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Hi there. I have been treating a 12 year old neutered male Beagle cross for diabetes and cushings disease. He weighs 30kg and we started him on 12 units NPH insulin BID and Vetoryl 60mg SID Dec. 8th. His glucose last week was 13.9 mml/L (only one done on this day), and his ACTH stim done yesterday 4-6 hours after morning Vetoryl was 4.5ug/dl 0 hour and was 15.7 ug/dl 1 hour post synacthen. What would your recommendation be for increasing the Vetoryl and should I be monitoring blood glucose more closely as we get the Cushings more under control. Thanks ☼

Sure that the vetoryl had been given with some food the morning of the test?

What exactly were the results for the acth stim and ldds?

Hi, I will try to be brief. "Max" is a 13 1/2 y.o. M/N Schnauzer who was diagnosed in early October 2012 with diabetes. He had a previous history of hypertriglyceridemia that honestly fell through the cracks and was not addressed. Owner is an elderly man with a dying wife. Max was started on NPH insulin at 5 units twice daily (25.4# at time of diagnosis) and gradually increased to 9 units BID based on spot checks of his glucose. On Nov. 12, he presented for depression and anorexia. He was found to be ketotic, without any evidence of pancreatitis on ultrasound. A urine culture was negative. He was treated at the local emergency clinic and improved. He was gradually worked up to 11 units BID, and a glucose curve was done on 12/12/12: 1h post insulin: 283 3 h post : 269 5h post : 232 7h post : 172 9h post : 176 We were pretty happy with this curve, but increased the morning dose to 12U, kept the evening dose at 11U. A spot check about a week later showed a glucose of 445, though he had gained weight and was not PU/PD. He presented about 2 weeks later, again ketotic. He had an elevated lipase; ultrasound was not repeated. He was again treated at the local ER and improved. He went home on 12 U BID. We did a curve yesterday: 2h post: 412 4h post: 211 6h post: 137 8h post: 87 10h post 89 11.5h 96 The dog is not PU/PD, but the owner thought he might have been hypoglycemic in the evening about 6 days ago. He is currently eating royal canin low-fat food with some small amount w/d canned. He does usually get some treats during the day, which did not happen while he was hospitalized for the curve. I was a little unsure as to best step. Insulin is lasting a while (still low almost 12 hours after injection), and is obviously effective. I was afraid of giving another 12 U when his sugar is only in the low 100s, and I wonder if he is having a Somogyi response, since he was so high in the morning. He is clinically doing very well, so I hesitate to change his insulin, and I do not want to see him have another ketotic episode, because I'm not sure how much more the owner can handle. I had him only give 4U the night of the curve, then dropped him to 9U BID, hoping to minimize the potential "over-correction" if he has been hypoglycemic. It would be difficult to do a 24 hour curve without sending him to the ER again. Any thoughts you have will be appreciated. /p

Did the ultrasound evaluate the kidneys?

Can you post a couple of his latest bg curves on the glargine?

Hi, I will try to be brief. "Max" is a 13 1/2 y.o. M/N Schnauzer who was diagnosed in early October 2012 with diabetes. He had a previous history of hypertriglyceridemia that honestly fell through the cracks and was not addressed. Owner is an elderly man with a dying wife. Max was started on NPH insulin at 5 units twice daily (25.4# at time of diagnosis) and gradually increased to 9 units BID based on spot checks of his glucose. On Nov. 12, he presented for depression and anorexia. He was found to be ketotic, without any evidence of pancreatitis on ultrasound. A urine culture was negative. He was treated at the local emergency clinic and improved. He was gradually worked up to 11 units BID, and a glucose curve was done on 12/12/12: 1h post insulin: 283 3 h post : 269 5h post : 232 7h post : 172 9h post : 176 We were pretty happy with this curve, but increased the morning dose to 12U, kept the evening dose at 11U. A spot check about a week later showed a glucose of 445, though he had gained weight and was not PU/PD. He presented about 2 weeks later, again ketotic. He had an elevated lipase; ultrasound was not repeated. He was again treated at the local ER and improved. He went home on 12 U BID. We did a curve yesterday: 2h post: 412 4h post: 211 6h post: 137 8h post: 87 10h post 89 11.5h 96 The dog is not PU/PD, but the owner thought he might have been hypoglycemic in the evening about 6 days ago. He is currently eating royal canin low-fat food with some small amount w/d canned. He does usually get some treats during the day, which did not happen while he was hospitalized for the curve. I was a little unsure as to best step. Insulin is lasting a while (still low almost 12 hours after injection), and is obviously effective. I was afraid of giving another 12 U when his sugar is only in the low 100s, and I wonder if he is having a Somogyi response, since he was so high in the morning. He is clinically doing very well, so I hesitate to change his insulin, and I do not want to see him have another ketotic episode, because I'm not sure how much more the owner can handle. I had him only give 4U the night of the curve, then dropped him to 9U BID, hoping to minimize the potential "over-correction" if he has been hypoglycemic. It would be difficult to do a 24 hour curve without sending him to the ER again. Any thoughts you have will be appreciated. /p

Did the gi tract look normal?

How long before lesions returned?

Hello, I have been treating a 6 yo female labrador with diabetes insipidus for 3 months with desmopressin at 100 ug orally. Initially treatment was TID, but she still seems to respond with EOD treatment. The owners have noticed since Christmas a rapid amount of muscle atrophy esp over the hindlegs (no underlying arthritis noted) and also the temporal muscles. Another interesting aspect about this dog was that there was a facial paralysis present for about 5 months prior to the signs of pu/pd. The owners feel this has improved but the paralysis is still evident. Do you think the muscle atrophy could be related to treatment with desmopressin (I suspect unlikely)? Could it be related to a pituitary dependent diabetes insipidus? Or is there another disease process going on here? I think most likely link between the facial paralysis and the diabetes insipidus would be a tumour but unfortunately I do not have any access locally to MRI/CT. Thanks for your help!

Is the dog spayed?

Did his water consumption change just before?

Hello, I have been treating a 6 yo female labrador with diabetes insipidus for 3 months with desmopressin at 100 ug orally. Initially treatment was TID, but she still seems to respond with EOD treatment. The owners have noticed since Christmas a rapid amount of muscle atrophy esp over the hindlegs (no underlying arthritis noted) and also the temporal muscles. Another interesting aspect about this dog was that there was a facial paralysis present for about 5 months prior to the signs of pu/pd. The owners feel this has improved but the paralysis is still evident. Do you think the muscle atrophy could be related to treatment with desmopressin (I suspect unlikely)? Could it be related to a pituitary dependent diabetes insipidus? Or is there another disease process going on here? I think most likely link between the facial paralysis and the diabetes insipidus would be a tumour but unfortunately I do not have any access locally to MRI/CT. Thanks for your help!

How exactly was di diagnosed?

This is a difficult case for you to be involved with as a relief vet; how long are you going to be at the clinic, available for follow-up?

Hello, I have been treating a 6 yo female labrador with diabetes insipidus for 3 months with desmopressin at 100 ug orally. Initially treatment was TID, but she still seems to respond with EOD treatment. The owners have noticed since Christmas a rapid amount of muscle atrophy esp over the hindlegs (no underlying arthritis noted) and also the temporal muscles. Another interesting aspect about this dog was that there was a facial paralysis present for about 5 months prior to the signs of pu/pd. The owners feel this has improved but the paralysis is still evident. Do you think the muscle atrophy could be related to treatment with desmopressin (I suspect unlikely)? Could it be related to a pituitary dependent diabetes insipidus? Or is there another disease process going on here? I think most likely link between the facial paralysis and the diabetes insipidus would be a tumour but unfortunately I do not have any access locally to MRI/CT. Thanks for your help!

What exactly does the complete neuro exam look like?

What's the total protein?

Hello, I have been treating a 6 yo female labrador with diabetes insipidus for 3 months with desmopressin at 100 ug orally. Initially treatment was TID, but she still seems to respond with EOD treatment. The owners have noticed since Christmas a rapid amount of muscle atrophy esp over the hindlegs (no underlying arthritis noted) and also the temporal muscles. Another interesting aspect about this dog was that there was a facial paralysis present for about 5 months prior to the signs of pu/pd. The owners feel this has improved but the paralysis is still evident. Do you think the muscle atrophy could be related to treatment with desmopressin (I suspect unlikely)? Could it be related to a pituitary dependent diabetes insipidus? Or is there another disease process going on here? I think most likely link between the facial paralysis and the diabetes insipidus would be a tumour but unfortunately I do not have any access locally to MRI/CT. Thanks for your help!

Is there any muscle weakness, exercise intolerance, etc?

I seem to remember that the potential danger was such stimulation of the gallbladder (with the oil) that it could contract around an obstructing stone and potentially rupture?

Hello, I have been treating a 6 yo female labrador with diabetes insipidus for 3 months with desmopressin at 100 ug orally. Initially treatment was TID, but she still seems to respond with EOD treatment. The owners have noticed since Christmas a rapid amount of muscle atrophy esp over the hindlegs (no underlying arthritis noted) and also the temporal muscles. Another interesting aspect about this dog was that there was a facial paralysis present for about 5 months prior to the signs of pu/pd. The owners feel this has improved but the paralysis is still evident. Do you think the muscle atrophy could be related to treatment with desmopressin (I suspect unlikely)? Could it be related to a pituitary dependent diabetes insipidus? Or is there another disease process going on here? I think most likely link between the facial paralysis and the diabetes insipidus would be a tumour but unfortunately I do not have any access locally to MRI/CT. Thanks for your help!

Is the cpk normal?

The dex suppression results?

I have a 10yr old M/C Schnauzer who was diagnosed with DKA 7/12, he stablized well, and we were able to gain good control of his diabetes, after some insulin adjustments by BG curves and spot checks. He was maintaining well on 8U Hum N q12h, with excellent curves until recently. He recently become profoundly Pu/Pd , we ran a BG curve and it appears to me that we are still getting excellent response , but duration is the issue. BG curve -pre insulin 479, 8 U HumN sq -2hr post 186 -4hr 142 -6hr 164 -8hr 175 Do you recommend change insulin type , and if so to what? The owner is willing to do tid injections would this be recommended, if so at what doses? We have this dog also on W/D diet , what are your diet recommendations? These folks want to change him to a "grain free " and I'm encouraging them to keep him on the W/D. Any input is much appreciated. Thank You. DVM

What's the dog's body weight and bcs?

How many calories/day does she currently get?

I have a 10yr old M/C Schnauzer who was diagnosed with DKA 7/12, he stablized well, and we were able to gain good control of his diabetes, after some insulin adjustments by BG curves and spot checks. He was maintaining well on 8U Hum N q12h, with excellent curves until recently. He recently become profoundly Pu/Pd , we ran a BG curve and it appears to me that we are still getting excellent response , but duration is the issue. BG curve -pre insulin 479, 8 U HumN sq -2hr post 186 -4hr 142 -6hr 164 -8hr 175 Do you recommend change insulin type , and if so to what? The owner is willing to do tid injections would this be recommended, if so at what doses? We have this dog also on W/D diet , what are your diet recommendations? These folks want to change him to a "grain free " and I'm encouraging them to keep him on the W/D. Any input is much appreciated. Thank You. DVM

What is the fasting triglyceride and cholesterol level?

Did she have an ultrasound then?

I have a 10yr old M/C Schnauzer who was diagnosed with DKA 7/12, he stablized well, and we were able to gain good control of his diabetes, after some insulin adjustments by BG curves and spot checks. He was maintaining well on 8U Hum N q12h, with excellent curves until recently. He recently become profoundly Pu/Pd , we ran a BG curve and it appears to me that we are still getting excellent response , but duration is the issue. BG curve -pre insulin 479, 8 U HumN sq -2hr post 186 -4hr 142 -6hr 164 -8hr 175 Do you recommend change insulin type , and if so to what? The owner is willing to do tid injections would this be recommended, if so at what doses? We have this dog also on W/D diet , what are your diet recommendations? These folks want to change him to a "grain free " and I'm encouraging them to keep him on the W/D. Any input is much appreciated. Thank You. DVM

Feeding before or after the shots and what time interval?

What are all the drugs this dog is currently on?

This is 8 yr male neutered DSH FIV [ositive. Had some liver elevation and vomiting issues last year, resolved. Pancretitis? Now 444 blood glucose on screen and PU/PD. Minimal weight loss Abdomen feels slightly full... teeth and gums look pretty good, no fever. CBC: HCT 34 5.9 million RBC Neuts 5992 lymphs 985 monos 640 eos 376 Chem: SAP 89 ALT 83 GGT 1 Alb 3.5 Glob 4.2 Bili 0.1 Glucose 444 Ca 9.8 p 5.1 Cl 114 Na 151 K 5.2 The cat was started on 2 units BID glargine, and wet and dry DM At recheck just before next dose of insulin and a meal the blood glucose was 550. I increased the dose of glargine to 3 units... is there something I am missing? I know that 550 is too high- am I seeing Somogyi? Thanks

When did you start this tx?

Have you tried any dietary therapy - like the cnm-dm or even canned kitten growth?

This is 8 yr male neutered DSH FIV [ositive. Had some liver elevation and vomiting issues last year, resolved. Pancretitis? Now 444 blood glucose on screen and PU/PD. Minimal weight loss Abdomen feels slightly full... teeth and gums look pretty good, no fever. CBC: HCT 34 5.9 million RBC Neuts 5992 lymphs 985 monos 640 eos 376 Chem: SAP 89 ALT 83 GGT 1 Alb 3.5 Glob 4.2 Bili 0.1 Glucose 444 Ca 9.8 p 5.1 Cl 114 Na 151 K 5.2 The cat was started on 2 units BID glargine, and wet and dry DM At recheck just before next dose of insulin and a meal the blood glucose was 550. I increased the dose of glargine to 3 units... is there something I am missing? I know that 550 is too high- am I seeing Somogyi? Thanks

Update today he had been on how long?

Do you have a urine c/s?

This is 8 yr male neutered DSH FIV [ositive. Had some liver elevation and vomiting issues last year, resolved. Pancretitis? Now 444 blood glucose on screen and PU/PD. Minimal weight loss Abdomen feels slightly full... teeth and gums look pretty good, no fever. CBC: HCT 34 5.9 million RBC Neuts 5992 lymphs 985 monos 640 eos 376 Chem: SAP 89 ALT 83 GGT 1 Alb 3.5 Glob 4.2 Bili 0.1 Glucose 444 Ca 9.8 p 5.1 Cl 114 Na 151 K 5.2 The cat was started on 2 units BID glargine, and wet and dry DM At recheck just before next dose of insulin and a meal the blood glucose was 550. I increased the dose of glargine to 3 units... is there something I am missing? I know that 550 is too high- am I seeing Somogyi? Thanks

Do you feel confident that the owner is able to administer the insulin correctly?

Why does your cat have a persistent hyperglobulinemia?

This is 8 yr male neutered DSH FIV [ositive. Had some liver elevation and vomiting issues last year, resolved. Pancretitis? Now 444 blood glucose on screen and PU/PD. Minimal weight loss Abdomen feels slightly full... teeth and gums look pretty good, no fever. CBC: HCT 34 5.9 million RBC Neuts 5992 lymphs 985 monos 640 eos 376 Chem: SAP 89 ALT 83 GGT 1 Alb 3.5 Glob 4.2 Bili 0.1 Glucose 444 Ca 9.8 p 5.1 Cl 114 Na 151 K 5.2 The cat was started on 2 units BID glargine, and wet and dry DM At recheck just before next dose of insulin and a meal the blood glucose was 550. I increased the dose of glargine to 3 units... is there something I am missing? I know that 550 is too high- am I seeing Somogyi? Thanks

What does this cat weigh?

Does the owner know what to do with the insulin dose if he doesn't eat well?

I have a 7 year old MN Brussels Griffon presented for DKA on Dec 4,2012. Responded very well to fluid therapy. On rads liver was slightly enlarged otherwise N.S.F. ALP was 1118 IU/L ( normal is 10-150) Amylase, Lipase were 2299, 2984 respectively. Spec CPL was 751 ( normal is 0-200). Sent home on Royal Canin low fat diet and clavamox. Started on caninsulin 8 units every 24 hours.He was 19 lbs. Glucose curve done after one week increase the dose to 9 units every 24 hours. Also ultrasound exam showed pacreatic nephrosis and pancreatitis.FNA of pancreas showed neutrophilic inflamation and possible calcification. Sent home on Clavamox for one week. Came back for recheck Fasting glucose is high, Lowest level after 8 hours is 8.9 mmol/L. Still pu/pd. ALP has gone higher now at 3290 (10-150) Amylase lipase is at 1360 ( 328-905)and 1915 ( 100-750). Spec CpL is 1000 . Fructosamine levels: 640 (260-378) Urine positive for glucose, no ketones, USG;1.036. Bile acid panel : WNL ACTH and LDDS test: WNL. I explained the owner again as how to give insulin. I added Panrease powder to the food. My main concern is to adress: Wt loss : he is 16 lbs now. Why ALP is going up. Why is pancreatic enzymes still high, Any way to better control glucose levels. Thanks ☼

Have you done a glucose curve?

Is she obese?

I have a 7 year old MN Brussels Griffon presented for DKA on Dec 4,2012. Responded very well to fluid therapy. On rads liver was slightly enlarged otherwise N.S.F. ALP was 1118 IU/L ( normal is 10-150) Amylase, Lipase were 2299, 2984 respectively. Spec CPL was 751 ( normal is 0-200). Sent home on Royal Canin low fat diet and clavamox. Started on caninsulin 8 units every 24 hours.He was 19 lbs. Glucose curve done after one week increase the dose to 9 units every 24 hours. Also ultrasound exam showed pacreatic nephrosis and pancreatitis.FNA of pancreas showed neutrophilic inflamation and possible calcification. Sent home on Clavamox for one week. Came back for recheck Fasting glucose is high, Lowest level after 8 hours is 8.9 mmol/L. Still pu/pd. ALP has gone higher now at 3290 (10-150) Amylase lipase is at 1360 ( 328-905)and 1915 ( 100-750). Spec CpL is 1000 . Fructosamine levels: 640 (260-378) Urine positive for glucose, no ketones, USG;1.036. Bile acid panel : WNL ACTH and LDDS test: WNL. I explained the owner again as how to give insulin. I added Panrease powder to the food. My main concern is to adress: Wt loss : he is 16 lbs now. Why ALP is going up. Why is pancreatic enzymes still high, Any way to better control glucose levels. Thanks ☼

Results?

So, when exactly does the owner work?

