulins differently than people do and it will take time and a lot of dogs trying it to know *generally what it will do in dogs. But dogs all process different insulins in their own way too. Lantus or NPH or Vetsulin will work great in a bunch of dogs and lousy for a bunch of others.

Levemir doesn't have a history yet in dogs and to some degree, all of the vets who are currently trying it are exploring unknown territory. "Experimenting" sounds harsh but that is basically what is going on. And it is really the only way to know if an insulin is going to work well for dogs. But it is an experiment nonetheless.

The discontinuation of Vetsulin is driving the experimentation. Without Vetsulin, there are very few options for alternative insulins. Lantus hasn't worked well enough for most vets to recommend it. Levemir has the potential to be a good alternative when NPH doesn't work.

Another good alternative is ProZinc, which is another longer lasting insulin that has both protamine, like NPH, and zinc, like Vetsulin. It is no good for dogs allergic to NPH as both contain the same offending protein. But it is one potential alternative for dogs who are fine with NPH but just don't get enough duration out of it.

I'm not sure why vets don't seem to be trying ProZinc in these cases. I believe it's getting some use in cats, who also do well - better than dogs generally - with Lantus and Levemir. Cats need long-acting insulins as they burn through something like NPH in a few hours.

The second "problem" is the potency. For a small dog like Silkie, the fact that every unit of Levemir is akin to 4 units of NPH means that small doses of 1-2 units of NPH can't be done with Levemir.

Silkie's dose is large enough right now that a reasonable dose of Levemir can be calculated for him. But fine adjustments to the dose are impossible. Every 1/4 unit of Levemir is like a full unit of NPH. So even with syringes with half units and eyeballing quarter units, you can at best do what are effectively 1-whole-unit changes to his dose.

That is not going to work for a lot of dogs.

There are also problems with the duration either not being any longer than NPH or being so long that it creates overlap.

Long answer short... Levemir is far from guaranteed to solve Silkie's blood sugar problems and has the potential to create new problems.

It could be perfect for him. It could be a nightmare. It could be somewhere in between. No one can say.

Maybe more important... I haven't seen detailed data on how Silkie uses NPH. If I had detailed curves you've done over the past couple of months to evaluate, I could tell you whether I think NPH is working and whether the adjustments you made worked. It is not easy to evaluate curves. Sometimes what looks like "all over the place" actually has some significant patterns when carefully evaluated. Someone with a lot of experience with these things could tell you a lot about how NPH is doing.

If I had the data, it's possible I would say "Wow, you're right. NPH stinks for Silkie!!!"

But I wouldn't leave that determination up to the general practice vet as I think it's clear that s/he doesn't have enough experience with this kind of analysis of food and insulin. It may be that the specialist does. But I honestly don't think you will find anyone better at it than the people here.

As for telling the specialist you haven't started Levemir, any vet worth his or her salt will think taking another few days to really sort things out is a good idea. No one should be pressuring you to start Levemir right now. If you're not comfortable making the switch at this moment, that should be all you have to say to the specialist.

I encourage you, if you haven't yet, to read "Speaking for Spot" by Dr. Nancy Kay. She's an internal medicine specialist who works tirelessly to help people become assertive advocates for their dogs in dealing with veterinarians.

Veterinarians are humans - some are more talented than others, some are more open-minded than others. As with our own health care, it's important to be assertive, ask questions, think about important decisions.

Natalie

[jesse girl]

Re: Update: Silkie Insulin, spoke to specialist...

natalie makes some good points

I to thought of levemir but how to dose for it would be to difficult and cost is a factor

there is allot of flexibility with are animals because we can feed give shots at the times we want and mostly there happy with that because they want to please us.

my jesse for example big drops first 3 hours after shot correlated by a sharp rise it was clear insulin got far ahead of food then food ahead of insulin it was like giving a full dose of insulin with no food for a temporary bases then like giving food without enough insulin ( I believe there was some food overlap going on where food wasnt completely digested and adding more food on the second meal just a theory)

I thought there was a digestion issue and we tried something quite adventurous by just giving her one full meal a day and a snack at other shot time . (specifics not given ) well what happened was quite amazing her food got going immediately no wait food was getting ahead of insulin for the first time where I had to use some fast acting insulin to tame it. and jesse having some good consistent numbers for the first time in over 5 months and improved health . I wish I had someone else to compare to but it appears there is know one else that I no of

the point being there are so many variables you can do to have some success some give 4 meals a day jesse was very problematic with additional issues honestly I didnt give her much of a chance just 6 months ago after surviving the near death experience at the beginning and now its about a year will a vet go along with this routine ? probably not we go it alone and use the site for are information and advice this routine was developed through this site not directly but indirectly peaces of the puzzle it gives you possibilities on what you can try maybe not direct answers all the time . as natalie said if you have a pattern the things that are problematic can be worked on and some very simple some more complex

you may have success with levemir give it a specific amount of time in your mind on seeing some good results there is a specific amount of time I will try something then move on kind of like an exit strategy and maybe relay this to your vet . have plan b ready to go and not just grabbing at straws if it doesn't work

good luck on whatever you decide and me and jesse hope for success for your fury friend.

[diggydog]

Re: Update: Silkie Insulin, spoke to specialist...

Hi Silikegal

Levemir has not been a great insulin for Alfie but we are making do with it just now.
Alfie has never been on NPH - we like in scotland and insulin for pets is differently regulated over here. Vets need to show that all the usual pet insulins dont work before they can start on human insulins.

He is now on both Levemir and caninsulin so is getting 4 injections a day.
I am going to try him on NPH this week coming just to see if it is any better for him than everything we have tried so far.
All vets - specialists included are not known to try diet modification to help regulate dogs as its not something that they are on the whole aware how to go about it but its a really important tool in dealing with diabetes.

I dont want you to think Levemir is a bad insulin, its difficult due to its potency but some people have had good results with it but as not many people have used it in dogs its hard to say how well it works for dogs.

Alfie is 7kg and for him 1/2 units levemir bid is way too much for him dropping him far too low but 1/4 unit bid is no where near enough so we have ended up combining it with Caninsulin to try and find somewhere in the middle for him - so far not having much luck be we keep trying.

Its really an individual choice and I know how difficult it can be when the vets are saying 1 things and everyone here is saying another. I think its worth remembering that people here are living with this day in day out and the vets are not so they dont have as much experience as everyone here.

Its worth giving the diet changes another try - if its not working well then Levemir can be a back up plan.
I know a few people using levemir and they are all having to combine it with other insulins to cover meal spikes and other issues.

Allison

[silkiegal]

Silkie's Ultrasound results....

Silkie's ultrasound came out showing no Cushings or any other diseases! (only diabetes, of course)The Cushings was false positive caused by stress hormones; cortisol. No adrenal tumor, nothing out of ordinary for a diabetic dog.So thank God! The specialist also suspected Simogi effect. He gave me a couple of options, but highly reccomended trying Levimeer. He has had a lot of success with it. So, I put my trust in him and we are trying it. Silkie did not have to go off NPH for more than 1 night.
We also went to the eye specialist. Silkie is a good candidate for cataract surgery. Right now he is legally blind. He has low pressure in both eyes, and no other issues usually present in diabetic dog's eyes. The cataracts are in its early stages. He gave us eye drops to reduce inflamation, and we also schedualed the surgery for 2 weeks, baring no other issues. Silkie is unhappy blind, and I want to give him a better quality of life. He is very independent, and does not like to depend on us for everything. He will get the gift of sight! I know about the complications and after care. The surgery has a 90% success rate. Follow up apt are important to catch possible complications. I have done my homework on this one!

Thanks everyone!
Silkiegal