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Doc Sara
Doc Sara, Veterinarian
Category: Dog Veterinary
Satisfied Customers: 952
Experience:  I am a dog and cat veterinarian with a lifetime of experience in our family veterinary hospital.
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My 9 year old Airedale Terrier, Greta, was diagnosed 5 years

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My 9 year old Airedale Terrier, Greta, was diagnosed 5 years ago as a diabetic. Just prior to diagnosis, Greta had a couple of seizures which led us first to our local emergency pet hospital followed by several visits and short term stays with our local vet. Post diagnosis, Greta was placed on insulin, Novalin to be specific. We are strict about her diet, feeding times, insulin administration, etc. With regular vet visits, Greta's diabetes seemed to be under control for about three years. During that time, she was diagnosed with hypothyroidism and placed on soloxin twice a day. Again, that issue seemed to be in control. At about the three year mark, Walmart (where we had always a purchased her insulin, stopped carrying Novalin and began substituting it with Humalin. Since we always kept everything consistent, we were concerned about the switch in insulin. The Walmart pharmacist insisted it was the same and our vet did not seem concerned. Whether it was a coincidence or not, after the switch, we found it difficult to keep Greta's diabetes under control. Our vet kept her on Humalin for a while and, in addition to her annual well visits, we took her for regular glucose curve tests and occasional blood work. During this time her ALT level became elevated and she was started on Denamarin once a day.Greta also started getting an occasional UTI and/or vaginitis which required oral and topical antibiotics. With her glucose readings continuing to be abnormal/irregular, the vet switched her to Vetsulin about 1-1/2 years ago. Her diabetes continues to be irregular and the doctor told us her curves were the opposite of what they should be...the Symonji effect we were told. The vet has kept her on the same food, given at the same time each day two meals 12 hrs apart and Vetsulin given after each meal in doses which have varied after each pet visit. And do we keep riding this roller coaster. Four weeks ago, Greta had two seizures in one day about 8 hours apart. I have since purchased an Alpha Trak2monitor so I can check her sugar at home...in the morning before her breakfast, again 5-6 hours later(midday) and after her evening meal. Her readings are all over the place. She just had a curve done by the vet two days ago and they say that her insulin only appears to be working the first couple hours after it is given after which her sugar begins to climb again. She's had highs of 687 and lows of 89, sometimes as much as 400 point variance in one day. The vet is going to do another curve in two days including giving her her morning meal and insulin. If this doesn't divulge anything, the vet wants to send her to a vetinary endocrinologist 2-1/2 hrs away. We're stressed and frustrated. I've done some reading online and I'm not sure that the vet is going everything possible before sending us to a specialist. For instance, I learned that there are different types of insulin of different control durations and yet Greta has been on the same for so long. I also understand that certain insulins can be used in combination to greater effect. Even changes in food, meal time and insulin administration can have a positive effect on diabetes control. Yet none of these alternatives have been tried. What should we do? Insist that the vet try some/all of these alternatives before sending us to a specialist? Get a second opinion locally/switch vets? Skip all of these and go straight to a specialist? We've already lost two Airedales in the last two years, one of cancer at age 11 and another other of a heart defect discovered just days before she died. She was almost 12. Greta has a brother who (thank God) is pretty healthy. We've always followed the advice, treatment plans, surgeries etc recommended by the vet because we want the very best for our furry friends. But I have to also ask, can a specialist reasonably be expected to find a solution? Please help! We are still mourning the loss of our beloved Gracie and Griffin and the situation with Greta had us frightened.
Submitted: 1 year ago.
Category: Dog Veterinary
Expert:  Doc Sara replied 1 year ago.

Good evening - I'm Dr. Sara. I'm a licensed veterinarian who works exclusively with dogs and cats. I'm so sorry that you've been having such a rough go with Greta's diabetes! It took me a few moments to read through your detailed history - thank you so much for that. I do have to say, though, that to be still managing her diabetes after this many years is quite good. We don't always get more than a year or two with our diabetic pets, so she is a bit ahead of the curve here.