I have somewhat recently inherited an insulin resistent diabetic cat. He is a neutered male DSH. I have had some recent success with getting his insulin resistence partially resolved, but would love help from the experts on where to go from here. He has a long history, I will send many of the details and I can fill in any holes if needed. For whatever reason I decided to type his history in reverse order. Prior History****************************** -Nov 16, 2012 8am 461 spot glucose, gave 9.5 U glargine SQ with food. eating dry DM. No weight. -Nov 7, 2012 8am 431, gave 9 U glargine SQ with food. eating evo canned turkey and chicken. 15.4#. hungry always. PUPD. soft stool. New bottle of insulin today. 11am 383 2pm 284 430pm 232 -October 24th in for curve- never performed? rec increasing dose to 9U BID. has intermittent diarrhea. Changing diet from DM to Evo kitten and cat food/ turkey and chicken. wt 16.56# -Oct 9, 2012 830am 402, gave food 7 U glargine SQ. eating DM, good appetite. O cannot afford. wants new diet. soft stool. fecal O and P: negative. -Sept 23, 2012 9am 389 gave insulin 6.5 U with food. PUPD at home. 1pm 350 -Sept 17 2012 16.88# 8am 370 gave 6 U glargine SQ BID 12pm 354 4pm 359 445pm 427 For following curves: values taken 8am, 12pm, 4pm usually -Sept 11 glucose curve values 336-465, wt 17.4#, 5.5 U glargine BID -Sept 4 glucose curve values 370-409, 17.06 #, 5U glargine BID -Aug 28 glucose curve values 418-390, 17.19#, 4.5 U glargine BID -Aug 19th liver enzymes elevated again. ALT 379, alk Phos 114, random sampling of bloodwork. eating well- very hungry. spot glucose 430 increase insulin to 4.5 U BID -Aug 15th fructosamine 699, eating canned DM only. 17.8#, o report very hungry -July 2 presented for respiratory distress, open mouth breathing. R/O cardiac disease- hx of dynamic subaortic stenosis? o decline cardiology referral. Chem and CBC WNL. ALT 56, Alk Phos 65, No GGT or bilirubin on panel. -May 10 glucose curve values 127-186, 19.6#, 4 U glargine BID -May 3 glucose curve values 269-153, No weight, 4 U glargine BID -April 25th glucose curve values 324-120, 19.6#, 4 U glargine BID + hospitation -April 24th glucose curve values 313-272, No weight, 4 U glargine BID + hospitation -April 23rd Presented for inappetence, ADR. diagnosed with DM. CBC: WNL, Chem: ALT 220, Alk Phos 566, GGT 10, hyperbilirubin 3.6, No other significant abnormalities. FIV/FeLK neg/neg. HWT: neg. started metronidazole 50 mg PO BID x 14 days and enrofloxacin 22.7mg PO SID x 14 days, 3 days of hospitation with 4 U glargine SQ BID Feb 15th Ultrasound with Cardiologist. A: dynamic subaortic stenosis P: no treatment at this time but US exam every 6-12 months. Jan 23rd: seen for ADR, limping RF limb. grade 3/5 systolic murmur. no lameness on PE. bloodwork ran. CBC shows mild anemia HCT 28.8 (29-48), RBC 6.73 (5.92-9.93) x 10^6. T4 WNL 2.0. Chem shows glucose inc 171 (64-170) and no other abnormalities. ALT was 18, Alk Phos 18 Total bilirubin 0.2. Jan 8th: seen at a referral facility for "vaccine reaction" No other notes on what this was, or how it was treated. O reported very bad diarrhea, little vomiting and lethargic. Jan 7th 2012 PE is WNL except referred upper airway noises but no difficulty breathing. BCS 9/10. Weight 23#. given Rabies (purevax) and FVRCP- not sure where, not noted. End of Prior History************** He presented to me On Dec 6th, 2012. I ran bloodwork and sent a UA. I also added on the Spec pli for pancreatitis and scheduled him for an abdominal ultrasound. I also collected a blood pressure. Chem: ALT low 26 (28-100) inc lipase, albulmin glucose 405 ( 70-150) rest no significant abnormalities CBC: no sign abn T4: 1.8 WNL UA cysto USG 1041 3+ glucose, no bilirubin, blood no WBC no RBC No bacteria No crystals O declines a C and S BP = 130, verified x 3. Spec fPL 15.8 high- consistent with pancreatitis. conclusions from abdominal ultrasound: 1. moderate chronic active pancreatitis 2. moderate vacuolar hepatopathy, from DM likely 3. mild to mod bilateral adrenomegaly- R/O incidental, hypertrophy from chronic illness, cushings. Go Home Medications: -Bup (0.3 mg/ml) Give 0.2 BID -Amoxi (50 mg) give 1 tablet BID x15 days (because could not do culture) -Metronidazole 50 mg BID x 10 days -Increase glargine to 10 U BID just to have a round number - less than 7% carb diet OTC- I forgot which one but o got it off a list we have at the clinic. At home glucose curve. 12/14/12 6:49am 405 fed at 7:10 gave 10u insulin. 8:47am 396 11:31am 391 1:28pm 337 3:34pm 417 5:31pm 443 6:51pm 453 fed at 7pm gave 10u In the month of december, patient had a small amount of intermittent loose stool. He has switched to the new diet however then. New Plan Dec 28, 2012: -1/2 tsp of live culture yogurt at home for probiotics once daily. -buprenex 0.2 ml by mouth twice daily for 2 weeks. -SQ fluids 100 ml SID SQ -Metronidazole 50 mg tablets: 1 tablet by mouth twice daily -Ursodial (250mg tablet): give 1/4 tablet once daily for 2 weeks. (#4)- (pick up at a regular pharmacy). can get it from a compounding pharmacy in a liquid if needed.- o declines this for now -Take glucose curves weekly and call with results. -Come in for a pancreatitis test and recheck appt in 2-3 weeks. -If not improved in 2 weeks then internal medicine referral (where they can possibly start steroids). Jan 14th Curve at home: 6:22am - 287 fed at 6:30am. 3 oz of evo 95% and 10 units of insulin 8:29am - 339 8:35am - 320 (re-test) 10:35am - 165 12:21pm - 110 2:50pm - 157 4:27pm - 259 6:17pm - 418 fed at 6:30 pm. 3 oz of evo 95% and 10 units of insulin I am happy that he seems to be responding to insulin again. My questions are: 1. What should I do with the insulin dose? 2. should I start the ursodial now? 3. When should I recheck the pancreatitis? Could I send out the Feline SpPLI? 4. The owners do not have unlimited resources and nearing the end of their budget. They are having a hard time administering fluids. Which medications are necessary to continue? Help! I want to do what is right for this cat, and I am pleased we've made some progress. I've recommended that they see an internist but they are hesitant for financial reasons. Thanks in advance.

I don't think that he needs sq fluids unless he's not eating....it sounded like he had some diarrhea back in december, potentially associated with the diet change...so i think he's eating fine right now?

What made the owner think there was abdominal pain?

I have somewhat recently inherited an insulin resistent diabetic cat. He is a neutered male DSH. I have had some recent success with getting his insulin resistence partially resolved, but would love help from the experts on where to go from here. He has a long history, I will send many of the details and I can fill in any holes if needed. For whatever reason I decided to type his history in reverse order. Prior History****************************** -Nov 16, 2012 8am 461 spot glucose, gave 9.5 U glargine SQ with food. eating dry DM. No weight. -Nov 7, 2012 8am 431, gave 9 U glargine SQ with food. eating evo canned turkey and chicken. 15.4#. hungry always. PUPD. soft stool. New bottle of insulin today. 11am 383 2pm 284 430pm 232 -October 24th in for curve- never performed? rec increasing dose to 9U BID. has intermittent diarrhea. Changing diet from DM to Evo kitten and cat food/ turkey and chicken. wt 16.56# -Oct 9, 2012 830am 402, gave food 7 U glargine SQ. eating DM, good appetite. O cannot afford. wants new diet. soft stool. fecal O and P: negative. -Sept 23, 2012 9am 389 gave insulin 6.5 U with food. PUPD at home. 1pm 350 -Sept 17 2012 16.88# 8am 370 gave 6 U glargine SQ BID 12pm 354 4pm 359 445pm 427 For following curves: values taken 8am, 12pm, 4pm usually -Sept 11 glucose curve values 336-465, wt 17.4#, 5.5 U glargine BID -Sept 4 glucose curve values 370-409, 17.06 #, 5U glargine BID -Aug 28 glucose curve values 418-390, 17.19#, 4.5 U glargine BID -Aug 19th liver enzymes elevated again. ALT 379, alk Phos 114, random sampling of bloodwork. eating well- very hungry. spot glucose 430 increase insulin to 4.5 U BID -Aug 15th fructosamine 699, eating canned DM only. 17.8#, o report very hungry -July 2 presented for respiratory distress, open mouth breathing. R/O cardiac disease- hx of dynamic subaortic stenosis? o decline cardiology referral. Chem and CBC WNL. ALT 56, Alk Phos 65, No GGT or bilirubin on panel. -May 10 glucose curve values 127-186, 19.6#, 4 U glargine BID -May 3 glucose curve values 269-153, No weight, 4 U glargine BID -April 25th glucose curve values 324-120, 19.6#, 4 U glargine BID + hospitation -April 24th glucose curve values 313-272, No weight, 4 U glargine BID + hospitation -April 23rd Presented for inappetence, ADR. diagnosed with DM. CBC: WNL, Chem: ALT 220, Alk Phos 566, GGT 10, hyperbilirubin 3.6, No other significant abnormalities. FIV/FeLK neg/neg. HWT: neg. started metronidazole 50 mg PO BID x 14 days and enrofloxacin 22.7mg PO SID x 14 days, 3 days of hospitation with 4 U glargine SQ BID Feb 15th Ultrasound with Cardiologist. A: dynamic subaortic stenosis P: no treatment at this time but US exam every 6-12 months. Jan 23rd: seen for ADR, limping RF limb. grade 3/5 systolic murmur. no lameness on PE. bloodwork ran. CBC shows mild anemia HCT 28.8 (29-48), RBC 6.73 (5.92-9.93) x 10^6. T4 WNL 2.0. Chem shows glucose inc 171 (64-170) and no other abnormalities. ALT was 18, Alk Phos 18 Total bilirubin 0.2. Jan 8th: seen at a referral facility for "vaccine reaction" No other notes on what this was, or how it was treated. O reported very bad diarrhea, little vomiting and lethargic. Jan 7th 2012 PE is WNL except referred upper airway noises but no difficulty breathing. BCS 9/10. Weight 23#. given Rabies (purevax) and FVRCP- not sure where, not noted. End of Prior History************** He presented to me On Dec 6th, 2012. I ran bloodwork and sent a UA. I also added on the Spec pli for pancreatitis and scheduled him for an abdominal ultrasound. I also collected a blood pressure. Chem: ALT low 26 (28-100) inc lipase, albulmin glucose 405 ( 70-150) rest no significant abnormalities CBC: no sign abn T4: 1.8 WNL UA cysto USG 1041 3+ glucose, no bilirubin, blood no WBC no RBC No bacteria No crystals O declines a C and S BP = 130, verified x 3. Spec fPL 15.8 high- consistent with pancreatitis. conclusions from abdominal ultrasound: 1. moderate chronic active pancreatitis 2. moderate vacuolar hepatopathy, from DM likely 3. mild to mod bilateral adrenomegaly- R/O incidental, hypertrophy from chronic illness, cushings. Go Home Medications: -Bup (0.3 mg/ml) Give 0.2 BID -Amoxi (50 mg) give 1 tablet BID x15 days (because could not do culture) -Metronidazole 50 mg BID x 10 days -Increase glargine to 10 U BID just to have a round number - less than 7% carb diet OTC- I forgot which one but o got it off a list we have at the clinic. At home glucose curve. 12/14/12 6:49am 405 fed at 7:10 gave 10u insulin. 8:47am 396 11:31am 391 1:28pm 337 3:34pm 417 5:31pm 443 6:51pm 453 fed at 7pm gave 10u In the month of december, patient had a small amount of intermittent loose stool. He has switched to the new diet however then. New Plan Dec 28, 2012: -1/2 tsp of live culture yogurt at home for probiotics once daily. -buprenex 0.2 ml by mouth twice daily for 2 weeks. -SQ fluids 100 ml SID SQ -Metronidazole 50 mg tablets: 1 tablet by mouth twice daily -Ursodial (250mg tablet): give 1/4 tablet once daily for 2 weeks. (#4)- (pick up at a regular pharmacy). can get it from a compounding pharmacy in a liquid if needed.- o declines this for now -Take glucose curves weekly and call with results. -Come in for a pancreatitis test and recheck appt in 2-3 weeks. -If not improved in 2 weeks then internal medicine referral (where they can possibly start steroids). Jan 14th Curve at home: 6:22am - 287 fed at 6:30am. 3 oz of evo 95% and 10 units of insulin 8:29am - 339 8:35am - 320 (re-test) 10:35am - 165 12:21pm - 110 2:50pm - 157 4:27pm - 259 6:17pm - 418 fed at 6:30 pm. 3 oz of evo 95% and 10 units of insulin I am happy that he seems to be responding to insulin again. My questions are: 1. What should I do with the insulin dose? 2. should I start the ursodial now? 3. When should I recheck the pancreatitis? Could I send out the Feline SpPLI? 4. The owners do not have unlimited resources and nearing the end of their budget. They are having a hard time administering fluids. Which medications are necessary to continue? Help! I want to do what is right for this cat, and I am pleased we've made some progress. I've recommended that they see an internist but they are hesitant for financial reasons. Thanks in advance.

Great that the owner can do bg curves at home : ) we need to be sure that her glucometer is accurate, though...has one curve been done in the hospital, so that we can compare numbers on the owner's machine vs those on an in-house glucometer that you know to be accurate?

Is the amount of food measured at each meal?

I have somewhat recently inherited an insulin resistent diabetic cat. He is a neutered male DSH. I have had some recent success with getting his insulin resistence partially resolved, but would love help from the experts on where to go from here. He has a long history, I will send many of the details and I can fill in any holes if needed. For whatever reason I decided to type his history in reverse order. Prior History****************************** -Nov 16, 2012 8am 461 spot glucose, gave 9.5 U glargine SQ with food. eating dry DM. No weight. -Nov 7, 2012 8am 431, gave 9 U glargine SQ with food. eating evo canned turkey and chicken. 15.4#. hungry always. PUPD. soft stool. New bottle of insulin today. 11am 383 2pm 284 430pm 232 -October 24th in for curve- never performed? rec increasing dose to 9U BID. has intermittent diarrhea. Changing diet from DM to Evo kitten and cat food/ turkey and chicken. wt 16.56# -Oct 9, 2012 830am 402, gave food 7 U glargine SQ. eating DM, good appetite. O cannot afford. wants new diet. soft stool. fecal O and P: negative. -Sept 23, 2012 9am 389 gave insulin 6.5 U with food. PUPD at home. 1pm 350 -Sept 17 2012 16.88# 8am 370 gave 6 U glargine SQ BID 12pm 354 4pm 359 445pm 427 For following curves: values taken 8am, 12pm, 4pm usually -Sept 11 glucose curve values 336-465, wt 17.4#, 5.5 U glargine BID -Sept 4 glucose curve values 370-409, 17.06 #, 5U glargine BID -Aug 28 glucose curve values 418-390, 17.19#, 4.5 U glargine BID -Aug 19th liver enzymes elevated again. ALT 379, alk Phos 114, random sampling of bloodwork. eating well- very hungry. spot glucose 430 increase insulin to 4.5 U BID -Aug 15th fructosamine 699, eating canned DM only. 17.8#, o report very hungry -July 2 presented for respiratory distress, open mouth breathing. R/O cardiac disease- hx of dynamic subaortic stenosis? o decline cardiology referral. Chem and CBC WNL. ALT 56, Alk Phos 65, No GGT or bilirubin on panel. -May 10 glucose curve values 127-186, 19.6#, 4 U glargine BID -May 3 glucose curve values 269-153, No weight, 4 U glargine BID -April 25th glucose curve values 324-120, 19.6#, 4 U glargine BID + hospitation -April 24th glucose curve values 313-272, No weight, 4 U glargine BID + hospitation -April 23rd Presented for inappetence, ADR. diagnosed with DM. CBC: WNL, Chem: ALT 220, Alk Phos 566, GGT 10, hyperbilirubin 3.6, No other significant abnormalities. FIV/FeLK neg/neg. HWT: neg. started metronidazole 50 mg PO BID x 14 days and enrofloxacin 22.7mg PO SID x 14 days, 3 days of hospitation with 4 U glargine SQ BID Feb 15th Ultrasound with Cardiologist. A: dynamic subaortic stenosis P: no treatment at this time but US exam every 6-12 months. Jan 23rd: seen for ADR, limping RF limb. grade 3/5 systolic murmur. no lameness on PE. bloodwork ran. CBC shows mild anemia HCT 28.8 (29-48), RBC 6.73 (5.92-9.93) x 10^6. T4 WNL 2.0. Chem shows glucose inc 171 (64-170) and no other abnormalities. ALT was 18, Alk Phos 18 Total bilirubin 0.2. Jan 8th: seen at a referral facility for "vaccine reaction" No other notes on what this was, or how it was treated. O reported very bad diarrhea, little vomiting and lethargic. Jan 7th 2012 PE is WNL except referred upper airway noises but no difficulty breathing. BCS 9/10. Weight 23#. given Rabies (purevax) and FVRCP- not sure where, not noted. End of Prior History************** He presented to me On Dec 6th, 2012. I ran bloodwork and sent a UA. I also added on the Spec pli for pancreatitis and scheduled him for an abdominal ultrasound. I also collected a blood pressure. Chem: ALT low 26 (28-100) inc lipase, albulmin glucose 405 ( 70-150) rest no significant abnormalities CBC: no sign abn T4: 1.8 WNL UA cysto USG 1041 3+ glucose, no bilirubin, blood no WBC no RBC No bacteria No crystals O declines a C and S BP = 130, verified x 3. Spec fPL 15.8 high- consistent with pancreatitis. conclusions from abdominal ultrasound: 1. moderate chronic active pancreatitis 2. moderate vacuolar hepatopathy, from DM likely 3. mild to mod bilateral adrenomegaly- R/O incidental, hypertrophy from chronic illness, cushings. Go Home Medications: -Bup (0.3 mg/ml) Give 0.2 BID -Amoxi (50 mg) give 1 tablet BID x15 days (because could not do culture) -Metronidazole 50 mg BID x 10 days -Increase glargine to 10 U BID just to have a round number - less than 7% carb diet OTC- I forgot which one but o got it off a list we have at the clinic. At home glucose curve. 12/14/12 6:49am 405 fed at 7:10 gave 10u insulin. 8:47am 396 11:31am 391 1:28pm 337 3:34pm 417 5:31pm 443 6:51pm 453 fed at 7pm gave 10u In the month of december, patient had a small amount of intermittent loose stool. He has switched to the new diet however then. New Plan Dec 28, 2012: -1/2 tsp of live culture yogurt at home for probiotics once daily. -buprenex 0.2 ml by mouth twice daily for 2 weeks. -SQ fluids 100 ml SID SQ -Metronidazole 50 mg tablets: 1 tablet by mouth twice daily -Ursodial (250mg tablet): give 1/4 tablet once daily for 2 weeks. (#4)- (pick up at a regular pharmacy). can get it from a compounding pharmacy in a liquid if needed.- o declines this for now -Take glucose curves weekly and call with results. -Come in for a pancreatitis test and recheck appt in 2-3 weeks. -If not improved in 2 weeks then internal medicine referral (where they can possibly start steroids). Jan 14th Curve at home: 6:22am - 287 fed at 6:30am. 3 oz of evo 95% and 10 units of insulin 8:29am - 339 8:35am - 320 (re-test) 10:35am - 165 12:21pm - 110 2:50pm - 157 4:27pm - 259 6:17pm - 418 fed at 6:30 pm. 3 oz of evo 95% and 10 units of insulin I am happy that he seems to be responding to insulin again. My questions are: 1. What should I do with the insulin dose? 2. should I start the ursodial now? 3. When should I recheck the pancreatitis? Could I send out the Feline SpPLI? 4. The owners do not have unlimited resources and nearing the end of their budget. They are having a hard time administering fluids. Which medications are necessary to continue? Help! I want to do what is right for this cat, and I am pleased we've made some progress. I've recommended that they see an internist but they are hesitant for financial reasons. Thanks in advance.

