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Hoping with this discussion titile I don't send everyone scrambling. 13 year old DSH N/M cat presented 10/30/12 for increased water consumption and weight loss (was 21.8 pounds, 14.3 pounds at that time and near ideal weight at 14.3 lbs). Weight loss was considered acceptable and patient was diagnosed as diabetic based upon Glu 660 and glucosuria and began glargine (1 unit) BID, DM food. Case has progressed with little to no improvement. We are now giving 11 units galrgine BID with a curve done preceding each 1 unit increas and feel confident administration done properly. Repeat glucose curve on Monday was 8:00-448; 10:15-388; 12:25-381; 2:25-366; 4:25-425. Last UA and urine culture done 3/22/13-no bacteria noted or culture growth; 2+ protein and 3+ glucose. I have reached the threshold insulin dose of 1.5U/kg after which I understand have insulin resistance and should begin searching for underlying issue of which hyperadrenocorticism and acromegaly are at the top of the differential list. My questions are: has the sensitivity of the GH and or IGF tests made a point where they are worthwhile? My second question regards the owner. Per the animal caretaker, "he smokes weed all day long." The other three cats in the house have moved out of the house (on their on accord) and now live in the barn as they were "all wigged out." However the remaining cat (my diabetic patient) seems to mind nothing. The most laid back cat in the world regardless of if he has been around the owner or not (perhaps more mellow if owner is around). Can long term marijuana exposure create havoc with insulin therapy/diabetes? Just curious regarding ideas before going down this road. Thanks- ☼

Have you performed chest radiographs and abd us?

Does owner feed dogs meat from the table that has not been properly cooked?

Hoping with this discussion titile I don't send everyone scrambling. 13 year old DSH N/M cat presented 10/30/12 for increased water consumption and weight loss (was 21.8 pounds, 14.3 pounds at that time and near ideal weight at 14.3 lbs). Weight loss was considered acceptable and patient was diagnosed as diabetic based upon Glu 660 and glucosuria and began glargine (1 unit) BID, DM food. Case has progressed with little to no improvement. We are now giving 11 units galrgine BID with a curve done preceding each 1 unit increas and feel confident administration done properly. Repeat glucose curve on Monday was 8:00-448; 10:15-388; 12:25-381; 2:25-366; 4:25-425. Last UA and urine culture done 3/22/13-no bacteria noted or culture growth; 2+ protein and 3+ glucose. I have reached the threshold insulin dose of 1.5U/kg after which I understand have insulin resistance and should begin searching for underlying issue of which hyperadrenocorticism and acromegaly are at the top of the differential list. My questions are: has the sensitivity of the GH and or IGF tests made a point where they are worthwhile? My second question regards the owner. Per the animal caretaker, "he smokes weed all day long." The other three cats in the house have moved out of the house (on their on accord) and now live in the barn as they were "all wigged out." However the remaining cat (my diabetic patient) seems to mind nothing. The most laid back cat in the world regardless of if he has been around the owner or not (perhaps more mellow if owner is around). Can long term marijuana exposure create havoc with insulin therapy/diabetes? Just curious regarding ideas before going down this road. Thanks- ☼

Test for cushings?

What should he weigh?

Hoping with this discussion titile I don't send everyone scrambling. 13 year old DSH N/M cat presented 10/30/12 for increased water consumption and weight loss (was 21.8 pounds, 14.3 pounds at that time and near ideal weight at 14.3 lbs). Weight loss was considered acceptable and patient was diagnosed as diabetic based upon Glu 660 and glucosuria and began glargine (1 unit) BID, DM food. Case has progressed with little to no improvement. We are now giving 11 units galrgine BID with a curve done preceding each 1 unit increas and feel confident administration done properly. Repeat glucose curve on Monday was 8:00-448; 10:15-388; 12:25-381; 2:25-366; 4:25-425. Last UA and urine culture done 3/22/13-no bacteria noted or culture growth; 2+ protein and 3+ glucose. I have reached the threshold insulin dose of 1.5U/kg after which I understand have insulin resistance and should begin searching for underlying issue of which hyperadrenocorticism and acromegaly are at the top of the differential list. My questions are: has the sensitivity of the GH and or IGF tests made a point where they are worthwhile? My second question regards the owner. Per the animal caretaker, "he smokes weed all day long." The other three cats in the house have moved out of the house (on their on accord) and now live in the barn as they were "all wigged out." However the remaining cat (my diabetic patient) seems to mind nothing. The most laid back cat in the world regardless of if he has been around the owner or not (perhaps more mellow if owner is around). Can long term marijuana exposure create havoc with insulin therapy/diabetes? Just curious regarding ideas before going down this road. Thanks- ☼

When was the last time the insulin bottle was changed?

How did you base this assessment?

I had a client that came in a few months ago with a dog that you could smell the perio dz when you entered the room. He was shocked when I told him the dog needed dental work because for $150 he had her mouth cleaned at a low cost facility 6 weeks prior. This dog had severe furcation exposure... etc. I was so horrified that I called the Dr. at the facility and asked some questions: 1) do you have dental xray? Answer: I don't need it. If I see a tooth that needs to come out I take it. 2) Do you check/look at all your patients mouths? Answer: No, my techs are trained to tell me if there is a problem. Following is a before and after picture from their FB site! You can see root exposure and furcational exposure in the after photo. There is a good chance this dog went home with a still painful mouth that just looks better and smells better temporarily. I am not perfect... not even a little bit... never will be. I make mistakes... often... but I feel like I actively try to learn from them and strive for the gold standard of care. Do I report this vet? I just don't know what to do.

Here's the after! am i over-reacting?

Would he choose to drink over play a game with the owner if both were on offer?

I had a client that came in a few months ago with a dog that you could smell the perio dz when you entered the room. He was shocked when I told him the dog needed dental work because for $150 he had her mouth cleaned at a low cost facility 6 weeks prior. This dog had severe furcation exposure... etc. I was so horrified that I called the Dr. at the facility and asked some questions: 1) do you have dental xray? Answer: I don't need it. If I see a tooth that needs to come out I take it. 2) Do you check/look at all your patients mouths? Answer: No, my techs are trained to tell me if there is a problem. Following is a before and after picture from their FB site! You can see root exposure and furcational exposure in the after photo. There is a good chance this dog went home with a still painful mouth that just looks better and smells better temporarily. I am not perfect... not even a little bit... never will be. I make mistakes... often... but I feel like I actively try to learn from them and strive for the gold standard of care. Do I report this vet? I just don't know what to do.

Do i speak up?

What does this mean exactly?

Hello! "Teddy" is a 3 year-old castrated male Shih Tzu with a history of PU/PD throughout his life. Owner came to see us recently because she was concerned about diabetes. Bloodwork run that day (April 13) was all WNL except BUN was 49mg/dl (7-27), creat. normal at 1.5 (0.5-1.8) but this dog is small and thin. A urinalysis performed showed a S.G. of 1.018, with some WBC and cocci present from a free catch. The dog was placed on a two week course of Amoxicilin - 50 mg PO BID - this dog weighs 6.8 pounds. A recheck was recommended in 4 weeks for a renal panel and urine culture - we could not culture the urine that day because of mailing issues so decided to treat the dog prophylactically. On re-check 5/8 the BUN was 58, creat. 1.3. Urine was taken for a culture, which is pending but already shows enterococci organisms growing. An abdominal ultrasound was also performed at a referral center. The results were as follows: 1.) Right kidney totally absent, but right adrenal present. 2.) Left kidney - normal shape with abnormal parenchymal architecture (normal medullary pyramids and CM junction are absent), and a distended renal pelvis (DDX. dysplasia vs. pyelonephritis per ultrasonographer) So...given that this dog is 3 years old, wouldn't you expect that if he had dysplasia of the left kidney and no right kidney at all he would be deceased by now? What suggestions should I make to this owner - should we start on a kidney diet now or wait to see if this might just be a pyelonephritis and we can treat with 6-8 weeks of antibiotics? If so, she would like to use Royal Canin - would you recommend LP or MP? Would Calcitriol be appropriate yet? Would very much appreciate your advice with regard to a plan of action with this case. Obviously we should assume that the urine culture result is positive. Thanks very much! Sincerely, Dr. ☼

Did you know?

What do you estimate his ideal weight to be?

Good Evening! I have a 10 year old f/s Terrier mix, who weight approx 17.5#. She presented to me for severe PU/PD at the beginning of March. Her liver values were elevated at ALP 227, ALT 309. Her USG was 1.005, rest of UA was wnl. She was started on Metro, Ampicillin and Denamarin. She showed no other clinical signs. After 2 weeks, we rechecked her liver values and they returned at ALT 280, ALP 225. Her USG was rechecked and was actually lower at 1.002. We performed an ACTH stim the next day and her Pre was 3.1, Post was 18. After consulting with an internist, we decided that a DDAVP trial was appropriate. Other than her PU/PD, she feels great. After 2 drops of DDAVP bid, her USG increased to 1.028. The dog is doing great, her ALT is 208, ALP 300 at her recent recheck. The owner is frustrated with the drops and we discussed the injectable form and she is gung ho to try. She is a nurse with a diabetic cat. The question that I have is that, on previous threads, the Wedgewood compounded injectable is reported to be a 0.1% solution. However, I can only find the 0.01%. What sort of dose should I use? 2-3 units bid? And is it okay to use once daily? Thanks for the clarification! ☼

Have you considered an abdominal ultrasound?

How did the rest of the abd organs look?

Hello! "Teddy" is a 3 year-old castrated male Shih Tzu with a history of PU/PD throughout his life. Owner came to see us recently because she was concerned about diabetes. Bloodwork run that day (April 13) was all WNL except BUN was 49mg/dl (7-27), creat. normal at 1.5 (0.5-1.8) but this dog is small and thin. A urinalysis performed showed a S.G. of 1.018, with some WBC and cocci present from a free catch. The dog was placed on a two week course of Amoxicilin - 50 mg PO BID - this dog weighs 6.8 pounds. A recheck was recommended in 4 weeks for a renal panel and urine culture - we could not culture the urine that day because of mailing issues so decided to treat the dog prophylactically. On re-check 5/8 the BUN was 58, creat. 1.3. Urine was taken for a culture, which is pending but already shows enterococci organisms growing. An abdominal ultrasound was also performed at a referral center. The results were as follows: 1.) Right kidney totally absent, but right adrenal present. 2.) Left kidney - normal pe with abnormal parenchymal architecture (normal medullary pyramids and CM junction are absent), and a distended renal pelvis (DDX. dysplasia vs. pyelonephritis per ultrasonographer) So...given that this dog is 3 years old, wouldn't you expect that if he had dysplasia of the left kidney and no right kidney at all he would be deceased by now? What suggestions should I make to this owner - should we start on a kidney diet now or wait to see if this might just be a pyelonephritis and we can treat with 6-8 weeks of antibiotics? If so, she would like to use Royal Canin - would you recommend LP or MP? Would Calcitriol be appropriate yet? Would very much appreciate your advice with regard to a plan of action with this case. Obviously we should assume that the urine culture result is positive. Thanks very much! Sincerely, Dr. ☼

Did you mean for this to go in the urology folder?

Any chance that you can please post the lab work?

What would cause a USG of 1.090, 2+ protein, but inactive sediment? I have a feline patient that was given a depo-medrol injection 8 months ago for allergies, and became transiently diabetic. Once the depo wore off, the cat has been fine. He stopped eating 2 days ago and has had some infrequent vomiting. His bloodwork showed an inflammatory leukogram, although the overall WBC was normal. A chemistry with T4 was performed, and all were normal. Abdominal radiographs showed some gas. A barium swallow was also performed, and motility seemed normal although in the distal small instestine there was a segment of small intestine with thickened walls and filling defects. He was given Cerenia and SQ fluids. He is not vomiting, but still not eating and lethargic. My differentials include enteritis, IBD, triaditis, intestinal lymphoma, and heat stress. But I have never seen a urine so concentrated. This was confirmed by dilution at antech. The urine appeared normal in color, opacity, and odor. No glucosuria. Thanks!

How old is this kitty?

What color were they initially?

What would cause a USG of 1.090, 2+ protein, but inactive sediment? I have a feline patient that was given a depo-medrol injection 8 months ago for allergies, and became transiently diabetic. Once the depo wore off, the cat has been fine. He stopped eating 2 days ago and has had some infrequent vomiting. His bloodwork showed an inflammatory leukogram, although the overall WBC was normal. A chemistry with T4 was performed, and all were normal. Abdominal radiographs showed some gas. A barium swallow was also performed, and motility seemed normal although in the distal small instestine there was a segment of small intestine with thickened walls and filling defects. He was given Cerenia and SQ fluids. He is not vomiting, but still not eating and lethargic. My differentials include enteritis, IBD, triaditis, intestinal lymphoma, and heat stress. But I have never seen a urine so concentrated. This was confirmed by dilution at antech. The urine appeared normal in color, opacity, and odor. No glucosuria. Thanks!

Any history of possible foreign body or toxin ingestion?

Maybe the owner hasn't heard yet how big of a problem the dry food is?

What would cause a USG of 1.090, 2+ protein, but inactive sediment? I have a feline patient that was given a depo-medrol injection 8 months ago for allergies, and became transiently diabetic. Once the depo wore off, the cat has been fine. He stopped eating 2 days ago and has had some infrequent vomiting. His bloodwork showed an inflammatory leukogram, although the overall WBC was normal. A chemistry with T4 was performed, and all were normal. Abdominal radiographs showed some gas. A barium swallow was also performed, and motility seemed normal although in the distal small instestine there was a segment of small intestine with thickened walls and filling defects. He was given Cerenia and SQ fluids. He is not vomiting, but still not eating and lethargic. My differentials include enteritis, IBD, triaditis, intestinal lymphoma, and heat stress. But I have never seen a urine so concentrated. This was confirmed by dilution at antech. The urine appeared normal in color, opacity, and odor. No glucosuria. Thanks!

Are you able to post the full bloodwork results, including the normals and reference ranges?

Was the dog pretty relaxed during the ldds?

Mama is a 10y 11m FS DSH that I started seeing in January 2012. Mama is an extremely fractious cat! She was being treated for presumed vestibular disease at another animal hospital from October 2012. She had a spot BG of 180mg/dL on her Superchem with all other results wnl. No UA was done at that time. She was placed on long term Prednisone SID (I unfortunately do not know what dose). The first urine I see in the records was from 12/3/12 with 3+ Glucose neg Ketones. She was weaned off the Pred and placed on DM diet. I saw her for the first time on Jan 30th. In house BG was 534mg/dL. In house urine had 2+ glucose and negative ketones. I sent a Fructosamine level to Antech and gave information on Diabetes and recommended starting insulin injections. The Fructosamine level came back 663 (142-450)- poor regulation. The cat was used to free feeding but we got her on a twice a day feeding schedule. I had mom continue the DM canned and started 1 U of PZI BID. Her first BG curve was performed on 3/24/13 at home: 11:03AM 1U insulin was given 12:30PM BG 526 2:30PM BG 388 4:30PM BG 326 6:30PM BG 461 8:30PM BG 495 10:30PM BG 544 11:30PM Fed and gave 1U insulin She gained ¾ of a pound. She was still drinking a lot of water and urine glucose measurements at home were consistently between 1,000-2,000 with negative ketones. Her vestibular disease was improved but not 100% resolved- owners could not afford the MRI that the internal medicine specialist they had been referred to had recommended. I increased her insulin to 2U BID. Next BG curve was 4/21/13 at home: 11:10 BG 462 11:30AM Fed and gave 2U PZI 1:00PM BG 527 3:00PM BG 414 5:00PM BG 388 7:00PM BG 415 9:00PM BG 450 11:00PM BG 410 11:30PM Fed and gave 2U insulin She gained almost a pound. Urine glucose measurements at home were consistently between 500-1000. I increased her insulin to 3U BID. She came in and saw our per diem vet on 5/2/13 for 1 episode of vomiting. IH BG was 276mg/dL, glucose + ketones were negative. Fructosamine level was 465 (142-450)- good regulation. She was back to her normal self the following day and mom reported that her PUPD had resolved. On 5/5, 5/6, and 5/7 morning and evening urine glucoses were negative and spot BG’s were in the 200’s and low 100’s- she spoke with the other vet here who said to lower insulin back to 2U. Urine glucose was still negative 5/8. 5/9/13 morning BG was 120 and evening BG was only 70. I told the owner not to give insulin that night or the following morning and do a curve. Results are as follows (from yesterday) 10:40AM BG 178 12:40PM BG 201 2:40PM BG 238 4:40PM BG 270 6:40PM BG 317 8:40PM BG 355 10:40PM BG 353 10:50PM Fed 12:40AM BG 400 2:40AM BG 371. Urine glucose is back up to 1000. Help! Mom does give a little dry food around 5PM. Could this be screwing up all the results. I’m assuming the 3U was definitely too much for her but the 2U didn’t appear to be enough. Should I try 2.5U if she can measure it.? Should I change the insulin to Glargine? I hate Diabetes  Any help would be greatly appreciated. (Sorry so long)

What is her bcs now?

Is it a glucometer or other?

dear colleagues I have posted the entire record w/blood glucose, biopsy etc but his is the bottom line 10 yr old cat- goes to rdvm large wounds- no known cause- slow to heal- laser treatment- finally heals but also w/blood work - hyperglycemia and glucosuria (cat is stressed so they do it at home- glucouria w/Purina litter test kit but euglycemic. I see the cat- mildly hyperglycemic (177) but glucosuric and both rdvm and I have normal fructosamine- so my take on this is that the cat is a type II diabetic that is only occasionally hyperglycemic...ok no big deal but how does it tie into the wound? I think skin fragility due to cushings- how to prove- too mean to get meaningful dex suppression- so maybe MRI (concerned that u/s has poor specificity in DIAGNOSING HAC - ok w/ddx types)- help Patient History Report: Jasper - 5/11/2013 Clinic: Patient: Jasper Allergy, Skin and Ear Clinic for Pets/Animal Hospital PC ID: 25434 31205 Five Mile Tag: Livonia, MI 48154 Species: Feline, Domestic Short Hair Sex: male/neutered 734-425-2270 Age: 5 yrs, DOB: 4/29/2008 Client: Weight: 12.7 Lbs T. Trala & S. Bhat Color: Black/white 22330 Swan St Last visit: 5/2/2013 Apt 1138 Referred By: South Lyon, MI 48178 Home Phone: 734-474-0376 cell Work Phone1: ---- Work Phone2: ----- ID: 21835, File #: 23587 Tel: 810-220-1079 / Fax: 810-220-7996 Diagnoses: 5/11/2013, 1:01 PM Skin fragility - tdx (☼

Is the cat 5 yrs old or 10?

What brand is the owner's glucometer?

Dear colleagues I have a 10 year old MN cat w/PDH- he has type II diabetes (controlled quite well w/diet). Fragile skin syndrome- lesions from rdvm took 1-2 mnths to heal - needed laser- rest of the bloodwork, ua and urine culture normal. Skin biopsy revealed abnormal collagen consistent w/fragility syndrome. LDDS (0.1 mg/kg) revealed 13.9 ug/dL, 4.5 and 3.1 at 0, 4 and 8 hrs -so it appears at though trilostane is the drug of choice - dosage 10-15 mg bid to 30 mg sid- big range- where do you start? do you check acth stim 3-5 hrs post pill? - check electrolytes too? also I have done an ACTH stim already- resting was 3.1 - 30 min was 13.7 and 1 hr was 16.5 - so I have a starting point- but the ACTH (cortisyn) was given IV the first time- cat is a bit BAD so if I could give it IM during monitoring it would be easier. If given IV can I just do 0 and 60 minutes (no need for 30 minutes?) and if IM again do I do a 60 or 60 and 90 minutes any other comments? thanks ☼

Do you have photos of this cat's skin?

Has the owner's glucometer been tested on a whole curve?

Dear colleagues I have a 10 year old MN cat w/PDH- he has type II diabetes (controlled quite well w/diet). Fragile skin syndrome- lesions from rdvm took 1-2 mnths to heal - needed laser- rest of the bloodwork, ua and urine culture normal. Skin biopsy revealed abnormal collagen consistent w/fragility syndrome. LDDS (0.1 mg/kg) revealed 13.9 ug/dL, 4.5 and 3.1 at 0, 4 and 8 hrs -so it appears at though trilostane is the drug of choice - dosage 10-15 mg bid to 30 mg sid- big range- where do you start? do you check acth stim 3-5 hrs post pill? - check electrolytes too? also I have done an ACTH stim already- resting was 3.1 - 30 min was 13.7 and 1 hr was 16.5 - so I have a starting point- but the ACTH (cortisyn) was given IV the first time- cat is a bit BAD so if I could give it IM during monitoring it would be easier. If given IV can I just do 0 and 60 minutes (no need for 30 minutes?) and if IM again do I do a 60 or 60 and 90 minutes any other comments? thanks ☼

How many laser treatments did it take?

Does her skin ripple at times?

Dear colleagues I have a 10 year old MN cat w/PDH- he has type II diabetes (controlled quite well w/diet). Fragile skin syndrome- lesions from rdvm took 1-2 mnths to heal - needed laser- rest of the bloodwork, ua and urine culture normal. Skin biopsy revealed abnormal collagen consistent w/fragility syndrome. LDDS (0.1 mg/kg) revealed 13.9 ug/dL, 4.5 and 3.1 at 0, 4 and 8 hrs -so it appears at though trilostane is the drug of choice - dosage 10-15 mg bid to 30 mg sid- big range- where do you start? do you check acth stim 3-5 hrs post pill? - check electrolytes too? also I have done an ACTH stim already- resting was 3.1 - 30 min was 13.7 and 1 hr was 16.5 - so I have a starting point- but the ACTH (cortisyn) was given IV the first time- cat is a bit BAD so if I could give it IM during monitoring it would be easier. If given IV can I just do 0 and 60 minutes (no need for 30 minutes?) and if IM again do I do a 60 or 60 and 90 minutes any other comments? thanks ☼

Is the skin "normal" now -- tearing resolved?

Do you have any curves to document the need for additional insulin?

Snoopy-Dawg is a 13 yr MN DSH. I saw him ~ 6 weeks ago for a routine exam and noticed some dental disease. In preperation for that we did labwork and he was diagnosed as hyperthyroid: T4 3.4 Free T4-ed 4.7 (1.2-4.3)ng/dL or 60.5 (15.4-55.3)pmol/L - rest of the labs, including UA were all normal. I started the cat on 5mg methimazole SID and his T4 was 2.1 2 weeks later. The client wants to treat him with I131. So, in prep for that I saw him back the other day for a follow-up. He has lost another pound and is PU/PD. So, his labwork 6 weeks after starting methimazole looks great, except BG is 330. USG is 1.044 (we did not do a dipstick and I don't have that urine anymore). T4 is now 1.6. BUN (32), creat (1.7), and ALT are all great. Based on this I elected to have the lab run a fructosamine on the blood and the result is 393 (191-349). What say you? DM? boarderline? Should he go for the I131? Shall I put that off and recheck his blood and urine glucose in a bit? Angee (Dyer) DVM VIN Rep. Michigan State University 1995 "Stop having worms in your body, you IDIOT!" -- Tom Servo on MST3K Disclaimer: Opinions expressed are mine and not an official representation of VIN.

Does he have a palpable thyroid nodule?

If not, then why would she feed that to her dog?

Snoopy-Dawg is a 13 yr MN DSH. I saw him ~ 6 weeks ago for a routine exam and noticed some dental disease. In preperation for that we did labwork and he was diagnosed as hyperthyroid: T4 3.4 Free T4-ed 4.7 (1.2-4.3)ng/dL or 60.5 (15.4-55.3)pmol/L - rest of the labs, including UA were all normal. I started the cat on 5mg methimazole SID and his T4 was 2.1 2 weeks later. The client wants to treat him with I131. So, in prep for that I saw him back the other day for a follow-up. He has lost another pound and is PU/PD. So, his labwork 6 weeks after starting methimazole looks great, except BG is 330. USG is 1.044 (we did not do a dipstick and I don't have that urine anymore). T4 is now 1.6. BUN (32), creat (1.7), and ALT are all great. Based on this I elected to have the lab run a fructosamine on the blood and the result is 393 (191-349). What say you? DM? boarderline? Should he go for the I131? Shall I put that off and recheck his blood and urine glucose in a bit? Angee (Dyer) DVM VIN Rep. Michigan State University 1995 "Stop having worms in your body, you IDIOT!" -- Tom Servo on MST3K Disclaimer: Opinions expressed are mine and not an official representation of VIN.

Any polyphagia or weight loss on his original presentation?

Is this a male or female dog?