Firstly, even though the human pharmacists treat them as if they are equal, Novolin and Humulin absolutely do not work similarly in dogs. It's my understanding that in humans they work very similarly, but in veterinary medicine we frequently see that you cannot switch from one to the other without causing issues. I've had dogs regulated quite well on each insulin - sometimes my clients do need to use the Novolin because it's significantly cheaper. I just don't switch dogs back and forth without some conversation and some blood sugar checks. Our WalMarts where I live all carry Novolin and actually push it on my clients - suggesting it as a cheaper alternative to Humulin when I prescribe it, so I'm surprised to hear that your WalMart isn't carrying it.

Having said that, neither Novolin or Humulin are regarded as fantastically effective insulin choices for diabetic dogs, as they often don't have the right duration of action. So I'm glad to see that you're no longer using this. I did have good experiences with Vetsulin but I stopped using it some time ago when it went though a recall and period of time where it was not available for us to purchase. We had to switch all of my patients off of it, which was extremely frustrating for us and for our clients, so I'm not a big fan of the veterinary insulins anymore for fear that they could potentially have shortage or backorder problems again in the future. I trust the supply of human insulins a bit more.

Before we talk about insulin choice, we need to discuss some other things that could be going on that could interfere with her response to insulin. All diabetic dogs should have regular urine cultures and full blood panels (CBC, chemistry, heartworm and tick screening test), and physical exams focusing on any skin or dental infections that might be present. We are also looking for other diseases like cushing's syndrome, kidney issues, or evidence of infection or inflammation. Inflammatory or infectious conditions like skin infections or bladder infections can interfere with the effectiveness of the insulin, so if I'm having trouble managing a patient, I typically recommend the blood and urine tests. Diabetic pets are very prone to urinary tract infections, and they don't always show up on a typical in house urinalysis - they need to have urine sent to the lab to incubate and see if it grows anything. Many specialists will also do an abdominal ultrasound and/or some chest X-rays as a survey to look for other non-diabetic diseases, specifically masses or cancers. Any illness aside from the diabetes can interfere with the insulin's effectiveness.

Another thing to consider would be a switch to a prescription diabetic diet like Royal Canin Diabetic or Purina DCO. These can make the world of difference in maintaining a low insulin requirement because they are formulated specifically for diabetic pets and held to very high quality control standards. I've seen pets decrease their insulin requirements by 10-15 units after switching to one of these diets. Also, I suggest a high quality probiotic like Purina's FortiFlora to support overall GI tract health and digestion.

On to insulins - Both glargine (lantus) and detemir (levemir) are the new "darling" insulins in veterinary medicine. I say that tongue in cheek a bit because the favored insulins among the profession do seem to shift about every 5 years or so. In any case, if you are seeing a Somogyi effect where the sugar drops too low at any point in the day then rebounds quite high, it means that the dose of insulin is too high and we need to decrease it. Once we are no longer seeing her drop too low, then we can evaluate the duration of action. As long as she is going too low at some point in the day, she is going to rebound high, so the goal would be to decrease the insulin until we are no longer dipping below about 60-70 at our lowest point. At that point, if it seems that the vetsulin duration isn't long enough, I'd probably be heading toward the glargine (lantus) because it has a much longer duration of action. Unfortunately, lantus is quite expensive, however so is a trip to the specialist ;)

It's likely at this point that your vet is pitching the idea of referral because he can sense that you're becoming frustrated. I've been in that situation too as a vet - I can tell that the owners aren't happy with their results, so I try to send them "up the chain" so that they can hopefully get results faster. It may also be that your vet will need to step out of their normal comfort zone to deal with Greta's problems. Most of the time your vet knows academically what to do, but may be holding back on the recommendations for further expensive testing for fear that you'll become more frustrated by their suggestion that you spend more money. I'm always happy to enter unfamiliar territory with my clients as long as they're understanding of the fact that I'm treading on new ground for myself, but I'm doing it with all the support I can muster from my texts and consultations with peers and sometimes even with specialists. I do, however, always recommend that if a client is going to seek a second opinion, that they go "vertical" not "horizontal" - meaning that they move up to a specialty hospital rather than move laterally to another general practitioner who is likely just as far out of his comfort zone dealing with your pet than your current vet.