Are you referring to the recently-update list at www.catinfo.org with the carb content for over-the-counter canned cat foods?

Where does this fish oil recommendation in hyperlipidemia come from?

I have somewhat recently inherited an insulin resistent diabetic cat. He is a neutered male DSH. I have had some recent success with getting his insulin resistence partially resolved, but would love help from the experts on where to go from here. He has a long history, I will send many of the details and I can fill in any holes if needed. For whatever reason I decided to type his history in reverse order. Prior History****************************** -Nov 16, 2012 8am 461 spot glucose, gave 9.5 U glargine SQ with food. eating dry DM. No weight. -Nov 7, 2012 8am 431, gave 9 U glargine SQ with food. eating evo canned turkey and chicken. 15.4#. hungry always. PUPD. soft stool. New bottle of insulin today. 11am 383 2pm 284 430pm 232 -October 24th in for curve- never performed? rec increasing dose to 9U BID. has intermittent diarrhea. Changing diet from DM to Evo kitten and cat food/ turkey and chicken. wt 16.56# -Oct 9, 2012 830am 402, gave food 7 U glargine SQ. eating DM, good appetite. O cannot afford. wants new diet. soft stool. fecal O and P: negative. -Sept 23, 2012 9am 389 gave insulin 6.5 U with food. PUPD at home. 1pm 350 -Sept 17 2012 16.88# 8am 370 gave 6 U glargine SQ BID 12pm 354 4pm 359 445pm 427 For following curves: values taken 8am, 12pm, 4pm usually -Sept 11 glucose curve values 336-465, wt 17.4#, 5.5 U glargine BID -Sept 4 glucose curve values 370-409, 17.06 #, 5U glargine BID -Aug 28 glucose curve values 418-390, 17.19#, 4.5 U glargine BID -Aug 19th liver enzymes elevated again. ALT 379, alk Phos 114, random sampling of bloodwork. eating well- very hungry. spot glucose 430 increase insulin to 4.5 U BID -Aug 15th fructosamine 699, eating canned DM only. 17.8#, o report very hungry -July 2 presented for respiratory distress, open mouth breathing. R/O cardiac disease- hx of dynamic subaortic stenosis? o decline cardiology referral. Chem and CBC WNL. ALT 56, Alk Phos 65, No GGT or bilirubin on panel. -May 10 glucose curve values 127-186, 19.6#, 4 U glargine BID -May 3 glucose curve values 269-153, No weight, 4 U glargine BID -April 25th glucose curve values 324-120, 19.6#, 4 U glargine BID + hospitation -April 24th glucose curve values 313-272, No weight, 4 U glargine BID + hospitation -April 23rd Presented for inappetence, ADR. diagnosed with DM. CBC: WNL, Chem: ALT 220, Alk Phos 566, GGT 10, hyperbilirubin 3.6, No other significant abnormalities. FIV/FeLK neg/neg. HWT: neg. started metronidazole 50 mg PO BID x 14 days and enrofloxacin 22.7mg PO SID x 14 days, 3 days of hospitation with 4 U glargine SQ BID Feb 15th Ultrasound with Cardiologist. A: dynamic subaortic stenosis P: no treatment at this time but US exam every 6-12 months. Jan 23rd: seen for ADR, limping RF limb. grade 3/5 systolic murmur. no lameness on PE. bloodwork ran. CBC shows mild anemia HCT 28.8 (29-48), RBC 6.73 (5.92-9.93) x 10^6. T4 WNL 2.0. Chem shows glucose inc 171 (64-170) and no other abnormalities. ALT was 18, Alk Phos 18 Total bilirubin 0.2. Jan 8th: seen at a referral facility for "vaccine reaction" No other notes on what this was, or how it was treated. O reported very bad diarrhea, little vomiting and lethargic. Jan 7th 2012 PE is WNL except referred upper airway noises but no difficulty breathing. BCS 9/10. Weight 23#. given Rabies (purevax) and FVRCP- not sure where, not noted. End of Prior History************** He presented to me On Dec 6th, 2012. I ran bloodwork and sent a UA. I also added on the Spec pli for pancreatitis and scheduled him for an abdominal ultrasound. I also collected a blood pressure. Chem: ALT low 26 (28-100) inc lipase, albulmin glucose 405 ( 70-150) rest no significant abnormalities CBC: no sign abn T4: 1.8 WNL UA cysto USG 1041 3+ glucose, no bilirubin, blood no WBC no RBC No bacteria No crystals O declines a C and S BP = 130, verified x 3. Spec fPL 15.8 high- consistent with pancreatitis. conclusions from abdominal ultrasound: 1. moderate chronic active pancreatitis 2. moderate vacuolar hepatopathy, from DM likely 3. mild to mod bilateral adrenomegaly- R/O incidental, hypertrophy from chronic illness, cushings. Go Home Medications: -Bup (0.3 mg/ml) Give 0.2 BID -Amoxi (50 mg) give 1 tablet BID x15 days (because could not do culture) -Metronidazole 50 mg BID x 10 days -Increase glargine to 10 U BID just to have a round number - less than 7% carb diet OTC- I forgot which one but o got it off a list we have at the clinic. At home glucose curve. 12/14/12 6:49am 405 fed at 7:10 gave 10u insulin. 8:47am 396 11:31am 391 1:28pm 337 3:34pm 417 5:31pm 443 6:51pm 453 fed at 7pm gave 10u In the month of december, patient had a small amount of intermittent loose stool. He has switched to the new diet however then. New Plan Dec 28, 2012: -1/2 tsp of live culture yogurt at home for probiotics once daily. -buprenex 0.2 ml by mouth twice daily for 2 weeks. -SQ fluids 100 ml SID SQ -Metronidazole 50 mg tablets: 1 tablet by mouth twice daily -Ursodial (250mg tablet): give 1/4 tablet once daily for 2 weeks. (#4)- (pick up at a regular pharmacy). can get it from a compounding pharmacy in a liquid if needed.- o declines this for now -Take glucose curves weekly and call with results. -Come in for a pancreatitis test and recheck appt in 2-3 weeks. -If not improved in 2 weeks then internal medicine referral (where they can possibly start steroids). Jan 14th Curve at home: 6:22am - 287 fed at 6:30am. 3 oz of evo 95% and 10 units of insulin 8:29am - 339 8:35am - 320 (re-test) 10:35am - 165 12:21pm - 110 2:50pm - 157 4:27pm - 259 6:17pm - 418 fed at 6:30 pm. 3 oz of evo 95% and 10 units of insulin I am happy that he seems to be responding to insulin again. My questions are: 1. What should I do with the insulin dose? 2. should I start the ursodial now? 3. When should I recheck the pancreatitis? Could I send out the Feline SpPLI? 4. The owners do not have unlimited resources and nearing the end of their budget. They are having a hard time administering fluids. Which medications are necessary to continue? Help! I want to do what is right for this cat, and I am pleased we've made some progress. I've recommended that they see an internist but they are hesitant for financial reasons. Thanks in advance.

The adrenomegaly is interesting, i'm not sure what mild-moderate enlargement is?

Is there any way to get some of the test results that were performed at the emergency clinic?

I have somewhat recently inherited an insulin resistent diabetic cat. He is a neutered male DSH. I have had some recent success with getting his insulin resistence partially resolved, but would love help from the experts on where to go from here. He has a long history, I will send many of the details and I can fill in any holes if needed. For whatever reason I decided to type his history in reverse order. Prior History****************************** -Nov 16, 2012 8am 461 spot glucose, gave 9.5 U glargine SQ with food. eating dry DM. No weight. -Nov 7, 2012 8am 431, gave 9 U glargine SQ with food. eating evo canned turkey and chicken. 15.4#. hungry always. PUPD. soft stool. New bottle of insulin today. 11am 383 2pm 284 430pm 232 -October 24th in for curve- never performed? rec increasing dose to 9U BID. has intermittent diarrhea. Changing diet from DM to Evo kitten and cat food/ turkey and chicken. wt 16.56# -Oct 9, 2012 830am 402, gave food 7 U glargine SQ. eating DM, good appetite. O cannot afford. wants new diet. soft stool. fecal O and P: negative. -Sept 23, 2012 9am 389 gave insulin 6.5 U with food. PUPD at home. 1pm 350 -Sept 17 2012 16.88# 8am 370 gave 6 U glargine SQ BID 12pm 354 4pm 359 445pm 427 For following curves: values taken 8am, 12pm, 4pm usually -Sept 11 glucose curve values 336-465, wt 17.4#, 5.5 U glargine BID -Sept 4 glucose curve values 370-409, 17.06 #, 5U glargine BID -Aug 28 glucose curve values 418-390, 17.19#, 4.5 U glargine BID -Aug 19th liver enzymes elevated again. ALT 379, alk Phos 114, random sampling of bloodwork. eating well- very hungry. spot glucose 430 increase insulin to 4.5 U BID -Aug 15th fructosamine 699, eating canned DM only. 17.8#, o report very hungry -July 2 presented for respiratory distress, open mouth breathing. R/O cardiac disease- hx of dynamic subaortic stenosis? o decline cardiology referral. Chem and CBC WNL. ALT 56, Alk Phos 65, No GGT or bilirubin on panel. -May 10 glucose curve values 127-186, 19.6#, 4 U glargine BID -May 3 glucose curve values 269-153, No weight, 4 U glargine BID -April 25th glucose curve values 324-120, 19.6#, 4 U glargine BID + hospitation -April 24th glucose curve values 313-272, No weight, 4 U glargine BID + hospitation -April 23rd Presented for inappetence, ADR. diagnosed with DM. CBC: WNL, Chem: ALT 220, Alk Phos 566, GGT 10, hyperbilirubin 3.6, No other significant abnormalities. FIV/FeLK neg/neg. HWT: neg. started metronidazole 50 mg PO BID x 14 days and enrofloxacin 22.7mg PO SID x 14 days, 3 days of hospitation with 4 U glargine SQ BID Feb 15th Ultrasound with Cardiologist. A: dynamic subaortic stenosis P: no treatment at this time but US exam every 6-12 months. Jan 23rd: seen for ADR, limping RF limb. grade 3/5 systolic murmur. no lameness on PE. bloodwork ran. CBC shows mild anemia HCT 28.8 (29-48), RBC 6.73 (5.92-9.93) x 10^6. T4 WNL 2.0. Chem shows glucose inc 171 (64-170) and no other abnormalities. ALT was 18, Alk Phos 18 Total bilirubin 0.2. Jan 8th: seen at a referral facility for "vaccine reaction" No other notes on what this was, or how it was treated. O reported very bad diarrhea, little vomiting and lethargic. Jan 7th 2012 PE is WNL except referred upper airway noises but no difficulty breathing. BCS 9/10. Weight 23#. given Rabies (purevax) and FVRCP- not sure where, not noted. End of Prior History************** He presented to me On Dec 6th, 2012. I ran bloodwork and sent a UA. I also added on the Spec pli for pancreatitis and scheduled him for an abdominal ultrasound. I also collected a blood pressure. Chem: ALT low 26 (28-100) inc lipase, albulmin glucose 405 ( 70-150) rest no significant abnormalities CBC: no sign abn T4: 1.8 WNL UA cysto USG 1041 3+ glucose, no bilirubin, blood no WBC no RBC No bacteria No crystals O declines a C and S BP = 130, verified x 3. Spec fPL 15.8 high- consistent with pancreatitis. conclusions from abdominal ultrasound: 1. moderate chronic active pancreatitis 2. moderate vacuolar hepatopathy, from DM likely 3. mild to mod bilateral adrenomegaly- R/O incidental, hypertrophy from chronic illness, cushings. Go Home Medications: -Bup (0.3 mg/ml) Give 0.2 BID -Amoxi (50 mg) give 1 tablet BID x15 days (because could not do culture) -Metronidazole 50 mg BID x 10 days -Increase glargine to 10 U BID just to have a round number - less than 7% carb diet OTC- I forgot which one but o got it off a list we have at the clinic. At home glucose curve. 12/14/12 6:49am 405 fed at 7:10 gave 10u insulin. 8:47am 396 11:31am 391 1:28pm 337 3:34pm 417 5:31pm 443 6:51pm 453 fed at 7pm gave 10u In the month of december, patient had a small amount of intermittent loose stool. He has switched to the new diet however then. New Plan Dec 28, 2012: -1/2 tsp of live culture yogurt at home for probiotics once daily. -buprenex 0.2 ml by mouth twice daily for 2 weeks. -SQ fluids 100 ml SID SQ -Metronidazole 50 mg tablets: 1 tablet by mouth twice daily -Ursodial (250mg tablet): give 1/4 tablet once daily for 2 weeks. (#4)- (pick up at a regular pharmacy). can get it from a compounding pharmacy in a liquid if needed.- o declines this for now -Take glucose curves weekly and call with results. -Come in for a pancreatitis test and recheck appt in 2-3 weeks. -If not improved in 2 weeks then internal medicine referral (where they can possibly start steroids). Jan 14th Curve at home: 6:22am - 287 fed at 6:30am. 3 oz of evo 95% and 10 units of insulin 8:29am - 339 8:35am - 320 (re-test) 10:35am - 165 12:21pm - 110 2:50pm - 157 4:27pm - 259 6:17pm - 418 fed at 6:30 pm. 3 oz of evo 95% and 10 units of insulin I am happy that he seems to be responding to insulin again. My questions are: 1. What should I do with the insulin dose? 2. should I start the ursodial now? 3. When should I recheck the pancreatitis? Could I send out the Feline SpPLI? 4. The owners do not have unlimited resources and nearing the end of their budget. They are having a hard time administering fluids. Which medications are necessary to continue? Help! I want to do what is right for this cat, and I am pleased we've made some progress. I've recommended that they see an internist but they are hesitant for financial reasons. Thanks in advance.

What are the adrenal measurements?

So maybe some emerging cushings, emerging renal disease, partial di?

I have a 12 yr old cat dx'd with diabetes mellitus 2 1/2 yrs. ago. Initial control went well but then blood glucose was consistently low. We tried glipzide at that point but blood glucose stayed too high and we went back to insulin. Past 1 1/2 years has been doing well but now starting to be hypoglycemic again.The cat is only getting 1 unit once a day. Where do I go from here? try no insulin again? Would a cat become noninsulin dependent this long after diagnosis?

Can you give us more detail about diet and any other health issues?

Was the dog really stressed out during the test?

Hello! So I have an interesting case..."Sammy" is a 9 year-old 12 pound diabetic cat that has been on glargine insulin for a while. One of the vets that I work with has the owner measuring the BGs on a twice-daily basis at home and adjusting his dose on a twice-daily basis according to the measurement. THe owner has the following chart: >300 - give 3.5 units 250-300 give 3 units 200-250 give 2.5 units 150-200 give 2 units 150 give 1 unit So, the cat's dose varies between 1 and 4 units twice daily. What is your opinion on managing diabetes this way? I would think it would not be ideal since the cat would never really get "regulated." If you can point me to any articles to share with other vets here that would be great! The cat has had asthma for a while, which has recently become worse. Another vet here at the clinic prescribed some Aminophylline at 25mg PO BID, which has seemed to help. I don't think the owners would be able to do cyclosporine or an inhaler. Do you have a specific bronchodilator that you prefer, and if so at what dose? Any preferred compounding pharmacies? THanks very much, Dr. ☼

Also, what diet is sammy ingesting?

Is he on any topical steroids since the cataract surgery?

Hello! So I have an interesting case..."Sammy" is a 9 year-old 12 pound diabetic cat that has been on glargine insulin for a while. One of the vets that I work with has the owner measuring the BGs on a twice-daily basis at home and adjusting his dose on a twice-daily basis according to the measurement. THe owner has the following chart: >300 - give 3.5 units 250-300 give 3 units 200-250 give 2.5 units 150-200 give 2 units 150 give 1 unit So, the cat's dose varies between 1 and 4 units twice daily. What is your opinion on managing diabetes this way? I would think it would not be ideal since the cat would never really get "regulated." If you can point me to any articles to share with other vets here that would be great! The cat has had asthma for a while, which has recently become worse. Another vet here at the clinic prescribed some Aminophylline at 25mg PO BID, which has seemed to help. I don't think the owners would be able to do cyclosporine or an inhaler. Do you have a specific bronchodilator that you prefer, and if so at what dose? Any preferred compounding pharmacies? THanks very much, Dr. ☼

Do we have him on a low carb choice?

Can you please post photos of noir?

Hello! So I have an interesting case..."Sammy" is a 9 year-old 12 pound diabetic cat that has been on glargine insulin for a while. One of the vets that I work with has the owner measuring the BGs on a twice-daily basis at home and adjusting his dose on a twice-daily basis according to the measurement. THe owner has the following chart: >300 - give 3.5 units 250-300 give 3 units 200-250 give 2.5 units 150-200 give 2 units 150 give 1 unit So, the cat's dose varies between 1 and 4 units twice daily. What is your opinion on managing diabetes this way? I would think it would not be ideal since the cat would never really get "regulated." If you can point me to any articles to share with other vets here that would be great! The cat has had asthma for a while, which has recently become worse. Another vet here at the clinic prescribed some Aminophylline at 25mg PO BID, which has seemed to help. I don't think the owners would be able to do cyclosporine or an inhaler. Do you have a specific bronchodilator that you prefer, and if so at what dose? Any preferred compounding pharmacies? THanks very much, Dr. ☼

Any dental disease that needs to be addressed?

Glucose curve -- could this dog be over treated somogyi?

Hi there, I have a 10 year old female spayed DSH that was recently diagnosed with diabetes mellitus. It appeared she was not responding well to treatment, as we would spot check her glucose in house and it continued to rise for 2 weeks in a row. I observed the owner administer the insulin, and he was, in fact, giving it IM in the trapezius muscle. I reviewed the injection procedure with him and advised him that we may do well to purchase a glucometer and take readings at home to ensure accuracy. This plan was fine with the owner, except that he is on a fixed income and did not immediately have the funds to purchase a veterinary glucometer. OBVIOUSLY, a veterinary product is preferred, which I communicated to him. His wife is a diabetic also, however, and so he took this weeks reading with her glucometer. The glucose reading decreased from 600 to 347. Before I perform any doseage changes, my question is what is the percent error possible when using a human glucometer? In cases where clients have a human one, and can't af a veterinary product, is a human glucometer acceptable to use to check for extreme hyper or hypo glycemia? Obviously for fine tuning, we need a veterinary product...but in emergencies, how much can we rely on a human glucometer? Thanks, ☼

What insulin are you using?