Snoopy-Dawg is a 13 yr MN DSH. I saw him ~ 6 weeks ago for a routine exam and noticed some dental disease. In preperation for that we did labwork and he was diagnosed as hyperthyroid: T4 3.4 Free T4-ed 4.7 (1.2-4.3)ng/dL or 60.5 (15.4-55.3)pmol/L - rest of the labs, including UA were all normal. I started the cat on 5mg methimazole SID and his T4 was 2.1 2 weeks later. The client wants to treat him with I131. So, in prep for that I saw him back the other day for a follow-up. He has lost another pound and is PU/PD. So, his labwork 6 weeks after starting methimazole looks great, except BG is 330. USG is 1.044 (we did not do a dipstick and I don't have that urine anymore). T4 is now 1.6. BUN (32), creat (1.7), and ALT are all great. Based on this I elected to have the lab run a fructosamine on the blood and the result is 393 (191-349). What say you? DM? boarderline? Should he go for the I131? Shall I put that off and recheck his blood and urine glucose in a bit? Angee (Dyer) DVM VIN Rep. Michigan State University 1995 "Stop having worms in your body, you IDIOT!" -- Tom Servo on MST3K Disclaimer: Opinions expressed are mine and not an official representation of VIN.

What were the original bun/creatinine before treatment?

Could you do surgery yourself to get a biopsy of the thickened segment of intestine?

"Jimmy" is an approximately 4 year old male (now neutered) beagle that was brought in by our local shelter (ie therefore no previous history) to be neutered on April 16, 2013. He was adopted and taken home that day by one of our technicians. May 3, 2013 she brought in a urine sample because he was noted to be leaking when lying, sleeping or dribbling urine when walked. She really hasn't noticed him drinking an excessive amount. He urinated normally outside and marked like a normal boy. His urinalysis (in house) that day was unremarkable except his SG was 1.006. I asked her to bring in a free catch first morning sample to reassess the SG. His last drink was 10pm and his first morning sample was 1.012! An in house blood profile revealed no abnormalities. His ACTH stim was normal. I took a cysto sample the day of his ACTH stim and the following was his urinalysis done at the lab. (Culture results are still pending but I feel as though they will be negative.) SG = 1.016 pH = 7.5 Protein, glucose, ketones, bili, blood = negative Urobilinogen = normal RBC, WBC, Bacteria, Crystals = negative The dribbling and incontinence continues to worsen. My question is, assume the culture is negative, what would you say the next logical step would be: 1) Trial of ADH? 2) Trial of PPA? 3) Restriction of water? I've read the protocol for the water deprivation test. Not sure if that is possible as this technician has numerous other cats and dogs. Is it ok as we've ruled out the majority of the other diseases just to withhold water at this point? 4) Other?

What was the dog's sodium on the blood work?

The first question is: do the client and you consider this kitty well-controled by clinical signs?

Hi there, I am looking for some input on this case I have been managing over the last couple of months. This puppy came into to be spayed in March. Pre-anesthetic blood work: Crea- 117 (27-106) Bun- 9.5 (2.5-10.4) USG- 1.018 At this time she had a urinary tract infection, which was cultured and treated and resolved well. She was brought back in last week for a second attempt at a spay. Bloodwork: Crea- 155 (27-106) BUN- 11.3 (2.5-9.6) USG- 1.008 Culture came back negative. In talking to her owner it does appear that she's pu/pd. I have asked the owner to measure her daily water intake. Could this be primary diabetes insipidus? Is it possible that this is a primary renal issue with this low a USG? What would you recommend as a next step for working this dog up? Thanks for your time, ☼

What was her sodium and potassium?

He's absolutely not getting any jerky treats?

Quick question, I've gotten differing reports on this and I was hoping someone could clear things up for me. Does hyperthyroidism have a direct impact on immune system function like Cushing's or Diabetes? I have a cat on methimazole that has been battling recurring UTIs. Our next step is an ultrasound to look for lower urinary pathology but is it possible that this is simply secondary to the hyperthyroidism? Thanks for the help. /p

Have serial cultures been done (to diagnose, to check on treatment effectiveness and one-month post-treatment)?

Did she have an ultrasound or hdds to find this out?

Quick question, I've gotten differing reports on this and I was hoping someone could clear things up for me. Does hyperthyroidism have a direct impact on immune system function like Cushing's or Diabetes? I have a cat on methimazole that has been battling recurring UTIs. Our next step is an ultrasound to look for lower urinary pathology but is it possible that this is simply secondary to the hyperthyroidism? Thanks for the help. /p

What bacteria are being cultured?

Urine culture negative?

I have a 12 year old mc DSH cat with chronic diarrhea. As a kitten he had a wbc of 300 and high fever. was treated with iv antibiotics/fluids and resolved. He has retinal lesions suggestive of previous panleukopenia infection and has a chronic on and off serous discharge from eye (herpes?). He was dewormed several times with panacur, tylosin and has been tested felv/fiv negative several times when he was younger. Throughout his life he has always had on and off stools. When he was young his symptoms were controlled with an otc sensitive diet, As he aged rare short courses of prednisolone and metronidazole controlled his signs. During the past few months his diarrhea has increased and he cannot make it to the litter box. The consistency ranges from watery to loose. Sometimes he will howl when he goes. His recent cbc/chem/T4 and abdominal ultrasound results wherre normal. TLI, folate and spec fPL all normal. Cobalamin 1888 (276-1425). I have started Hill's id/ and prednisolone with little to no improvement (except not howling any more). I just addede in meteronidazole and fortiflora whcih does not seem to be helping either. Any suggestions?

Is there weight loss and other gi-related signs, like vomiting?

Does the cat have gi disease as well?

I have a 12 year old mc DSH cat with chronic diarrhea. As a kitten he had a wbc of 300 and high fever. was treated with iv antibiotics/fluids and resolved. He has retinal lesions suggestive of previous panleukopenia infection and has a chronic on and off serous discharge from eye (herpes?). He was dewormed several times with panacur, tylosin and has been tested felv/fiv negative several times when he was younger. Throughout his life he has always had on and off stools. When he was young his symptoms were controlled with an otc sensitive diet, As he aged rare short courses of prednisolone and metronidazole controlled his signs. During the past few months his diarrhea has increased and he cannot make it to the litter box. The consistency ranges from watery to loose. Sometimes he will howl when he goes. His recent cbc/chem/T4 and abdominal ultrasound results wherre normal. TLI, folate and spec fPL all normal. Cobalamin 1888 (276-1425). I have started Hill's id/ and prednisolone with little to no improvement (except not howling any more). I just addede in meteronidazole and fortiflora whcih does not seem to be helping either. Any suggestions?

Have you done a rectal exam?

Is the commercial product or compounded?

I have a 12 year old mc DSH cat with chronic diarrhea. As a kitten he had a wbc of 300 and high fever. was treated with iv antibiotics/fluids and resolved. He has retinal lesions suggestive of previous panleukopenia infection and has a chronic on and off serous discharge from eye (herpes?). He was dewormed several times with panacur, tylosin and has been tested felv/fiv negative several times when he was younger. Throughout his life he has always had on and off stools. When he was young his symptoms were controlled with an otc sensitive diet, As he aged rare short courses of prednisolone and metronidazole controlled his signs. During the past few months his diarrhea has increased and he cannot make it to the litter box. The consistency ranges from watery to loose. Sometimes he will howl when he goes. His recent cbc/chem/T4 and abdominal ultrasound results wherre normal. TLI, folate and spec fPL all normal. Cobalamin 1888 (276-1425). I have started Hill's id/ and prednisolone with little to no improvement (except not howling any more). I just addede in meteronidazole and fortiflora whcih does not seem to be helping either. Any suggestions?

How recently was his t4 checked and what was the result?

Is this patient off all medications for her bout with itp?

Hi, I was hoping for some advice on an old diabetic patient of mine. Bacardi is a16yr old, F/S DSH cat who has been diabetic for years. She has typically been a well controlled diabetic (on caninsulin 4iu BID), but has developed chronic pancreatitis in the last 7-8 months (diagnosed and monitored with the fpli test). On March 30, 2013 she was diagnosed with a hyperosmolar non-ketotic diabetic crisis and remarkably she pulled through. She was in the intensive care unit at our local referral clinic for about a week and is now home and pretty much back to normal. During her crisis her blood sugars were all over (ranging from over 70mmol/L at admission to less than 3mmol/L when she was restarted on insulin). She was sent home on 2 iu BID. Since her illness her owners have been checking blood glucose curves at home. Her last recorded weight is from about a month ago and was 4.25kg. These are her last 3 BG curves. April 13/13 8am BG 31.8mmol/L Gave 2iu caninsulin sq 10:15am 30.4 12:20pm 15.6 2pm 10.5 4pm 14.4 Apri 27/13 7:30am 31.9 Gave 2.5iu Caninsulin 8:30 am 39.5 9:30 am 36.1 10:30am 34.3 11:30 am 19.6 12:30pm 14.4 1:30pm 12.3 2:30pm 12.4 3:30pm 16.1 May 11/13 7:45am 35.1 Gave 3iu Caninsulin 8:45am 40.5 9:45am 37.9 10:45am 31.7 11:45 20.4 12:50pm 14.7 1:55pm 9.1 2:50 pm 11.7 It appears to me that the nadir is getting better with each curve, but I am at a loss as to why her initial values in the morning are getting higher. I don’t think this is a somoygi because she is curving down or am I incorrect an this could be a somoygi? Her weight is trending downwards a bit, she is eating very well, and she is still a bit PU/PD. Overall her owners feel she is doing well and her mobility is great. I am planning to increase her insulin to 4iu BID, but thought I would see if there are any other suggestions. Thanks so much for your help. ☼

Would it be possible for the owners to continue the curve until they go to sleep?

How long since he's had a urine culture?

Hi, I was hoping for some advice on an old diabetic patient of mine. Bacardi is a16yr old, F/S DSH cat who has been diabetic for years. She has typically been a well controlled diabetic (on caninsulin 4iu BID), but has developed chronic pancreatitis in the last 7-8 months (diagnosed and monitored with the fpli test). On March 30, 2013 she was diagnosed with a hyperosmolar non-ketotic diabetic crisis and remarkably she pulled through. She was in the intensive care unit at our local referral clinic for about a week and is now home and pretty much back to normal. During her crisis her blood sugars were all over (ranging from over 70mmol/L at admission to less than 3mmol/L when she was restarted on insulin). She was sent home on 2 iu BID. Since her illness her owners have been checking blood glucose curves at home. Her last recorded weight is from about a month ago and was 4.25kg. These are her last 3 BG curves. April 13/13 8am BG 31.8mmol/L Gave 2iu caninsulin sq 10:15am 30.4 12:20pm 15.6 2pm 10.5 4pm 14.4 Apri 27/13 7:30am 31.9 Gave 2.5iu Caninsulin 8:30 am 39.5 9:30 am 36.1 10:30am 34.3 11:30 am 19.6 12:30pm 14.4 1:30pm 12.3 2:30pm 12.4 3:30pm 16.1 May 11/13 7:45am 35.1 Gave 3iu Caninsulin 8:45am 40.5 9:45am 37.9 10:45am 31.7 11:45 20.4 12:50pm 14.7 1:55pm 9.1 2:50 pm 11.7 It appears to me that the nadir is getting better with each curve, but I am at a loss as to why her initial values in the morning are getting higher. I don’t think this is a somoygi because she is curving down or am I incorrect an this could be a somoygi? Her weight is trending downwards a bit, she is eating very well, and she is still a bit PU/PD. Overall her owners feel she is doing well and her mobility is great. I am planning to increase her insulin to 4iu BID, but thought I would see if there are any other suggestions. Thanks so much for your help. ☼

Has she had a recent t4?

Panting?

Hello, Bernie is a 5 year old, 19 lb 7.5 oz (!) MN kitty who presented with diabetes in March 2013. BG was 29.0 mmol/L on presentation - rest of bloodwork looked great. fPL wnl, U/A unremarkable, mom declined C&S at the time. Other than obesity, he had moderate dental tartar and mild gingivitis on GPE. No diabetic neuropathy at the time of dx. He has a history of struvite crystalluria and FLUTD signs - he was on S/O dry at the time of dx (does not eat canned food too well, owner working on this). I started Bernie on 2 IU Glargine SQ BID. Due to his crystal issues, I spoke with the food companies and on recommendation changed him to UR StOX canned and wet to account for both the DM and the previous crystalluria. His first curve went as follows - mom does them at home. Decrease in drinking noted. Owner steadily increasing proportion of canned to dry. I did tell owner that ok to let Bernie have snack throughout the day. 6 - 21.3 *Fasted, pre-insulin. 2 U insulin 8 - 28.6 10 - 29.8 12 - 30.1 2pm - 23.5 4 - 26.6 6 - 27.8 Upped the dose to 3 U BID, and told mom ok to do BG q3hrs now 6 am - 24.1 *Fasted, pre-insulin. 3 U 10 - 25.7 2 pm - 27.7 6 - 27.2 PU/PD improving, but owner has started to note diabetic neuropathy. Upped to 4 U BID 7 am - 20.3 10 - 24.4 3 - 25.7 6 - 21.8 ... Started to discuss concern for insulin resistance/need different insulin/etc with owner... and upped to 5 U BID. Convinced mom to do urine C&S to be sure - No growth. Weight down to 19.2 lbs. 5IU BID: 6 am - 21.2 9 - 22.9 12:30 - 19.1 3:30 pm - 18.6 6 pm - 26.4 ... Looking better, a bit more hopeful here, a steadier flatline... Same chat with owner with concern with ongoing increase in insulin, but tried going up to see as I know we cannot call it insulin resistance at this dose yet. 6Iu BID: 6am - 22.8 9 - 23.4 12pm - 23.3 3 - 25.3 6 - 16.8 Then mom did 10:30 pm - 5.1 !! She double checked this, and checked on him the following day: 6 am -25.1 12 pm - 25 10 pm - 23.1 Diabetic neuropathy is worsening, understandably as his blood glucose level is disappointingly poorly controlled at this time. I don't feel that continuing to increase the dose is the right answer, and wondering if glargine is at all the right insulin for him - I feel he fared better at the 5 U BID dose. Obviously open to ideas here. I don't want to blindly continuing to go up and up, I feel that I should be doing better for him at this point. Other question I'm considering is if there is better for him diet-wise that will take care of the DM as well as the crystalluria? Would you recommend an insulin change at this time? Should I look deeper for an underlying problem? Thank you in advance, Emmanuelle

Is this the only time this has happened that the owner is aware of?

Is the current diet hill's prescription diet m/d canned or dry (or both)?

I inherited a complicated case. It is a 13 year old FS DSH who has been previously diagnosed with likely IBD by biopsy ( I say likely because the biopsy could not differentiated between IBD and lymphoma) and HCM in 2010. IBD has been managed with prednisolone EOD and HCM by atenolol. Back in 2006 at another veterinarian's office she was diagnosed with hypokalemia after a few "episodes" of twitching. She has been doing well being maintained on potassium gluconate. Recently the owner came home to find her having an episode and took her to the e-clinic where she was given IV fluids with KCl supplementation. On presentation K was 2.8 (3.5-5.8), all other blood work (CBC, CS, T4, U/A) was WNL. After fluids K was 5.3. Cat was doing great and was discharged. We increased the cat's potassium gluconate to 2 mEq BID (previously on 2 in AM and 1.5 PM) and recheck chemistry in 1 week. What could be causing this hypokalemia? Could it be the IBD? Should I just continue to supplement or try to find a cause?

Has this client been adherent to the dosing schedule?

Should i bump him up to 6 units?

I inherited a complicated case. It is a 13 year old FS DSH who has been previously diagnosed with likely IBD by biopsy ( I say likely because the biopsy could not differentiated between IBD and lymphoma) and HCM in 2010. IBD has been managed with prednisolone EOD and HCM by atenolol. Back in 2006 at another veterinarian's office she was diagnosed with hypokalemia after a few "episodes" of twitching. She has been doing well being maintained on potassium gluconate. Recently the owner came home to find her having an episode and took her to the e-clinic where she was given IV fluids with KCl supplementation. On presentation K was 2.8 (3.5-5.8), all other blood work (CBC, CS, T4, U/A) was WNL. After fluids K was 5.3. Cat was doing great and was discharged. We increased the cat's potassium gluconate to 2 mEq BID (previously on 2 in AM and 1.5 PM) and recheck chemistry in 1 week. What could be causing this hypokalemia? Could it be the IBD? Should I just continue to supplement or try to find a cause?

Is this cat maintaining good body weight on the above regimen?

For dogs or for cats?

Apologies for the long summary, but this case has been going on for a month and is driving me somewhat crazy. Any help much appreciated. "Ginger" is an 8 year old FS labrador. Presented April 2nd with history: "hasn't ate in two days; about 2 weeks age she drank river water, got into garbage and was vomiting frequently for about 2 days". At that time weighed 38.8 kg. On exam was febrile (T = 40.7 C). A chem and CBC were run, with the following abnormalities: ALT = 388 U/l (0-120 U/l) ALP = 219 U/l (0-140 U/l) GGT = 13 U/l (0-14 U/l) TBili = 15 umol/l (0-9 umol/l) the serum ws noticeably icteric. Importantly: Glucose was w/in the RR @ 4.9 mmol/l (4.2 - 6.9 mmol/l) Neutropenia @ 2.9 x 10 9/l (3.5-12.0 x 10 9/l [Potential] Thrombocytopenia @ 54 x 10 9/l (200-500 x 10 9/l). I say "potemtial" as the slide review revealed platelet clumps in the tails and platelet numbers were judged to be adequate - but this finding does persist to a certain extent, regardless of how easy the blood draw was). We prescribed Zentonil 400 mg for liver and AventiClav 400 mg. 2 days later on recheck temp = 40.8 C; had a repeat CBC: Normal neutrophil count @ 3.6 x 10 9/l; platelets 53 x 10 9/l (again platelets were clumped and likely were normal in number). Seemed a little painful on cranial abdominal palpation; peripheral LN all WNL. Still not eating. Performed abdominal radiographs - saw thickening at chosto-chondral junctions and some spondylosis; mild hepatomegaly. (I can post the rads if anyone would like to see them). Gave Cerenia SQ and started Metronidazole 250 mg BID. Cerenia was repeated the following day. Temperature was 40.3 (this is April 5th) On April 8th had an abdominal U/S, with the following findings: 1) Splenic nodule - hypoechoic heterogenous nodules (larges 1.3x0.8 cm) 2) Lymphadenopathy - mild to moderate 3) Adrenomegally, bilateral; however both 1 cm so determined to likely be benign) 4) Pyelectasaia - mild, bilateral We performed urine culture on urine collected April 9 (USG = 1.042). Culture negative (though was on AventiClav and Metronidazole at the time). April 10th Temperature = 40.3. Had eaten a little the night before. Hospitalized for the afternoon on IVF. Given Meloxicam injection and temperature decreased to 37.4 within 2 hours. temp = 39.4 at discharge and again @ 9:00 am the following morning (April 11). By 4:00 pm, i.e. 25 hours after the Meloxicam injection T = 39.9 Repeated the CBC: now mildly anemic with Hct = 0.360 L/L (0.370 - 0.550 L/L) Platelets still low @ 73 x 10 9/L - did a slide directly from the vein and platelets appeared to be mildly decreased. Suspected GI bleed? and started Ranitidine 150 mg and Sulcrate 1g BID. April 14 T = 40.9. Ginger is eating a little bit. Repeat CBC - Hct has worsened @ 0.326 . Reticulocytes 1 %, so determined to be non-regnerative; most likely anemia of chronic disease. Platelets = 93 x 10 9/L on the machine. I considered IMHA / ITP (Evan's syndrome), but no spherocytes and non-regenerative anemia. Repeated in house liver panel: Albumin 21 g/l (25-40 g/L) Glucose 4 mmol/l (4.2 - 6.9 mmol/L) ALT 326 (lower than previous) ALP >993 GGT 13 TBili 34 (serum and dog clearly icteric). So biliary stasis, rather than ongoing hepatice disease. Antibiotics were finished at that time. I considered giving another dose of Meloxicam for the fever, but am also starting to consider using prednisone for some unknown immunomodulatory or neoplastic disease, so held off on the NSAID. April 15th: Consulted an internal medicine specialist @ IDEXX. She suggested that a pyelonephritis due to gram negative bacteria (E. coli) could release endotoxin, which can interfere the bilirubin enzyme uptake system. So this could be the mechanism causing hyperbilirubinemia. She suggested a fluoroquinolone would be the best antibiotic. The urine culture *may* have been negative due to Ginger being on AventiClav and Metronidazole at the time of the culture. She suggested reassess urine - do UPC ratio if there is still proteinuria. Also she suggested a spec CPL to rule out pancreatitis. Lastly, a liver biopsy may be indicated if there is no response to these meds. Took blood for IDEXX liver panel: TBili 40 umol/L (0-7 umol/L) ALP 1116 (10-150 U/L) ALT 267 (5-60 U/L) AST 250 (8-56 U/L) GGT 4 (o-4 U/L) SDH 9.9 (2.9-8.2) Spec CPL = 163 ug/L (0-200) UPC = 4.38 (sediment and culture quiet, but remember, is still febrile) Had Ginger in the next day (April 16) to start with Baytril injection. Temp = 40.1. She has lost weight - is now 35.1 kg. Is eating when coaxed. Sent home Baytril 300 mg po q24 hours x 1 week. Also started with Ursodiol. April 18th. Ginger has been vomiting a lot. Weighs 33.4 kg. Is a little weak when walking. Starting to have a pendulous abdomen, hanging from her spine which is very obviously noticeable; but no fluid wave. Temp = 40.1 C Repeat in house liver panel: Albumin 20 (low) Glucose 4.3 (just barely normal) ALT 384 ALP >993 GGT 16 TBili 55 Gave Cerenia injection. Finally started Prednisone @ 50 mg q12h. April 19. Has eaten a little, with no vomit. Temperature = 36.8. April 21st Temp = 37.0. Is eating. April 28 Temp = 38.2C weight = 33.8 kg. So I have a steroid-responsive something-or-other and all is going well. So why am I posting this on VIN? May 3, Ginger presented: seems to be very "weak", seems to take a long to time to get up and move around. was walking down stairs and seemed to "slide" down the stairs. Weight = 33.4 kg Temp = 39.6. Last Prednisone had been given ~ 30 hours previously (O was decreasing the dose to 50 mg q24 hours and the appointment was a little after the days dose should have been given). I noted that Ginger is weak in the hind end, and advised a towel or a sling under her hind end. When walking, her hind feet knuckle over. However if I support her body and place her foot on the dorsal surface, she will slowly replace the foot, i.e. there are proprioceptive defects, with right hind worse than left. CBC results: Stress leukon (as would be expected) Hct 0.197 (0.370-0.550 L/L). Reticulocyte count ~ 2%, so minimally regenerative. No spherocytes. Plateles on the machine 15 x 10 9/L. Clumping noted. Liver Panel to IDEXX: TBili 9 umol/L (0-7 umol/L) much improved ALP 793 (10-150 U/L) quite a bit lower; remember - is on pred!! ALT 388 (5-60 U/L) has increased AST 84 (8-56 U/L) much improved GGT 15 (0-4 U/L) But: Glucose = 28.7 mmol/L (3-7 mmol/L). Remember - has been low normal, even sub-normal, so this has to be a mistake!!! Restarted sucralfate in case GI bleeding is the cause of the regenerative anemia. O notes Ginger is much brighter; not as weak, is eating well and not vomiting. O brought Ginger in for a weight check and also BG reading on our glucometer on May 7th. She weighed 28.6 kg. BG = 31.8 mmol/L. Confirmed glucosuria, but no ketonuria, protein = 2+ on the stick. USG = 1.030. Ginger continues to be weak on the hind end - needing help to get up, and towel support to walk. - diabetic neuropathy? or is it muscle weakness? her hindleg muscles are very atrophied. or another cause of neurologic problems? May 10th: Consulted with IDEXX internal medicine. Advised start insulin at lowish dose as Ginger is still not eating well. Wean and stop prednisone; may need to start another immunosuppressive drug such as cyclosporine. On admission Temp = 39.2 BG = 35.0 mmol/L. Oh, her Hct was up to 0.301, so regenerating nicely. Started Caninsulin @ 10 units (wanted to start really consrvative) - lowest the BG got was 22.7 mmol/L @ 4 hours post insulin. Taught O how to give injections - she gave 10 units that night; then 12 units the following day and @ 4 hours post injection BG = 32.3 mmol/L. Temp = 38.5C May 12th BG 4 hours after 12 Units Caninsulin = 23.8 mmol/L. Temp = 38.3 May 13th. Ginger was in today for repeat U/S - the ultrasonographer and his tech could not believe what a change there has been in her appearance - and the spleen, liver, lymph nodes and pancreas were all essentially unchanged form April 10th (a very long month ago). No evidence of lymphaadenopathy in the lumbar area (I was concerned re: this as a cause of her hind end weakness). We took 3 views chest rads - lungs clear; abdominal rads - Ginger's colon is full of feces - all the way bak to the distal small intestine. Not looking firm - just "full" (can post rads if needed). I think that she just cannot posture and poop, as she is so weak. However, O notes that she does defecate and we did see her poop 2 days ago, even with towel support of her hind end. Weight = 28.8 kg. Temp = 38.3 C 4 hours after Caninsulin 12 Units given - BG = 40.1 mmol/L Sorry, am now at the point where I have questions: 1) What on earth am I treating? 2) I advised drop prednisone to 12.5 mg po q24 hrs x 3 days, then q48 hours x 3 doses. Should I decrease the pred faster? On the one hand, I feel we need to monitor appetite and temperature while the pred is being tapered and stopped. On the other hand - I don't think I will get the diabetes under control until the pred is stopped. AAARRRGGGHHH!!! 3) I advised to increase the Caninsulin to 15 Units q12h. Am concerned about dropping her sugars too low, with decreasing the pred at the same time. Am aware that I should'nt do BG curve until Gunger has been on a dose for ~ 1 week, but am worried about other diabetic side effects. 4) Best food for this girl? She had decreased appetite for so long, that we have been letting her eat "whatever". She has been eating well since I started the insulin - has been eating fish and chicken from O; also RC GI canned and her regular food is RC "lab 30". Am very concerned at this time about starting her on a fibre diet (is this still the diet of choice for a canine diabetic?) as her colon is so exceedingly full of feces. 5) Would cisapride help her move her bowels? 6) Am I missing something re: hind end weakness and knuckling? The owner has been absolutley marvelous about this whole thing - has spent a ton of money, and we have never been able to give her a diagnosis. Frustrating for all concerned. if, in the end, I am dealing wil a diabetic dog, I know how to handle that (or will, with a little help from you folks). But I just would like to know the best guess for why Ginger went from a 38 kg beautiful, bouncy lab, to a 28 kg diabetic dog who needs towel support to go out for wlaks, and can't defecate properly. Sorry about the long post - I couldn't condense a month of tests and set backs any further. Ginger would definitely appreciate a fresh brain and eyes on this whole thing. Cheers, Kate

Anemia - do you have indices or any retic counts here?