Please let me know what other questions I can handle for you :)

~Dr. Sara

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Customer: replied 1 year ago.
Thank you Dr Sara. Greta had a series of blood tests the day she had the seizures 4 wks ago (although I'm not sure if she had a urinalysis). All results were normal except for her glucose reading (687) and slightly elevated ALT and kidney function test. Would you suggest I have our vet run the tests you mentioned even if some/all were done 4 wks ago? If so, what should we be looking for? What would indicatewhether X-rays or a sonogram is needed? Is one more informative than the other? Despite the indication of the Somogyi effect, the vet has continues to alternate the dosage up and down which seems contrary to what you suggest. Is it possible that she needs to be fed and dosed at different times of the day than she is currently fed/dosed? Is there any precautions that must be taken when changing foods and/or insulin? Would you suggest making changes one at a time and spaced apart to determine the impact of each change, what works/what doesn't work? Do you think the recurring infections are impacting the effectiveness of the insulin or is it possible that the uncontrolled diabetes is making her susceptible to infection? Is it possible that Greta has built up some sort of immunity to the different insulins by being on them for so long? I understand your comments about cost and, of course, I'd be less than truthful if I said it wasn't a concern, but it is not and has never been our primary concern. Our vet knows the lengths and cost to which we've gone to give our departed friends the best chance possible. We don't have a money tree in our yard, but we've found ways to manage the cost to give our pups the best care possible. We want to do what makes sense and that's why we've come to you. We value your guidance since, as you can see, we are scared, frustrated and don't know what to do next.
Expert:  Doc Sara replied 1 year ago.

Thanks for the reply. I would definitely recommend a urinalysis and a urine culture in any diabetic pet that we're having difficulty regulating. The blood work is pretty recent so I don't think that needs to be done again. X-rays and sonogram are indicated as a "survey" - that is to search out other reasons why she might not be regulating - adrenal tumors, masses on the liver or spleen, nodules in the chest. It's kind of like searching the beach with a metal detector - you're just looking for anything at all that might be helpful to explain what's going on. Be cautious, though, in that you may not really be able to DO anything about what you find without involving more specialized care (like an oncologist or board certified surgeon) - so just finding something may not change what you do about it, because you might opt not to pursue aggressive surgery, for instance, if you find a tumor.

It's of vital importance that she NOT get hypoglycemic at any point during the day, otherwise you can't interpret anything from those high readings. A reading of 600+ doesn't mean the insulin dose is too low if it's been preceded by a reading of 50. It's a normal compensatory mechanism for the sugar to shoot up high after it's been made too low. So the dose may still need to be decreased if she's having low spots that are triggering her body's normal defense mechanism of releasing hormones that will cause the sugar to spike high. This is the very first thing I'd address - curving to be absolutely sure that she doesn't go too low. If we find that we've got that nadir (lowest reading of the day) too early in the day and it's no lower than about 80, that's when I'd consider insulin switch. The timing of feeding isn't as important and what we are feeding, and if we're going to be aggressive about controlling a patient, I do sometimes switch insulin and food at the same time, but we have to follow up with close monitoring with curves over the next week or two to get things under control again. Recurring infections can both be caused by diabetes AND cause your insulin to not work as well, so they need to be addressed at the same time. It's not likely that she's built up a tolerance, although there is some evidence that pets might develop antibiodies to insulins over time that decrease their effectiveness. I'd say that's likely academic, though. It seems far more likely in your case that we just haven't done the right things to get her sugar controlled yet.

If your vet has seen that you've pursued referral in the past, that's another reason they may be suggesting it again - like I said, if we see that our owners are getting frustrated and we're potentially stepping into expensive and/or slightly new territory, we are going to always offer that "out" to a specialty clinic for the owners to get them the fastest results possible. Thanks for the reply :) Let me know what other questions I can handle for you!

~Dr. Sara