Initially there were a lot of spherocytes?

Hi there, I have a 10 year old female spayed DSH that was recently diagnosed with diabetes mellitus. It appeared she was not responding well to treatment, as we would spot check her glucose in house and it continued to rise for 2 weeks in a row. I observed the owner administer the insulin, and he was, in fact, giving it IM in the trapezius muscle. I reviewed the injection procedure with him and advised him that we may do well to purchase a glucometer and take readings at home to ensure accuracy. This plan was fine with the owner, except that he is on a fixed income and did not immediately have the funds to purchase a veterinary glucometer. OBVIOUSLY, a veterinary product is preferred, which I communicated to him. His wife is a diabetic also, however, and so he took this weeks reading with her glucometer. The glucose reading decreased from 600 to 347. Before I perform any doseage changes, my question is what is the percent error possible when using a human glucometer? In cases where clients have a human one, and can't af a veterinary product, is a human glucometer acceptable to use to check for extreme hyper or hypo glycemia? Obviously for fine tuning, we need a veterinary product...but in emergencies, how much can we rely on a human glucometer? Thanks, ☼

Dose?

Was lab work done in-house or sent to commercial lab?

Hi there, I have a 10 year old female spayed DSH that was recently diagnosed with diabetes mellitus. It appeared she was not responding well to treatment, as we would spot check her glucose in house and it continued to rise for 2 weeks in a row. I observed the owner administer the insulin, and he was, in fact, giving it IM in the trapezius muscle. I reviewed the injection procedure with him and advised him that we may do well to purchase a glucometer and take readings at home to ensure accuracy. This plan was fine with the owner, except that he is on a fixed income and did not immediately have the funds to purchase a veterinary glucometer. OBVIOUSLY, a veterinary product is preferred, which I communicated to him. His wife is a diabetic also, however, and so he took this weeks reading with her glucometer. The glucose reading decreased from 600 to 347. Before I perform any doseage changes, my question is what is the percent error possible when using a human glucometer? In cases where clients have a human one, and can't af a veterinary product, is a human glucometer acceptable to use to check for extreme hyper or hypo glycemia? Obviously for fine tuning, we need a veterinary product...but in emergencies, how much can we rely on a human glucometer? Thanks, ☼

Is the cat on a canned, low carb, high protein diet?

What diet is he eating?

Tuffy is a 13 yr old NM DSH weighing 13 lbs. He was diagnosed with DM 3 months ago (BG 523). Tuffy was placed on 1 U of lantus BID. Food 1/2 can Fancy feast BID and 1/4 C indoor formula BID. We increased to 2 U Lantus BID and in 1 month his BG was 87. Then 1 U lantus BID in 2 weeks BG 85. then 1 U SID for 1 week and the 1/2U SID for 1 week-BG 110. No insulin for 2 weeks then BG 150mg/dl. Started DM dry food and 1/2can fancy feast BID and 1 U Lantus SID. Today the BG is 130mg/dl. So it looked like he may not need insulin-now he's back on it. Was going to increase the Fancy feast to 1 can BID. Continue on 1 U Lantus SID. Do you have other suggestions or thoughts on food or insulin dosage?

Was tuffy an overweight cat to begin with?

No dry at all?

Tuffy is a 13 yr old NM DSH weighing 13 lbs. He was diagnosed with DM 3 months ago (BG 523). Tuffy was placed on 1 U of lantus BID. Food 1/2 can Fancy feast BID and 1/4 C indoor formula BID. We increased to 2 U Lantus BID and in 1 month his BG was 87. Then 1 U lantus BID in 2 weeks BG 85. then 1 U SID for 1 week and the 1/2U SID for 1 week-BG 110. No insulin for 2 weeks then BG 150mg/dl. Started DM dry food and 1/2can fancy feast BID and 1 U Lantus SID. Today the BG is 130mg/dl. So it looked like he may not need insulin-now he's back on it. Was going to increase the Fancy feast to 1 can BID. Continue on 1 U Lantus SID. Do you have other suggestions or thoughts on food or insulin dosage?

Was his t4 normal and was a urine culture checked and negative?

Are them mixing/shaking the vetsulin as directed by manufacturer?

Myrtle is a 13 year old FS DLH that was diagnosed with diabetes in late july, 2012. she weighed 9.36 lbs at that time. she was placed on 2 units Lantus subQ BID and started on Fancy feast chunky chicken (or turkey). she came in for her first curve on 9-13-12 at 9.54 lbs. here are results. fed and given insulin at 7 am 8:15 450 10:15 455 12:15 489 2:15 510 4:00 497 6:00 509 7:00 510 i increased her insulin from 2 to 2.5 units BID. she came in yesterday at 10.32 lbs. fed at 7 am and given insulin at 7:20 am 8:15 433 9:26 479 10:20 492 11:26 468 12:21 482 1:20 495 2:19 487 3:23 472 4:20 517 5:25 511 6:20 474 7:00 473 i learned thatr the owner is using a bottle of insulin purchased on 11-11-12, but was NOT refrigerated. (i had told her to always refrigerate the insulin so it will last 3 months, but the pharmacy put a sticker on it saying to leave it at room temperature because cold insulin stings the cat when injected.) so as i understand it, room temperature insulin is only good for ONE month. should i ignore the curve and just get a new bottle and re-curve in a few weeks? if i trust the current curve, should i increase dose by half a unit or can i go up by a full unit? i did a half unit last time as it was first dosage change, but it seems i have the room to increase up to 3.5 units BID. thanks,

Is there any chance for this client to pursue in-home testing?

I'm not quite sure what you're describing as skin fragility?

Myrtle is a 13 year old FS DLH that was diagnosed with diabetes in late july, 2012. she weighed 9.36 lbs at that time. she was placed on 2 units Lantus subQ BID and started on Fancy feast chunky chicken (or turkey). she came in for her first curve on 9-13-12 at 9.54 lbs. here are results. fed and given insulin at 7 am 8:15 450 10:15 455 12:15 489 2:15 510 4:00 497 6:00 509 7:00 510 i increased her insulin from 2 to 2.5 units BID. she came in yesterday at 10.32 lbs. fed at 7 am and given insulin at 7:20 am 8:15 433 9:26 479 10:20 492 11:26 468 12:21 482 1:20 495 2:19 487 3:23 472 4:20 517 5:25 511 6:20 474 7:00 473 i learned thatr the owner is using a bottle of insulin purchased on 11-11-12, but was NOT refrigerated. (i had told her to always refrigerate the insulin so it will last 3 months, but the pharmacy put a sticker on it saying to leave it at room temperature because cold insulin stings the cat when injected.) so as i understand it, room temperature insulin is only good for ONE month. should i ignore the curve and just get a new bottle and re-curve in a few weeks? if i trust the current curve, should i increase dose by half a unit or can i go up by a full unit? i did a half unit last time as it was first dosage change, but it seems i have the room to increase up to 3.5 units BID. thanks,

No other issues in this kitty that could be causing insulin resistance, including oral pathology, a uti, gi disease, etc.?

You've checked the accuracy of your glucometer?

Boo is a 6yr old golden retriever. She's been on phenobarbital at gradually increasing doses over three years now. She was having some breakthroughs 6 months ago so we started KBr since her phenobarb level is consistently in mid therapeutic range. Boo did not tolerate the kbr well. We hospitalized her for a week while she recovered from her severe neurologic and gi side effects. She has a very sensitive gi tract so she's on sensitive stomach only The most recent problem also includes hyperlipidemia. Bloodwork has ruled out diabetes, pancreatitis, hypothyroid and cushings disease but her lipids are 980 and the diet is definitely not the cause. So for now we have her on 180 mg phenobarb BID with diazepam for seizure emergency. Any ideas for the high fats and breakthrough seizures? I apologize for typps as I'm working from phone tpday:)

I am assuming by lipid that you mean triglycerides?

Any bg curves yet on the prozinc?

Boo is a 6yr old golden retriever. She's been on phenobarbital at gradually increasing doses over three years now. She was having some breakthroughs 6 months ago so we started KBr since her phenobarb level is consistently in mid therapeutic range. Boo did not tolerate the kbr well. We hospitalized her for a week while she recovered from her severe neurologic and gi side effects. She has a very sensitive gi tract so she's on sensitive stomach only The most recent problem also includes hyperlipidemia. Bloodwork has ruled out diabetes, pancreatitis, hypothyroid and cushings disease but her lipids are 980 and the diet is definitely not the cause. So for now we have her on 180 mg phenobarb BID with diazepam for seizure emergency. Any ideas for the high fats and breakthrough seizures? I apologize for typps as I'm working from phone tpday:)

Was cholesterol normal?

Why was the dog started on 10 units -- usual starting dose would be around 20?

Hello, I have a 12 year old 16# DSH male neutered cat who has been given several Depo-MEdrol injections (20 mg) recently for asthma. Through 10/12-- 1/13 he has had to have them about every 2-4 wks. I KNOW this is not ideal; the owner initially told us that he could absolutely not do oral meds with this cat. The most recent Depo injection was on 1/5/13. He came in today for one more injection and has appeared to have lost a pound in 2 wks. so we decided to check a urinalysis for glucose and this was positive++++. U/A also showed trace blood, protein, SG>1.050, and + leukocytes. Chem panel showed blood glucose of 357. I started this cat on Humulin N 2 units BID. Does this seem like the correct thing to do? I know that a fructosamine level is recommended and I will recommend this to the owner. Considering that ideally this cat needs to be off steroids, how effective is Atopica for asthma? How quickly does it take effect? Any other alternatives to treat the asthma? This cat is also on theophylline. THANK YOU ☼

How is the cat getting the theophylline?

I'm not quite following this but it sounds like you're monitoring with single bg readings, not bg curves?

We lost a patient recently and are still bothered by a lack of answers. A 1.5yr old whippet was quite small but other wise normal. She was fed a raw diet. Presented to us acutely down and hypoglycemic, with brick red mucous membranes and hypothermia. She was treated with antibiotics, fluids w/Dextrose. Labs: neutropenia, maybe hypocalcemic, but not repeatable. Although she improved she continued to be hypoglycemic, even on the Dextrose. The owner opted for euthanasia, necropsy showed no evidence of an insulinoma, did see hemorrhage in small foci on the spleen, hemorrhage in the lungs with bacteria and some white cells, but considered an insufficient immune response to the bacteria. My rule outs included sepsis. Any others? Thanks!

Sighthounds usually have a lowish neutrophil count...how low was this one?

Was dog treated with anything else (palladia, vinblastine, ccnu)?

We lost a patient recently and are still bothered by a lack of answers. A 1.5yr old whippet was quite small but other wise normal. She was fed a raw diet. Presented to us acutely down and hypoglycemic, with brick red mucous membranes and hypothermia. She was treated with antibiotics, fluids w/Dextrose. Labs: neutropenia, maybe hypocalcemic, but not repeatable. Although she improved she continued to be hypoglycemic, even on the Dextrose. The owner opted for euthanasia, necropsy showed no evidence of an insulinoma, did see hemorrhage in small foci on the spleen, hemorrhage in the lungs with bacteria and some white cells, but considered an insufficient immune response to the bacteria. My rule outs included sepsis. Any others? Thanks!

Was the albumin low?

What does she currently weigh?

Oscar is a 12 yr old m/n cat, diagnosed with DM 3 years ago. He reverted back to normoglycemic for 2 years on high protein, low carb diet. Recently, he became diabetic again and we are having trouble getting his glucose under control. We have rechecked his full chem panel (WNL) and a urine culture - no growth. The owners are doing blood glucose curves every 2 weeks. They are checking blood glucose twice daily. He is presently getting 2.5 U of Lantus. His blood sugar drops to approximately 6 mmol but when they check at night, it has climbed to over 20. Can we expect better control? He is overweight and I am having trouble getting his owners to decrease his food intake as he has a voracious appetite. We have gone back over injections with the owners to ensure that they are giving them properly. On the first curve, the bg dropped to 6.4. On the next curve, his bg didnt change at all. I am wondering if there is something else we can be doing to get this cat's blood sugar more controlled. Will it always climb back up over 20, even on insuling? Or can we expect it to stay in a lower range? Thanks

How much of what diet is he eating?

What site is this owner using?

Oscar is a 12 yr old m/n cat, diagnosed with DM 3 years ago. He reverted back to normoglycemic for 2 years on high protein, low carb diet. Recently, he became diabetic again and we are having trouble getting his glucose under control. We have rechecked his full chem panel (WNL) and a urine culture - no growth. The owners are doing blood glucose curves every 2 weeks. They are checking blood glucose twice daily. He is presently getting 2.5 U of Lantus. His blood sugar drops to approximately 6 mmol but when they check at night, it has climbed to over 20. Can we expect better control? He is overweight and I am having trouble getting his owners to decrease his food intake as he has a voracious appetite. We have gone back over injections with the owners to ensure that they are giving them properly. On the first curve, the bg dropped to 6.4. On the next curve, his bg didnt change at all. I am wondering if there is something else we can be doing to get this cat's blood sugar more controlled. Will it always climb back up over 20, even on insuling? Or can we expect it to stay in a lower range? Thanks

Body weight and bcs?

No possibility of obstruction/ mucocele?

Hey , Are diabetic dogs the only ones where you would preferentially do an ACTH stim to diagnose Cushings Ds. over a LDDS test? I didn't know this fact- certainly could have forgotten :( - it from the CE courses I have have had (one on VIN) that said LDDS was the test of choice. The dog I am currently dealing with has an owner who doesn't listen well, does not want to spend money, but wants a diagnosis. And is now convinced that cushings ds caused the diabetes m. and that she will no longer need insulin after we treat for Cushings ds, that we don't even know she has yet. (She is a 50 ish # ten year old dalmation cross diagnosed elsewhere with DM and started on NPH. She is potbellied with thin skin. She is currently at 26 units BID with no drop in BG. Changes in insulin level have not led to any change in BG. I know she needs to be around 50 units BID to call her insulin resistant, but owner is down the road of no return on this Hyperadrenocorticism diagnosis. I already did a urine C&S with negative result). So I plan to do an ACTH stim test. How easy is it to interpret these in a diabetic dog? If she has hyperadrenocorticism, looks like I should start trilostane. What is the long term prognosis for these dogs? Thanks (a little disorganized post-I was only going to ask the first question... sorry!)

Is the dog a spayed female?

How many calories/day does she get?

Hey , Are diabetic dogs the only ones where you would preferentially do an ACTH stim to diagnose Cushings Ds. over a LDDS test? I didn't know this fact- certainly could have forgotten :( - it from the CE courses I have have had (one on VIN) that said LDDS was the test of choice. The dog I am currently dealing with has an owner who doesn't listen well, does not want to spend money, but wants a diagnosis. And is now convinced that cushings ds caused the diabetes m. and that she will no longer need insulin after we treat for Cushings ds, that we don't even know she has yet. (She is a 50 ish # ten year old dalmation cross diagnosed elsewhere with DM and started on NPH. She is potbellied with thin skin. She is currently at 26 units BID with no drop in BG. Changes in insulin level have not led to any change in BG. I know she needs to be around 50 units BID to call her insulin resistant, but owner is down the road of no return on this Hyperadrenocorticism diagnosis. I already did a urine C&S with negative result). So I plan to do an ACTH stim test. How easy is it to interpret these in a diabetic dog? If she has hyperadrenocorticism, looks like I should start trilostane. What is the long term prognosis for these dogs? Thanks (a little disorganized post-I was only going to ask the first question... sorry!)

Can you post a few of the curves?

Can you comment specifically on the albumin?

Hello, I have a 15 yr old MN cat with multiple health issues: DM that is well controlled on lantus he is currently also on 1/2 tumil K BID, (last potassium level 7 months ago was 3.6 normal 3.9) 1/4 taurine BID, 1/2 lysine BID, 2000mcg B12 BID, (for a diabetic neuropathy that has since improved) 5mg pred BID (was started years ago after a stroke-like event and neruologic symptoms, and since his DM is well controlled, owner is reluctant to take him off the pred for fear of return of the neuro signs) 1/4 tsp miralax BID, 100mg DSS BID he has had three episodes of obstipation requiring manual evacuation in the last year, he has had a couple episodes of requring enemas as well. He is currently eating Wild Blue Dry food and fancy feast canned, and since his DM is well managed, they are reluctant to switch foods. today we got bloodwork back showing that his potassium is now down to 3.0 (3.9-5.3) HCT dropped from 29% to 24% but this time shows very slight increase in reticulocytes (.2%) or 1212 K/ul (3-50) I am going to have him increase the tumil K to 1 tab po BID (he weighs 9.6# and has gradual weight loss over the last year) He is difficult to draw blood on, could we wait up to 4 weeks to check electrolytes again? do you agree with this increase in the tumil K? Also, would you recommend any EPO for the advancing anemia, and if so, I am not sure where to get it at this point? BUN/creat look okay at 28 and 1.5 Any other ideas for the occasional obstipation? Thanks,

Has this been measured?

I honestly can't imagine any owner would want that....but maybe her only value to this owner is as a breeding dog?

Hi, Can you please help me interpret this dog's blood work? I'm confused....(surprise). Cali is a 10 yo MN Saluki. His BCS is 4/9. He presented with a primary complaint of PU (no PD), and possible urinary incontinence. Full cbc/chem/ua done in Nov 2012 was wnl. I repeated cbc/chem/ua here, and found a 324 blood glucose along with 2+ glucosuria. SG was 1.024. I submitted a fructosamine, which came back 364 (normal: 142-450), supposedly indicating good regulation. I did not see any evidence of a UTI, although I did put him on abx (cefpodoxime) for a skin infection yesterday. Is this dog truly diabetic? What would next step be? Thank you

Also, was this a fasting bg?

What dose would you advise?

Hello, I examined a 8 year old, neutered male dog that was presented for dribbling of urine. Upon palpation, appreciated this large, firm, hard bladder. Initially, I thought it was a large bladder stone. I was surprised after taking the radiograph. I have never encountered a bladder wall calcified like this. Any explanation? Couldn't find anything on a VIN search. thanks.

Is this dog diabetic?

What does a fundic exam show?