How bout a fructosamine?

Apologies for the long summary, but this case has been going on for a month and is driving me somewhat crazy. Any help much appreciated. "Ginger" is an 8 year old FS labrador. Presented April 2nd with history: "hasn't ate in two days; about 2 weeks age she drank river water, got into garbage and was vomiting frequently for about 2 days". At that time weighed 38.8 kg. On exam was febrile (T = 40.7 C). A chem and CBC were run, with the following abnormalities: ALT = 388 U/l (0-120 U/l) ALP = 219 U/l (0-140 U/l) GGT = 13 U/l (0-14 U/l) TBili = 15 umol/l (0-9 umol/l) the serum ws noticeably icteric. Importantly: Glucose was w/in the RR @ 4.9 mmol/l (4.2 - 6.9 mmol/l) Neutropenia @ 2.9 x 10 9/l (3.5-12.0 x 10 9/l [Potential] Thrombocytopenia @ 54 x 10 9/l (200-500 x 10 9/l). I say "potemtial" as the slide review revealed platelet clumps in the tails and platelet numbers were judged to be adequate - but this finding does persist to a certain extent, regardless of how easy the blood draw was). We prescribed Zentonil 400 mg for liver and AventiClav 400 mg. 2 days later on recheck temp = 40.8 C; had a repeat CBC: Normal neutrophil count @ 3.6 x 10 9/l; platelets 53 x 10 9/l (again platelets were clumped and likely were normal in number). Seemed a little painful on cranial abdominal palpation; peripheral LN all WNL. Still not eating. Performed abdominal radiographs - saw thickening at chosto-chondral junctions and some spondylosis; mild hepatomegaly. (I can post the rads if anyone would like to see them). Gave Cerenia SQ and started Metronidazole 250 mg BID. Cerenia was repeated the following day. Temperature was 40.3 (this is April 5th) On April 8th had an abdominal U/S, with the following findings: 1) Splenic nodule - hypoechoic heterogenous nodules (larges 1.3x0.8 cm) 2) Lymphadenopathy - mild to moderate 3) Adrenomegally, bilateral; however both 1 cm so determined to likely be benign) 4) Pyelectasaia - mild, bilateral We performed urine culture on urine collected April 9 (USG = 1.042). Culture negative (though was on AventiClav and Metronidazole at the time). April 10th Temperature = 40.3. Had eaten a little the night before. Hospitalized for the afternoon on IVF. Given Meloxicam injection and temperature decreased to 37.4 within 2 hours. temp = 39.4 at discharge and again @ 9:00 am the following morning (April 11). By 4:00 pm, i.e. 25 hours after the Meloxicam injection T = 39.9 Repeated the CBC: now mildly anemic with Hct = 0.360 L/L (0.370 - 0.550 L/L) Platelets still low @ 73 x 10 9/L - did a slide directly from the vein and platelets appeared to be mildly decreased. Suspected GI bleed? and started Ranitidine 150 mg and Sulcrate 1g BID. April 14 T = 40.9. Ginger is eating a little bit. Repeat CBC - Hct has worsened @ 0.326 . Reticulocytes 1 %, so determined to be non-regnerative; most likely anemia of chronic disease. Platelets = 93 x 10 9/L on the machine. I considered IMHA / ITP (Evan's syndrome), but no spherocytes and non-regenerative anemia. Repeated in house liver panel: Albumin 21 g/l (25-40 g/L) Glucose 4 mmol/l (4.2 - 6.9 mmol/L) ALT 326 (lower than previous) ALP >993 GGT 13 TBili 34 (serum and dog clearly icteric). So biliary stasis, rather than ongoing hepatice disease. Antibiotics were finished at that time. I considered giving another dose of Meloxicam for the fever, but am also starting to consider using prednisone for some unknown immunomodulatory or neoplastic disease, so held off on the NSAID. April 15th: Consulted an internal medicine specialist @ IDEXX. She suggested that a pyelonephritis due to gram negative bacteria (E. coli) could release endotoxin, which can interfere the bilirubin enzyme uptake system. So this could be the mechanism causing hyperbilirubinemia. She suggested a fluoroquinolone would be the best antibiotic. The urine culture *may* have been negative due to Ginger being on AventiClav and Metronidazole at the time of the culture. She suggested reassess urine - do UPC ratio if there is still proteinuria. Also she suggested a spec CPL to rule out pancreatitis. Lastly, a liver biopsy may be indicated if there is no response to these meds. Took blood for IDEXX liver panel: TBili 40 umol/L (0-7 umol/L) ALP 1116 (10-150 U/L) ALT 267 (5-60 U/L) AST 250 (8-56 U/L) GGT 4 (o-4 U/L) SDH 9.9 (2.9-8.2) Spec CPL = 163 ug/L (0-200) UPC = 4.38 (sediment and culture quiet, but remember, is still febrile) Had Ginger in the next day (April 16) to start with Baytril injection. Temp = 40.1. She has lost weight - is now 35.1 kg. Is eating when coaxed. Sent home Baytril 300 mg po q24 hours x 1 week. Also started with Ursodiol. April 18th. Ginger has been vomiting a lot. Weighs 33.4 kg. Is a little weak when walking. Starting to have a pendulous abdomen, hanging from her spine which is very obviously noticeable; but no fluid wave. Temp = 40.1 C Repeat in house liver panel: Albumin 20 (low) Glucose 4.3 (just barely normal) ALT 384 ALP >993 GGT 16 TBili 55 Gave Cerenia injection. Finally started Prednisone @ 50 mg q12h. April 19. Has eaten a little, with no vomit. Temperature = 36.8. April 21st Temp = 37.0. Is eating. April 28 Temp = 38.2C weight = 33.8 kg. So I have a steroid-responsive something-or-other and all is going well. So why am I posting this on VIN? May 3, Ginger presented: seems to be very "weak", seems to take a long to time to get up and move around. was walking down stairs and seemed to "slide" down the stairs. Weight = 33.4 kg Temp = 39.6. Last Prednisone had been given ~ 30 hours previously (O was decreasing the dose to 50 mg q24 hours and the appointment was a little after the days dose should have been given). I noted that Ginger is weak in the hind end, and advised a towel or a sling under her hind end. When walking, her hind feet knuckle over. However if I support her body and place her foot on the dorsal surface, she will slowly replace the foot, i.e. there are proprioceptive defects, with right hind worse than left. CBC results: Stress leukon (as would be expected) Hct 0.197 (0.370-0.550 L/L). Reticulocyte count ~ 2%, so minimally regenerative. No spherocytes. Plateles on the machine 15 x 10 9/L. Clumping noted. Liver Panel to IDEXX: TBili 9 umol/L (0-7 umol/L) much improved ALP 793 (10-150 U/L) quite a bit lower; remember - is on pred!! ALT 388 (5-60 U/L) has increased AST 84 (8-56 U/L) much improved GGT 15 (0-4 U/L) But: Glucose = 28.7 mmol/L (3-7 mmol/L). Remember - has been low normal, even sub-normal, so this has to be a mistake!!! Restarted sucralfate in case GI bleeding is the cause of the regenerative anemia. O notes Ginger is much brighter; not as weak, is eating well and not vomiting. O brought Ginger in for a weight check and also BG reading on our glucometer on May 7th. She weighed 28.6 kg. BG = 31.8 mmol/L. Confirmed glucosuria, but no ketonuria, protein = 2+ on the stick. USG = 1.030. Ginger continues to be weak on the hind end - needing help to get up, and towel support to walk. - diabetic neuropathy? or is it muscle weakness? her hindleg muscles are very atrophied. or another cause of neurologic problems? May 10th: Consulted with IDEXX internal medicine. Advised start insulin at lowish dose as Ginger is still not eating well. Wean and stop prednisone; may need to start another immunosuppressive drug such as cyclosporine. On admission Temp = 39.2 BG = 35.0 mmol/L. Oh, her Hct was up to 0.301, so regenerating nicely. Started Caninsulin @ 10 units (wanted to start really consrvative) - lowest the BG got was 22.7 mmol/L @ 4 hours post insulin. Taught O how to give injections - she gave 10 units that night; then 12 units the following day and @ 4 hours post injection BG = 32.3 mmol/L. Temp = 38.5C May 12th BG 4 hours after 12 Units Caninsulin = 23.8 mmol/L. Temp = 38.3 May 13th. Ginger was in today for repeat U/S - the ultrasonographer and his tech could not believe what a change there has been in her appearance - and the spleen, liver, lymph nodes and pancreas were all essentially unchanged form April 10th (a very long month ago). No evidence of lymphaadenopathy in the lumbar area (I was concerned re: this as a cause of her hind end weakness). We took 3 views chest rads - lungs clear; abdominal rads - Ginger's colon is full of feces - all the way bak to the distal small intestine. Not looking firm - just "full" (can post rads if needed). I think that she just cannot posture and poop, as she is so weak. However, O notes that she does defecate and we did see her poop 2 days ago, even with towel support of her hind end. Weight = 28.8 kg. Temp = 38.3 C 4 hours after Caninsulin 12 Units given - BG = 40.1 mmol/L Sorry, am now at the point where I have questions: 1) What on earth am I treating? 2) I advised drop prednisone to 12.5 mg po q24 hrs x 3 days, then q48 hours x 3 doses. Should I decrease the pred faster? On the one hand, I feel we need to monitor appetite and temperature while the pred is being tapered and stopped. On the other hand - I don't think I will get the diabetes under control until the pred is stopped. AAARRRGGGHHH!!! 3) I advised to increase the Caninsulin to 15 Units q12h. Am concerned about dropping her sugars too low, with decreasing the pred at the same time. Am aware that I should'nt do BG curve until Gunger has been on a dose for ~ 1 week, but am worried about other diabetic side effects. 4) Best food for this girl? She had decreased appetite for so long, that we have been letting her eat "whatever". She has been eating well since I started the insulin - has been eating fish and chicken from O; also RC GI canned and her regular food is RC "lab 30". Am very concerned at this time about starting her on a fibre diet (is this still the diet of choice for a canine diabetic?) as her colon is so exceedingly full of feces. 5) Would cisapride help her move her bowels? 6) Am I missing something re: hind end weakness and knuckling? The owner has been absolutley marvelous about this whole thing - has spent a ton of money, and we have never been able to give her a diagnosis. Frustrating for all concerned. if, in the end, I am dealing wil a diabetic dog, I know how to handle that (or will, with a little help from you folks). But I just would like to know the best guess for why Ginger went from a 38 kg beautiful, bouncy lab, to a 28 kg diabetic dog who needs towel support to go out for wlaks, and can't defecate properly. Sorry about the long post - I couldn't condense a month of tests and set backs any further. Ginger would definitely appreciate a fresh brain and eyes on this whole thing. Cheers, Kate

What does the rest of her neuro exam look like?

Is anyone able to give insight into whether this is chronic degenerative changes or suspect it is related to this injury?

Apologies for the long summary, but this case has been going on for a month and is driving me somewhat crazy. Any help much appreciated. "Ginger" is an 8 year old FS labrador. Presented April 2nd with history: "hasn't ate in two days; about 2 weeks age she drank river water, got into garbage and was vomiting frequently for about 2 days". At that time weighed 38.8 kg. On exam was febrile (T = 40.7 C). A chem and CBC were run, with the following abnormalities: ALT = 388 U/l (0-120 U/l) ALP = 219 U/l (0-140 U/l) GGT = 13 U/l (0-14 U/l) TBili = 15 umol/l (0-9 umol/l) the serum ws noticeably icteric. Importantly: Glucose was w/in the RR @ 4.9 mmol/l (4.2 - 6.9 mmol/l) Neutropenia @ 2.9 x 10 9/l (3.5-12.0 x 10 9/l [Potential] Thrombocytopenia @ 54 x 10 9/l (200-500 x 10 9/l). I say "potemtial" as the slide review revealed platelet clumps in the tails and platelet numbers were judged to be adequate - but this finding does persist to a certain extent, regardless of how easy the blood draw was). We prescribed Zentonil 400 mg for liver and AventiClav 400 mg. 2 days later on recheck temp = 40.8 C; had a repeat CBC: Normal neutrophil count @ 3.6 x 10 9/l; platelets 53 x 10 9/l (again platelets were clumped and likely were normal in number). Seemed a little painful on cranial abdominal palpation; peripheral LN all WNL. Still not eating. Performed abdominal radiographs - saw thickening at chosto-chondral junctions and some spondylosis; mild hepatomegaly. (I can post the rads if anyone would like to see them). Gave Cerenia SQ and started Metronidazole 250 mg BID. Cerenia was repeated the following day. Temperature was 40.3 (this is April 5th) On April 8th had an abdominal U/S, with the following findings: 1) Splenic nodule - hypoechoic heterogenous nodules (larges 1.3x0.8 cm) 2) Lymphadenopathy - mild to moderate 3) Adrenomegally, bilateral; however both 1 cm so determined to likely be benign) 4) Pyelectasaia - mild, bilateral We performed urine culture on urine collected April 9 (USG = 1.042). Culture negative (though was on AventiClav and Metronidazole at the time). April 10th Temperature = 40.3. Had eaten a little the night before. Hospitalized for the afternoon on IVF. Given Meloxicam injection and temperature decreased to 37.4 within 2 hours. temp = 39.4 at discharge and again @ 9:00 am the following morning (April 11). By 4:00 pm, i.e. 25 hours after the Meloxicam injection T = 39.9 Repeated the CBC: now mildly anemic with Hct = 0.360 L/L (0.370 - 0.550 L/L) Platelets still low @ 73 x 10 9/L - did a slide directly from the vein and platelets appeared to be mildly decreased. Suspected GI bleed? and started Ranitidine 150 mg and Sulcrate 1g BID. April 14 T = 40.9. Ginger is eating a little bit. Repeat CBC - Hct has worsened @ 0.326 . Reticulocytes 1 %, so determined to be non-regnerative; most likely anemia of chronic disease. Platelets = 93 x 10 9/L on the machine. I considered IMHA / ITP (Evan's syndrome), but no spherocytes and non-regenerative anemia. Repeated in house liver panel: Albumin 21 g/l (25-40 g/L) Glucose 4 mmol/l (4.2 - 6.9 mmol/L) ALT 326 (lower than previous) ALP >993 GGT 13 TBili 34 (serum and dog clearly icteric). So biliary stasis, rather than ongoing hepatice disease. Antibiotics were finished at that time. I considered giving another dose of Meloxicam for the fever, but am also starting to consider using prednisone for some unknown immunomodulatory or neoplastic disease, so held off on the NSAID. April 15th: Consulted an internal medicine specialist @ IDEXX. She suggested that a pyelonephritis due to gram negative bacteria (E. coli) could release endotoxin, which can interfere the bilirubin enzyme uptake system. So this could be the mechanism causing hyperbilirubinemia. She suggested a fluoroquinolone would be the best antibiotic. The urine culture *may* have been negative due to Ginger being on AventiClav and Metronidazole at the time of the culture. She suggested reassess urine - do UPC ratio if there is still proteinuria. Also she suggested a spec CPL to rule out pancreatitis. Lastly, a liver biopsy may be indicated if there is no response to these meds. Took blood for IDEXX liver panel: TBili 40 umol/L (0-7 umol/L) ALP 1116 (10-150 U/L) ALT 267 (5-60 U/L) AST 250 (8-56 U/L) GGT 4 (o-4 U/L) SDH 9.9 (2.9-8.2) Spec CPL = 163 ug/L (0-200) UPC = 4.38 (sediment and culture quiet, but remember, is still febrile) Had Ginger in the next day (April 16) to start with Baytril injection. Temp = 40.1. She has lost weight - is now 35.1 kg. Is eating when coaxed. Sent home Baytril 300 mg po q24 hours x 1 week. Also started with Ursodiol. April 18th. Ginger has been vomiting a lot. Weighs 33.4 kg. Is a little weak when walking. Starting to have a pendulous abdomen, hanging from her spine which is very obviously noticeable; but no fluid wave. Temp = 40.1 C Repeat in house liver panel: Albumin 20 (low) Glucose 4.3 (just barely normal) ALT 384 ALP >993 GGT 16 TBili 55 Gave Cerenia injection. Finally started Prednisone @ 50 mg q12h. April 19. Has eaten a little, with no vomit. Temperature = 36.8. April 21st Temp = 37.0. Is eating. April 28 Temp = 38.2C weight = 33.8 kg. So I have a steroid-responsive something-or-other and all is going well. So why am I posting this on VIN? May 3, Ginger presented: seems to be very "weak", seems to take a long to time to get up and move around. was walking down stairs and seemed to "slide" down the stairs. Weight = 33.4 kg Temp = 39.6. Last Prednisone had been given ~ 30 hours previously (O was decreasing the dose to 50 mg q24 hours and the appointment was a little after the days dose should have been given). I noted that Ginger is weak in the hind end, and advised a towel or a sling under her hind end. When walking, her hind feet knuckle over. However if I support her body and place her foot on the dorsal surface, she will slowly replace the foot, i.e. there are proprioceptive defects, with right hind worse than left. CBC results: Stress leukon (as would be expected) Hct 0.197 (0.370-0.550 L/L). Reticulocyte count ~ 2%, so minimally regenerative. No spherocytes. Plateles on the machine 15 x 10 9/L. Clumping noted. Liver Panel to IDEXX: TBili 9 umol/L (0-7 umol/L) much improved ALP 793 (10-150 U/L) quite a bit lower; remember - is on pred!! ALT 388 (5-60 U/L) has increased AST 84 (8-56 U/L) much improved GGT 15 (0-4 U/L) But: Glucose = 28.7 mmol/L (3-7 mmol/L). Remember - has been low normal, even sub-normal, so this has to be a mistake!!! Restarted sucralfate in case GI bleeding is the cause of the regenerative anemia. O notes Ginger is much brighter; not as weak, is eating well and not vomiting. O brought Ginger in for a weight check and also BG reading on our glucometer on May 7th. She weighed 28.6 kg. BG = 31.8 mmol/L. Confirmed glucosuria, but no ketonuria, protein = 2+ on the stick. USG = 1.030. Ginger continues to be weak on the hind end - needing help to get up, and towel support to walk. - diabetic neuropathy? or is it muscle weakness? her hindleg muscles are very atrophied. or another cause of neurologic problems? May 10th: Consulted with IDEXX internal medicine. Advised start insulin at lowish dose as Ginger is still not eating well. Wean and stop prednisone; may need to start another immunosuppressive drug such as cyclosporine. On admission Temp = 39.2 BG = 35.0 mmol/L. Oh, her Hct was up to 0.301, so regenerating nicely. Started Caninsulin @ 10 units (wanted to start really consrvative) - lowest the BG got was 22.7 mmol/L @ 4 hours post insulin. Taught O how to give injections - she gave 10 units that night; then 12 units the following day and @ 4 hours post injection BG = 32.3 mmol/L. Temp = 38.5C May 12th BG 4 hours after 12 Units Caninsulin = 23.8 mmol/L. Temp = 38.3 May 13th. Ginger was in today for repeat U/S - the ultrasonographer and his tech could not believe what a change there has been in her appearance - and the spleen, liver, lymph nodes and pancreas were all essentially unchanged form April 10th (a very long month ago). No evidence of lymphaadenopathy in the lumbar area (I was concerned re: this as a cause of her hind end weakness). We took 3 views chest rads - lungs clear; abdominal rads - Ginger's colon is full of feces - all the way bak to the distal small intestine. Not looking firm - just "full" (can post rads if needed). I think that she just cannot posture and poop, as she is so weak. However, O notes that she does defecate and we did see her poop 2 days ago, even with towel support of her hind end. Weight = 28.8 kg. Temp = 38.3 C 4 hours after Caninsulin 12 Units given - BG = 40.1 mmol/L Sorry, am now at the point where I have questions: 1) What on earth am I treating? 2) I advised drop prednisone to 12.5 mg po q24 hrs x 3 days, then q48 hours x 3 doses. Should I decrease the pred faster? On the one hand, I feel we need to monitor appetite and temperature while the pred is being tapered and stopped. On the other hand - I don't think I will get the diabetes under control until the pred is stopped. AAARRRGGGHHH!!! 3) I advised to increase the Caninsulin to 15 Units q12h. Am concerned about dropping her sugars too low, with decreasing the pred at the same time. Am aware that I should'nt do BG curve until Gunger has been on a dose for ~ 1 week, but am worried about other diabetic side effects. 4) Best food for this girl? She had decreased appetite for so long, that we have been letting her eat "whatever". She has been eating well since I started the insulin - has been eating fish and chicken from O; also RC GI canned and her regular food is RC "lab 30". Am very concerned at this time about starting her on a fibre diet (is this still the diet of choice for a canine diabetic?) as her colon is so exceedingly full of feces. 5) Would cisapride help her move her bowels? 6) Am I missing something re: hind end weakness and knuckling? The owner has been absolutley marvelous about this whole thing - has spent a ton of money, and we have never been able to give her a diagnosis. Frustrating for all concerned. if, in the end, I am dealing wil a diabetic dog, I know how to handle that (or will, with a little help from you folks). But I just would like to know the best guess for why Ginger went from a 38 kg beautiful, bouncy lab, to a 28 kg diabetic dog who needs towel support to go out for wlaks, and can't defecate properly. Sorry about the long post - I couldn't condense a month of tests and set backs any further. Ginger would definitely appreciate a fresh brain and eyes on this whole thing. Cheers, Kate

This seems reasonable - after it is discontinued, then reassess the situation - how is the anemia, the diabetes, the hind limb weakness, the liver values, etc.?

When does he normally get the food/insulin in the am and pm on days when he's not having a curve?

Apologies for the long summary, but this case has been going on for a month and is driving me somewhat crazy. Any help much appreciated. "Ginger" is an 8 year old FS labrador. Presented April 2nd with history: "hasn't ate in two days; about 2 weeks age she drank river water, got into garbage and was vomiting frequently for about 2 days". At that time weighed 38.8 kg. On exam was febrile (T = 40.7 C). A chem and CBC were run, with the following abnormalities: ALT = 388 U/l (0-120 U/l) ALP = 219 U/l (0-140 U/l) GGT = 13 U/l (0-14 U/l) TBili = 15 umol/l (0-9 umol/l) the serum ws noticeably icteric. Importantly: Glucose was w/in the RR @ 4.9 mmol/l (4.2 - 6.9 mmol/l) Neutropenia @ 2.9 x 10 9/l (3.5-12.0 x 10 9/l [Potential] Thrombocytopenia @ 54 x 10 9/l (200-500 x 10 9/l). I say "potemtial" as the slide review revealed platelet clumps in the tails and platelet numbers were judged to be adequate - but this finding does persist to a certain extent, regardless of how easy the blood draw was). We prescribed Zentonil 400 mg for liver and AventiClav 400 mg. 2 days later on recheck temp = 40.8 C; had a repeat CBC: Normal neutrophil count @ 3.6 x 10 9/l; platelets 53 x 10 9/l (again platelets were clumped and likely were normal in number). Seemed a little painful on cranial abdominal palpation; peripheral LN all WNL. Still not eating. Performed abdominal radiographs - saw thickening at chosto-chondral junctions and some spondylosis; mild hepatomegaly. (I can post the rads if anyone would like to see them). Gave Cerenia SQ and started Metronidazole 250 mg BID. Cerenia was repeated the following day. Temperature was 40.3 (this is April 5th) On April 8th had an abdominal U/S, with the following findings: 1) Splenic nodule - hypoechoic heterogenous nodules (larges 1.3x0.8 cm) 2) Lymphadenopathy - mild to moderate 3) Adrenomegally, bilateral; however both 1 cm so determined to likely be benign) 4) Pyelectasaia - mild, bilateral We performed urine culture on urine collected April 9 (USG = 1.042). Culture negative (though was on AventiClav and Metronidazole at the time). April 10th Temperature = 40.3. Had eaten a little the night before. Hospitalized for the afternoon on IVF. Given Meloxicam injection and temperature decreased to 37.4 within 2 hours. temp = 39.4 at discharge and again @ 9:00 am the following morning (April 11). By 4:00 pm, i.e. 25 hours after the Meloxicam injection T = 39.9 Repeated the CBC: now mildly anemic with Hct = 0.360 L/L (0.370 - 0.550 L/L) Platelets still low @ 73 x 10 9/L - did a slide directly from the vein and platelets appeared to be mildly decreased. Suspected GI bleed? and started Ranitidine 150 mg and Sulcrate 1g BID. April 14 T = 40.9. Ginger is eating a little bit. Repeat CBC - Hct has worsened @ 0.326 . Reticulocytes 1 %, so determined to be non-regnerative; most likely anemia of chronic disease. Platelets = 93 x 10 9/L on the machine. I considered IMHA / ITP (Evan's syndrome), but no spherocytes and non-regenerative anemia. Repeated in house liver panel: Albumin 21 g/l (25-40 g/L) Glucose 4 mmol/l (4.2 - 6.9 mmol/L) ALT 326 (lower than previous) ALP >993 GGT 13 TBili 34 (serum and dog clearly icteric). So biliary stasis, rather than ongoing hepatice disease. Antibiotics were finished at that time. I considered giving another dose of Meloxicam for the fever, but am also starting to consider using prednisone for some unknown immunomodulatory or neoplastic disease, so held off on the NSAID. April 15th: Consulted an internal medicine specialist @ IDEXX. She suggested that a pyelonephritis due to gram negative bacteria (E. coli) could release endotoxin, which can interfere the bilirubin enzyme uptake system. So this could be the mechanism causing hyperbilirubinemia. She suggested a fluoroquinolone would be the best antibiotic. The urine culture *may* have been negative due to Ginger being on AventiClav and Metronidazole at the time of the culture. She suggested reassess urine - do UPC ratio if there is still proteinuria. Also she suggested a spec CPL to rule out pancreatitis. Lastly, a liver biopsy may be indicated if there is no response to these meds. Took blood for IDEXX liver panel: TBili 40 umol/L (0-7 umol/L) ALP 1116 (10-150 U/L) ALT 267 (5-60 U/L) AST 250 (8-56 U/L) GGT 4 (o-4 U/L) SDH 9.9 (2.9-8.2) Spec CPL = 163 ug/L (0-200) UPC = 4.38 (sediment and culture quiet, but remember, is still febrile) Had Ginger in the next day (April 16) to start with Baytril injection. Temp = 40.1. She has lost weight - is now 35.1 kg. Is eating when coaxed. Sent home Baytril 300 mg po q24 hours x 1 week. Also started with Ursodiol. April 18th. Ginger has been vomiting a lot. Weighs 33.4 kg. Is a little weak when walking. Starting to have a pendulous abdomen, hanging from her spine which is very obviously noticeable; but no fluid wave. Temp = 40.1 C Repeat in house liver panel: Albumin 20 (low) Glucose 4.3 (just barely normal) ALT 384 ALP >993 GGT 16 TBili 55 Gave Cerenia injection. Finally started Prednisone @ 50 mg q12h. April 19. Has eaten a little, with no vomit. Temperature = 36.8. April 21st Temp = 37.0. Is eating. April 28 Temp = 38.2C weight = 33.8 kg. So I have a steroid-responsive something-or-other and all is going well. So why am I posting this on VIN? May 3, Ginger presented: seems to be very "weak", seems to take a long to time to get up and move around. was walking down stairs and seemed to "slide" down the stairs. Weight = 33.4 kg Temp = 39.6. Last Prednisone had been given ~ 30 hours previously (O was decreasing the dose to 50 mg q24 hours and the appointment was a little after the days dose should have been given). I noted that Ginger is weak in the hind end, and advised a towel or a sling under her hind end. When walking, her hind feet knuckle over. However if I support her body and place her foot on the dorsal surface, she will slowly replace the foot, i.e. there are proprioceptive defects, with right hind worse than left. CBC results: Stress leukon (as would be expected) Hct 0.197 (0.370-0.550 L/L). Reticulocyte count ~ 2%, so minimally regenerative. No spherocytes. Plateles on the machine 15 x 10 9/L. Clumping noted. Liver Panel to IDEXX: TBili 9 umol/L (0-7 umol/L) much improved ALP 793 (10-150 U/L) quite a bit lower; remember - is on pred!! ALT 388 (5-60 U/L) has increased AST 84 (8-56 U/L) much improved GGT 15 (0-4 U/L) But: Glucose = 28.7 mmol/L (3-7 mmol/L). Remember - has been low normal, even sub-normal, so this has to be a mistake!!! Restarted sucralfate in case GI bleeding is the cause of the regenerative anemia. O notes Ginger is much brighter; not as weak, is eating well and not vomiting. O brought Ginger in for a weight check and also BG reading on our glucometer on May 7th. She weighed 28.6 kg. BG = 31.8 mmol/L. Confirmed glucosuria, but no ketonuria, protein = 2+ on the stick. USG = 1.030. Ginger continues to be weak on the hind end - needing help to get up, and towel support to walk. - diabetic neuropathy? or is it muscle weakness? her hindleg muscles are very atrophied. or another cause of neurologic problems? May 10th: Consulted with IDEXX internal medicine. Advised start insulin at lowish dose as Ginger is still not eating well. Wean and stop prednisone; may need to start another immunosuppressive drug such as cyclosporine. On admission Temp = 39.2 BG = 35.0 mmol/L. Oh, her Hct was up to 0.301, so regenerating nicely. Started Caninsulin @ 10 units (wanted to start really consrvative) - lowest the BG got was 22.7 mmol/L @ 4 hours post insulin. Taught O how to give injections - she gave 10 units that night; then 12 units the following day and @ 4 hours post injection BG = 32.3 mmol/L. Temp = 38.5C May 12th BG 4 hours after 12 Units Caninsulin = 23.8 mmol/L. Temp = 38.3 May 13th. Ginger was in today for repeat U/S - the ultrasonographer and his tech could not believe what a change there has been in her appearance - and the spleen, liver, lymph nodes and pancreas were all essentially unchanged form April 10th (a very long month ago). No evidence of lymphaadenopathy in the lumbar area (I was concerned re: this as a cause of her hind end weakness). We took 3 views chest rads - lungs clear; abdominal rads - Ginger's colon is full of feces - all the way bak to the distal small intestine. Not looking firm - just "full" (can post rads if needed). I think that she just cannot posture and poop, as she is so weak. However, O notes that she does defecate and we did see her poop 2 days ago, even with towel support of her hind end. Weight = 28.8 kg. Temp = 38.3 C 4 hours after Caninsulin 12 Units given - BG = 40.1 mmol/L Sorry, am now at the point where I have questions: 1) What on earth am I treating? 2) I advised drop prednisone to 12.5 mg po q24 hrs x 3 days, then q48 hours x 3 doses. Should I decrease the pred faster? On the one hand, I feel we need to monitor appetite and temperature while the pred is being tapered and stopped. On the other hand - I don't think I will get the diabetes under control until the pred is stopped. AAARRRGGGHHH!!! 3) I advised to increase the Caninsulin to 15 Units q12h. Am concerned about dropping her sugars too low, with decreasing the pred at the same time. Am aware that I should'nt do BG curve until Gunger has been on a dose for ~ 1 week, but am worried about other diabetic side effects. 4) Best food for this girl? She had decreased appetite for so long, that we have been letting her eat "whatever". She has been eating well since I started the insulin - has been eating fish and chicken from O; also RC GI canned and her regular food is RC "lab 30". Am very concerned at this time about starting her on a fibre diet (is this still the diet of choice for a canine diabetic?) as her colon is so exceedingly full of feces. 5) Would cisapride help her move her bowels? 6) Am I missing something re: hind end weakness and knuckling? The owner has been absolutley marvelous about this whole thing - has spent a ton of money, and we have never been able to give her a diagnosis. Frustrating for all concerned. if, in the end, I am dealing wil a diabetic dog, I know how to handle that (or will, with a little help from you folks). But I just would like to know the best guess for why Ginger went from a 38 kg beautiful, bouncy lab, to a 28 kg diabetic dog who needs towel support to go out for wlaks, and can't defecate properly. Sorry about the long post - I couldn't condense a month of tests and set backs any further. Ginger would definitely appreciate a fresh brain and eyes on this whole thing. Cheers, Kate

Can this owner monitor at all at home?

Is this a multiple cat household?

Apologies for the long summary, but this case has been going on for a month and is driving me somewhat crazy. Any help much appreciated. "Ginger" is an 8 year old FS labrador. Presented April 2nd with history: "hasn't ate in two days; about 2 weeks age she drank river water, got into garbage and was vomiting frequently for about 2 days". At that time weighed 38.8 kg. On exam was febrile (T = 40.7 C). A chem and CBC were run, with the following abnormalities: ALT = 388 U/l (0-120 U/l) ALP = 219 U/l (0-140 U/l) GGT = 13 U/l (0-14 U/l) TBili = 15 umol/l (0-9 umol/l) the serum ws noticeably icteric. Importantly: Glucose was w/in the RR @ 4.9 mmol/l (4.2 - 6.9 mmol/l) Neutropenia @ 2.9 x 10 9/l (3.5-12.0 x 10 9/l [Potential] Thrombocytopenia @ 54 x 10 9/l (200-500 x 10 9/l). I say "potemtial" as the slide review revealed platelet clumps in the tails and platelet numbers were judged to be adequate - but this finding does persist to a certain extent, regardless of how easy the blood draw was). We prescribed Zentonil 400 mg for liver and AventiClav 400 mg. 2 days later on recheck temp = 40.8 C; had a repeat CBC: Normal neutrophil count @ 3.6 x 10 9/l; platelets 53 x 10 9/l (again platelets were clumped and likely were normal in number). Seemed a little painful on cranial abdominal palpation; peripheral LN all WNL. Still not eating. Performed abdominal radiographs - saw thickening at chosto-chondral junctions and some spondylosis; mild hepatomegaly. (I can post the rads if anyone would like to see them). Gave Cerenia SQ and started Metronidazole 250 mg BID. Cerenia was repeated the following day. Temperature was 40.3 (this is April 5th) On April 8th had an abdominal U/S, with the following findings: 1) Splenic nodule - hypoechoic heterogenous nodules (larges 1.3x0.8 cm) 2) Lymphadenopathy - mild to moderate 3) Adrenomegally, bilateral; however both 1 cm so determined to likely be benign) 4) Pyelectasaia - mild, bilateral We performed urine culture on urine collected April 9 (USG = 1.042). Culture negative (though was on AventiClav and Metronidazole at the time). April 10th Temperature = 40.3. Had eaten a little the night before. Hospitalized for the afternoon on IVF. Given Meloxicam injection and temperature decreased to 37.4 within 2 hours. temp = 39.4 at discharge and again @ 9:00 am the following morning (April 11). By 4:00 pm, i.e. 25 hours after the Meloxicam injection T = 39.9 Repeated the CBC: now mildly anemic with Hct = 0.360 L/L (0.370 - 0.550 L/L) Platelets still low @ 73 x 10 9/L - did a slide directly from the vein and platelets appeared to be mildly decreased. Suspected GI bleed? and started Ranitidine 150 mg and Sulcrate 1g BID. April 14 T = 40.9. Ginger is eating a little bit. Repeat CBC - Hct has worsened @ 0.326 . Reticulocytes 1 %, so determined to be non-regnerative; most likely anemia of chronic disease. Platelets = 93 x 10 9/L on the machine. I considered IMHA / ITP (Evan's syndrome), but no spherocytes and non-regenerative anemia. Repeated in house liver panel: Albumin 21 g/l (25-40 g/L) Glucose 4 mmol/l (4.2 - 6.9 mmol/L) ALT 326 (lower than previous) ALP >993 GGT 13 TBili 34 (serum and dog clearly icteric). So biliary stasis, rather than ongoing hepatice disease. Antibiotics were finished at that time. I considered giving another dose of Meloxicam for the fever, but am also starting to consider using prednisone for some unknown immunomodulatory or neoplastic disease, so held off on the NSAID. April 15th: Consulted an internal medicine specialist @ IDEXX. She suggested that a pyelonephritis due to gram negative bacteria (E. coli) could release endotoxin, which can interfere the bilirubin enzyme uptake system. So this could be the mechanism causing hyperbilirubinemia. She suggested a fluoroquinolone would be the best antibiotic. The urine culture *may* have been negative due to Ginger being on AventiClav and Metronidazole at the time of the culture. She suggested reassess urine - do UPC ratio if there is still proteinuria. Also she suggested a spec CPL to rule out pancreatitis. Lastly, a liver biopsy may be indicated if there is no response to these meds. Took blood for IDEXX liver panel: TBili 40 umol/L (0-7 umol/L) ALP 1116 (10-150 U/L) ALT 267 (5-60 U/L) AST 250 (8-56 U/L) GGT 4 (o-4 U/L) SDH 9.9 (2.9-8.2) Spec CPL = 163 ug/L (0-200) UPC = 4.38 (sediment and culture quiet, but remember, is still febrile) Had Ginger in the next day (April 16) to start with Baytril injection. Temp = 40.1. She has lost weight - is now 35.1 kg. Is eating when coaxed. Sent home Baytril 300 mg po q24 hours x 1 week. Also started with Ursodiol. April 18th. Ginger has been vomiting a lot. Weighs 33.4 kg. Is a little weak when walking. Starting to have a pendulous abdomen, hanging from her spine which is very obviously noticeable; but no fluid wave. Temp = 40.1 C Repeat in house liver panel: Albumin 20 (low) Glucose 4.3 (just barely normal) ALT 384 ALP >993 GGT 16 TBili 55 Gave Cerenia injection. Finally started Prednisone @ 50 mg q12h. April 19. Has eaten a little, with no vomit. Temperature = 36.8. April 21st Temp = 37.0. Is eating. April 28 Temp = 38.2C weight = 33.8 kg. So I have a steroid-responsive something-or-other and all is going well. So why am I posting this on VIN? May 3, Ginger presented: seems to be very "weak", seems to take a long to time to get up and move around. was walking down stairs and seemed to "slide" down the stairs. Weight = 33.4 kg Temp = 39.6. Last Prednisone had been given ~ 30 hours previously (O was decreasing the dose to 50 mg q24 hours and the appointment was a little after the days dose should have been given). I noted that Ginger is weak in the hind end, and advised a towel or a sling under her hind end. When walking, her hind feet knuckle over. However if I support her body and place her foot on the dorsal surface, she will slowly replace the foot, i.e. there are proprioceptive defects, with right hind worse than left. CBC results: Stress leukon (as would be expected) Hct 0.197 (0.370-0.550 L/L). Reticulocyte count ~ 2%, so minimally regenerative. No spherocytes. Plateles on the machine 15 x 10 9/L. Clumping noted. Liver Panel to IDEXX: TBili 9 umol/L (0-7 umol/L) much improved ALP 793 (10-150 U/L) quite a bit lower; remember - is on pred!! ALT 388 (5-60 U/L) has increased AST 84 (8-56 U/L) much improved GGT 15 (0-4 U/L) But: Glucose = 28.7 mmol/L (3-7 mmol/L). Remember - has been low normal, even sub-normal, so this has to be a mistake!!! Restarted sucralfate in case GI bleeding is the cause of the regenerative anemia. O notes Ginger is much brighter; not as weak, is eating well and not vomiting. O brought Ginger in for a weight check and also BG reading on our glucometer on May 7th. She weighed 28.6 kg. BG = 31.8 mmol/L. Confirmed glucosuria, but no ketonuria, protein = 2+ on the stick. USG = 1.030. Ginger continues to be weak on the hind end - needing help to get up, and towel support to walk. - diabetic neuropathy? or is it muscle weakness? her hindleg muscles are very atrophied. or another cause of neurologic problems? May 10th: Consulted with IDEXX internal medicine. Advised start insulin at lowish dose as Ginger is still not eating well. Wean and stop prednisone; may need to start another immunosuppressive drug such as cyclosporine. On admission Temp = 39.2 BG = 35.0 mmol/L. Oh, her Hct was up to 0.301, so regenerating nicely. Started Caninsulin @ 10 units (wanted to start really consrvative) - lowest the BG got was 22.7 mmol/L @ 4 hours post insulin. Taught O how to give injections - she gave 10 units that night; then 12 units the following day and @ 4 hours post injection BG = 32.3 mmol/L. Temp = 38.5C May 12th BG 4 hours after 12 Units Caninsulin = 23.8 mmol/L. Temp = 38.3 May 13th. Ginger was in today for repeat U/S - the ultrasonographer and his tech could not believe what a change there has been in her appearance - and the spleen, liver, lymph nodes and pancreas were all essentially unchanged form April 10th (a very long month ago). No evidence of lymphaadenopathy in the lumbar area (I was concerned re: this as a cause of her hind end weakness). We took 3 views chest rads - lungs clear; abdominal rads - Ginger's colon is full of feces - all the way bak to the distal small intestine. Not looking firm - just "full" (can post rads if needed). I think that she just cannot posture and poop, as she is so weak. However, O notes that she does defecate and we did see her poop 2 days ago, even with towel support of her hind end. Weight = 28.8 kg. Temp = 38.3 C 4 hours after Caninsulin 12 Units given - BG = 40.1 mmol/L Sorry, am now at the point where I have questions: 1) What on earth am I treating? 2) I advised drop prednisone to 12.5 mg po q24 hrs x 3 days, then q48 hours x 3 doses. Should I decrease the pred faster? On the one hand, I feel we need to monitor appetite and temperature while the pred is being tapered and stopped. On the other hand - I don't think I will get the diabetes under control until the pred is stopped. AAARRRGGGHHH!!! 3) I advised to increase the Caninsulin to 15 Units q12h. Am concerned about dropping her sugars too low, with decreasing the pred at the same time. Am aware that I should'nt do BG curve until Gunger has been on a dose for ~ 1 week, but am worried about other diabetic side effects. 4) Best food for this girl? She had decreased appetite for so long, that we have been letting her eat "whatever". She has been eating well since I started the insulin - has been eating fish and chicken from O; also RC GI canned and her regular food is RC "lab 30". Am very concerned at this time about starting her on a fibre diet (is this still the diet of choice for a canine diabetic?) as her colon is so exceedingly full of feces. 5) Would cisapride help her move her bowels? 6) Am I missing something re: hind end weakness and knuckling? The owner has been absolutley marvelous about this whole thing - has spent a ton of money, and we have never been able to give her a diagnosis. Frustrating for all concerned. if, in the end, I am dealing wil a diabetic dog, I know how to handle that (or will, with a little help from you folks). But I just would like to know the best guess for why Ginger went from a 38 kg beautiful, bouncy lab, to a 28 kg diabetic dog who needs towel support to go out for wlaks, and can't defecate properly. Sorry about the long post - I couldn't condense a month of tests and set backs any further. Ginger would definitely appreciate a fresh brain and eyes on this whole thing. Cheers, Kate

Any chance of referral to neurologist to help you with this case?

Is it only sensitive to baytril?

"Doby" is an 11 yo min pin I saw 4/18 for about 1 week's duration of severe PU/PD. The dog was recently re-obtained by the owner from an ex, so any histo before this time was unavailable. Initial Bloodwork: ALP- 619, Glucose- 483, Triglycerides- 664, Neutrophils- 13,360, Monocytes- 1169, T4 0.5, 3+ glucose, no ketones, 1+ protein, no urine sediment We started Humulin-N on 4/20 at 3 units eve 12 hours Following are his curves and adjustments so far. The owner feeds and doses the insulin at home right before dropping off. I realize it is harder to interpret by having the curve start after the insulin is given at home, but I have been burned too many times when an animal won't eat in the hospital and we can't do the curve. We use an Alpha-Trak glucometer, and Doby is fed Purina One d 1/2 cup BID. He weighed 13.2 lbs at presentation, now 13.8 lbs. On 4/29: 3 units given and fed at 7 AM 7:40 a- 501 9:40 a- 462 11:40 a- 575 1:40 p- 554 3:40 p- 579 5:40 p- 513 7:00 p- 487 Increased dose to 5 units q 12 hr On 5/6: 5 units given and fed at 7:30 AM 8:15 a- 290 10:15 a- 235 12:15 p- 430 2:15 p- 482 4:15 p- 506 6:15 p- 431 Increased dose to 7 units q 12 hr. On 5/13: 7 units given and fed at 7:30 AM 8:10 a- 285 10:10 a- 261 12:10 p- 309 2:10 p- 320 4:10 p- 399 6:10 p- 364 No adjustments made yet Urine accidents have stopped completely. He still occasionally takes a long drink, and when owner gets home from work he goes out and takes a long pee, but otherwise owner feels he is back to his normal self. Obviously would like to see these numbers a little better. My inclination is to increase to 9 units and recheck in another 7-10 days. However, I do have some concern about how long the insulin is lasting, and wondering if an insulin switch should be considered. It seems to be peaking between 3-4 hours. And what would be the best one to switch to? I have never used anything other than NPH in dogs. Any input would be appreciated. I have managed plenty of cats but not ve many dogs. Oh, and we plan to recheck blood and urine once diabetes is regulated before any further work up for the ALP and T4. Thanks!!!!! ☼

Just out of curiosity, is he using humulin n or novolin n?

Have you cultured the dog's urine?

Reading some past posts about recurring E coli UTI's and I had some questions. I know in some cases (maybe diabetics & others) the suggestion is to culture urines even if there are no signs or obvious bacteria & treat accordingly. On some posts the indication I got was if there were no signs with the E coli & not a pyelonephritis, don't treat them. What is the difference in the two? Are you diagnosing pyelonephritis by seeing casts? I also thought that ongoing bacteria in the urine could predispose to calculi so it seems that they should be treated to prevent them. Comments? The probiotic that was mentioned for the E coli dogs, would that be the GI ones like Fortiflora? OTC cranberry concentrate OK? Thanks, /p

I'm not sure what you mean, like a juice?

Moving the injections around on her body every day?

Hi there, Nina is 8 yr old intact female overwt pitbull who was in heat a month or two ago. She presented today because last friday she started drinking water excessively and stopped eating. Her serum glucose is 380 and other chems normal or close to normal. I recommended pyometra spay and scheduled it for tomorrow. Owners want to have her spayed anyway. I also told them that we have to worry about the high blood glucose too but didn't say much else about it... My question is about the glucose. Is it a concern going in to surgery? Can we deal with that afterward? Like wait until she's recovered to see if it is persistent before pursuing treatment for that? Thanks, ☼

This is really a good time to teach the owner how to generate curves at home---any chance of that?

She'd be rather young for cushings....are we sure about the age?

VIN POST - brittle, 8 year old, diabetic cat with FIV -male neutered cat, diagnosed with Diabetes in September of 2012. Had comprehensive dental in April /12 and 9 teeth were removed. Potassium was 3.4 at this time. Normal thyroid and normal snap Fpl in April/13. He weighed about 15 pounds on initial diagnosis and now is down to 12 pounds. We initially tried feeding Purina DM canned but the BG never moved after two weeks. His initial BG was 19.8 and after two weeks on the DM it was 18.9. We started Glargine insulin at 1 unit BID and  within a week the BG was 4.4 so we dropped the dose to 1/2 unit BID and a week later the BG was 21.7 so we stayed at same dose and a week later BG was 22.3. We then increased the dose of  Glargine  back to 1 unit BID and a week later the BG was 23.9!!!! We then increased the dose to 1 1/2 units bid and a week later the BG was 24.4. We test about 6 hours post injection.    UAS did not reveal any abnormalities. Chem profile revealed a slight increase in cholesterol--6.76(1.6-5.8) Electrolytes showed hypokalemia(3.1) a recheck a month later the K was 3.6. A glucose curve was done and there was not much change.(17.8-14.6) We are currently using 5 units BID and the BG goes from 3 one day to 19 next day!!!! We are currently feeding a canned food low in carbs.  Any ideas. Could a low potassium be the cause of insulin resistance from one day to the next?Could FIV be the cause? Acromegaly? Thanks ☼

How are clinical signs?

The owner can accurately measure and then inject the insulin--when she got changed to the nph, did the syringes change to u100 syringes?