Hello, I am dealing with a very difficult case right now, and I am not sure about the cause of the changes in the blood work. Maragaret 10 year old FS DSH presented to our clinic 4 days ago (I did not see her at this visit) with severe respiratory distress, both inspiratory and expiratory difficulty, congestion, nasal discharge, inappetance. One week prior another cat in the same house was hospitalized for severe URI, and a multitude of other issues (hypertension, retinal detachments, CHF). Cats are all indoor w no contact w other animals. O reports that she is feeding an outdoor stary cat, but wases thoroughly and no sharing of bowls. According to the vet who saw her a few days ago, she was in extreme respiratory distress, xrays were fairly NSF, Blood work NSF (HCT 33%, Glucose 248). Treated with IV doxycycline, albuterol inhaler, IV dex. Sent home with oral pred, doxy and theophylline. Presented to me Yestaerday for anorexia (has not eaten in 5 days). O noted no v/d. Since her intitial visit o noted that she was extremely polydipsic. Increased RR noted (42 breaths/min), still some upper respiratory congestion, but major improevement from the previous visit. BCS 7/9. T: 101.6 Repeat radiographs showed mild bronchial changes and aerophagia. Vomited foamy material once in clinic, but o reports no hx of v/d. Blood work as follows: CBC: HCT 25% no autoagglutination on saline slide test blood smear, RBC's mostly all crenated WBC: WNL Chem: Liver values WNL BUN 47 Creat 3.2 Glucose 190 (WNL) Total Bilirubin: 3.3 Na: 130 K: 5.0 (WNL) Na:K: 26 Cl: 95 U/A: bilirubinuria bilirubin crystals USG > 1.050 no WBC's or bacteria seen RBC's ++++ "Flash scan" US: no ascites seen hyperechoic structures in bladder - likely blood clots Placed on IVF (NaCl,w vit B complex), mirtazepine, azithromycin, pepcid, cerenia, little noses nasal spray, IV baytril, continued pred SID. At this point, I assumed that most her issues were due to prolnged anorexia, inlfammation/infection, stress. But still concerned about the hyponatremia. Repeat Blood work next day: Still not eating, but BAR, no neuro signs, purring Azotemia resolved (BUN, Creat WNL) HCT 29% Na: 125!!! K: 5.7 (WNL) Na:K: 21 Cl: 92 Plasma Osmolality 260 (low) Glucose: 190 (WNL) Alb: 2.3 Liver values WNL I have no idea what is causing her hyponatremia. Could she be addisonian? I can't run ACTH stim right now bc she has been on pred for 4 days. If it had something to do with aldosterone, inappropriate ADH release or HOC - shouldn't she have dilute urine? She does not have a hx of GI issues (pancreatitis, etc), liver appears WNL, kidney's WNL, no diabetes and polydipsia noted in the clinic. Bladder intact and not oliguric. Any other ideas what could be going on with this cat? Thanks for your help!

Does this cat still have active components of each?

Any chance for an ultrasound?

A student asked, “What can a student do to start preparing for a feline specialization during their first year of school?” I got a bit involved in thinking about this answer asked by a 1st year student, so I thought I would share my response with you all. 1) Attention to detail, 2) Attention to l cases, l medicine, 3) Attention to online cases, 4) Educational and Life balance Attention to detail: Observe more, touch less, and talk less. Learn to ask incisive questions, not question for the sake of asking questions. In the exam room, 95% of my time is spent examining past records (ours and referral records); most of the answers are there. Our records are exhaustive, but not verbose. Hand written records from many practices are not very helpful; digital electronic medical records from some practices are even worse. About 5% of my time is spent talking to the client and examining the cat. I definitely observe the cat when it moves and interacts with the client and with its surroundings; even when I am not actively "examining" the cat. Attention to l cases: Find them, in the teaching hospital or local practices and follow them. Get a job, or volunteer, in a l practice on weekends/holidays. MSU’s ER, private practice; anywhere! Good or bad practice? You will still learn. Better, spend a day at an array of practices...so you can learn what is good/bad in your opinion. Before you graduate you should make it a goal to examine 1000 cats: - Look at 1000 eyes: buy a ophthalmoscope on eBay, set the to -3 diopters and look grossly, then inspect the retina. It will take many exams before you start to "see." - Look at 1000 ears it will take many exams before you stop hurting the cats, and then then will start cooperating. See the anatomy of the TM and figure out what is is! - Palpate 1000 kidneys....you should be able to feel bilateral kidneys in 95% of the cats you see. - Look in 1000 mouths. You should be able to diagram the anatomy of the mouth in your sleep. - Listen to 1000 hearts. Get used to your own pediatric (or neonatal scope). After many, you will stop over interpreting everything grin> - Aspirate 1000 things (masses, inflammation, and normal tissues even) and do cytology!! o “You miss more by not looking, than you will by not knowing,” said Thomas McCrae (1870–1935). Do not make a microscopic diagnosis from your fingers (or with a shadow or echoes). You need cells (aspirates; better, biopsies). - Don't always believe your specialists! Do talk to them. - Assess 1000 ECG's. These are gold standards for assessing rhythm issues...but we refer too many heart issues automatically to a cardiologist and we have forgotten this simple tool! These are simple things that do not get done (well) by 90% of the veterinarians. But they are such EASY skills to acquire and your findings will add ‘problems’ to your ‘problem list’ which will help you to better consider differentials. You will be a better diagnostician and help your clients to better care for the cats (save money, selecting fewer, yet more incisive tests).

Pick some thds and follow them?

When you say there has been 'no response' how do you define that?

I have a client with a 6-7 yr old 60 LB terrier cross that is a well controlled Diabetic that has been pruritic for past couple of weeks-When I saw him last week he had an area of moist dermatitis on lateral thigh-no other skin lesions-this was main area that he was bothering.Home with Cephalex and Hyydroxyzine-did well for first week but owner came in yesterday as for past 2-3 days increased pruritis-scratching some at lateral trunk and neck area and has been licking abit at the original area-still on both meds. He has had 3-4 episodes of mild pruritis over the past few years that usually clear up with Hydroxyzine. No skin lesions were noted yesterday other than the thigh area still abit inflammed. Can I use Atpoica on him for couple of weeks to see if I can get him to settle down? I recommended to put him on Revolution every 2 weeks for 3x to R/O any poss parasites. Thanks

How's the rest of the bloodwork inc thyroid?

Dyspnea?

I am treating a 6 year MC Min Schnauzer with diabetes mellitus and need some advice on insulin dose and diet. LONG "summary": Max originally presented to me 8/31/12 for and annual exam with PU/PD and weight loss (6 pound loss over 12 months; weight at that time: 18 lbs) noted by owner. Lab work was consistent with a ketotic diabetic. He was hospitalized and responded well to treatment. Urine culture was negative. Abdominal ultrasound (by radiologist) showed mild/active pancreatitis. Once stable he was discharged on NPH 3 units BID, amoxicillin, pepcid, and w/d diet. 9/11/12: Wt: 17 lbs. Energy much improved. BG curve (insulin given at home at 830a) 9am: 444, 11am: 362, 1p: 493, 3pm: 606 NPH increased to 5 units BID 9/26/12: Weight: 17 lbs PU/PD much improved BG curve (insulin given at 830a) 9a: 425, 11a: 95, 1p: 127, 3p: 180, 5p: 241, 7p: 281, 8p: 242 NPH continued at 5 units BID 12/8/12: Wt. 16 lb 5 oz PU/PD again BG curve (5 units NPH at 830a) 9a: 462, 11a: 168, 1p: 168, 3 p: 218, 5p: 413 NPH increased to 6 units BID 1/7/13: Wt. 16 lbs; cataracts have developed, epaxial muscle wasting has progressed, PU/PD improved but persists Some mornings has neg urine gluc, others there is 3 +, most of the time there is trace-1+ (o only able to check in am) BG curve (NPH 6 untis given at 830a) 9a: 436, 11a: 138, 1p: 106, 3p: 121, 5p 306 7p: 440 Questions: 1) The recent curve along with fact that on average there is trace-1+ glucose in urine reflect fairly good control to me. However, dog is PU/PD with weight loss and more muscle wasting. Is this dose of insulin appropriate? Is there any chance I am overdosing insulin with occasional neg gluc in urine? 2) The owner is feeding Max 1 entire can of w/d and 1.5 cups of dry w/d and 1 ounce of chicken per day. Should she be increasing calories? More w/d? more chicken? 3) The owner is motivated to consult with an ophthamologist for cataract removal. Is this an appropriate time to consider that given current clinical signs (pu/pd, wt. loss etc.)? 4) Given continued weight loss and PU/PD, should I be running more tests for concurrent disease? Thank you so much for any help!!!

Is he on any steroids in the eyes for the cataracts?

Is it possible to evaluate this in this cat?

I am treating a 6 year MC Min Schnauzer with diabetes mellitus and need some advice on insulin dose and diet. LONG "summary": Max originally presented to me 8/31/12 for and annual exam with PU/PD and weight loss (6 pound loss over 12 months; weight at that time: 18 lbs) noted by owner. Lab work was consistent with a ketotic diabetic. He was hospitalized and responded well to treatment. Urine culture was negative. Abdominal ultrasound (by radiologist) showed mild/active pancreatitis. Once stable he was discharged on NPH 3 units BID, amoxicillin, pepcid, and w/d diet. 9/11/12: Wt: 17 lbs. Energy much improved. BG curve (insulin given at home at 830a) 9am: 444, 11am: 362, 1p: 493, 3pm: 606 NPH increased to 5 units BID 9/26/12: Weight: 17 lbs PU/PD much improved BG curve (insulin given at 830a) 9a: 425, 11a: 95, 1p: 127, 3p: 180, 5p: 241, 7p: 281, 8p: 242 NPH continued at 5 units BID 12/8/12: Wt. 16 lb 5 oz PU/PD again BG curve (5 units NPH at 830a) 9a: 462, 11a: 168, 1p: 168, 3 p: 218, 5p: 413 NPH increased to 6 units BID 1/7/13: Wt. 16 lbs; cataracts have developed, epaxial muscle wasting has progressed, PU/PD improved but persists Some mornings has neg urine gluc, others there is 3 +, most of the time there is trace-1+ (o only able to check in am) BG curve (NPH 6 untis given at 830a) 9a: 436, 11a: 138, 1p: 106, 3p: 121, 5p 306 7p: 440 Questions: 1) The recent curve along with fact that on average there is trace-1+ glucose in urine reflect fairly good control to me. However, dog is PU/PD with weight loss and more muscle wasting. Is this dose of insulin appropriate? Is there any chance I am overdosing insulin with occasional neg gluc in urine? 2) The owner is feeding Max 1 entire can of w/d and 1.5 cups of dry w/d and 1 ounce of chicken per day. Should she be increasing calories? More w/d? more chicken? 3) The owner is motivated to consult with an ophthamologist for cataract removal. Is this an appropriate time to consider that given current clinical signs (pu/pd, wt. loss etc.)? 4) Given continued weight loss and PU/PD, should I be running more tests for concurrent disease? Thank you so much for any help!!!

If so, which one?

Have you done radiographs?

Raven is a 9 year old MN previously DLH cat with diabetes (on DM and 1 unit lantus SID, well controlled) and HCM (on 5 mg of aspirin q 3 days). Also on zylkene 75 mg PO SID. Presented today with spot of hair loss and bruising which can be explained by trauma. However Raven's coat has changed dramatically since he was diagnosed with diabetes a year ago. It has become shorter, thinner over all of body, has more red in his hair (is black but previously very little red tinge, now he is almost a reddish brown) and is balding on his caudal abdomen and inner back legs. Owner does not see him overgrooming and she is very observant of him (one of our techs). Any thoughts? Thanks,

Were the hairs that fell out and did not regrow discoloured like this?

Why do you think cushings?

Raven is a 9 year old MN previously DLH cat with diabetes (on DM and 1 unit lantus SID, well controlled) and HCM (on 5 mg of aspirin q 3 days). Also on zylkene 75 mg PO SID. Presented today with spot of hair loss and bruising which can be explained by trauma. However Raven's coat has changed dramatically since he was diagnosed with diabetes a year ago. It has become shorter, thinner over all of body, has more red in his hair (is black but previously very little red tinge, now he is almost a reddish brown) and is balding on his caudal abdomen and inner back legs. Owner does not see him overgrooming and she is very observant of him (one of our techs). Any thoughts? Thanks,

I guess it is also possible that there is underlying gi disease which may result in nutritional imbalance?

What brand is the owner's glucometer?

Raven is a 9 year old MN previously DLH cat with diabetes (on DM and 1 unit lantus SID, well controlled) and HCM (on 5 mg of aspirin q 3 days). Also on zylkene 75 mg PO SID. Presented today with spot of hair loss and bruising which can be explained by trauma. However Raven's coat has changed dramatically since he was diagnosed with diabetes a year ago. It has become shorter, thinner over all of body, has more red in his hair (is black but previously very little red tinge, now he is almost a reddish brown) and is balding on his caudal abdomen and inner back legs. Owner does not see him overgrooming and she is very observant of him (one of our techs). Any thoughts? Thanks,

I also read about immune-mediated/inflammatory attack on the melanocytes but secondary to?

Is the owner able to give the injections easily?

Hi, I need some help with a diabetic dog I am treating. Riley is a 12yr old FS lab mix. She first presented on 11/5/12 with the complaint of bloody urine. I also learned that she was pu/pd/pp for the past two months or so. Owner did not think there was any weight loss. We did bloodwork and ruled out diabetes at that time, but there was mixed liver enzyme elevation ( ALT 290 ALP 790 GGT 36) and major suspicion for UTI. Here is a summary of the bloodwork findings. CBC: HCT 44.7 WBC 8500 (stress leukogram) PLT 510k Chem: GLU 132 ALT 290 ALP 790 GGT 36 Chol 412 Trigly 225 UA (free catch): pH 6.0 SG 1.027 Neg glu, ket, bili 3+ bld 4+ prot Sediment: 30-50 wbc/hpf 50-75 rbc/hpf Marked bacteria No cystals or casts seen 1+ epi cells T4: 0.9 Fructosamine: 246 Spec cPL - 819 I started her on Clavamox (14 days), Tramadol, and fortiflora with instructions to return 10 days after finishing clavamox for cysto UA and urine culture. I would not do this now - would have them come back for cysto and culture right away but finances were a concern. We talked at the time about needing a urine culture, hopefully negative culture, before we would test for Cushing's. Riley came in again on 12/6/12. She had finished clavamox two weeks before. She was very pu/pd, and new complaint of bloody urine and bloody diarrhea. We repeated UA and urine culture, grew E coli (2 days later), and started treatment with baytril (2 days later when culture results were back) and metronidazole and proviable for the diarrhea. Her weight was down 0.5lb at this visit. UA showed evidence of UTI, and also 3+ glucosuria. UA (voided): pH 6.0 SG 1.023 1+ prot 3+ glucose Neg ketones 3+ bld Neg bili Sediment: 20-30 wbc/hpf 75-100 rbc/hpf Marked bacteria (>40/hpf) Rare epi cells, no crystals or casts I feel really dumb, but I am really not good at getting blind cystos on dogs, even a pu/pd dog like this. I can do cats without a problem because I can hold the bladder (unless it is a really fat cat) and stick. So I'm still working on my blind cystos in dogs. We repeated bloodwork in-house because of the new finding of glucosuria. It confirmed diabetes (glucose 575, ALP 1651, ALT 352), and Riley was started on Novolin N at 0.5 units/kg (16 units BID). Educated owner about how to draw up and give insulin, moving injection sites around on the body, administering insulin after she eats, meal feeding and measuring her food, signs of hypoglycemia, and the importance of monitoring her thirst, urinations, and appetite. We planned to do a curve 1 week later and why frequent curves are necessary in the beginning when we are evaluating the dosage. I discussed with her at the time that Riley is likely to be more difficult to regulate than "normal" diabetic because we have a recent history of pancreatitis and suspicion for Cushing's. However, I wanted to try to get UTI treated and diabetes under control before we did an ACTH stim test. Plan was to treat with baytril for 7 weeks, recheck urine culture 10 days off baytril, again a month later, then every 4-6 months longterm. I called to check on Riley several times, and owner felt comfortable with everything. We had to call a few times to remind owner about BG curve. She brought Riley is on 12/21/12. She fed her breakfast at home around 7:45am, gave insulin at 7:50am, and drove to the clinic. 8:10 AM - HI 10:07 AM - 691 12:15 PM - 688 2:08 PM - HI I spoke with an internist at idexx, and she recommended stopping curve after 6 hours because no response at all and increasing insulin by 3 units to 19 units BID. Riley had not lost any weight at this visit. We also started on royal canin low fat canned and dry food. I spoke with owner a couple of days later to check on Riley. She said Riley was drinking less water (not a huge difference, but detectable), and she had slept through the night without needing to go out. So this sounded positive to me. There were no signs of hypoglycemia at home. Owner again did not come in for curve a week later. Had to call her a few times and leave messages. When I talked to her on 1/5/13, owner said the pu/pd was much better, but Riley seemed lethargic. There were no other obvious signs of hypoglycemia after questioning her. I told her again that Riley needs to come in for another curve now. She said she would be paid on the 15th of the month, so she would bring her in then. She brought Riley in on 1/16/13, and she looked really depressed. She was down 3.6# to 57.9#. She was not eating as well per owner (the first that I was told this, even though she was always instructed to call if Riley didn't eat) and was more pu/pd. BG was 602 and UA showed large glucose but no ketones. I was surprised that she was not DKA. Next curve is from 1/17/13. Owner fed and gave insulin at home. Food - canned and dry royal canin low fat (7:30 AM) Insulin - 19 units BID (given at 7:10 AM) Dropped off for BG curve at 8:30 AM. Owner says that Riley's water consumption is normal to possibly a little bit increased; she is eating regularly (eating better now that they are mixing canned and dry together) and she seems hungry (looking for more food); her urinations are 50% more than normal; she is having normal BMs; and her activity level is less than normal. BG Curve 8:30 AM - HI 10:30 AM - HI 12:30 PM - 731 2:30 PM - 492 4:30 PM - 443 6:00 PM - 429 Riley looked much better, not depressed like the day before. But I still feel like I'm doing a terrible job. I knew she was going to be harder to regulate because she might have Cushing's, but I'm getting even more worried about this dog. I increased her insulin by 2 units to 21 units BID. I discussed referral to internist for ACTH stim, urine culture, abdominal ultrasound, and if Cushing's is confirmed, starting treatment for Cushing's while treating the diabetes. At this point, owner is very worried about her dog (she has lost weight, appetite is not consistent like usual, she is much less energetic). I hoped that she would pursue referral, but the cost of ACTH stim and follow up testing was not feasible. We are doing another curve today, 7 days after last curve. I think I finally got through to her about how serious this is. Owner fed Riley at 7:15am and gave insulin 21 units at 8am. She dropped her off at 8:35am. Riley is down to 56.4# (from 57# on 1/17). Today's curve: 8:40 am - 695 I'm sorry for the really long post. I can provide more info about bloodwork, PEs as well, but I just wanted to start writing up this case while I could. I'm wondering at this point if it is time to start thinking about a different insulin. I know we are not at the level of insulin resistance yet (I think that is around 60 units BID), but I just want to make sure I am doing everything I can to help this dog. I think ACTH stim and abdominal ultrasound are not in the cards right now with owner finances. I will post the rest of today's curve when I have it. Thanks very much,

Do you think she just doesn't like the rc diet?

Did we happen to check a urinalysis for glucosuria?