VIN POST - brittle, 8 year old, diabetic cat with FIV -male neutered cat, diagnosed with Diabetes in September of 2012. Had comprehensive dental in April /12 and 9 teeth were removed. Potassium was 3.4 at this time. Normal thyroid and normal snap Fpl in April/13. He weighed about 15 pounds on initial diagnosis and now is down to 12 pounds. We initially tried feeding Purina DM canned but the BG never moved after two weeks. His initial BG was 19.8 and after two weeks on the DM it was 18.9. We started Glargine insulin at 1 unit BID and  within a week the BG was 4.4 so we dropped the dose to 1/2 unit BID and a week later the BG was 21.7 so we stayed at same dose and a week later BG was 22.3. We then increased the dose of  Glargine  back to 1 unit BID and a week later the BG was 23.9!!!! We then increased the dose to 1 1/2 units bid and a week later the BG was 24.4. We test about 6 hours post injection.    UAS did not reveal any abnormalities. Chem profile revealed a slight increase in cholesterol--6.76(1.6-5.8) Electrolytes showed hypokalemia(3.1) a recheck a month later the K was 3.6. A glucose curve was done and there was not much change.(17.8-14.6) We are currently using 5 units BID and the BG goes from 3 one day to 19 next day!!!! We are currently feeding a canned food low in carbs.  Any ideas. Could a low potassium be the cause of insulin resistance from one day to the next?Could FIV be the cause? Acromegaly? Thanks ☼

Pupd?

Because she's your dog, is it possible to do a curve (like at home?) so that we can see more numbers?

VIN POST - brittle, 8 year old, diabetic cat with FIV -male neutered cat, diagnosed with Diabetes in September of 2012. Had comprehensive dental in April /12 and 9 teeth were removed. Potassium was 3.4 at this time. Normal thyroid and normal snap Fpl in April/13. He weighed about 15 pounds on initial diagnosis and now is down to 12 pounds. We initially tried feeding Purina DM canned but the BG never moved after two weeks. His initial BG was 19.8 and after two weeks on the DM it was 18.9. We started Glargine insulin at 1 unit BID and  within a week the BG was 4.4 so we dropped the dose to 1/2 unit BID and a week later the BG was 21.7 so we stayed at same dose and a week later BG was 22.3. We then increased the dose of  Glargine  back to 1 unit BID and a week later the BG was 23.9!!!! We then increased the dose to 1 1/2 units bid and a week later the BG was 24.4. We test about 6 hours post injection.    UAS did not reveal any abnormalities. Chem profile revealed a slight increase in cholesterol--6.76(1.6-5.8) Electrolytes showed hypokalemia(3.1) a recheck a month later the K was 3.6. A glucose curve was done and there was not much change.(17.8-14.6) We are currently using 5 units BID and the BG goes from 3 one day to 19 next day!!!! We are currently feeding a canned food low in carbs.  Any ideas. Could a low potassium be the cause of insulin resistance from one day to the next?Could FIV be the cause? Acromegaly? Thanks ☼

Polyphagic?

I'm not familiar with the idea that melatonin causes insulin resistance---where did you read that?

VIN POST - brittle, 8 year old, diabetic cat with FIV -male neutered cat, diagnosed with Diabetes in September of 2012. Had comprehensive dental in April /12 and 9 teeth were removed. Potassium was 3.4 at this time. Normal thyroid and normal snap Fpl in April/13. He weighed about 15 pounds on initial diagnosis and now is down to 12 pounds. We initially tried feeding Purina DM canned but the BG never moved after two weeks. His initial BG was 19.8 and after two weeks on the DM it was 18.9. We started Glargine insulin at 1 unit BID and  within a week the BG was 4.4 so we dropped the dose to 1/2 unit BID and a week later the BG was 21.7 so we stayed at same dose and a week later BG was 22.3. We then increased the dose of  Glargine  back to 1 unit BID and a week later the BG was 23.9!!!! We then increased the dose to 1 1/2 units bid and a week later the BG was 24.4. We test about 6 hours post injection.    UAS did not reveal any abnormalities. Chem profile revealed a slight increase in cholesterol--6.76(1.6-5.8) Electrolytes showed hypokalemia(3.1) a recheck a month later the K was 3.6. A glucose curve was done and there was not much change.(17.8-14.6) We are currently using 5 units BID and the BG goes from 3 one day to 19 next day!!!! We are currently feeding a canned food low in carbs.  Any ideas. Could a low potassium be the cause of insulin resistance from one day to the next?Could FIV be the cause? Acromegaly? Thanks ☼

The cat is 12pounds now but has it remained stable at this for some weeks?

Is he indoor-only?

VIN POST - brittle, 8 year old, diabetic cat with FIV -male neutered cat, diagnosed with Diabetes in September of 2012. Had comprehensive dental in April /12 and 9 teeth were removed. Potassium was 3.4 at this time. Normal thyroid and normal snap Fpl in April/13. He weighed about 15 pounds on initial diagnosis and now is down to 12 pounds. We initially tried feeding Purina DM canned but the BG never moved after two weeks. His initial BG was 19.8 and after two weeks on the DM it was 18.9. We started Glargine insulin at 1 unit BID and  within a week the BG was 4.4 so we dropped the dose to 1/2 unit BID and a week later the BG was 21.7 so we stayed at same dose and a week later BG was 22.3. We then increased the dose of  Glargine  back to 1 unit BID and a week later the BG was 23.9!!!! We then increased the dose to 1 1/2 units bid and a week later the BG was 24.4. We test about 6 hours post injection.    UAS did not reveal any abnormalities. Chem profile revealed a slight increase in cholesterol--6.76(1.6-5.8) Electrolytes showed hypokalemia(3.1) a recheck a month later the K was 3.6. A glucose curve was done and there was not much change.(17.8-14.6) We are currently using 5 units BID and the BG goes from 3 one day to 19 next day!!!! We are currently feeding a canned food low in carbs.  Any ideas. Could a low potassium be the cause of insulin resistance from one day to the next?Could FIV be the cause? Acromegaly? Thanks ☼

Is this an appropriate weight for the cat?

I'm assuming that the owner gave the insulin and breakfast at home and then brought the cat in?

Zeke is a new 15# feline and a relatively new diabetic. We started him on 3 U glargine bid initially. in aglucose curve 2 weeks later the lowest BG level was 379 at about 2:30-3pm. We increased the insulin to 4 U bid and he would vomit within 1/2 hour. He is on M/D diet. We repeated his glucose curve today; ran a mini chemistry panel; T4 and fPLI - all looked okay except increased high blood glucose. His glucose curve was very similar to what was mentioned above. His urine was negative for ketones. In talking to the owner; she mentioned that he vomits 3-4 times/week about 15 min to 1 hour after getting the insulin. This is not every day nor after each injection. What do you think is going on? Should we consider a different insulin? I am not sure what the options are any more. Prozinc is back on. Is that a good option? Any help in this regard would be greatly appreciated. Dr. ☼

Does the owner give any sort of treat after administration of the injection?

Has he been treated empirically for tick-borne disease?

I have a miniature poodle patient with diabetes (fairly well controlled), chronic intermittent pancreatitis and historically very high triglyceride levels. A variety of treatments have been tried with regards to the triglycerides (latest level was 1741 after a 12 hour fast - has been over 2000). She will not eat the Royal Canin LF, so is on W/D. She has been on omega fatty acids, niacin, chitosan and gemfibrozil, but none of these treatments have resulted in triglyceride levels below 850. An internist at our lab suggested CoQ10 before a statin, but did not have a dose for it. I found a dose of 30mg per 25-30 pounds of weight. Does anyone have any experience or opinions on this? This supplement comes in a capsule, so dosing for an eleven pound dog like this is tricky. Would 30mg be safe for this sized dog? Thank you, ☼

I have not heard of caq10 used for this ...does the internist have a refece?

I understand this patient has crf - is there a significant azotemia?

I have a miniature poodle patient with diabetes (fairly well controlled), chronic intermittent pancreatitis and historically very high triglyceride levels. A variety of treatments have been tried with regards to the triglycerides (latest level was 1741 after a 12 hour fast - has been over 2000). She will not eat the Royal Canin LF, so is on W/D. She has been on omega fatty acids, niacin, chitosan and gemfibrozil, but none of these treatments have resulted in triglyceride levels below 850. An internist at our lab suggested CoQ10 before a statin, but did not have a dose for it. I found a dose of 30mg per 25-30 pounds of weight. Does anyone have any experience or opinions on this? This supplement comes in a capsule, so dosing for an eleven pound dog like this is tricky. Would 30mg be safe for this sized dog? Thank you, ☼

How should i treat elevated triglycerides?

(e.g. he was on 2.2 units/kg of the vetsulin with no appreciable decrease in the bg's on bg curves?)   is he being monitored with bg curves?

I need some advice about a FS 11 year old Border Terrier. Today she weighed in at 11 lbs which is up from the 9.8 lbs she weighed on April 3 this year. She initially presented March 6 for the first time with a complaint of weight loss. At a previous vet they had performed blood work at which time her blood glucose was starting to become elevated but this unfortunately wasn’t discussed with the owner. Instead, she was started on levothyroxine for a low T4. The owner thought that the medication was making her drink and urinate more so he discontinued it. We ran a chemistry and CBC and U/A. These were the abnormal results: ALP 218 (5-131) H GGT 68 (1-12) H BUN/CREA Ratio 45 (4-27) H GLU 745 (70-138) H Calcium 8.7 (8.9-11.4) L Potassium 5.3 (3.6-5.5) Sodium 137 (139-154) L Na/K Ratio 26 (27-38) L Triglyceride 443 (29-291) H Platelet Count 492 (170-400) Monocytes 896 (0-840) Total T4 0.5 (0.8-3.5) Dipstick- Glucose 3+ Dipstick- Ketones 1+ From here we performed a urine culture which was negative. A free T4 and TSH were within normal range as well. Carmen was started on Royal Canin Diabetic diet, a 1000 mg fish oil capsule per day and one Dasuquin chew per day for arthritis. She was also started on Humulin-N at 1 U BID. The owner called two weeks later (and 2 days before scheduled blood glucose curve) to say that he had been giving Karo syrup to her almost daily because she seemed to be exhibiting signs of hypoglycemia. He was advised to lower her dose to ½ U BID. He brought her in a few days later on April 4, for an exam and recheck of complete blood work. These were the abnormalities: ALP 261 (20-150) CA 6.6 (8.6-11.8) (I wondered if this was due to pancreatitis?) GLU 504 (60-110) HCT 56.36 (37-55) PLT 703 (200-500) She also had developed large cataracts in this time which we determined was the cause of her disorientation and bumping into furniture and likely not hypoglycemia. We put her back at 1 U BID and she came back April 19 for a BG curve. Her owner reported that she seemed to be drinking a bit less water and has been adjusting to her decreased vision. She received 1U of insulin at 7:40 am. Her curve went as followed: 8:20 am-- 397 10:20 am--526 12:10 pm—598 We stopped the curve at this point because it was increasing. Advised o to give 2 U of Humulin-N BID. At her second curve 2 weeks later, her owner said that he hasn’t been filling up the water bowl as frequently. She received insulin at 8:10 am. 8:30 am: 328 10:30 am: 429 12:30 pm: 430 2:30 pm : 409 4:30 pm: 450 We increased her dose to 3U BID. She presented today and o says that she is doing much better. He thinks that she is drinking a lot in the morning but not as much during the day. She received 3 U Humulin N at 8:00 am. 8:40 am: 351 10:40 am: 350 12:40 pm: 367 2:40 pm: 431 4:40 pm We haven’t reached insulin resistant levels yet but it seems like the insulin helps for the first reading and then isn’t very effective. Should I be increasing her insulin dose further? Should I go up to 5 Units from 3? Should I be investigating Cushing’s disease at this point even though her ALP was only 218? When should I consider switching to a new insulin and what insulin do you think would be best to try next if it came to that? Thanks in advance for the help.

Certain that insulin is being administered properly?

What are the reflexes?

I need some advice about a FS 11 year old Border Terrier. Today she weighed in at 11 lbs which is up from the 9.8 lbs she weighed on April 3 this year. She initially presented March 6 for the first time with a complaint of weight loss. At a previous vet they had performed blood work at which time her blood glucose was starting to become elevated but this unfortunately wasn’t discussed with the owner. Instead, she was started on levothyroxine for a low T4. The owner thought that the medication was making her drink and urinate more so he discontinued it. We ran a chemistry and CBC and U/A. These were the abnormal results: ALP 218 (5-131) H GGT 68 (1-12) H BUN/CREA Ratio 45 (4-27) H GLU 745 (70-138) H Calcium 8.7 (8.9-11.4) L Potassium 5.3 (3.6-5.5) Sodium 137 (139-154) L Na/K Ratio 26 (27-38) L Triglyceride 443 (29-291) H Platelet Count 492 (170-400) Monocytes 896 (0-840) Total T4 0.5 (0.8-3.5) Dipstick- Glucose 3+ Dipstick- Ketones 1+ From here we performed a urine culture which was negative. A free T4 and TSH were within normal range as well. Carmen was started on Royal Canin Diabetic diet, a 1000 mg fish oil capsule per day and one Dasuquin chew per day for arthritis. She was also started on Humulin-N at 1 U BID. The owner called two weeks later (and 2 days before scheduled blood glucose curve) to say that he had been giving Karo syrup to her almost daily because she seemed to be exhibiting signs of hypoglycemia. He was advised to lower her dose to ½ U BID. He brought her in a few days later on April 4, for an exam and recheck of complete blood work. These were the abnormalities: ALP 261 (20-150) CA 6.6 (8.6-11.8) (I wondered if this was due to pancreatitis?) GLU 504 (60-110) HCT 56.36 (37-55) PLT 703 (200-500) She also had developed large cataracts in this time which we determined was the cause of her disorientation and bumping into furniture and likely not hypoglycemia. We put her back at 1 U BID and she came back April 19 for a BG curve. Her owner reported that she seemed to be drinking a bit less water and has been adjusting to her decreased vision. She received 1U of insulin at 7:40 am. Her curve went as followed: 8:20 am-- 397 10:20 am--526 12:10 pm—598 We stopped the curve at this point because it was increasing. Advised o to give 2 U of Humulin-N BID. At her second curve 2 weeks later, her owner said that he hasn’t been filling up the water bowl as frequently. She received insulin at 8:10 am. 8:30 am: 328 10:30 am: 429 12:30 pm: 430 2:30 pm : 409 4:30 pm: 450 We increased her dose to 3U BID. She presented today and o says that she is doing much better. He thinks that she is drinking a lot in the morning but not as much during the day. She received 3 U Humulin N at 8:00 am. 8:40 am: 351 10:40 am: 350 12:40 pm: 367 2:40 pm: 431 4:40 pm We haven’t reached insulin resistant levels yet but it seems like the insulin helps for the first reading and then isn’t very effective. Should I be increasing her insulin dose further? Should I go up to 5 Units from 3? Should I be investigating Cushing’s disease at this point even though her ALP was only 218? When should I consider switching to a new insulin and what insulin do you think would be best to try next if it came to that? Thanks in advance for the help.

When and how much are they feeding the dog?

Are the urine s.g.'s always measured on an in-house refractometer or have some been at a commercial lab?

After years of smugly managing relatively straightforward diabetic patients, I now have THREE who are driving me crazy. I'll start with the one I have the most information on, and see if it helps me with the rest. The information is not as much as I'd like, as the owner has some serious financial limitations. "Chloe" is an 8yo intact female Lab who came to me last September as an uncontrolled diabetic, emaciated and with mature cataracts OU. She had been placed on Humulin N by the emergency clinic a few weeks or months previously, but the owner had not understood that dosage adjustments were necessary after that. With some rather sporadic rechecks, she was regulated by December at 18U BID and a prescription diet. Fructosamine was low in late February, but we did not hear from the owner until mid-April, when the dog was PU/PD again with a blood glucose of 601 mid-afternoon. We have steadily incsed the insulin, an initially seemed to get decsing blood glucose dings, then steadily higher into the mid-700's when we got to 22 units BID. Assumed "rebound" response and have started lowering dosage. Owner reported no PU/PD when dog was in the 700's, but PU/PD returned as the dosage was lowered. At present dog is at 20U BID, and the curve from yesterday the owner gave us goes like this: 6:30am 458 (just before meal and insulin) 9:30am above 500 12:30pm above 500 3:30pm above 500 6:30pm 493 (just before meal and insulin) 6:30am today 139 The other part of the history is that, after 6 years of not cycling, the dog went through a brief heat in March, which I assume has complicated our lives. The owner had been told to spay her once regulated, but we had not re-visited this in the winter as the owner was reluctant since the dog had not cycled in years. I told her to drop the insulin by 2 more units and re-evaluate next week. Is this still some sort of Samogyi effect? When do I know it is time to change insulin? I'm not even sure the owner could afford anything else. Thanks so much for any direction. ☼

This is really a good time to teach the owner how to generate curves at home---any chance of that?

Had pu/pd been noted at home?

After years of smugly managing relatively straightforward diabetic patients, I now have THREE who are driving me crazy. I'll start with the one I have the most information on, and see if it helps me with the rest. The information is not as much as I'd like, as the owner has some serious financial limitations. "Chloe" is an 8yo intact female Lab who came to me last September as an uncontrolled diabetic, emaciated and with mature cataracts OU. She had been placed on Humulin N by the emergency clinic a few weeks or months previously, but the owner had not understood that dosage adjustments were necessary after that. With some rather sporadic rechecks, she was regulated by December at 18U BID and a prescription diet. Fructosamine was low in late February, but we did not hear from the owner until mid-April, when the dog was PU/PD again with a blood glucose of 601 mid-afternoon. We have steadily incsed the insulin, an initially seemed to get decsing blood glucose dings, then steadily higher into the mid-700's when we got to 22 units BID. Assumed "rebound" response and have started lowering dosage. Owner reported no PU/PD when dog was in the 700's, but PU/PD returned as the dosage was lowered. At present dog is at 20U BID, and the curve from yesterday the owner gave us goes like this: 6:30am 458 (just before meal and insulin) 9:30am above 500 12:30pm above 500 3:30pm above 500 6:30pm 493 (just before meal and insulin) 6:30am today 139 The other part of the history is that, after 6 years of not cycling, the dog went through a brief heat in March, which I assume has complicated our lives. The owner had been told to spay her once regulated, but we had not re-visited this in the winter as the owner was reluctant since the dog had not cycled in years. I told her to drop the insulin by 2 more units and re-evaluate next week. Is this still some sort of Samogyi effect? When do I know it is time to change insulin? I'm not even sure the owner could afford anything else. Thanks so much for any direction. ☼

If the owner is declining the curves based on $$ considerations, then i'd strongly recommend that she learn how to generate the curves at home if possible...is she doing that aldy?

I have thought about medullary washout, but how could i gradually restrict a abetic cat without making her sick?

Hi, Bailey is a 14 year old cock a poo 8 kg who has a long hx of (pancreatitis, calcium ox stones ( that were removed), cushings and diabetes. His owners are very limited financially at this point. He is currently on trilostane 7.5 mg BID which is controlling his cushings well. He is a picky eater and generally get w/d though his owners often have to change up his diet to get him to eat. His owners also work odd hours which does not help with his insulin administration. His owners monitor his B.G at home as they can not afford in clinic curves and Bailey is hysterical when he is in the clinic. For these reasons this is a challenging case however clinically Bailey is doing well and I am trying to work around Bailey's needs and his owners limited finances as to not have to put him down. Bailey is currently on 5 units of caninsulin BID. His last full curve was done a few weeks ago and looked as follows. 8 am 2.3 ( owners held off on insulin because it was so low though fed him) 11 am 19.5 ( insulin given) 1 pm HI 3 pm 18.8 5 pm 14.3 7 pm 27.1. ( food and insulin given) His owners have also been taking his B.G every morning and night and as long as his b.g does not drop below 10 then they give him his insulin. I have been bothering them for his b.g number for several months now and they just sent them to me. They are as follows. 03/18/13 * 7:25am - 8.2 * 12:30pm – HI (I) 03/19/13 * 7:30am – 28.8 (I) * 6:45pm – 3.8 03/20/13 * 7:30am – HI (I) * 7:30pm – 21.1 (I) 03/21/13 * 7:30am – 2.6 * 5:35pm – 29.3 (I) 03/22/13 * 8:00am – 23.4 (I) * 7:00pm – 13.0 * 10:00pm – HI (I) 03/23/13 * 8:00am – 23.4 (I) * 7:00pm – 13.0 * 10:00pm – HI (I) 03/24/13 * 8:00am – 11.8 * 1:00pm – 23.0 (I) * 8:30pm – 13.7 03/25/13 * 6:40am – HI (I) * 8:30pm - HI (I) 03/26/13 * 7:15am – 7.5 * 12:30pm - HI (I) * 12:30am – 28.3 (I) 03/27/13 * 6:30am – 18.9 (gave insulin @7:30) * 7:15pm – 15.0 * 10:30pm - HI (I) 03/28/13 * 7:30am – 16.6 (I) * 7:30pm – 8.8 03/29/13 * 6:18am – 25.3 (I) * 6:45pm – 31.2 (I) 03/30/13 * 7:45am – 4.4 * 4:00pm – 31.8 (I) 03/31/13 * 4:00am – HI (I) * 11:15am – 10.3 * 7:00pm – 33.1 (I) 04/01/13 * 10:30am – 25.1(I) * 7:15pm – 14.2 * 10:30pm – 26.7(I) 04/02/13 * 7:30am – 4.0 * 12:30pm – 26.4 (I) * 10:30pm – 26.7 (I) 04/03/13 * 7:30am – 12.2 * 12:30pm – HI (I) * 10:30pm – 16.6(I) 04/04/13 * 7:30am – 2.7 * 12:30pm – 10.4 * 7:30pm 32.2 (I) 04/05/13 * 7:30am – 2.4 * 12:45pm – 32.3(I) * 9:00pm – 8.1 * 1:30am – 4.7 04/06/13 * 8:45am – 14.7 * 2:00pm - HI(I) 04/07/13 * 12:30pm – 3,2 * 6:15pm - HI(I) 04/08/13 * 7:30am – 2.8 * 1:15pm – 28.3 (I) * 6:00pm – 17.1 * 9:00pm – 10.3 04/09/13 * 7:30am – 30.3 (I) * 6:15pm – 16.7 (I) 04/10/13 * 7:30am – 20.7(I) * 7:30pm – HI(I) 04/11/13 * 7:30am – 4.7 * 4:15pm – 26.9 (I) 04/12/13 * 7:30am – 29.3 (I) 04/13/13 * 9:00am – 6.4 * 6:00pm – 22.1 (I) 04/14/13 * 8:00am – 5.7 * 12:00pm - HI(I) * 9:30pm – 18.6(I) 04/15/13 * 7:30am – 2.6 * 12:30pm – 6.9 * 7:00pm - HI(I) 04/16/13 * 7:30am – 5.0 * 12:30pm – 15.4(I) * 12:00am – 10.2 04/17/13 * 7:30am – 29.7(I) * 5:30pm - HI(I) * 2:39am – 29.3(I) 04/18/13 * 7:30am – 9.7 * 12:30pm – 9.7 * 7:15pm – 23.5(I) 04/19/13 * 7:30am – 8.2 * 12:00pm – 17.8(I) 04/20/13 * 8:30am – 14.9(I) * 6:10pm – 5.2 * 2:30am – 31.8(I) 04/21/13 * 1:50pm – 20.4(I) * 9:30pm – 22.7(I) 04/22/13 * 7:15am – 4.8 * 12:30pm – 8.8 * 4:30pm - HI(I) 04/23/13 * 6:15am – 31.2(I) * 7:30pm – 28.1(I) 04/24/13 * 7:30am – 5.3 * 12:30pm – 29.1(I) * 8:30pm – 11.2 04/25/13 * 7:30am – 28.9(I) * 7:00pm – 15.7(I) 04/26/13 * 11:00am – 28.9(I) * 7:30pm – 13.5 (I) 04/27/13 * 7:00am – 10.9 * 4:00pm - HI(I) 04/28/13 * 10:00am – 24.2 * 7:00pm – 15.5(I) 04/29/13 * 7:30am – 3.1 * 5:00pm – 27.7(I) 04/30/13 * 7:30am – 25.3(I) * 5:30pm – 5.8 * 2:30am - HI(I) 05/01/13 * 12:30pm – 16.5(I) * 7:30pm – 5.6 * 11:00pm – 12.9 05/02/13 * 7:30am – 21.3(I) * 7:30pm HI(I) As you can see his numbers are really all over the place. I am not sure what is best to do. He is responding to the Caninsulin but each day is different. Any advice as to how to best tackle this situation would be much appreciated. Thanks so much. ☼

So the first question is how long was the last stim and what exactly did the cortisols look like?

So i guess what i'm getting at is, are these good numbers for a 3 doctor mixed practice?