Hi, I need some help with a diabetic dog I am treating. Riley is a 12yr old FS lab mix. She first presented on 11/5/12 with the complaint of bloody urine. I also learned that she was pu/pd/pp for the past two months or so. Owner did not think there was any weight loss. We did bloodwork and ruled out diabetes at that time, but there was mixed liver enzyme elevation ( ALT 290 ALP 790 GGT 36) and major suspicion for UTI. Here is a summary of the bloodwork findings. CBC: HCT 44.7 WBC 8500 (stress leukogram) PLT 510k Chem: GLU 132 ALT 290 ALP 790 GGT 36 Chol 412 Trigly 225 UA (free catch): pH 6.0 SG 1.027 Neg glu, ket, bili 3+ bld 4+ prot Sediment: 30-50 wbc/hpf 50-75 rbc/hpf Marked bacteria No cystals or casts seen 1+ epi cells T4: 0.9 Fructosamine: 246 Spec cPL - 819 I started her on Clavamox (14 days), Tramadol, and fortiflora with instructions to return 10 days after finishing clavamox for cysto UA and urine culture. I would not do this now - would have them come back for cysto and culture right away but finances were a concern. We talked at the time about needing a urine culture, hopefully negative culture, before we would test for Cushing's. Riley came in again on 12/6/12. She had finished clavamox two weeks before. She was very pu/pd, and new complaint of bloody urine and bloody diarrhea. We repeated UA and urine culture, grew E coli (2 days later), and started treatment with baytril (2 days later when culture results were back) and metronidazole and proviable for the diarrhea. Her weight was down 0.5lb at this visit. UA showed evidence of UTI, and also 3+ glucosuria. UA (voided): pH 6.0 SG 1.023 1+ prot 3+ glucose Neg ketones 3+ bld Neg bili Sediment: 20-30 wbc/hpf 75-100 rbc/hpf Marked bacteria (>40/hpf) Rare epi cells, no crystals or casts I feel really dumb, but I am really not good at getting blind cystos on dogs, even a pu/pd dog like this. I can do cats without a problem because I can hold the bladder (unless it is a really fat cat) and stick. So I'm still working on my blind cystos in dogs. We repeated bloodwork in-house because of the new finding of glucosuria. It confirmed diabetes (glucose 575, ALP 1651, ALT 352), and Riley was started on Novolin N at 0.5 units/kg (16 units BID). Educated owner about how to draw up and give insulin, moving injection sites around on the body, administering insulin after she eats, meal feeding and measuring her food, signs of hypoglycemia, and the importance of monitoring her thirst, urinations, and appetite. We planned to do a curve 1 week later and why frequent curves are necessary in the beginning when we are evaluating the dosage. I discussed with her at the time that Riley is likely to be more difficult to regulate than "normal" diabetic because we have a recent history of pancreatitis and suspicion for Cushing's. However, I wanted to try to get UTI treated and diabetes under control before we did an ACTH stim test. Plan was to treat with baytril for 7 weeks, recheck urine culture 10 days off baytril, again a month later, then every 4-6 months longterm. I called to check on Riley several times, and owner felt comfortable with everything. We had to call a few times to remind owner about BG curve. She brought Riley is on 12/21/12. She fed her breakfast at home around 7:45am, gave insulin at 7:50am, and drove to the clinic. 8:10 AM - HI 10:07 AM - 691 12:15 PM - 688 2:08 PM - HI I spoke with an internist at idexx, and she recommended stopping curve after 6 hours because no response at all and increasing insulin by 3 units to 19 units BID. Riley had not lost any weight at this visit. We also started on royal canin low fat canned and dry food. I spoke with owner a couple of days later to check on Riley. She said Riley was drinking less water (not a huge difference, but detectable), and she had slept through the night without needing to go out. So this sounded positive to me. There were no signs of hypoglycemia at home. Owner again did not come in for curve a week later. Had to call her a few times and leave messages. When I talked to her on 1/5/13, owner said the pu/pd was much better, but Riley seemed lethargic. There were no other obvious signs of hypoglycemia after questioning her. I told her again that Riley needs to come in for another curve now. She said she would be paid on the 15th of the month, so she would bring her in then. She brought Riley in on 1/16/13, and she looked really depressed. She was down 3.6# to 57.9#. She was not eating as well per owner (the first that I was told this, even though she was always instructed to call if Riley didn't eat) and was more pu/pd. BG was 602 and UA showed large glucose but no ketones. I was surprised that she was not DKA. Next curve is from 1/17/13. Owner fed and gave insulin at home. Food - canned and dry royal canin low fat (7:30 AM) Insulin - 19 units BID (given at 7:10 AM) Dropped off for BG curve at 8:30 AM. Owner says that Riley's water consumption is normal to possibly a little bit increased; she is eating regularly (eating better now that they are mixing canned and dry together) and she seems hungry (looking for more food); her urinations are 50% more than normal; she is having normal BMs; and her activity level is less than normal. BG Curve 8:30 AM - HI 10:30 AM - HI 12:30 PM - 731 2:30 PM - 492 4:30 PM - 443 6:00 PM - 429 Riley looked much better, not depressed like the day before. But I still feel like I'm doing a terrible job. I knew she was going to be harder to regulate because she might have Cushing's, but I'm getting even more worried about this dog. I increased her insulin by 2 units to 21 units BID. I discussed referral to internist for ACTH stim, urine culture, abdominal ultrasound, and if Cushing's is confirmed, starting treatment for Cushing's while treating the diabetes. At this point, owner is very worried about her dog (she has lost weight, appetite is not consistent like usual, she is much less energetic). I hoped that she would pursue referral, but the cost of ACTH stim and follow up testing was not feasible. We are doing another curve today, 7 days after last curve. I think I finally got through to her about how serious this is. Owner fed Riley at 7:15am and gave insulin 21 units at 8am. She dropped her off at 8:35am. Riley is down to 56.4# (from 57# on 1/17). Today's curve: 8:40 am - 695 I'm sorry for the really long post. I can provide more info about bloodwork, PEs as well, but I just wanted to start writing up this case while I could. I'm wondering at this point if it is time to start thinking about a different insulin. I know we are not at the level of insulin resistance yet (I think that is around 60 units BID), but I just want to make sure I am doing everything I can to help this dog. I think ACTH stim and abdominal ultrasound are not in the cards right now with owner finances. I will post the rest of today's curve when I have it. Thanks very much,

E.g. is she begging for other food?

Stress leukogram, coat changes, pot belly, muscle wastage, comedones?

Tiger Lily is obese 4 year old SF indoor cat with a history of otitis and anal gland impaction. She lives in a mulit-cat household. She was started on atopica 4 weeks ago and a wt loss program with w/d (17lb). On recheck 4 days ago, she was down to 16lb and ears looked great. I vaccinated her with DRC and Rabies and instructed the owner to taper to EOD on the atopica. She came in 3 days after vaccination for lethargy and anorexia. Owners said she started not acting right the day after vaccination. On presentation, she was dehydrated and febrile, T 105, 15.2lb. We hospitalized, submitted CBC/Chem/T4, admin SQ fluids, and started clavamox (62.5mg) 1 and 1/2 tab BID. Temp was 104.2 at the end of the day. BW was WNL except for: GLUCOSE 199 (70 - 165) mg/dL ...stress, diabetes (rechecking BG) CREATININE 0.81 (0.9 - 1.7) mg/dL ALK PHOS 13 (30 - 160) U/L ALT (SGPT) 30 (35 - 120) U/L WBC 4.4 (5.0 - 19.00) th/mm3 ACANTHOCYTES NIL NIL COMMENTS Platelet Clumps seen on smear.... NIL NIL Yesterday, she was seen by the other doctor in the practice. T 105. seemed lame in the rear with sensitivity on palpation of spine. She was given a dose of ketoprofen, no atopica for 2 days. She is eating today, urinated and defecated. Today: T 104.3. BAR. eating, tense on abdominal palpation, but nervous cat. o said there is 1 cat in the house that is indoor/outdoor. Felv/FIV negative BG 212 this am, 167 at noon UA: 3+leukocytosis, 2+protein, neg glucose, USGr 1.030, 2+protein, sediment: NSF (large full bladder, easily expressed today) Abdominal rads: NSF Is this potentially a vaccine reaction? Should I continue the atopica on EOD, start doxycycline? other diagnostics? Thank you for your assistance.

Was this a mlv vaccine?

Was she previously diagnosed as hypot4?

15 year old 12 lb m/n cat who is both diabetic and hyperthyroid. Hyperthyroidism is controlled at 2.5 mg Tapazole bid, but having trouble getting the diabetes under control. Started on glargine insulin at 3 U bid. Owner feeding canned low carb food. First curve 5 days later - lowest BG was 14.7 mmol/L. Gradually increased dose of insulin but could not get it under control. Eventually reached 8U bid of the Lantus insulin, and his BG was in the 20s (mmol/L) for the whole curve at that dose. Switched him to Humulin N, started at 3 U bid. Curve revealed poor control. Eventually reached 10 U Humulin. Latest curve (owner did at home) as follows - 8am BG HI, gave 10 U Humulin N. 10 am - BG 20.3 mmol/L 12 pm BG 10.3 mmol/L 2 pm BG 17.6 mmol/L 5 pm BG HI 8 pm gave 10 U Humulin N 9 pm BG 27.3 mmol/L 11 pm BG 13.9 mmol/L. So, the Humulin N is dropping the BG quickly, but not for very long. I was thinking of combining Lantus insulin @ 2 U bid with the Humulin N @ 4 U bid. Any other suggestions?

The owner is only feeding the canned version of the high protein/low carb food---which one is he on?

Was this a fasting sample?

15 year old 12 lb m/n cat who is both diabetic and hyperthyroid. Hyperthyroidism is controlled at 2.5 mg Tapazole bid, but having trouble getting the diabetes under control. Started on glargine insulin at 3 U bid. Owner feeding canned low carb food. First curve 5 days later - lowest BG was 14.7 mmol/L. Gradually increased dose of insulin but could not get it under control. Eventually reached 8U bid of the Lantus insulin, and his BG was in the 20s (mmol/L) for the whole curve at that dose. Switched him to Humulin N, started at 3 U bid. Curve revealed poor control. Eventually reached 10 U Humulin. Latest curve (owner did at home) as follows - 8am BG HI, gave 10 U Humulin N. 10 am - BG 20.3 mmol/L 12 pm BG 10.3 mmol/L 2 pm BG 17.6 mmol/L 5 pm BG HI 8 pm gave 10 U Humulin N 9 pm BG 27.3 mmol/L 11 pm BG 13.9 mmol/L. So, the Humulin N is dropping the BG quickly, but not for very long. I was thinking of combining Lantus insulin @ 2 U bid with the Humulin N @ 4 U bid. Any other suggestions?

How long since the last urine culture?

Diabetic cats can be fed throughout the day, but the total amount should be measured and reasonable for a cat this size?

15 year old 12 lb m/n cat who is both diabetic and hyperthyroid. Hyperthyroidism is controlled at 2.5 mg Tapazole bid, but having trouble getting the diabetes under control. Started on glargine insulin at 3 U bid. Owner feeding canned low carb food. First curve 5 days later - lowest BG was 14.7 mmol/L. Gradually increased dose of insulin but could not get it under control. Eventually reached 8U bid of the Lantus insulin, and his BG was in the 20s (mmol/L) for the whole curve at that dose. Switched him to Humulin N, started at 3 U bid. Curve revealed poor control. Eventually reached 10 U Humulin. Latest curve (owner did at home) as follows - 8am BG HI, gave 10 U Humulin N. 10 am - BG 20.3 mmol/L 12 pm BG 10.3 mmol/L 2 pm BG 17.6 mmol/L 5 pm BG HI 8 pm gave 10 U Humulin N 9 pm BG 27.3 mmol/L 11 pm BG 13.9 mmol/L. So, the Humulin N is dropping the BG quickly, but not for very long. I was thinking of combining Lantus insulin @ 2 U bid with the Humulin N @ 4 U bid. Any other suggestions?

What exactly are the post-pill t4 levels?

Was there a 12 hour fast before the cholesterol was measured?

15 year old 12 lb m/n cat who is both diabetic and hyperthyroid. Hyperthyroidism is controlled at 2.5 mg Tapazole bid, but having trouble getting the diabetes under control. Started on glargine insulin at 3 U bid. Owner feeding canned low carb food. First curve 5 days later - lowest BG was 14.7 mmol/L. Gradually increased dose of insulin but could not get it under control. Eventually reached 8U bid of the Lantus insulin, and his BG was in the 20s (mmol/L) for the whole curve at that dose. Switched him to Humulin N, started at 3 U bid. Curve revealed poor control. Eventually reached 10 U Humulin. Latest curve (owner did at home) as follows - 8am BG HI, gave 10 U Humulin N. 10 am - BG 20.3 mmol/L 12 pm BG 10.3 mmol/L 2 pm BG 17.6 mmol/L 5 pm BG HI 8 pm gave 10 U Humulin N 9 pm BG 27.3 mmol/L 11 pm BG 13.9 mmol/L. So, the Humulin N is dropping the BG quickly, but not for very long. I was thinking of combining Lantus insulin @ 2 U bid with the Humulin N @ 4 U bid. Any other suggestions?

How long ago was this last run?

(if you can examine it without losing a finger.) has anything changed in the house?

Dx diabetes in a DLH 6 yr old m/n last nov. They had noticed pu/pd for 6wk. 15#, (19# just the month before). Looks healthy. Did large panel and glu 470, Ca 11.4, T4 1, u/a 1.051 with 2+ prot, 3+ glu, rest wnl. Almost no tartar. Started 11-3-12 on glargine, 3 IU bid, eating generic dry 11-10-12: 15#, glu 317 (nadir pt). go to 4 IU bid 11-24: 15#, glu 318 (nadir pt), go to 5 IU bid 12-7: 15.5#, 356, go to 6 IU bid. Did 2 wk amoxi to see if infection. came back 12-12, can't give amoxi so gave convenia shot. 15.75#, 1-5-13: 16.5#, glu 319 nadir pt. go to 7 IU bid. 1-22: 16#, glu 397 nadir pt, 16# came back 1-23 close to closing (so closer to injection time) and glu 465. Fructosamine 619. Did dip stick urine, sp gr 1.040, 4+ glu, rest neg. Went to seminar with Dr. Nichols and said if >1.5IU/kg/dose indicates too much. But I also read >6 IU/cat too much (though this is large cat). I would like to con't what I'm doing based on the labwork (no curves done, hate them) but want to see what you thought cut off point would be. Is fairly youngish diabetic cat. I don't see any obvious acroaly but if diabetic at younger age are there different worries? We have talked about food alot. She is going to use m/d or equivalent and see if that helps. Thanks.

What is it you hate about the bg curves?

Do you have purina dm canned in israel?

I have a question regarding monitoring of a recently dx diabetic who I spayed today. We dx her diabetes approximately 1 month ago, and did sx today. She was doing fairly well on her insulin pre-sx. How do you monitor these dogs-hoping that she will be one of the lucky dogs whose diabetes resolves post ovh. Don't think these owners are going to be able to handle doing at home glucose checks, tho we can have that conversation. Thanks in advance for your help.

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

Urinalysis?

Hello! I have another diabetic to figure out. She is newly diagnosed on 12/31/12 and is an 11 yr FS mixed breed with a history of PU/PD and was otherwise normal. On her physical exam, the only real concern is a fractured upper fourth premolar and gr 2 periodontal disease. She is 65#. Her preliminary labwork results: CBC - WNL except mild eosinophilia 1428 (->1250) TT4 - WNL UA - 1.029 USG, 3+ glucose, no ketones negative urine culture Chem ALP 915 (->150) Glucose 605 (->125) Chloride 100 (105->) Na 135 (141->) My only question on her labwork is whether or not the low chloride and Na could be from any other cause besides polyuria with her diabetes. We started her on NPH insulin (novolin) at 7 units BID. We did not change her food (canidae senior) yet and the owner is feeding her just before or at same time as giving her her insulin. She normally only eats once daily at night and owner does not feel she is a predictable eater as she never has been. We performed a BG curve on 1/18/13: 8:00am = 342 8:10 fed (ate her own food) 7 units of insulin NPH SQ 10 am = 183 12 pm = 397 2pm =397 4pm=383 6pm=386 I decided to increase her insulin to 9 units BID. But I am concerned about the short duration of action of the NPH insulin. As we increase her dose, will we see the same time frame of effects? Do you have any suggestions as to how we can improve her control? Thanks,

How does the time that she was fed the day of the curve compare to the normal time?

What dose atopica?

I have a patient who's diabetes is not well controlled on NPH. The duration of action is not long enough for her. Is there as chance that vetsulin will go back off the market with the specific problem it had? Also, how do I change from NPH to vetsulin? Thank you,

She's a spayed female?

Does the owner consult with you on the insulin dose?