Hi, Bailey is a 14 year old cock a poo 8 kg who has a long hx of (pancreatitis, calcium ox stones ( that were removed), cushings and diabetes. His owners are very limited financially at this point. He is currently on trilostane 7.5 mg BID which is controlling his cushings well. He is a picky eater and generally get w/d though his owners often have to change up his diet to get him to eat. His owners also work odd hours which does not help with his insulin administration. His owners monitor his B.G at home as they can not afford in clinic curves and Bailey is hysterical when he is in the clinic. For these reasons this is a challenging case however clinically Bailey is doing well and I am trying to work around Bailey's needs and his owners limited finances as to not have to put him down. Bailey is currently on 5 units of caninsulin BID. His last full curve was done a few weeks ago and looked as follows. 8 am 2.3 ( owners held off on insulin because it was so low though fed him) 11 am 19.5 ( insulin given) 1 pm HI 3 pm 18.8 5 pm 14.3 7 pm 27.1. ( food and insulin given) His owners have also been taking his B.G every morning and night and as long as his b.g does not drop below 10 then they give him his insulin. I have been bothering them for his b.g number for several months now and they just sent them to me. They are as follows. 03/18/13 * 7:25am - 8.2 * 12:30pm – HI (I) 03/19/13 * 7:30am – 28.8 (I) * 6:45pm – 3.8 03/20/13 * 7:30am – HI (I) * 7:30pm – 21.1 (I) 03/21/13 * 7:30am – 2.6 * 5:35pm – 29.3 (I) 03/22/13 * 8:00am – 23.4 (I) * 7:00pm – 13.0 * 10:00pm – HI (I) 03/23/13 * 8:00am – 23.4 (I) * 7:00pm – 13.0 * 10:00pm – HI (I) 03/24/13 * 8:00am – 11.8 * 1:00pm – 23.0 (I) * 8:30pm – 13.7 03/25/13 * 6:40am – HI (I) * 8:30pm - HI (I) 03/26/13 * 7:15am – 7.5 * 12:30pm - HI (I) * 12:30am – 28.3 (I) 03/27/13 * 6:30am – 18.9 (gave insulin @7:30) * 7:15pm – 15.0 * 10:30pm - HI (I) 03/28/13 * 7:30am – 16.6 (I) * 7:30pm – 8.8 03/29/13 * 6:18am – 25.3 (I) * 6:45pm – 31.2 (I) 03/30/13 * 7:45am – 4.4 * 4:00pm – 31.8 (I) 03/31/13 * 4:00am – HI (I) * 11:15am – 10.3 * 7:00pm – 33.1 (I) 04/01/13 * 10:30am – 25.1(I) * 7:15pm – 14.2 * 10:30pm – 26.7(I) 04/02/13 * 7:30am – 4.0 * 12:30pm – 26.4 (I) * 10:30pm – 26.7 (I) 04/03/13 * 7:30am – 12.2 * 12:30pm – HI (I) * 10:30pm – 16.6(I) 04/04/13 * 7:30am – 2.7 * 12:30pm – 10.4 * 7:30pm 32.2 (I) 04/05/13 * 7:30am – 2.4 * 12:45pm – 32.3(I) * 9:00pm – 8.1 * 1:30am – 4.7 04/06/13 * 8:45am – 14.7 * 2:00pm - HI(I) 04/07/13 * 12:30pm – 3,2 * 6:15pm - HI(I) 04/08/13 * 7:30am – 2.8 * 1:15pm – 28.3 (I) * 6:00pm – 17.1 * 9:00pm – 10.3 04/09/13 * 7:30am – 30.3 (I) * 6:15pm – 16.7 (I) 04/10/13 * 7:30am – 20.7(I) * 7:30pm – HI(I) 04/11/13 * 7:30am – 4.7 * 4:15pm – 26.9 (I) 04/12/13 * 7:30am – 29.3 (I) 04/13/13 * 9:00am – 6.4 * 6:00pm – 22.1 (I) 04/14/13 * 8:00am – 5.7 * 12:00pm - HI(I) * 9:30pm – 18.6(I) 04/15/13 * 7:30am – 2.6 * 12:30pm – 6.9 * 7:00pm - HI(I) 04/16/13 * 7:30am – 5.0 * 12:30pm – 15.4(I) * 12:00am – 10.2 04/17/13 * 7:30am – 29.7(I) * 5:30pm - HI(I) * 2:39am – 29.3(I) 04/18/13 * 7:30am – 9.7 * 12:30pm – 9.7 * 7:15pm – 23.5(I) 04/19/13 * 7:30am – 8.2 * 12:00pm – 17.8(I) 04/20/13 * 8:30am – 14.9(I) * 6:10pm – 5.2 * 2:30am – 31.8(I) 04/21/13 * 1:50pm – 20.4(I) * 9:30pm – 22.7(I) 04/22/13 * 7:15am – 4.8 * 12:30pm – 8.8 * 4:30pm - HI(I) 04/23/13 * 6:15am – 31.2(I) * 7:30pm – 28.1(I) 04/24/13 * 7:30am – 5.3 * 12:30pm – 29.1(I) * 8:30pm – 11.2 04/25/13 * 7:30am – 28.9(I) * 7:00pm – 15.7(I) 04/26/13 * 11:00am – 28.9(I) * 7:30pm – 13.5 (I) 04/27/13 * 7:00am – 10.9 * 4:00pm - HI(I) 04/28/13 * 10:00am – 24.2 * 7:00pm – 15.5(I) 04/29/13 * 7:30am – 3.1 * 5:00pm – 27.7(I) 04/30/13 * 7:30am – 25.3(I) * 5:30pm – 5.8 * 2:30am - HI(I) 05/01/13 * 12:30pm – 16.5(I) * 7:30pm – 5.6 * 11:00pm – 12.9 05/02/13 * 7:30am – 21.3(I) * 7:30pm HI(I) As you can see his numbers are really all over the place. I am not sure what is best to do. He is responding to the Caninsulin but each day is different. Any advice as to how to best tackle this situation would be much appreciated. Thanks so much. ☼

Was the test started 3-5 hours after the am trilostane was given with food and did you use synacthen?

_askaquestion: what are the chances that it is a prion?

Hello, I have a 12 year old female, spayed Lhasa who is diabetic and has a history of struvite stones and calcium oxalate crystals. She is on 8 units BID and normally eats Purina EN. She weighed 19.2 lbs. Last Glucose curve was 8:30 342 (insulin given @ 6:30) 10:30 371 12:30 341 2:30 295 4:30 393 On day of the curve, o reported that that dog's appetite was decreased and the dog had lost 1 lbs. They feel the dog is getting weak. May 13 April 25 CHEM: Glu 383 (17-143) Glu 189 ALT 135 (10-100) ALT 101 ALKP 250 (23-212) ALKP 240 T bil 0.9 (0-0.9) T bil 1.0 CHOL > 520 (110-320) CHOL 449 CBC: HCT 61.7 (37-55) HCT 54.6 HgB 18.5 (12-18) HgB 21.2 MCHC 29.9 (30-37.5) MCHC 38.8 RETIC 118.8 (10-110) RETIC 212.8 UA: Glu: 1000-2000 Ket trace SG 1.033 Blood small-mod Pro 30-100 Urine Culture: neg The only concerns I really had with this blood work was the elevation of the T bil which normalized when we rechecked. The dog is not having any vomiting or diarrhea but my recommendation were an ultrasound and a cPLI to evaluate the pancreas. I am afraid to increase the insulin dosage because the dog is not eating as well as she should. Should I still increase the insulin 1 unit? Any other ideas that you would have for this girl? Thank you, ☼

How long has she been diabetic?

Can you perform an epidural?

Hello, I have a 12 year old female, spayed Lhasa who is diabetic and has a history of struvite stones and calcium oxalate crystals. She is on 8 units BID and normally eats Purina EN. She weighed 19.2 lbs. Last Glucose curve was 8:30 342 (insulin given @ 6:30) 10:30 371 12:30 341 2:30 295 4:30 393 On day of the curve, o reported that that dog's appetite was decreased and the dog had lost 1 lbs. They feel the dog is getting weak. May 13 April 25 CHEM: Glu 383 (17-143) Glu 189 ALT 135 (10-100) ALT 101 ALKP 250 (23-212) ALKP 240 T bil 0.9 (0-0.9) T bil 1.0 CHOL > 520 (110-320) CHOL 449 CBC: HCT 61.7 (37-55) HCT 54.6 HgB 18.5 (12-18) HgB 21.2 MCHC 29.9 (30-37.5) MCHC 38.8 RETIC 118.8 (10-110) RETIC 212.8 UA: Glu: 1000-2000 Ket trace SG 1.033 Blood small-mod Pro 30-100 Urine Culture: neg The only concerns I really had with this blood work was the elevation of the T bil which normalized when we rechecked. The dog is not having any vomiting or diarrhea but my recommendation were an ultrasound and a cPLI to evaluate the pancreas. I am afraid to increase the insulin dosage because the dog is not eating as well as she should. Should I still increase the insulin 1 unit? Any other ideas that you would have for this girl? Thank you, ☼

What kind of insulin is she getting?

Are these lungs normal?

Hello, I have a 12 year old female, spayed Lhasa who is diabetic and has a history of struvite stones and calcium oxalate crystals. She is on 8 units BID and normally eats Purina EN. She weighed 19.2 lbs. Last Glucose curve was 8:30 342 (insulin given @ 6:30) 10:30 371 12:30 341 2:30 295 4:30 393 On day of the curve, o reported that that dog's appetite was decreased and the dog had lost 1 lbs. They feel the dog is getting weak. May 13 April 25 CHEM: Glu 383 (17-143) Glu 189 ALT 135 (10-100) ALT 101 ALKP 250 (23-212) ALKP 240 T bil 0.9 (0-0.9) T bil 1.0 CHOL > 520 (110-320) CHOL 449 CBC: HCT 61.7 (37-55) HCT 54.6 HgB 18.5 (12-18) HgB 21.2 MCHC 29.9 (30-37.5) MCHC 38.8 RETIC 118.8 (10-110) RETIC 212.8 UA: Glu: 1000-2000 Ket trace SG 1.033 Blood small-mod Pro 30-100 Urine Culture: neg The only concerns I really had with this blood work was the elevation of the T bil which normalized when we rechecked. The dog is not having any vomiting or diarrhea but my recommendation were an ultrasound and a cPLI to evaluate the pancreas. I am afraid to increase the insulin dosage because the dog is not eating as well as she should. Should I still increase the insulin 1 unit? Any other ideas that you would have for this girl? Thank you, ☼

Any other curves to look at?

Is she on the canned version of a high protein/low carb diet?

HI Jiggy is a 9 year old M/N DSH. AT JIggy's annual 6 months ago, we did a senior wellness and his creatinine was 202 umol/L and urea 13.6 mmol/L. His urine had 3 plus blood in a sample that was voided. Sg. 1.035. There was no glucose in the urine and blood glucose was normal. There was 1 plus ketones. I kind of ignored it as he was doing well. He's on canned Fancy Feast fish flavours and dry pet store food. He will only eat fishy canned foods. Now, Jiggy's creatinine is 209 and urea 14.2. He still had blood in his urine. HIs urine also had 3 plus glucose and again 1 plus ketones. I did a glucometer reading as the renal profile I ran did not have glucose and the glucose was 6.6 mmo.L. I also took and xray laterally right and left and his right kidney has 2 radiodensities which could be renoliths but look more like calcification. The owners report that Jiggy didn't eat as well as usual for 2 days a few days ago but he's back to normal now. Questions. 1. Would the calcification cause the increased creatinine? BTW his calcium is in the normal range. 2. What can we do about it? The owner has declined U/S. I recommend lots of water and canned food. We showed the owner how to do SQ fluids but this cat is very fractious with us. 3. What diet do you recommend? He will only eat fishy canned food according to the owner. Help! Thanks. ☼

Can you share your normal ranges?

Do you know if sample was fasting or postprandial?

HI Jiggy is a 9 year old M/N DSH. AT JIggy's annual 6 months ago, we did a senior wellness and his creatinine was 202 umol/L and urea 13.6 mmol/L. His urine had 3 plus blood in a sample that was voided. Sg. 1.035. There was no glucose in the urine and blood glucose was normal. There was 1 plus ketones. I kind of ignored it as he was doing well. He's on canned Fancy Feast fish flavours and dry pet store food. He will only eat fishy canned foods. Now, Jiggy's creatinine is 209 and urea 14.2. He still had blood in his urine. HIs urine also had 3 plus glucose and again 1 plus ketones. I did a glucometer reading as the renal profile I ran did not have glucose and the glucose was 6.6 mmo.L. I also took and xray laterally right and left and his right kidney has 2 radiodensities which could be renoliths but look more like calcification. The owners report that Jiggy didn't eat as well as usual for 2 days a few days ago but he's back to normal now. Questions. 1. Would the calcification cause the increased creatinine? BTW his calcium is in the normal range. 2. What can we do about it? The owner has declined U/S. I recommend lots of water and canned food. We showed the owner how to do SQ fluids but this cat is very fractious with us. 3. What diet do you recommend? He will only eat fishy canned food according to the owner. Help! Thanks. ☼

Why the 1 plus ketones in 2 u/a's?

Finally, i would look closely at the clinical picture; is there now still pu/pd?

HI Jiggy is a 9 year old M/N DSH. AT JIggy's annual 6 months ago, we did a senior wellness and his creatinine was 202 umol/L and urea 13.6 mmol/L. His urine had 3 plus blood in a sample that was voided. Sg. 1.035. There was no glucose in the urine and blood glucose was normal. There was 1 plus ketones. I kind of ignored it as he was doing well. He's on canned Fancy Feast fish flavours and dry pet store food. He will only eat fishy canned foods. Now, Jiggy's creatinine is 209 and urea 14.2. He still had blood in his urine. HIs urine also had 3 plus glucose and again 1 plus ketones. I did a glucometer reading as the renal profile I ran did not have glucose and the glucose was 6.6 mmo.L. I also took and xray laterally right and left and his right kidney has 2 radiodensities which could be renoliths but look more like calcification. The owners report that Jiggy didn't eat as well as usual for 2 days a few days ago but he's back to normal now. Questions. 1. Would the calcification cause the increased creatinine? BTW his calcium is in the normal range. 2. What can we do about it? The owner has declined U/S. I recommend lots of water and canned food. We showed the owner how to do SQ fluids but this cat is very fractious with us. 3. What diet do you recommend? He will only eat fishy canned food according to the owner. Help! Thanks. ☼

What is your concern?

Are there any gi signs in this cat?

Hi, Maxwell is a 15-year-old neutered male DSH that has been a patient in our hospital since kittenhood. He was diagnosed with diabetes mellitus initially in August 2011. He was initially treated with glargine insulin and some dietary modification (a mixture of DM and SO was fed because Max also had a history of FLUTD, including an episode of urethral obstruction in 2004. A mixture of dry and canned was fed because owner had difficulty getting this cat to eat a strictly canned diet). Max was almost immediately regulated on 2 units of glargine insulin bid (blood glucose curves showed blood glucose values in the 120-150 range), and he remained well regulated between August 2011 and October 2012 on the 2 units glargine bid. In February 2013, the owner felt that Max had become more PU/PD. He had lost a little weight (0.6 lbs. in 4 months), and a glucose curve showed blood glucoses ranging from 385 to 535. There was 4+ glucose in his urine, and his fructosamine was 660. Since that time (February 2013), I have been trying to regulate him. He is now eating canned DM only, and Max's glargine insulin dose has been gradually increased to 6 units bid. I recently (4/25/13) did a cystocentesed urine culture and sensitivity, which was negative. A fasting spec fPL on the same date was high (7.7 ug/mL), so I suspect Max probably does have pancreatitis; however, he is not really showing any clinical signs currently (no vomiting, decent appetite, no weight loss in the past couple of weeks). I have had the owner replace her old bottle of glargine and try a fresh/new bottle during this time as well. The most recent CBC and serum chemistry profile and U/A were performed on 2/26/13. Other than hyperglycemia and glucosuria, the BUN was 48, the USG was 1.054, and everything else was normal. I just saw Max again yesterday. He has gained a little weight over the past 2 weeks (was 12.0 lbs. 2 weeks ago and is now 12.8), and the owner feels he is eating well (but not ravenous, as he has been in the past), and is not particularly PU/PD. His blood glucoses ranged from 360-370 in the early a.m. to a gradual decline to a low of 238 at 7:10 p.m. (he showed a similar pattern/similar values 2 weeks ago as well). He is still eating strictly canned DM (except when he steals the other cats' dry food) and is getting 6 units glargine twice daily. I also checked a fructosamine on him yesterday, and it is still pretty high at 652. In addition, Max does have a heart murmur (was diagnosed with mild mitral regurgitation and mild left ventricular concentric/papillary muscle hypertrophy) by a board-certified cardiologist in May 2011--no cardiac medications were indicated at that time and the owner has not gone back to the cardiologist for a follow up since then. Max also has dental disease. The most recent dental cleaning/extractions were done in March 2012. He does have a recurrence of marked tartar on his remaining teeth. I'm not sure what to do with this patient at this point. I was thinking he might be doing better because the blood glucoses values are coming down a little and the owner feels he is less PU/PD, but the fructosamine doesn't reflect good control. Should I try another type of insulin? If so, what would you suggest? Should I continue to look for other diseases that might be complicating matters (was thinking of suggesting an abdominal sonogram to the client)? Should we consider a dentistry? Should we just keep on with the 6 units of glargine twice daily and see how things go? Thanks so much for your help with this case! ☼

Was there a t4 on his recent labwork?

Is the cat on the canned form of the dm diet?

Hi, Maxwell is a 15-year-old neutered male DSH that has been a patient in our hospital since kittenhood. He was diagnosed with diabetes mellitus initially in August 2011. He was initially treated with glargine insulin and some dietary modification (a mixture of DM and SO was fed because Max also had a history of FLUTD, including an episode of urethral obstruction in 2004. A mixture of dry and canned was fed because owner had difficulty getting this cat to eat a strictly canned diet). Max was almost immediately regulated on 2 units of glargine insulin bid (blood glucose curves showed blood glucose values in the 120-150 range), and he remained well regulated between August 2011 and October 2012 on the 2 units glargine bid. In February 2013, the owner felt that Max had become more PU/PD. He had lost a little weight (0.6 lbs. in 4 months), and a glucose curve showed blood glucoses ranging from 385 to 535. There was 4+ glucose in his urine, and his fructosamine was 660. Since that time (February 2013), I have been trying to regulate him. He is now eating canned DM only, and Max's glargine insulin dose has been gradually increased to 6 units bid. I recently (4/25/13) did a cystocentesed urine culture and sensitivity, which was negative. A fasting spec fPL on the same date was high (7.7 ug/mL), so I suspect Max probably does have pancreatitis; however, he is not really showing any clinical signs currently (no vomiting, decent appetite, no weight loss in the past couple of weeks). I have had the owner replace her old bottle of glargine and try a fresh/new bottle during this time as well. The most recent CBC and serum chemistry profile and U/A were performed on 2/26/13. Other than hyperglycemia and glucosuria, the BUN was 48, the USG was 1.054, and everything else was normal. I just saw Max again yesterday. He has gained a little weight over the past 2 weeks (was 12.0 lbs. 2 weeks ago and is now 12.8), and the owner feels he is eating well (but not ravenous, as he has been in the past), and is not particularly PU/PD. His blood glucoses ranged from 360-370 in the early a.m. to a gradual decline to a low of 238 at 7:10 p.m. (he showed a similar pattern/similar values 2 weeks ago as well). He is still eating strictly canned DM (except when he steals the other cats' dry food) and is getting 6 units glargine twice daily. I also checked a fructosamine on him yesterday, and it is still pretty high at 652. In addition, Max does have a heart murmur (was diagnosed with mild mitral regurgitation and mild left ventricular concentric/papillary muscle hypertrophy) by a board-certified cardiologist in May 2011--no cardiac medications were indicated at that time and the owner has not gone back to the cardiologist for a follow up since then. Max also has dental disease. The most recent dental cleaning/extractions were done in March 2012. He does have a recurrence of marked tartar on his remaining teeth. I'm not sure what to do with this patient at this point. I was thinking he might be doing better because the blood glucoses values are coming down a little and the owner feels he is less PU/PD, but the fructosamine doesn't reflect good control. Should I try another type of insulin? If so, what would you suggest? Should I continue to look for other diseases that might be complicating matters (was thinking of suggesting an abdominal sonogram to the client)? Should we consider a dentistry? Should we just keep on with the 6 units of glargine twice daily and see how things go? Thanks so much for your help with this case! ☼

Does he look like he has developed this?

Weight loss?

Hi all- I have a 12 year old MC DLH who I am currently treating for diabetes. His levels have always been just beyond high, but he's spilling glucose into his urine and his fructosamine was high (540). His first curve after starting glargine was a good curve. He is currently on glargine 1 unit once daily and on DM. This kitty has been inappropriately urinating around the house for years off and on. Mom is fed up (and quite honestly not taking advice well) and was interested in trying medication by mouth to help get the behavior under control. I was going to put him on Fluoxetine, but I saw in plumb that it can affect insulin requirements. Has anyone seen this clinically or have any thoughts on this. I need to do another fructosamine on this cat, to see if he's currently controlled and one that can be possibly controlled with just diet, but the owner may not want to wait to see if he needs insulin or not before starting the behavior medications. Any thoughts/ help would be appreciated. -☼

Is he eating strictly the canned-only version of the dm diet?

Will the owner's let you ultrasound the dog?

hello, Charlie is a 6 yr old 88 lb, M/I lab mix that presented Dec 26, 2012 (what was I doing working the day after Christmas when I should have been skiing?) and was found to be a DKA............a very sick DKA. Long story made short, after some efforts, he did very well and I started him on NPH insulin in Jan. Since early March he has been on 23 units NPH bid and I have spot checked his glucose as well as a recent curve. His glucose seems to be all over the place: March 1 BG=180, 6 1/2 hrs post insulin March 15 BG=338 7 hrs post insulin April 2 BG=188 7 hours post ins April 19 BG=249 7 hrs post ins A glucose curve done earlier this past week: BG=167, one hour post insulin BG=200, 3 hours post insulin BG=403, 5 1/2 hours post insulin BG=519, 7 1/2 hours post insulin Clinically, Charlie is doing well and the owners do not notice any PU/PD, he has great appetite and activity. But I'm a bit stymied by his glucose results. It appears that the insulin (NPH) may be too short acting? Should I check something else before changing insulin (something causing insulin resistence?) or would he benefit from a different insulin such as Vetsulin or detimir (I've had good luck in 2 other labs with detimir). Thank you, br/

Does this dog have a very constant diet?

0.6 or 6mg bid?

hello, Charlie is a 6 yr old 88 lb, M/I lab mix that presented Dec 26, 2012 (what was I doing working the day after Christmas when I should have been skiing?) and was found to be a DKA............a very sick DKA. Long story made short, after some efforts, he did very well and I started him on NPH insulin in Jan. Since early March he has been on 23 units NPH bid and I have spot checked his glucose as well as a recent curve. His glucose seems to be all over the place: March 1 BG=180, 6 1/2 hrs post insulin March 15 BG=338 7 hrs post insulin April 2 BG=188 7 hours post ins April 19 BG=249 7 hrs post ins A glucose curve done earlier this past week: BG=167, one hour post insulin BG=200, 3 hours post insulin BG=403, 5 1/2 hours post insulin BG=519, 7 1/2 hours post insulin Clinically, Charlie is doing well and the owners do not notice any PU/PD, he has great appetite and activity. But I'm a bit stymied by his glucose results. It appears that the insulin (NPH) may be too short acting? Should I check something else before changing insulin (something causing insulin resistence?) or would he benefit from a different insulin such as Vetsulin or detimir (I've had good luck in 2 other labs with detimir). Thank you, br/

How is the weight?

Is the ibd mild, moderate or severe?

hello, Charlie is a 6 yr old 88 lb, M/I lab mix that presented Dec 26, 2012 (what was I doing working the day after Christmas when I should have been skiing?) and was found to be a DKA............a very sick DKA. Long story made short, after some efforts, he did very well and I started him on NPH insulin in Jan. Since early March he has been on 23 units NPH bid and I have spot checked his glucose as well as a recent curve. His glucose seems to be all over the place: March 1 BG=180, 6 1/2 hrs post insulin March 15 BG=338 7 hrs post insulin April 2 BG=188 7 hours post ins April 19 BG=249 7 hrs post ins A glucose curve done earlier this past week: BG=167, one hour post insulin BG=200, 3 hours post insulin BG=403, 5 1/2 hours post insulin BG=519, 7 1/2 hours post insulin Clinically, Charlie is doing well and the owners do not notice any PU/PD, he has great appetite and activity. But I'm a bit stymied by his glucose results. It appears that the insulin (NPH) may be too short acting? Should I check something else before changing insulin (something causing insulin resistence?) or would he benefit from a different insulin such as Vetsulin or detimir (I've had good luck in 2 other labs with detimir). Thank you, br/

Are we sure owners are giving insulin properly?

Was this a pre-insulin sample?

We adopted a 10 year old m/c cat from the humane society 2 years ago(since he wasn't being adopted after about a year and they asked us for some help, happy to have taken him in,he is a great greeter for the hospital)...and we transitionned him to DM canned and got him on lantus. We have never been able to get him off insulin, never in remission, needs 1-1.5 u bid, despite normal fPL/PLIs. He is not thriving, is bony, we actually did an exploratory on him 1 year ago and found a mild ibd colitis but nothing too exciting. We do ultrasounds and labs and all are normal. He had a hypoglycemic crash on 1 u lantus in Dec and so we switched him to PZI at that point and he needs 1-1.5 units to be minimally controlled (Bgs range from 120-350). From the shaving in Dec for the catheter he has still not grown his hair back, which seems really odd. No pruritis. We tested TLI, normal. GI panel, normal. Next thought was a Cushing's test, altho no pot bellied belly or thin skin, just not growing hair back. He is on flovent inhaler for an asthmatic cough. Echo was normal, so cough all appeared lower airway and cough is well controlled on flovent inhaler 220, 2 puffs bid. When I tried to drop it down to 1 puff bid he started coughing. I was wondering about systemic effects of the steroids and if he was becoming iatrogenic cushings (tho I have never seen that w flovent inhaler) Does anything jump out to you to help him? He is on PZI, DM canned, cerenia, probiotic, denamarin....and he has happy moments but he is not thriving. He is I think the only diabetic we have not in remission, and the only diabetic on PZI..most all our diabetics get in remission and all are on Lantus.He is just an odd one and I want to be certain we really are not missing something here....good he lives in a vet clinic, eh? Thanks, ☼

How "normal" were his values when last measured?

Unfortunately, never reached end point usg 1.030 or 5% dehydration?

Hello, I am treating "Dobie," an 11 yr. old MN lab/husky mix weighing 112# (50.9kg) BCS 7/9. He was diagnosed with Diabetes Mellitus in 9/2010 and was doing well clinically on 33 units NPH SQ q12 for 2+ yrs. This dog is a bad actor and will not tolerate a cage, so we have not done any curves until the one below. The owner brought him in every 2 hrs. for the curve below. Fructosamine 10/2012 was 566 umol/L on 33 units. Started to lose a little weight and owner described polydipsia 12/2012. Fructosamine 12/18/12=637. Have been increasing dose of insulin and monitoring clinical signs and spot checking glucoses until this curve. Currently on NPH insulin 43 units SQ q 12 hrs. BG curve is as follows: 43 units NPH given @ 7:25 AM BG 7:30AM= 308 mg/dl 9:30=330 11:30=228 2:30PM=130 4:30=86 6:00PM=127 I have decreased the dose to 41 units BID and had the owner give 20 units last night. I need some suggestions for this dog as far as dosing and insulin type. Thanks for your time.

When was the most recent blood work done?

Pathologists description?

Hello, I am treating "Dobie," an 11 yr. old MN lab/husky mix weighing 112# (50.9kg) BCS 7/9. He was diagnosed with Diabetes Mellitus in 9/2010 and was doing well clinically on 33 units NPH SQ q12 for 2+ yrs. This dog is a bad actor and will not tolerate a cage, so we have not done any curves until the one below. The owner brought him in every 2 hrs. for the curve below. Fructosamine 10/2012 was 566 umol/L on 33 units. Started to lose a little weight and owner described polydipsia 12/2012. Fructosamine 12/18/12=637. Have been increasing dose of insulin and monitoring clinical signs and spot checking glucoses until this curve. Currently on NPH insulin 43 units SQ q 12 hrs. BG curve is as follows: 43 units NPH given @ 7:25 AM BG 7:30AM= 308 mg/dl 9:30=330 11:30=228 2:30PM=130 4:30=86 6:00PM=127 I have decreased the dose to 41 units BID and had the owner give 20 units last night. I need some suggestions for this dog as far as dosing and insulin type. Thanks for your time.

Has he had a recent ua/culture?

Some basic info - when was full bloodwork last performed?

Hello, I am treating "Dobie," an 11 yr. old MN lab/husky mix weighing 112# (50.9kg) BCS 7/9. He was diagnosed with Diabetes Mellitus in 9/2010 and was doing well clinically on 33 units NPH SQ q12 for 2+ yrs. This dog is a bad actor and will not tolerate a cage, so we have not done any curves until the one below. The owner brought him in every 2 hrs. for the curve below. Fructosamine 10/2012 was 566 umol/L on 33 units. Started to lose a little weight and owner described polydipsia 12/2012. Fructosamine 12/18/12=637. Have been increasing dose of insulin and monitoring clinical signs and spot checking glucoses until this curve. Currently on NPH insulin 43 units SQ q 12 hrs. BG curve is as follows: 43 units NPH given @ 7:25 AM BG 7:30AM= 308 mg/dl 9:30=330 11:30=228 2:30PM=130 4:30=86 6:00PM=127 I have decreased the dose to 41 units BID and had the owner give 20 units last night. I need some suggestions for this dog as far as dosing and insulin type. Thanks for your time.

Which brand of nph is he getting?

The pzi is prozinc?

Hello, I am treating "Dobie," an 11 yr. old MN lab/husky mix weighing 112# (50.9kg) BCS 7/9. He was diagnosed with Diabetes Mellitus in 9/2010 and was doing well clinically on 33 units NPH SQ q12 for 2+ yrs. This dog is a bad actor and will not tolerate a cage, so we have not done any curves until the one below. The owner brought him in every 2 hrs. for the curve below. Fructosamine 10/2012 was 566 umol/L on 33 units. Started to lose a little weight and owner described polydipsia 12/2012. Fructosamine 12/18/12=637. Have been increasing dose of insulin and monitoring clinical signs and spot checking glucoses until this curve. Currently on NPH insulin 43 units SQ q 12 hrs. BG curve is as follows: 43 units NPH given @ 7:25 AM BG 7:30AM= 308 mg/dl 9:30=330 11:30=228 2:30PM=130 4:30=86 6:00PM=127 I have decreased the dose to 41 units BID and had the owner give 20 units last night. I need some suggestions for this dog as far as dosing and insulin type. Thanks for your time.

Am i correct in assuming that he ate normally the morning of the curve?

Was the cat thin?

Hello, I am treating "Dobie," an 11 yr. old MN lab/husky mix weighing 112# (50.9kg) BCS 7/9. He was diagnosed with Diabetes Mellitus in 9/2010 and was doing well clinically on 33 units NPH SQ q12 for 2+ yrs. This dog is a bad actor and will not tolerate a cage, so we have not done any curves until the one below. The owner brought him in every 2 hrs. for the curve below. Fructosamine 10/2012 was 566 umol/L on 33 units. Started to lose a little weight and owner described polydipsia 12/2012. Fructosamine 12/18/12=637. Have been increasing dose of insulin and monitoring clinical signs and spot checking glucoses until this curve. Currently on NPH insulin 43 units SQ q 12 hrs. BG curve is as follows: 43 units NPH given @ 7:25 AM BG 7:30AM= 308 mg/dl 9:30=330 11:30=228 2:30PM=130 4:30=86 6:00PM=127 I have decreased the dose to 41 units BID and had the owner give 20 units last night. I need some suggestions for this dog as far as dosing and insulin type. Thanks for your time.

Did he get breakfast/insulin at home or in the hospital?

What diets is kitty eating presently?

Hello, We've been having some "difficult to explain" urine culture results and I'd like a quick review of what we're doing and how we can improve. Like a lot of clinics we weren't running many urine cultures on dogs and cats with suspected UTIs...doing a lot more treating than diagnosing. But a few years ago we had a bunch of cases that didn't improve and we ended up in a "diagnostic dead end"....which was frustrating. So we decided to get an incubator, some petrie dishes, and culture everything we can culture. Overall it's worked well and nearly every "possible UTI", diabetic, or kidney patient gets an in-house culture. We do our cysto, UA, and put a few drops on a 1/2 macconkey, 1/2 blood dish, put it into the incubator at 90 degrees, and look for growth. If we find it then we recommend sending it to the lab for ID and sensitivity testing. Our problem is that we are seeing what we believe are bacteria, sometimes lots of bacteria, and then getting negative cultures. Often....or even nearly every time we put these patients (bacteria seen on the UA) on antibiotics while we wait for confirmation, get our negative culture, call and find the signs have resolved in 2-3 days. Those are somewhat difficult conversations ("we thought it was infection, now we don't, but she got better with antibiotics, thanks, have a nice day :)" What are we missing here? How can we do better? Thanks for the help :) Joe

Are you trying to read bacteriuria on wet ua?

And starting insulin on a weekend if you are not going to check on the kitty sunday?

This is pably the wrong place to post this, I'm sorry. I have a client who has diabetes and checks his blood glucose 10 times daily. He has heard of dogs that can detect ketones or sense "pre-ictal" phase, to prevent owner from having hypoglycemic seizures. I don't know exactly (seems like sensing ketones would be the opposite?), but he wants me to find him one of these dogs. He said he has talked to some people that sell these dogs, but has some concern it may be a scam. Does anyone have any experience with any service dogs in this sort of role? Any advice on where I can direct this client? Thanks ☼

I don't know where to look but maybe through dog trainers?

How does the cat's lab work look?

I have a 4 year old 15 pound male diabetic cat getting 1 unit of Lantus insulin twice daily. The globulins have been increasing over the past year. The gamma globulins are elevated (TP10.0 gamma glob 3.53 (0.5 - 1.9). Can a cat develop antibodies, increased gamma globulins to insulin (this cat's on Lantus)? Is it more likely that the increased globulin is secondary to some other condition? The diabetes is well controlled. ☼

A monoclonal gamma globulin spike is often seen with antigenic stimulation or neoplasia : http://www.vin.com/members/boards/discussionviewer.aspx?documentid=3448882&said=1 how is this kitty doing otherwise?

Are the lab results recent or are they the ones from original diagnosis of dm?

I have a 4 year old 15 pound male diabetic cat getting 1 unit of Lantus insulin twice daily. The globulins have been increasing over the past year. The gamma globulins are elevated (TP10.0 gamma glob 3.53 (0.5 - 1.9). Can a cat develop antibodies, increased gamma globulins to insulin (this cat's on Lantus)? Is it more likely that the increased globulin is secondary to some other condition? The diabetes is well controlled. ☼

Any gi-related signs?

Have you tried budesonide for the ibd?

I have a 4 year old 15 pound male diabetic cat getting 1 unit of Lantus insulin twice daily. The globulins have been increasing over the past year. The gamma globulins are elevated (TP10.0 gamma glob 3.53 (0.5 - 1.9). Can a cat develop antibodies, increased gamma globulins to insulin (this cat's on Lantus)? Is it more likely that the increased globulin is secondary to some other condition? The diabetes is well controlled. ☼

Weight loss?

If you do so, clients blame you should there be a problem with a claim - isn't there always?

Hello! I have come across a newly diagnosed diabetic who is fed (usually) four times per day (three times during the day, once in the middle of the night). I'm having a little trouble regulating her, likely because of this and also some other factors. She is a 13 yo FS Lab mix, 35kg in weight, fed w/d. She presented to me with signs of lethargy, and decreased appetite for two months, then a few days of pu/pd. Her BG that day was 699 mg/dL, no ketones in the urine. Rest of the CBC and chem was normal, but for a slightly elevated ALP. Her blood work previous to these signs was normal (just 3 months ago). Given the fast onset of signs and the odd appetite changes I ran a PLI at the same time, which was 785 ug/L (0-200). We changed her over to i/d low fat, and started her on insulin therapy. Client is doing his own curves at home using an Alphatrak2. First curve: Novolin N, 14u q12hr. She was fed at 8am, 3pm and 8pm. No more pu/pd, appetite good. Feeding w/d. 8am 356 10am 390 12pm 426 2pm 375 4pm 401 6pm 541 8pm 619 I recommended increasing the insulin to 16u q12hr. I asked the client not to feed her afternoon amount, as I wanted to see what happens on the days she doesn't get it. The client confessed he gave her a "tiny amount" of food at 5. Good thing, though! Still good appetite, no pu/pd. Client started the i/d low fat a few days before the curve. 8am 578 10am 485 12pm 427 2pm 416 4pm 332 6pm 109 8pm 153 So, I asked him to back her down to 14units q12hr again. I am concerned this last curve could be showing us the end of a Somoygi effect, but not sure. I haven't seen a curve with quite this extreme of a distribution before. Obviously the duration of action is too long (if we're skipping that afternoon feeding). Please advise. Thank you! ☼

Guess i don't understand what you are saying/asking?

Has the owner's glucometer been checked for accuracy?

Hello! I have come across a newly diagnosed diabetic who is fed (usually) four times per day (three times during the day, once in the middle of the night). I'm having a little trouble regulating her, likely because of this and also some other factors. She is a 13 yo FS Lab mix, 35kg in weight, fed w/d. She presented to me with signs of lethargy, and decreased appetite for two months, then a few days of pu/pd. Her BG that day was 699 mg/dL, no ketones in the urine. Rest of the CBC and chem was normal, but for a slightly elevated ALP. Her blood work previous to these signs was normal (just 3 months ago). Given the fast onset of signs and the odd appetite changes I ran a PLI at the same time, which was 785 ug/L (0-200). We changed her over to i/d low fat, and started her on insulin therapy. Client is doing his own curves at home using an Alphatrak2. First curve: Novolin N, 14u q12hr. She was fed at 8am, 3pm and 8pm. No more pu/pd, appetite good. Feeding w/d. 8am 356 10am 390 12pm 426 2pm 375 4pm 401 6pm 541 8pm 619 I recommended increasing the insulin to 16u q12hr. I asked the client not to feed her afternoon amount, as I wanted to see what happens on the days she doesn't get it. The client confessed he gave her a "tiny amount" of food at 5. Good thing, though! Still good appetite, no pu/pd. Client started the i/d low fat a few days before the curve. 8am 578 10am 485 12pm 427 2pm 416 4pm 332 6pm 109 8pm 153 So, I asked him to back her down to 14units q12hr again. I am concerned this last curve could be showing us the end of a Somoygi effect, but not sure. I haven't seen a curve with quite this extreme of a distribution before. Obviously the duration of action is too long (if we're skipping that afternoon feeding). Please advise. Thank you! ☼

For this size dog should start at 35 kg x 0.5 unit/kg - 17.5 units?

Should we still consider radioactive iodine?

Hi. 4 wk old kitten presented with neurological dysfunction ( shaking, imbalance), seizure like activity, and BG of 720. hx ingested piece of nipple 2 days prior. was acting normally and eating/drinking/urinating and defecating up to presentation. Any differentials? Thanks in advance ☼

How was the blood collected and what was the bg measure on?

How well controlled is the diabetes?

Hi. 4 wk old kitten presented with neurological dysfunction ( shaking, imbalance), seizure like activity, and BG of 720. hx ingested piece of nipple 2 days prior. was acting normally and eating/drinking/urinating and defecating up to presentation. Any differentials? Thanks in advance ☼

Are you able to asses serum ketones (specifically beta hydroxybutyrate, bhb)?

If we could feed her a canned low-carb diet, i think she might stay non-diabetic longer...it sounds like that's an impossibility?

Hi. 4 wk old kitten presented with neurological dysfunction ( shaking, imbalance), seizure like activity, and BG of 720. hx ingested piece of nipple 2 days prior. was acting normally and eating/drinking/urinating and defecating up to presentation. Any differentials? Thanks in advance ☼

How does the kitten's growth compare with litter mates?

Are you using a handheld glucose meter?

I have a head scratcher that I am having trouble with. Dudley is an 11 year old MN Basset Hound that was diagnosed as diabetic in September of 2012. He was a difficult case to work up originally because he had a persistent glucosuria for 8-10 months but his BG's were only around 150mg/dl, and his fructosamine was low (175umol/L). This went on for quite a few months until his BG's started to rise and once he was hitting the 300's we started insulin therapy. His fructosamine levels have never really correlated with his high BG's so it has made regulating him difficult, but we are getting close. He presented recently with an acute onset of prolapse of his nictatans in one eye. Ocular exam showed normal PLR's direct and indirect, equal pupil sizes, the conjunctiva was mildly hyperemic (but he is a Basset), and his IOP's were low averaging around 10 in the affected eye and only 8 in the non-affected eye (surprisingly). There was no evidence of cataracts at this time. A complete blood cell count and chem were run and all values were normal except an elevated BG 298mg/dL and a low t4 = 0.5ug/dL (1-4). Chest x-rays were mostly unremarkable - looking for a possible chest mass to rule out Horner's. There was no history of trauma to the chest although the owner did state that he took a tumble down a couple stairs about a week before the prolapse occurred. I started him on flubriprofen in each eye for presumptive uveitis and saw no response after 1 week. I stopped the flubriprofen in favor of Neopoly Dex drops and still saw no improvement. 3-4 days into the NPD drops his other nictatans prolapsed. So now I have a bilateral nictatans prolapse with low IOP's in a unregulated (but not untreated) diabetic dog with neuropathic signs in his pelvic limbs (mild ataxia) which I attributed to his diabetic condition. My question is - what are my rule outs for the prolapse and low IOP in this case that I am over looking? Thanks

Did you do a dilated exam?

Is the owner able to monitor urine glucose at all?

Hello! This question is about my own dog, who I love more than anything in the world He was a rescue we got 6 years ago with diabetes (I diagnosed him and owner couldn't care for him). So we think he might be about 11 years old now. We got the extra 30# off him and he became a slim 65# male(n) Basset on 14 units humulin and 3c w/d BID. He has been absolutely perfectly regulated w/ no PU/PD or weight loss for 6 years. Last year he had an abscessed PM4 removed and later his cataracts removed (which took 5 years to pop up). He's been doing great, then all of a sudden he started not being able to jump into the car and not being as perky or wanting to go on long walks. He doesn't seem in pain and his appetite is fine and no v/d. I tried 2 weeks of carprofen with no improvement and did some blood work. His AST and ALT were 204 and 368 respectively and ALP and T bili were 467 and 0.3 respectively. His BG was 247 (right before next injection) and fructosamine was 496, which at our lab is in the "good" range. So I was a little worried about hepatitis or pancreatitis and put him on 2 weeks of denamarin, amoxicillin, and metronidazole. 2 weeks later his blood work was: ALT = 422 ALP = 645 AST = 59 T. bili = 0.1 BG = 410 (6.5 hours post-injection!) T4 = 2.0 ACTH stim test WNL (1.1 pre and 10.0 post) So now he's PU/PD and losing weight and still lethargic and very weak in hind legs. What am I missing? I plan on doing a glucose curve, but he's a challenge. Should I do an ultrasound to look at his liver? I've never had a diabetic dog live so well this long. Do they ever just stop being well-regulated and need a dose adjustment? It's very hard to make decisions when it's your own pet, so I appreciate your thoughts! Dr. ☼

What exactly does his neuro exam look like?

Weight stable?

Hello, I have a 13 YO MC Maine Coon cat presented for a history of having siezures happened 3 times over the last few weeks. He was put by a different vet on oral tablets (Glipizide) for DM (he had a PU/PD history before and was treated for DM by another vet.). on exam his BCS is 4/5 , body weight 8.6 kg and the rest of his exam was unremarkable. BW was done and showed the following abnormalities: WBC 5 LYM 1.37 MCHC 30 ALB 46 ALT 380 BUN 11.1 CA 3.06 I gave a convenia injection and recommended to stop the oral Glipizide and discussed the possible DDX list with high CA and booked a recheck week later for glucose and electrolytes recheck. Today was the recheck, the cat was doing good at home, had no siezures , no PU/PD and eating drinking OK today abnormal values are: ALB 47 ALT 585 AMY 1211 CA 3.53 glucose still normal when the cat had no Glipizide for a week. Now I'm concerned about neoplasia since his Ca is high I think it could be either parathyroid or liver tumor? What do you think? I have no US . is there anything can be done to help with that diagnosis? waht is the prognosis with that cat's condition? Thanks for your time ☼

Were bg's checked at the times of the seizures?

Is the duration of insulin action long enough?

I am a volunteer veterinarian for a small dog shelter and adoption agency in Hood River, Oregon called Hood River Adopt a Dog. My question is: many of our dogs come in (predominantly male, by the way) with polydipsia, polyuria. I keep some UA strips (we don't have a clinic, just a cabinet), and so far we haven't found much of interest and the problems seem to resolve by the time the dogs get adopted for the most part. (We did have one chihuahua who ended up being diagnosed by a local vet with diabetes insipidus -- he was adopted by one of our founders). So I'm curious, could this be behavioral? Or perhaps the result of less than adequate food (maybe salted or sugary?). Does anyone else have any experience with this? Thanks.

Are you actually tracking intake and output, or is this more of a subjective thing?

Is he on bid trilostane?

I am a volunteer veterinarian for a small dog shelter and adoption agency in Hood River, Oregon called Hood River Adopt a Dog. My question is: many of our dogs come in (predominantly male, by the way) with polydipsia, polyuria. I keep some UA strips (we don't have a clinic, just a cabinet), and so far we haven't found much of interest and the problems seem to resolve by the time the dogs get adopted for the most part. (We did have one chihuahua who ended up being diagnosed by a local vet with diabetes insipidus -- he was adopted by one of our founders). So I'm curious, could this be behavioral? Or perhaps the result of less than adequate food (maybe salted or sugary?). Does anyone else have any experience with this? Thanks.

Could it be stress related?

Maybe being dead for a while restarted his pancreas for a when everything else reset?

Hello. I was hoping for some thoughts on this case. Sully is a 5 kg, MN, 5 year old, DLH; indoors only, no other pets on first presentation for problem in Sep 2012 BUT did get dog before second presentation in Feb 2013. Sully presented for scabbing on ears 09/14/2012. The duration was about 3 weeks The lesions were scabby but sometimes moist and owner reported that one lesion opened and there was some fluid or pus. On physical examination, I noted the following: -severe dental disease (not new), dependent surface of pinna 0.5-1 cm diameter circular lesions red, raw with some scabbing; ears clean to ear drum; -bilateral submandibular lymphadenomegaly -not slightly itchy, pinna lesions bothering cat somewhat -no bx done at that time; -I had started the cat on revolution for the season, he used to just get advantage; owner thought maybe cause, so we briefly d/c; Therapy at this time was empirical prednisolone According to owner over phone, the lesions got worse but then got better, resolved after few weeks Sully presented again Feb 21, 2013 for same problem-ear crusts and ears bothering cat -diffuse lymphadenopathy noted this time (not just submandibular) -some recent vomiting-food; not usually a 'vomiter' -ears same as in september- clean to eardrum, scab and scale on pinna -low grade murmur new-left, right, sternal Bloodwork -CBC wnl, FelV/FIV negative -TP high at 89 (60-85 g/L); Glob 59 (25-51 g/L) -A/G ratio 0.5 (0.6-1.3) -CK increased at 717 (11-224 IU/L) rest wnl FNA of LN: Laboratory number: C4068-13

SAMPLE SOURCE: lymph nodes; 2 slide submandibular (rest of label has washed
off), 1 slide popliteal R, and 1 slide popliteal L (stained)

DESCRIPTION:
Excellent quality sample. High cellularity and good preservation. All sites are
similar. There is a heterogeneous population of mostly small lymphocytes with
low numbers of medium and large lymphocytes. Few Mott cells noted. Low numbers
of plasma cells also noted in the popliteal samples. Moderate degree of
hemorrhage. No evidence of an infectious agent or neoplasia in this sample.

INTERPRETATION:
Lymphoid hyperplasia (submandibular)
Mild plasma cell hyperplasia (popliteal)

COMMENT:
This is consistent with reactive lymph nodes. This change is secondary to
antigenic stimulation, either local or systemic. Search for evidence of
inflammation or infection.

 My diagnostic r/o at the time included viral (FHV-1, FV, FelV/FIV (negative ELISA), other; bacterial, fungal, neoplasia elsewhere, lymphoma internally with reactive LN externally, pancreatitis (V initially), URT polyp (some URT noises initially) Options for treatment/diagnostics offered and pursued at the time: -wedge biopsy of LN and biopsy ear (which by this time had cleared up on their own)-not done The following treatments were in sequence, not done at same time: -treatment: antibiotics--> empirical, while awaiting cytology-no response to this medication -treatment: famvir--> empirical, no response -treatment, prednisolone--> empirical--response-while on 10 mg a day cat’s LN size all wnl, As we started to wean the dosage down, I began to observe shifting lymphadenopathy. I was checking cat weekly and some LN would be normal, other enlarged; next week, different ones normal, others enlarged. Now that he is off prednisolone, cat has generalized peripheral lymphadenopathy again. Not sure if relevant, but IS back on revolution for season. He has had revolution in past-once timing seemed associated with ear lesions (sept 2012) but before that, no problems. The cat was groomed this past week and had severe matting with generalized erythema below matting. At the time of the groom, owner noted that cat was vomiting again for past few days. My thoughts on OPTIONS at this time: -wedge biopsy of LN and histopathology; immunohistochemistry for what? -abdominal ultrasound and /or screening radiography for assessment of rest of body/lymphoid organs (bone marrow biopsy?) -repeat bloodwork and include GI related testing- B12, sfPLI The owners were already cost restricted when we started this (which is why I did FNA and empirical drugs in first place), so I am not sure where this will end up, however, I really wanted others’ opinion(s) on what to do. Am I missing something? How would you prioritize diagnostic tests? Thank you for your thoughts. ☼

Forgot to say that this cat has always been finicky eater-goes off food types then back on, eats really well for awhile, then back off food again and onto something else- makes me suspicious of gi disease, pancreatitis?