Hello there Angus is a 5 year old M/N Labrador I diagnosed w/ Diabetes Insipidus in September 2009. I did not do a water deprivation test, but he responded very well to Desmopressin .05mg PO BID. (Eye drops were not possible, this dog is extremely active and O unable to administer via conjuctiva). He has been very stable, still drinking more water than most dogs, but USG, increased from 1005 initially to 1030 or so, and stayed there through December 2012. At that time, the owner noted increasing water intake, and accidents in the house. BW and UA were unchanged, electrolytes chems, CBC all normal, USG at 1033. Because of the signs I increased the desmopressin to 0.05mg in am, and 0.1 mg in pm. According to the owner, the signs worsened at that dose for about 3 weeks. The owner decreased the dose back to the original 0.05mg BID, and noted fewer accidents in the house, and bright yellow color to the urine. However, a UA this week showed USG at 1010, otherwise very quiet sediment. Lab results follow, starting with the most recent. 1-22-2013: Urinalysis Urine pH 6 5.0-9.5 Sp Gravity 1.010 1.005-1.055 Appearance CLEAR Color YELLOW Protein NEG mg/dL Glucose NEG Ketone NEG Bili NEG Blood NEG Hyal Cast NEG Gran Cast NEG Bacteria NEG Mucus NEG WBC 0 - 4 RBC NEG Epith FEW Crystal Type NONE SEEN Comment Collection method = free catch Moderate amount of fat droplets. 12-03-2012: CBC WBC 5.7 L K/uL 6.0-17.0 RBC 6.64 M/uL 5.50-8.50 HGB 16.4 g/dl 12.0-18.0 HCT 51.2 % 37.0-55.0 MCV 77.1 H fL 60.0-77.0 MCH 24.7 pg 19.0-25.0 MCHC 32.1 % 32.0-36.0 Platelet count 199 L K/uL 200-500 Differential Count: % ABS Polys 49.9 2840 L /ul 3600-11500 Lymph 33.3 1900 /ul 1000-4800 Monos 4.9 280 /ul 150-1350 Eos 11.4 650 /ul 0-1250 Baso 0.6 30 /ul 0-500 COMMENTS: Cannot get accurate platelet count due to clumping Platelet estimate is adequate. Glucose, Plasma QNS mg/dl 65-130 Comment Plasma Glucose may be falsely decreased due to insufficient volume and/or hemolysis in the grey top tube. Serum glucose is the higher value and therefore more accurate. Canine Geriatric Chem Screen Glucose, Serum 64 L mg/dl 65-130 BUN 16 mg/dl 6-29 Creatinine 1.0 mg/dl 0.6-1.6 Sodium 146 meq/l 140-158 Potassium 4.8 meq/l 4.0-5.7 Na/K Ratio 30 27-40 Chloride 111 meq/l 100-118 Carbon Dioxide 23 meq/l 18-26 Anion Gap 17 13-25 Calcium 8.0 mg/dl 8.0-12.0 Phosphorus 4.6 mg/dl 3.0-7.0 Osm, Calc 290 270-310 Total Protein 5.9 g/dl 5.4-7.6 Albumin 3.4 g/dl 2.3-4.0 Globulin 2.5 g/dl 2.4-4.4 Alb/Glob Ratio 1.4 H 0.6-1.2 Bilirubin, Total 0.2 mg/dl 0.0-0.5 ALP 6 L U/L 10-84 GGT 0 U/L 0-10 ALT 41 U/L 5-65 AST 30 U/L 16-60 CK 110 U/L 50-300 Cholesterol 201 mg/dl 150-275 Amylase 329 U/L 300-1500 Lipase 199 U/L 0-425 T4, Canine 1.4 ug/dl 1.0-4.0 Prot/Creat Ratio, Urine Creatinine, Urine 224 mg/dl Protein, Urine 23.4 mg/dl Prot/Creat Ratio, 0.1 0-1 Urine Comment Canine and Feline Interpretation: Ratio is Less than 0.5 = Normal Ratio 0.5-1.0 = Borderline Greater than 1.0. = Suggestive of glomerular proteinuria. Urinalysis Urine pH 7 5.0-9.5 Sp Gravity 1.033 1.005-1.055 Appearance Sl CLOUDY Color YELLOW Protein 30 mg/dL Glucose NEG Ketone NEG Bili NEG Blood NEG Hyal Cast NEG Gran Cast NEG Bacteria NEG Mucus NEG WBC 0 - 4 RBC 0 - 4 Epith FEW Crystal Type NONE SEEN Crystal Amount NEG Comment Presence of protein has been verified by Sulfosalicylic Acid (SSA). Moderate amount of fat droplets. Amorphous debris present. Collection method = free catch 6-17-11: USG in house, 1.030 CBC WBC 5.5 L K/uL 6.0-17.0 RBC 7.05 M/uL 5.50-8.50 HGB 17.4 g/dl 12.0-18.0 HCT 50.4 % 37.0-55.0 MCV 71.4 fL 60.0-77.0 MCH 24.7 pg 19.0-25.0 MCHC 34.5 % 32.0-36.0 Platelet count 191 L K/uL 200-500 Differential Count: % ABS Polys 45.5 2500 L /ul 3600-11500 Lymph 37.5 2060 /ul 1000-4800 Monos 5.0 270 /ul 150-1350 Eos 11.7 640 /ul 0-1250 Baso 0.3 20 /ul 0-500 COMMENTS: Cannot get accurate platelet count due to clumping. Platelet estimate adequate. Few stimulated lymphocytes present. Glucose, Plasma 137 H mg/dl 65-130 Chemistry Screen Glucose, Serum 85 mg/dl 65-130 BUN 17 mg/dl 6-29 Creatinine 1.2 mg/dl 0.6-1.6 Sodium 146 meq/l 140-158 Potassium 5.1 meq/l 4.0-5.7 Na/K Ratio 29 27-40 Chloride 111 meq/l 100-118 Carbon Dioxide 22 meq/l 18-26 Anion Gap 18 13-25 Calcium 8.7 mg/dl 8.0-12.0 Phosphorus 3.9 mg/dl 3.0-7.0 Osm, Calc 292 270-310 Total Protein 6.2 g/dl 5.4-7.6 Albumin 3.8 g/dl 2.3-4.0 Globulin 2.4 g/dl 2.4-4.4 Alb/Glob Ratio 1.6 H 0.6-1.2 Bilirubin, Total 0.0 mg/dl 0.0-0.5 ALP SAMPLE TOO HEMOLYSU/L 10-84 GGT SAMPLE TOO HEMOLYSU/L 0-10 ALT 54 U/L 5-65 AST 54 U/L 16-60 Cholesterol 169 mg/dl 150-275 Hemolytic Index Marked Hemolysis Present Comment DUE TO THE SIGNIFICANT HEMOLYSIS THE FOLLOWING MAY BE AFFECTED. FALSELY INCREASED CONCENTRATION: Bun, Phosphorus, T.Protein, Albumin, ALT, AST, T. Bili, D. Bili, CPK, Mg, Calcium and Uric Acid. FALSELY DECREASED CONCENTRATION: Alk. Phos., GGT, Amylase, Lipase, CO2, and Glucose. ? I have advised a urine culture on the sample, though it was very inactive, but I'm not sure where to go from here. Sodium restriction? Can a thiazide diuretic be given in conjunction w/ desmopressin?

How exactly was di diagnosed?

Inspired co2 zero?

Hello there Angus is a 5 year old M/N Labrador I diagnosed w/ Diabetes Insipidus in September 2009. I did not do a water deprivation test, but he responded very well to Desmopressin .05mg PO BID. (Eye drops were not possible, this dog is extremely active and O unable to administer via conjuctiva). He has been very stable, still drinking more water than most dogs, but USG, increased from 1005 initially to 1030 or so, and stayed there through December 2012. At that time, the owner noted increasing water intake, and accidents in the house. BW and UA were unchanged, electrolytes chems, CBC all normal, USG at 1033. Because of the signs I increased the desmopressin to 0.05mg in am, and 0.1 mg in pm. According to the owner, the signs worsened at that dose for about 3 weeks. The owner decreased the dose back to the original 0.05mg BID, and noted fewer accidents in the house, and bright yellow color to the urine. However, a UA this week showed USG at 1010, otherwise very quiet sediment. Lab results follow, starting with the most recent. 1-22-2013: Urinalysis Urine pH 6 5.0-9.5 Sp Gravity 1.010 1.005-1.055 Appearance CLEAR Color YELLOW Protein NEG mg/dL Glucose NEG Ketone NEG Bili NEG Blood NEG Hyal Cast NEG Gran Cast NEG Bacteria NEG Mucus NEG WBC 0 - 4 RBC NEG Epith FEW Crystal Type NONE SEEN Comment Collection method = free catch Moderate amount of fat droplets. 12-03-2012: CBC WBC 5.7 L K/uL 6.0-17.0 RBC 6.64 M/uL 5.50-8.50 HGB 16.4 g/dl 12.0-18.0 HCT 51.2 % 37.0-55.0 MCV 77.1 H fL 60.0-77.0 MCH 24.7 pg 19.0-25.0 MCHC 32.1 % 32.0-36.0 Platelet count 199 L K/uL 200-500 Differential Count: % ABS Polys 49.9 2840 L /ul 3600-11500 Lymph 33.3 1900 /ul 1000-4800 Monos 4.9 280 /ul 150-1350 Eos 11.4 650 /ul 0-1250 Baso 0.6 30 /ul 0-500 COMMENTS: Cannot get accurate platelet count due to clumping Platelet estimate is adequate. Glucose, Plasma QNS mg/dl 65-130 Comment Plasma Glucose may be falsely decreased due to insufficient volume and/or hemolysis in the grey top tube. Serum glucose is the higher value and therefore more accurate. Canine Geriatric Chem Screen Glucose, Serum 64 L mg/dl 65-130 BUN 16 mg/dl 6-29 Creatinine 1.0 mg/dl 0.6-1.6 Sodium 146 meq/l 140-158 Potassium 4.8 meq/l 4.0-5.7 Na/K Ratio 30 27-40 Chloride 111 meq/l 100-118 Carbon Dioxide 23 meq/l 18-26 Anion Gap 17 13-25 Calcium 8.0 mg/dl 8.0-12.0 Phosphorus 4.6 mg/dl 3.0-7.0 Osm, Calc 290 270-310 Total Protein 5.9 g/dl 5.4-7.6 Albumin 3.4 g/dl 2.3-4.0 Globulin 2.5 g/dl 2.4-4.4 Alb/Glob Ratio 1.4 H 0.6-1.2 Bilirubin, Total 0.2 mg/dl 0.0-0.5 ALP 6 L U/L 10-84 GGT 0 U/L 0-10 ALT 41 U/L 5-65 AST 30 U/L 16-60 CK 110 U/L 50-300 Cholesterol 201 mg/dl 150-275 Amylase 329 U/L 300-1500 Lipase 199 U/L 0-425 T4, Canine 1.4 ug/dl 1.0-4.0 Prot/Creat Ratio, Urine Creatinine, Urine 224 mg/dl Protein, Urine 23.4 mg/dl Prot/Creat Ratio, 0.1 0-1 Urine Comment Canine and Feline Interpretation: Ratio is Less than 0.5 = Normal Ratio 0.5-1.0 = Borderline Greater than 1.0. = Suggestive of glomerular proteinuria. Urinalysis Urine pH 7 5.0-9.5 Sp Gravity 1.033 1.005-1.055 Appearance Sl CLOUDY Color YELLOW Protein 30 mg/dL Glucose NEG Ketone NEG Bili NEG Blood NEG Hyal Cast NEG Gran Cast NEG Bacteria NEG Mucus NEG WBC 0 - 4 RBC 0 - 4 Epith FEW Crystal Type NONE SEEN Crystal Amount NEG Comment Presence of protein has been verified by Sulfosalicylic Acid (SSA). Moderate amount of fat droplets. Amorphous debris present. Collection method = free catch 6-17-11: USG in house, 1.030 CBC WBC 5.5 L K/uL 6.0-17.0 RBC 7.05 M/uL 5.50-8.50 HGB 17.4 g/dl 12.0-18.0 HCT 50.4 % 37.0-55.0 MCV 71.4 fL 60.0-77.0 MCH 24.7 pg 19.0-25.0 MCHC 34.5 % 32.0-36.0 Platelet count 191 L K/uL 200-500 Differential Count: % ABS Polys 45.5 2500 L /ul 3600-11500 Lymph 37.5 2060 /ul 1000-4800 Monos 5.0 270 /ul 150-1350 Eos 11.7 640 /ul 0-1250 Baso 0.3 20 /ul 0-500 COMMENTS: Cannot get accurate platelet count due to clumping. Platelet estimate adequate. Few stimulated lymphocytes present. Glucose, Plasma 137 H mg/dl 65-130 Chemistry Screen Glucose, Serum 85 mg/dl 65-130 BUN 17 mg/dl 6-29 Creatinine 1.2 mg/dl 0.6-1.6 Sodium 146 meq/l 140-158 Potassium 5.1 meq/l 4.0-5.7 Na/K Ratio 29 27-40 Chloride 111 meq/l 100-118 Carbon Dioxide 22 meq/l 18-26 Anion Gap 18 13-25 Calcium 8.7 mg/dl 8.0-12.0 Phosphorus 3.9 mg/dl 3.0-7.0 Osm, Calc 292 270-310 Total Protein 6.2 g/dl 5.4-7.6 Albumin 3.8 g/dl 2.3-4.0 Globulin 2.4 g/dl 2.4-4.4 Alb/Glob Ratio 1.6 H 0.6-1.2 Bilirubin, Total 0.0 mg/dl 0.0-0.5 ALP SAMPLE TOO HEMOLYSU/L 10-84 GGT SAMPLE TOO HEMOLYSU/L 0-10 ALT 54 U/L 5-65 AST 54 U/L 16-60 Cholesterol 169 mg/dl 150-275 Hemolytic Index Marked Hemolysis Present Comment DUE TO THE SIGNIFICANT HEMOLYSIS THE FOLLOWING MAY BE AFFECTED. FALSELY INCREASED CONCENTRATION: Bun, Phosphorus, T.Protein, Albumin, ALT, AST, T. Bili, D. Bili, CPK, Mg, Calcium and Uric Acid. FALSELY DECREASED CONCENTRATION: Alk. Phos., GGT, Amylase, Lipase, CO2, and Glucose. ? I have advised a urine culture on the sample, though it was very inactive, but I'm not sure where to go from here. Sodium restriction? Can a thiazide diuretic be given in conjunction w/ desmopressin?

E.g. what testing led up to that?

Anyone else with opinions?

I have a dog (10yr FS german shepherd mix, 59#) who needs treatment for UTI/possible pyelonephritis. She has been PU/PD for the last few months (owner just moved here from OR in Nov), and they have appreciated a distended abdomen for about 6 months. Her liver feels enlarged on PE. Recent bloodwork showed a mixed liver enzyme elevation (ALT 214 ALP 2041 GGT 86), no diabetes, and no major renal disease. So I am suspicious of Cushing's in this dog too. Her urine culture grew 2 biotypes of E. coli. Both are sensitive to baytril, but also Clavamox, TMS, and tetracycline. I will list all of the bloodwork and culture results below. I spoke to an internist at Idexx about the susceptibility and MIC to help determine if the MIC for Clavamox was considered good, and she answered this plus showed me a table in my idexx test directory book that breaks the MICs into S, I, and R ranges. She said that she likes TMS for UTIs. It is not an antibiotic that I reach for much because I worry about KCS and other adverse effects. I should also say that the owners of this dog have financial constraints because they are starting a new business and money is tight. 6-8 weeks of Clavamox for this size dog is going to be expensive. Do you think TMS at 15mg/kg BID would be ok? We can check a STT a 3 weeks and 6 weeks and stop it if there are any adverse effects like she stops eating, vomiting, etc. Or, do you think it would be safer to select tetracycline since she needs to be on it for 6-8 weeks? Thanks again,

How was this urine for culture obtained?

Any signs of problems?

I have a dog (10yr FS german shepherd mix, 59#) who needs treatment for UTI/possible pyelonephritis. She has been PU/PD for the last few months (owner just moved here from OR in Nov), and they have appreciated a distended abdomen for about 6 months. Her liver feels enlarged on PE. Recent bloodwork showed a mixed liver enzyme elevation (ALT 214 ALP 2041 GGT 86), no diabetes, and no major renal disease. So I am suspicious of Cushing's in this dog too. Her urine culture grew 2 biotypes of E. coli. Both are sensitive to baytril, but also Clavamox, TMS, and tetracycline. I will list all of the bloodwork and culture results below. I spoke to an internist at Idexx about the susceptibility and MIC to help determine if the MIC for Clavamox was considered good, and she answered this plus showed me a table in my idexx test directory book that breaks the MICs into S, I, and R ranges. She said that she likes TMS for UTIs. It is not an antibiotic that I reach for much because I worry about KCS and other adverse effects. I should also say that the owners of this dog have financial constraints because they are starting a new business and money is tight. 6-8 weeks of Clavamox for this size dog is going to be expensive. Do you think TMS at 15mg/kg BID would be ok? We can check a STT a 3 weeks and 6 weeks and stop it if there are any adverse effects like she stops eating, vomiting, etc. Or, do you think it would be safer to select tetracycline since she needs to be on it for 6-8 weeks? Thanks again,

Has this dog been diagnosed with hac?

Where exactly is this large 'cyst-like structure' on the ultrasound?

I have a dog (10yr FS german shepherd mix, 59#) who needs treatment for UTI/possible pyelonephritis. She has been PU/PD for the last few months (owner just moved here from OR in Nov), and they have appreciated a distended abdomen for about 6 months. Her liver feels enlarged on PE. Recent bloodwork showed a mixed liver enzyme elevation (ALT 214 ALP 2041 GGT 86), no diabetes, and no major renal disease. So I am suspicious of Cushing's in this dog too. Her urine culture grew 2 biotypes of E. coli. Both are sensitive to baytril, but also Clavamox, TMS, and tetracycline. I will list all of the bloodwork and culture results below. I spoke to an internist at Idexx about the susceptibility and MIC to help determine if the MIC for Clavamox was considered good, and she answered this plus showed me a table in my idexx test directory book that breaks the MICs into S, I, and R ranges. She said that she likes TMS for UTIs. It is not an antibiotic that I reach for much because I worry about KCS and other adverse effects. I should also say that the owners of this dog have financial constraints because they are starting a new business and money is tight. 6-8 weeks of Clavamox for this size dog is going to be expensive. Do you think TMS at 15mg/kg BID would be ok? We can check a STT a 3 weeks and 6 weeks and stop it if there are any adverse effects like she stops eating, vomiting, etc. Or, do you think it would be safer to select tetracycline since she needs to be on it for 6-8 weeks? Thanks again,

Is the dog on therapy?

Do you do curves to monitor the insulin or single bg checks?

I was just wondering if I could get some input or opinions on this case. The urine culture results were strange and I've never seen this before. Montana is a 10year old male neutered shepherd mix. He came in for a yearly wellness exam. Nothing significant was seen on physical exam. His bloodwork came back completely normal. However, his free catch U/A displayed signs of a UTI the results are as follows. Free catch U/A: S.G 1.028 protein 2+ Blood 3+ WBC 21-50 RBC 11-20 Bacteria rods 26-50 Because of the sediment and bacteria present the owner agreed to a urine C+S. The sample was taken via urinary catheter and the results were a Salmonella Sp. at about 100,000 colonies/ml. The dog was placed on enrofloxacin right after obtaining the urine sample and the mic results were sensitive at = 0.50. I was just wondering if there is any great concern considering the bacterial species. In all my readings I haven't come across Salmonella Sp. affecting the urinary tract. I did recommend rechecking the U/A and C+S after the antibiotic course to be on the safe side. Is there anything more that I should be doing? Any input on this would be much appreciated. Thanks

Prostate exam was normal?

Maybe take spinal rads?

I have 6yo MN feline who was diagnosed last year with DM. We treated with insuluin for about 4-5 months and were able to get the cat into remission and stopped Insulin therapy. Unfortunatly last week the O fed a high carbohydrate food and the cat relapsed with DKA, pancreatitits and hepatopathy. We have stabilized the pet and he is back on twice daily insulin injections and is doing well. My question is this: 1. Can we supplement his current diet (Hills w/d) with Fish oil? 2. Can the cat be supplemented with petro-malt which is a hairball laxative? (similar to laxatone)

You can, but w/d (canned or dry?) is perhaps not the best option and why do you want to add fish oil?

The owner moves the insulin injections around on his body every day?