How many calories/meal does he currently get?

Hi there! I would so greatly appreciate some help with this case that I am currently managing...I am just one year out of vet school and am met with what to me seems like a very tough DKA case! I think that through the help of the Karol Matthews diabetic ketoacidosis management guidelines I have finally gotten the dog out of his ketoacidotic state (I actually cried when I got the negative ketones result! haha) but now I am trying to get him onto longer acting insulin and I'm having some trouble - mostly because I don't know how to interpret the values I'm getting for glucose! He is now at the point where he is eating and drinking on his own, no longer has ketones, has been on IV ampicillin for urinary tract infection (a culture of the urine is unlikely due to money, etc, so I went with the recommended starting antibiotic) and is overall in much better spirits. So I switched him to Caninsulin Tuesday, May 21st (yesterday) and have been monitoring his glucose very closely ever since. I first gave him 0.5 U/kg which for him was 10 units (19 kg dog) and checked glucose hourly for the next 12 hours, and quite frequently for the following 24 hour after that...the numbers were not encouraging to me at all, and what I don't know is whether this is an issue with the type of insulin, or the dose that we are using, or if it just doesn't make sense at all? Also, although he IS eating, he has thus far been quite particular about WHEN and WHAT he feels like eating. Continuing him on Humulin for any longer before switching to caninsulin was not really an option due to the cost of the long term hospitalization he had while dealing with his diabetic crisis. So I'm wondering if it is possible to manage glucose levels in a dog that eats when he feels like it or if it is just going to be a big mess unless he switches to two meals per day? I want to show you the curves, but I am hoping to know what to do tomorrow and don't have them with me so I'm wondering if any insight can be given if I just explain what has happened... I started his caninsulin at 11 AM and measured hourly...the readings were all in the 20's and teens (mmol/L) but about 5 hours post insulin there was a reading of 7.2 mmol/L and around two hours before the next dose it had creeped back into the 20's (I believe around 26 mmol/L). I was very displeased with the whole 12 hours due to the fact that his low was low enough that I didn't feel I could increase the insulin, but he still spent a LOT of the 12 hours with higher glucose than I was happy with. The next 2 twelve hour periods were similar except they weren't checked every single hour so I did not see any other readings QUITE as low as that 7.2, but the beginning and end of both 12 hour stretches had horrific readings - with the latest 12 hours ending with a "too high to read" reading on the glucometre. It seems that for some of the 12 hour stretch he has "okay" readings, but around 8 hours post insulin he is almost always unacceptably high, and there are even some confusing readings that jump around - like going from 22 to 13 and then back to 29 without insulin being given. As I said, I have the curves at work and could post them, but I am wondering if I can get any insight on what to do in the meantime. I really do not want this dog to go back into making ketones, but also don't know if it is too early to do something rash like change types of insulin? Please help! Thank you so much for reading!

Could that nadir just have been due to the fact that he wasn't getting enough nutrition to offset the glucose on that first day?

I guess my first question is:  how do you know when the mid-day nadir is?

Hi there! I would so greatly appreciate some help with this case that I am currently managing...I am just one year out of vet school and am met with what to me seems like a very tough DKA case! I think that through the help of the Karol Matthews diabetic ketoacidosis management guidelines I have finally gotten the dog out of his ketoacidotic state (I actually cried when I got the negative ketones result! haha) but now I am trying to get him onto longer acting insulin and I'm having some trouble - mostly because I don't know how to interpret the values I'm getting for glucose! He is now at the point where he is eating and drinking on his own, no longer has ketones, has been on IV ampicillin for urinary tract infection (a culture of the urine is unlikely due to money, etc, so I went with the recommended starting antibiotic) and is overall in much better spirits. So I switched him to Caninsulin Tuesday, May 21st (yesterday) and have been monitoring his glucose very closely ever since. I first gave him 0.5 U/kg which for him was 10 units (19 kg dog) and checked glucose hourly for the next 12 hours, and quite frequently for the following 24 hour after that...the numbers were not encouraging to me at all, and what I don't know is whether this is an issue with the type of insulin, or the dose that we are using, or if it just doesn't make sense at all? Also, although he IS eating, he has thus far been quite particular about WHEN and WHAT he feels like eating. Continuing him on Humulin for any longer before switching to caninsulin was not really an option due to the cost of the long term hospitalization he had while dealing with his diabetic crisis. So I'm wondering if it is possible to manage glucose levels in a dog that eats when he feels like it or if it is just going to be a big mess unless he switches to two meals per day? I want to show you the curves, but I am hoping to know what to do tomorrow and don't have them with me so I'm wondering if any insight can be given if I just explain what has happened... I started his caninsulin at 11 AM and measured hourly...the readings were all in the 20's and teens (mmol/L) but about 5 hours post insulin there was a reading of 7.2 mmol/L and around two hours before the next dose it had creeped back into the 20's (I believe around 26 mmol/L). I was very displeased with the whole 12 hours due to the fact that his low was low enough that I didn't feel I could increase the insulin, but he still spent a LOT of the 12 hours with higher glucose than I was happy with. The next 2 twelve hour periods were similar except they weren't checked every single hour so I did not see any other readings QUITE as low as that 7.2, but the beginning and end of both 12 hour stretches had horrific readings - with the latest 12 hours ending with a "too high to read" reading on the glucometre. It seems that for some of the 12 hour stretch he has "okay" readings, but around 8 hours post insulin he is almost always unacceptably high, and there are even some confusing readings that jump around - like going from 22 to 13 and then back to 29 without insulin being given. As I said, I have the curves at work and could post them, but I am wondering if I can get any insight on what to do in the meantime. I really do not want this dog to go back into making ketones, but also don't know if it is too early to do something rash like change types of insulin? Please help! Thank you so much for reading!

Ahhhh i guess i can simplify all of this by asking: should i continue him on caninsulin before drawing conclusions (+/- increasing the dose of caninsulin?) or should i be trying a potentially longer acting insulin?

What diagnostics have you done so far?

I have a dilemma with the diabetic golden SF about 60# - - in general 16 units bid is the stable dose of Humilin she has been on and W/D and regular exercise. This client is beyond excellent and takes buccal stick bgs all the time (numb golden who does not care). She has been diabetic since November - every once in a while her BG's are either hi or low - we have fussed with starting a new bottle of insulin, and in general 16 units has seemed a stable dose BID. This weekend,t her BGs in the midday went to 20!! NO seizure or weird behavior, and she took it several times even with a new glucometer and strips - but the dog also was terribley PD during this period of low! Nothing else had changed. The dog was quiet but PD, never seizured and with food, karo and time, her BG went up. Since the owner could not reach me, she only gave the dog 10 units that night, and by the next day was better and restarted 16 units. From May 3 to May 17th - her daily BG's were in the low 300's am and mid 200's pm. ON May 18th got 16 units in the morning when her bg was 370 - so maybe too high - at 12:00 22, at 1:00 38, at 4:00 22 at 5:45 79 at 7:00 133 9:00 60 - gave the dog 10 units at 7:00(partly because she had not spoken to me) - when the bg's are 22 she give sugar, cookies etc and still had trouble getting it up. Dog was fine but again PD!! Is this Somoygi? May 19th : 6:00 243 and gave 16 units. 7:40 270, 11:00 163, 2:00 60, 4:15 210 6:40 173 gave 16 units, 7:40 229. May 20th 6:00 103, fed and waited - 6:45 159, 7:15 233 gave 16 units. Now I am calling on you for your expertise - I almost wish she didn't check sugars so much but - I think the dog was acting lethargic when she was in the 20's - I have done bloodwork and urine - no uti, not Cushings or hyothyroid. Over the past few days, staying on 16 units bid and her regular food and exercise regimine, she is now running in the low 300's to mid 200s midday. She is a little PD. I am not sure what to do - is it time to change insulin, to what and how? The owner and I are hesitant to increase the dose since she had such low lows! Thank you!! Confused!! Dr. ☼

That said, is there any chance that the brand of nph with owner is using has changed?

Should i stop him?--drop to like 10 units?

I have a dilemma with the diabetic golden SF about 60# - - in general 16 units bid is the stable dose of Humilin she has been on and W/D and regular exercise. This client is beyond excellent and takes buccal stick bgs all the time (numb golden who does not care). She has been diabetic since November - every once in a while her BG's are either hi or low - we have fussed with starting a new bottle of insulin, and in general 16 units has seemed a stable dose BID. This weekend,t her BGs in the midday went to 20!! NO seizure or weird behavior, and she took it several times even with a new glucometer and strips - but the dog also was terribley PD during this period of low! Nothing else had changed. The dog was quiet but PD, never seizured and with food, karo and time, her BG went up. Since the owner could not reach me, she only gave the dog 10 units that night, and by the next day was better and restarted 16 units. From May 3 to May 17th - her daily BG's were in the low 300's am and mid 200's pm. ON May 18th got 16 units in the morning when her bg was 370 - so maybe too high - at 12:00 22, at 1:00 38, at 4:00 22 at 5:45 79 at 7:00 133 9:00 60 - gave the dog 10 units at 7:00(partly because she had not spoken to me) - when the bg's are 22 she give sugar, cookies etc and still had trouble getting it up. Dog was fine but again PD!! Is this Somoygi? May 19th : 6:00 243 and gave 16 units. 7:40 270, 11:00 163, 2:00 60, 4:15 210 6:40 173 gave 16 units, 7:40 229. May 20th 6:00 103, fed and waited - 6:45 159, 7:15 233 gave 16 units. Now I am calling on you for your expertise - I almost wish she didn't check sugars so much but - I think the dog was acting lethargic when she was in the 20's - I have done bloodwork and urine - no uti, not Cushings or hyothyroid. Over the past few days, staying on 16 units bid and her regular food and exercise regimine, she is now running in the low 300's to mid 200s midday. She is a little PD. I am not sure what to do - is it time to change insulin, to what and how? The owner and I are hesitant to increase the dose since she had such low lows! Thank you!! Confused!! Dr. ☼

Have we done recent blood work?

Is the insulin injection being moved around on the cat's body every day?

I have a tough case, and the owner is really unsure what to do. Patches is an 8 year old MN Shih Tzu that has always suffered from allergies. We have had him controlled reasonably well on Atopica. He has not been on steroids for years. Now however he has been diagnosed with both Diabetes Mellitus and Cushings disease. Initially we have gotten the diabetes managed on BID caninsulin, and clinically the PU/PD has drastically improved. To the point that the owner does not think there is a problem anymore. I repeated the ACTH stim test last week, and of course he is still Cushingnoid. We did identify it as PD Cushings previously. I have contacted the local internal medicine specialist, and he was the one that recommended managing the diabetes first, retest, and then start on trilostane. I was thinking of starting on 20 mg (about 2.2 mg/kg) trilostane SID, and then rechecking ACTH stim on day 7-10, etc. However owner is hesitant to start on meds because clinically she feels he is better. She was wondering about other options, and quality of life. I know Anipryl has been used as a treatment option, but again, trilostane or lysodren tend to be my first choices, so I have no experience with this option. Any suggestions how to manage this case, and make the owner happy. She is a great client, and just wants to make sure she is doing what is best for Patches. Thanks!

How did we diagnose the cushing's disease?

I see that the alkp was elevated, any other abnormalities?

I have a tough case, and the owner is really unsure what to do. Patches is an 8 year old MN Shih Tzu that has always suffered from allergies. We have had him controlled reasonably well on Atopica. He has not been on steroids for years. Now however he has been diagnosed with both Diabetes Mellitus and Cushings disease. Initially we have gotten the diabetes managed on BID caninsulin, and clinically the PU/PD has drastically improved. To the point that the owner does not think there is a problem anymore. I repeated the ACTH stim test last week, and of course he is still Cushingnoid. We did identify it as PD Cushings previously. I have contacted the local internal medicine specialist, and he was the one that recommended managing the diabetes first, retest, and then start on trilostane. I was thinking of starting on 20 mg (about 2.2 mg/kg) trilostane SID, and then rechecking ACTH stim on day 7-10, etc. However owner is hesitant to start on meds because clinically she feels he is better. She was wondering about other options, and quality of life. I know Anipryl has been used as a treatment option, but again, trilostane or lysodren tend to be my first choices, so I have no experience with this option. Any suggestions how to manage this case, and make the owner happy. She is a great client, and just wants to make sure she is doing what is best for Patches. Thanks!

Can we see all the results of your cushing's screening tests?

Which one?

I have a tough case, and the owner is really unsure what to do. Patches is an 8 year old MN Shih Tzu that has always suffered from allergies. We have had him controlled reasonably well on Atopica. He has not been on steroids for years. Now however he has been diagnosed with both Diabetes Mellitus and Cushings disease. Initially we have gotten the diabetes managed on BID caninsulin, and clinically the PU/PD has drastically improved. To the point that the owner does not think there is a problem anymore. I repeated the ACTH stim test last week, and of course he is still Cushingnoid. We did identify it as PD Cushings previously. I have contacted the local internal medicine specialist, and he was the one that recommended managing the diabetes first, retest, and then start on trilostane. I was thinking of starting on 20 mg (about 2.2 mg/kg) trilostane SID, and then rechecking ACTH stim on day 7-10, etc. However owner is hesitant to start on meds because clinically she feels he is better. She was wondering about other options, and quality of life. I know Anipryl has been used as a treatment option, but again, trilostane or lysodren tend to be my first choices, so I have no experience with this option. Any suggestions how to manage this case, and make the owner happy. She is a great client, and just wants to make sure she is doing what is best for Patches. Thanks!

Has the dog had an abdominal ultrasound?

When was it diagnosed?

I have a tough case, and the owner is really unsure what to do. Patches is an 8 year old MN Shih Tzu that has always suffered from allergies. We have had him controlled reasonably well on Atopica. He has not been on steroids for years. Now however he has been diagnosed with both Diabetes Mellitus and Cushings disease. Initially we have gotten the diabetes managed on BID caninsulin, and clinically the PU/PD has drastically improved. To the point that the owner does not think there is a problem anymore. I repeated the ACTH stim test last week, and of course he is still Cushingnoid. We did identify it as PD Cushings previously. I have contacted the local internal medicine specialist, and he was the one that recommended managing the diabetes first, retest, and then start on trilostane. I was thinking of starting on 20 mg (about 2.2 mg/kg) trilostane SID, and then rechecking ACTH stim on day 7-10, etc. However owner is hesitant to start on meds because clinically she feels he is better. She was wondering about other options, and quality of life. I know Anipryl has been used as a treatment option, but again, trilostane or lysodren tend to be my first choices, so I have no experience with this option. Any suggestions how to manage this case, and make the owner happy. She is a great client, and just wants to make sure she is doing what is best for Patches. Thanks!

Does the dog look like a cushing's dog clinically?

Is she eating the canned-only version of a high protein/low carb diet?

I have a tough case, and the owner is really unsure what to do. Patches is an 8 year old MN Shih Tzu that has always suffered from allergies. We have had him controlled reasonably well on Atopica. He has not been on steroids for years. Now however he has been diagnosed with both Diabetes Mellitus and Cushings disease. Initially we have gotten the diabetes managed on BID caninsulin, and clinically the PU/PD has drastically improved. To the point that the owner does not think there is a problem anymore. I repeated the ACTH stim test last week, and of course he is still Cushingnoid. We did identify it as PD Cushings previously. I have contacted the local internal medicine specialist, and he was the one that recommended managing the diabetes first, retest, and then start on trilostane. I was thinking of starting on 20 mg (about 2.2 mg/kg) trilostane SID, and then rechecking ACTH stim on day 7-10, etc. However owner is hesitant to start on meds because clinically she feels he is better. She was wondering about other options, and quality of life. I know Anipryl has been used as a treatment option, but again, trilostane or lysodren tend to be my first choices, so I have no experience with this option. Any suggestions how to manage this case, and make the owner happy. She is a great client, and just wants to make sure she is doing what is best for Patches. Thanks!

If mom is happy...maybe you do nothing as an option?

The owner moves the injections around on her body every day?

Hi, I'm a fairly new small animal vet (started September 2012) and I've been working with an 11 year old Female spayed husky mix dog who has been PU/PD and urinating in the house since January. U/A at that time was wnl but small amount of blood (250 Ery/uL). We tried an antibiotic trial of clavamox with some improvement until I saw her again today. Now she is peeing in the house 4-5 times per day and the owner is understandably frustrated. Today: She is still PU/PD, even more so than in January. mm pink moist, CRT 2 seconds, bilateral nuclear sclerosis. Abdomen wnl on palpation. Urinalysis: pH 7.0 Leuk neg Prot trace**** Glucose neg Ketones neg UBG normal Bil neg Blood 10Ery/uL**** SG 1.000****** Chemistry: Glucose 116 (70-143) BUN 18 (7-27) Creat 1.1 (0.5-1.8) Phos 4.0 (2.5-6.8) Calcium 9.9 (7.9-12.0) TP 7.0 (5.2-8.2) Alb 3.1 (2.2-3.9) Glob 3.9 (2.5-4.5) ALT 68 (10-100) ALP 118 (23-212) GGT 23 (0-7) HIGH** TBIL 0.6 (0-0.9) Chol 276 (110-320) Amylase 791 (500-1500) Lipase 533 (200-1800) Na 154 (144-160) K 2.7 (3.5-5.8) LOW*** Na/K 57 Cl 119 (109-122) Osm Calc 304 mmol/kg I didn't get enough blood to run a CBC...she's pretty aggressive/hard to get blood from so we stopped there today. Any thoughts for why the GGT and K would be abnormal, and how this could be related to her PU/PD or do you think it is unrelated? It's a remarkably low K:( I started her on another trial of clavamox with incurin 2mg SID for two weeks to see if she has any improvement on urinating in the house but I realize that probably doesn't explain her polydipsia. She will be coming for a recheck before the end of her antibiotics. Money is always an issue for my clients, so I would love your help deciding the next best use of their money. I am planning on doing abdominal xrays next if there is no improvement (at our clinic, costs ~$120 for a large dog) to look for a stone, tumor, etc. Otherwise I could do a cystocentesis + culture (~$300) to check for another UTI? We don't have ultrasound available here. Thanks for your help! I'm always eager to learn from your comments. ☼

So do you think that it's all pu/pd: frequent large volume accidents?

By no apparent plems i'm assuming he has responded at least clinically to insulin despite the high bgs?

Hi, I'm a fairly new small animal vet (started September 2012) and I've been working with an 11 year old Female spayed husky mix dog who has been PU/PD and urinating in the house since January. U/A at that time was wnl but small amount of blood (250 Ery/uL). We tried an antibiotic trial of clavamox with some improvement until I saw her again today. Now she is peeing in the house 4-5 times per day and the owner is understandably frustrated. Today: She is still PU/PD, even more so than in January. mm pink moist, CRT 2 seconds, bilateral nuclear sclerosis. Abdomen wnl on palpation. Urinalysis: pH 7.0 Leuk neg Prot trace**** Glucose neg Ketones neg UBG normal Bil neg Blood 10Ery/uL**** SG 1.000****** Chemistry: Glucose 116 (70-143) BUN 18 (7-27) Creat 1.1 (0.5-1.8) Phos 4.0 (2.5-6.8) Calcium 9.9 (7.9-12.0) TP 7.0 (5.2-8.2) Alb 3.1 (2.2-3.9) Glob 3.9 (2.5-4.5) ALT 68 (10-100) ALP 118 (23-212) GGT 23 (0-7) HIGH** TBIL 0.6 (0-0.9) Chol 276 (110-320) Amylase 791 (500-1500) Lipase 533 (200-1800) Na 154 (144-160) K 2.7 (3.5-5.8) LOW*** Na/K 57 Cl 119 (109-122) Osm Calc 304 mmol/kg I didn't get enough blood to run a CBC...she's pretty aggressive/hard to get blood from so we stopped there today. Any thoughts for why the GGT and K would be abnormal, and how this could be related to her PU/PD or do you think it is unrelated? It's a remarkably low K:( I started her on another trial of clavamox with incurin 2mg SID for two weeks to see if she has any improvement on urinating in the house but I realize that probably doesn't explain her polydipsia. She will be coming for a recheck before the end of her antibiotics. Money is always an issue for my clients, so I would love your help deciding the next best use of their money. I am planning on doing abdominal xrays next if there is no improvement (at our clinic, costs ~$120 for a large dog) to look for a stone, tumor, etc. Otherwise I could do a cystocentesis + culture (~$300) to check for another UTI? We don't have ultrasound available here. Thanks for your help! I'm always eager to learn from your comments. ☼

The dog is not getting any steroids right?

Was the bowel biopsied at the time of the obstruction?

Hi, I'm a fairly new small animal vet (started September 2012) and I've been working with an 11 year old Female spayed husky mix dog who has been PU/PD and urinating in the house since January. U/A at that time was wnl but small amount of blood (250 Ery/uL). We tried an antibiotic trial of clavamox with some improvement until I saw her again today. Now she is peeing in the house 4-5 times per day and the owner is understandably frustrated. Today: She is still PU/PD, even more so than in January. mm pink moist, CRT 2 seconds, bilateral nuclear sclerosis. Abdomen wnl on palpation. Urinalysis: pH 7.0 Leuk neg Prot trace**** Glucose neg Ketones neg UBG normal Bil neg Blood 10Ery/uL**** SG 1.000****** Chemistry: Glucose 116 (70-143) BUN 18 (7-27) Creat 1.1 (0.5-1.8) Phos 4.0 (2.5-6.8) Calcium 9.9 (7.9-12.0) TP 7.0 (5.2-8.2) Alb 3.1 (2.2-3.9) Glob 3.9 (2.5-4.5) ALT 68 (10-100) ALP 118 (23-212) GGT 23 (0-7) HIGH** TBIL 0.6 (0-0.9) Chol 276 (110-320) Amylase 791 (500-1500) Lipase 533 (200-1800) Na 154 (144-160) K 2.7 (3.5-5.8) LOW*** Na/K 57 Cl 119 (109-122) Osm Calc 304 mmol/kg I didn't get enough blood to run a CBC...she's pretty aggressive/hard to get blood from so we stopped there today. Any thoughts for why the GGT and K would be abnormal, and how this could be related to her PU/PD or do you think it is unrelated? It's a remarkably low K:( I started her on another trial of clavamox with incurin 2mg SID for two weeks to see if she has any improvement on urinating in the house but I realize that probably doesn't explain her polydipsia. She will be coming for a recheck before the end of her antibiotics. Money is always an issue for my clients, so I would love your help deciding the next best use of their money. I am planning on doing abdominal xrays next if there is no improvement (at our clinic, costs ~$120 for a large dog) to look for a stone, tumor, etc. Otherwise I could do a cystocentesis + culture (~$300) to check for another UTI? We don't have ultrasound available here. Thanks for your help! I'm always eager to learn from your comments. ☼

Owner is not using any topical steroid or hormone creams?

The are creative, aren't they?

HI Zoe is a 13 year old M/N DSH. 7.4 kg In October 2012, he was seen for Pu/PD, increased appetite and 7.8 % wt loss. HIs BG was 21.9 mmol/L and frucotsamine 508 umol/L. Unable to get urine at clinic and at home. Clients will NOT leave cat at clinic. So can't do BG curve (although I don't usually, anyways). Owners will not do a curve at home either. The owners are a bit strange about their cat. Really protective, more so than even my strangest cat client. They have gotten better. Just so you know why I've done what I've done. The owners wanted to try Zoe on only canned food first. 1 month later, his BG was 19, fruc 471. Although very reluctant, owners started on lantus 1 unit BID. I start here as I've had cats become hypoglycemic on this dose. 1 month later BG 21.7 fruc 659. Only canned, owners insistent giving insulin properly, storing properly. Won't come in for anosther demo. Wouldn't increase insulin. Stayed at 1 unit BID, Tried Canned DM only, no other diets. 1 month later BG 23.1 fruc 667, Increased insulin to 2 units BID 1 month later BG 24.9 fruc 559. Finally U/S sg 1.045, glucose 4 plus Increased insulin to 2.5 units BID 2 months later BG 20.8, fruc 565. Increased insulin to 3 units BID 1 month later BG 24.2, fruc 487. Cat is very stressed and fractious so not sure how accurate BG is. Owners won't do BG's at home. Zoe was gaining weight but lost 3 % at last visit. No more Pu/PD since off dry. Can't do BG curve. spec fpli was normal. Haven't been able to get more urine. Should I increase insulin with this info? or do you suggest anything I'm not thinking of? Thanks! I usuallly get my diabetics off insulin after the first month!

What canned food is kitty eating?

I am thinking we should treat for pyelonephritis even if we get no growth on urine culture?