History: Chloe is a 12 year old FN DSH that was first diagnosed with diabetes at a branch clinic approximately 3 months prior to presentation for DKA at the hospital. She had been on 2 U cansulin BID. Ultrasound demonstrated a hypoechocic complex mas in the right lobe of the liver likely to be cystadenoma. There was a slight difference between the size of the left (32mm) kidney and right (42mm) kidney. Both of these findings were thought to be unrelated to the diabetes. Fpli/folate and cobalamin were WNL The urinalysis demonstrated USG 1.040, dipstick initially +4 ketones +4 glucose and bacteria seen. Streptococcus grown on culture. She was subseqeuntly treated with synulox 50mg BID for 4 weeks and cultured prior to removal and one week after this with negative growth. She was stabalised at the hospital and swapped to lantus insulin at 3 U BID. Since this time she has been back weekly for curves. The insulin based on hypoglycemia at 6 hours after the insulin dose at each curve has steadily been reduced to 1 U lantus BID. She came in for her curve yesterday and the following is the resutls. Good body condition, has gained total of 0.5kg since original presentation. All vitals WNL. Small mass palpalbe in the right cranial abdomen consitent with ultrsound findings. Remainder WNL. USG 1.040, distpick clear (no glucose or ketones) pH 6.0 and -ve culture BG curve: 8am 6.5mmol/L 11am 7.4mmol/L 1pm 7.2mmol/L 3pm 7.5mmol/L 5pm 5.5mmol/L Does this cat still require insulin? If we are to remain on this dose how often should we monitor her curve for potential developemnt of hypoglcyemia? Any suggestions would be much appreciated.

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

Does she sound like a diabetes insipidus to anyone?

History: Chloe is a 12 year old FN DSH that was first diagnosed with diabetes at a branch clinic approximately 3 months prior to presentation for DKA at the hospital. She had been on 2 U cansulin BID. Ultrasound demonstrated a hypoechocic complex mas in the right lobe of the liver likely to be cystadenoma. There was a slight difference between the size of the left (32mm) kidney and right (42mm) kidney. Both of these findings were thought to be unrelated to the diabetes. Fpli/folate and cobalamin were WNL The urinalysis demonstrated USG 1.040, dipstick initially +4 ketones +4 glucose and bacteria seen. Streptococcus grown on culture. She was subseqeuntly treated with synulox 50mg BID for 4 weeks and cultured prior to removal and one week after this with negative growth. She was stabalised at the hospital and swapped to lantus insulin at 3 U BID. Since this time she has been back weekly for curves. The insulin based on hypoglycemia at 6 hours after the insulin dose at each curve has steadily been reduced to 1 U lantus BID. She came in for her curve yesterday and the following is the resutls. Good body condition, has gained total of 0.5kg since original presentation. All vitals WNL. Small mass palpalbe in the right cranial abdomen consitent with ultrsound findings. Remainder WNL. USG 1.040, distpick clear (no glucose or ketones) pH 6.0 and -ve culture BG curve: 8am 6.5mmol/L 11am 7.4mmol/L 1pm 7.2mmol/L 3pm 7.5mmol/L 5pm 5.5mmol/L Does this cat still require insulin? If we are to remain on this dose how often should we monitor her curve for potential developemnt of hypoglcyemia? Any suggestions would be much appreciated.

Which one?

Any mid day snacks?

I encourage you to get comfy, and thank you so much in advance for any guidance, advice, or critique you can spare. This is my office manager's cat so of course we are headed to the land of complication. If anything, much will be learned! My goal was to provide lab results in some kind of non-nauseating and confusing form. I hope I succeeded! Rosemary 9.5 yr FS DSH BCS 7/9 12.7lb Eats Blue Buffalo Indoor Formula, Indoor only cat. Hx of allergic dermatitis and occasional vomiting food (1 time/month) Treated with low dose prednisolone at 0.25mg/kg PO SID as needed (usually 7 day course)- symptoms resolved during tx and would not return again until months later. 1/4/13: One depo medrol injection at 20mg given (regretfully) when she had scabs on face on neck and very pruritic, O could not give any PO meds. 1/11/13: lethargy, vomiting, anorexia, staring at water bowl. T 103.5 cranial abd pain, listless but responsive. BG 548 mg/dL Urine dipstick Glucose 3+, Ketones negative Blood work sent out to Idexx - serum was very lipemic - strawberry milkshake color and consistency Tx - lantus 1 unit SC, cerenia SC, sc fluids, ate readily in clinic. Admitted to hospital for IVF and supportive care. Dx - Diabetes Mellitus, Poss pancreatitis (steroid induced vs idiopathic) 1/12/13: Supportive care continues, appetite is decreased to 10% normal, picking at DM canned and dry offered. Tx - BG q2h, ampicillin IV q8h, famotidine sc sid, Lantus SC SID, cerenia SC SID BG: 8a - 113 mg/dL 10a - 96 mg/dL 12p - 98 mg/dL BW results: Panel/Profile: Senior Profile with Spec fPL® -Feline RBC 11.74 6 - 10 M/μL H Hematocrit 62.9 29 - 45 % H Hemoglobin 19.5 9.5 - 15 g/dL H MCV 54 41 - 58 fL MCH 16.6 11.0 - 17.5 pg MCHC 31.0 29 - 36 g/dL % Reticulocyte 1.2 % Reticulocyte 141 3 - 50 K/μL H Reticulocyte WBC 2 4.2 - 15.6 K/μL L % Neutrophil 79.3 35 - 75 % H % Lymphocyte 8.4 20 - 55 % L % Monocyte 5.9 1 - 4 % H % Eosinophil 6.4 2 - 12 % % Basophil 0.0 0 - 1 % Neutrophil 1.586 2.5 - 12.5 K/μL L Lymphocyte 0.168 1.5 - 7 K/μL L Monocyte 0.118 0 - 0.85 K/μL Eosinophil 0.128 0 - 1.5 K/μL Basophil 0 0 - 0.1 K/μL Auto Platelet 390 170 - 600 K/μL Remarks SLIDE REVIEWED MICROSCOPICALLY. Glucose 637 70 - 150 mg/dL H BUN 35 15 - 34 mg/dL H Creatinine 1.6 0.8 - 2.3 mg/dL BUN / Creatinine Ratio 21.9 Phosphorus 5.1 3.0 - 7.0 m g/dL Calcium 9.1 8.2 - 11.8 mg/dL Sodium 138 147 - 156 mmol/L L Potassium 4.5 3.9 - 5.3 mmol/L Na / K Ratio 31 Chloride 102 111 - 125 mmol/L L TCO2 14 13 - 25 mmol/L Anion Gap 27 13 - 27 mmol/L Total Protein 7.8 5.9 - 8.5 g/dL Albumin 3.7 2.3 - 3.9 g/dL Globulin 4.1 3.0 - 5.6 g/dL Alb / Glob Ratio 0.9 0.4 - 0.8 H ALT 135 28 - 100 U/L H AST 106 5 - 55 U/L H ALP 107 0 - 62 U/L H GGT 5 0 - 6 U/L Bilirubin - Total 0.0 0.0 - 0.4 mg/dL Bilirubin - Unconjugated 0.0 0 - 0.3 mg/dL Bilirubin - Conjugated 0.0 0.0 - 0.2 mg/dL Cholesterol 366 82 - 218 mg/dL H Triglyceride 2766 20 - 90 mg/dL H Amylase 1317 520 - 2060 U/L Lipase 308 10 - 195 U/L H Creatine Kinase 575 64 - 440 U/L H Hemolysis Index ABN Lipemia Index ABN Spec fPL > 50.0 ug/L or = 3.5 ug/L - Serum Spec fPL concentration is in the normal range. It is unlikely that the cat has pancreatitis. Investigate for other diseases that could cause observed clinical signs. 3.6 - 5.3 ug/L - Serum Spec fPL concentration is increased. The cat may have pancreatitis and Spec fPL should be reevaluated in two weeks if clinical signs persist. Investigate for other diseases that could cause observed clinical signs. > or = 5.4 ug/L - Serum Spec fPL concentration is consistent with pancreatitis. The cat most likely has pancreatitis. Consider investigating for risk factors and concurrent diseases (e.g. IBD, Cholangitis, Hepatic Lipidosis, Diabetes Mellitus). Periodic monitoring of Spec fPL may help assess response to therapy. Urinalysis Collection CYSTOCENTESIS Color YELLOW Clarity CLOUDY Specific Gravity 1.060 pH 6.0 Protein 2+ (200-300 mg/dL) Glucose 3+ Ketones NEGATIVE Blood / TRACE Hemoglobin Bilirubin NEGATIVE Urobilinogen NORMAL White Blood 0-2 Cells 0 - 5 HPF Red Blood Cells 2-5 0 - 5 HPF Bacteria NONE SEEN HPF Epithelial Cells NONE SEEN HPF Mucus PRESENT Casts NONE SEEN HPF Crystals NONE SEEN HPF Other LIPID DROPLETS PRESENT Protein test is performed and confirmed by the sulfosalicylic acid test. Endocrinology Total T4 0.4 0.8 - 4.7 μg/dL RESULT VERIFIED BY REPEAT ANALYSIS Interpretive ranges: 0.8 Subnormal 0.8-4.7 Normal 2.3-4.7 Grey zone in old or symptomatic cats >4.7 Consistent with hyperthyroidism Cats with subnormal T4 values are almost exclusively euthyroid sick or overtreated for their hyperthyroidism. Older cats with consistent clinical signs and T4 values in the grey zone may have early hyperthyroidism or a concurrent non-thyroidal illness. Hyperthyroidism may be confirmed in these cats by adding on a free T4 or by performing a T3 suppression test. Following treatment with methimazole, T4 values will generally fall within the lower end of the reference range (0.8 - 2.3). **End Lab Results for 1/12/13** Transfer to local ER for continued supportive care through the weekend (Sat night through Monday AM) 1/12 - 1/14 (at ER) did okay, still not wanting to eat, they started to syringe feed her A/D - said that it went well but not eating on her own. Unsure of amount fed. Temp still 102-103.3 Continued Famotidine 5mg PO SID, started Amoxi 100mg PO BID, Buprenex 0.03mg/kg TM BID, Cerenia SC SID BG's every 2-4 hours were between 104 and 177 until next morning dose of Lantus. Lantus given 1.5 units in AM SC PlasmaLyte continued - Reglan CRI started Baytril 22.7mg (1/2 PO SID) started. BG's increased to 300-350 mg/dL towards end of weekend, so she was increased to 3 units Lantus SC SID AUS by certified sonographer, read by Sonopath - signif pancreatic changes "Enlarged with mottled echogenic appearance - prominent left limb, hyperechoic appearance of mesentery and fat" All other structures were WNL 1/15/13: Transfer back to our hospital from ER - Lantus still at 3units SID AM Temp 103.0 Still anorexic - would act like she was interested in food (smell it) but no intake. Drinking water okay. Normal urination in litter box. Tx - continued IVF support, baytril, famotidine, amoxi, cerenia (day 4), Buprenorphine. Started Vit K BID x 3 dose in prep for E-tube. Mirtazipine 3.75mg PO Ate WELL overnight! about 50% of her daily caloric value! Offered A/D, DM dry and canned. 1/16/13: No changes in meds (see above) or insulin - well controlled at 3units SID in AM Again, ate well overnight (when no one is around) - about 40% daily caloric req. Overall looking a little brighter, very friendly, walking around cage and wants to come out to walk around. 1/17 - Hiding now, vomit small pile of liquid. Temp 102.1 All meds are same. Recheck Lab Work (In hospital - Abaxis machines) MUCH RESOLVED! ALKP 40 (90) ALT 75 (100) Tbil 0.4 (0.6) Amy 760 (1100) Na 145 (142-164) K 4.5 (3.7-5.8) Still WNL Bun, Creat CBC: WBC Normal 5.86 (5.5 - 19.5) Lymph LOW 0.1 (1.5-7) Lymph LOW 10.4% (20-55%) HCT 33.7% RBC 6.96 Normal (5-10) PLT Normal 406 1/18/13: Started BID insulin - her 4pm insulin curve chck was 241 - so now Lantus 2units AM, 1 unit PM Ate small amt overnight, and ate again in the afternoon - total about 50% of caloric req for the day. **Pulled IVC - sent home on meds in hopes of more comfort there and continued progress** 1/19 - 1/20 - ER again on Sunday- very lethargic, no water or food intake since leaving the hospital. Recheck AUS - pancreas now more involved with single lymph node enlargement. "This still looks like acute on chronic smoldering pancreatitis and likely gastritis given the mildly enlarged but uniform epigastric ln. The image done at 1:58:34 demonstrates left limp panc but early pancreatic carcinoma and pancreatic lsa or dry fip can do this as well and wax and wane clinically. I would start by fna of the exemplary hypechoic part of the pancreas but may need full thickness bx gi ln and panc to get the dx. If he is not turning the corner in 24 hours this is what I would do if he were my cat. In the meantime pain manage aggressively, zithromax metronidazole, feeding tube if need be and gi protice along with fluids fluids fluids." 1/21/13 - back to our hospital - Temp has Normalized consistently now to 101.4 - 102.0 continued supportive care with IVF, baytril, flagyl PO, famotidine, Lantus bid, buprenorphine bid (changed to SC b/c TM was making her hypersalivate) Rechecked Lab Work: (Idexx Senior Profile with spec fPL) Glucose 198 REST is WNL!!! (values can be provided if needed or requested) spec fPL also Normal at 3.8 But she continues to do So-So. Not really matching her much improved lab work. 1/22 - 1/24 - Eats well overnight - she still is about 40-50% of her daily caloric needs - still on IVF Stop PO meds, transition to injectables b/c she becomes nauseous and hypersalivates. Started the 3 dose protocol for Vit K - planned E-tube 1/25 1/25/13 - E-tube placed - red rubber 12 french. ICS 8, confirmed with xray post-placement, negative pressure before feeding. She is getting A/D gruel through (IAMS max Cal is on the way!) - calculated RER - 70 x BW (superscript) 3/4. which is about 249 kcal/day. Started today at 30% total - she did very well with feeding. Seems very comfortable during and after. IVF discontinued - her legs cannot tolerate any more cephalic iv's - and I sent her home with her e-tube instructions to hopefully become comfortable in her own surroundings and show improvement in general activity and behavior. Also , we stopped checking BG's, her 12-hr curves were between 110 - 250. So she stays at 1unit sc BID. ( I changed this dose on 1/23 b/c her BG curve was dipping lower on the 2 units AM/1 unit PM) I had been hoping that the resolution of her pancreatitis may give resolution of DM, so had been checking curves daily. 1/27/13 TODAY: Just talked to O - Rosemary is doing kind of BLAH - laying downstairs but did come out to lay on sofa with them just recently. Overall water intake is down, no BM yet in litter box - still normal urinations. Tired all of the time, sleeping a lot. Just seems to not be doing as well as I would have hoped after now giving her 100% of her calories for 2 days. Maybe it takes a bit longer to see the normalcy back in her eyes - but in the back of my mind I think: 1. Do I need to aspirate this pancreas to definitely r/o neoplasia? Since this would drastically affect our px - I am thus far trying to manage and treat acute pancreatitis with DM. 2. Did Depo bring this whole thing to life? Or just a contributing factor? O thinks she may have been pu/pd in basement for a little while but we just can't be sure...the vomiting may have been underestimated as well. Regardless the depo absolutely made this problem so much worse. 3. What else can I do for this girl? In your experiences, does severe acute pancreatitis carry a guarded px? The studies show a varied px given the signs, some are mild, some are more severe- and to me hers are pretty dismal at the moment. 4. I am rechecking lab work tomorrow and possibly a pancreatic aspirate on Wed to r/o neoplasia. Chest films btw are fine. I am so sure I forgot some details, but I hope I have covered the high points. Thanks again for sticking in to the end of this - and thanks for the help!

For an us guided pancreatic diagnosis - aspirate okay?

Also hard to understand why a congenital disease would worsen recently?

I encourage you to get comfy, and thank you so much in advance for any guidance, advice, or critique you can spare. This is my office manager's cat so of course we are headed to the land of complication. If anything, much will be learned! My goal was to provide lab results in some kind of non-nauseating and confusing form. I hope I succeeded! Rosemary 9.5 yr FS DSH BCS 7/9 12.7lb Eats Blue Buffalo Indoor Formula, Indoor only cat. Hx of allergic dermatitis and occasional vomiting food (1 time/month) Treated with low dose prednisolone at 0.25mg/kg PO SID as needed (usually 7 day course)- symptoms resolved during tx and would not return again until months later. 1/4/13: One depo medrol injection at 20mg given (regretfully) when she had scabs on face on neck and very pruritic, O could not give any PO meds. 1/11/13: lethargy, vomiting, anorexia, staring at water bowl. T 103.5 cranial abd pain, listless but responsive. BG 548 mg/dL Urine dipstick Glucose 3+, Ketones negative Blood work sent out to Idexx - serum was very lipemic - strawberry milkshake color and consistency Tx - lantus 1 unit SC, cerenia SC, sc fluids, ate readily in clinic. Admitted to hospital for IVF and supportive care. Dx - Diabetes Mellitus, Poss pancreatitis (steroid induced vs idiopathic) 1/12/13: Supportive care continues, appetite is decreased to 10% normal, picking at DM canned and dry offered. Tx - BG q2h, ampicillin IV q8h, famotidine sc sid, Lantus SC SID, cerenia SC SID BG: 8a - 113 mg/dL 10a - 96 mg/dL 12p - 98 mg/dL BW results: Panel/Profile: Senior Profile with Spec fPL® -Feline RBC 11.74 6 - 10 M/μL H Hematocrit 62.9 29 - 45 % H Hemoglobin 19.5 9.5 - 15 g/dL H MCV 54 41 - 58 fL MCH 16.6 11.0 - 17.5 pg MCHC 31.0 29 - 36 g/dL % Reticulocyte 1.2 % Reticulocyte 141 3 - 50 K/μL H Reticulocyte WBC 2 4.2 - 15.6 K/μL L % Neutrophil 79.3 35 - 75 % H % Lymphocyte 8.4 20 - 55 % L % Monocyte 5.9 1 - 4 % H % Eosinophil 6.4 2 - 12 % % Basophil 0.0 0 - 1 % Neutrophil 1.586 2.5 - 12.5 K/μL L Lymphocyte 0.168 1.5 - 7 K/μL L Monocyte 0.118 0 - 0.85 K/μL Eosinophil 0.128 0 - 1.5 K/μL Basophil 0 0 - 0.1 K/μL Auto Platelet 390 170 - 600 K/μL Remarks SLIDE REVIEWED MICROSCOPICALLY. Glucose 637 70 - 150 mg/dL H BUN 35 15 - 34 mg/dL H Creatinine 1.6 0.8 - 2.3 mg/dL BUN / Creatinine Ratio 21.9 Phosphorus 5.1 3.0 - 7.0 m g/dL Calcium 9.1 8.2 - 11.8 mg/dL Sodium 138 147 - 156 mmol/L L Potassium 4.5 3.9 - 5.3 mmol/L Na / K Ratio 31 Chloride 102 111 - 125 mmol/L L TCO2 14 13 - 25 mmol/L Anion Gap 27 13 - 27 mmol/L Total Protein 7.8 5.9 - 8.5 g/dL Albumin 3.7 2.3 - 3.9 g/dL Globulin 4.1 3.0 - 5.6 g/dL Alb / Glob Ratio 0.9 0.4 - 0.8 H ALT 135 28 - 100 U/L H AST 106 5 - 55 U/L H ALP 107 0 - 62 U/L H GGT 5 0 - 6 U/L Bilirubin - Total 0.0 0.0 - 0.4 mg/dL Bilirubin - Unconjugated 0.0 0 - 0.3 mg/dL Bilirubin - Conjugated 0.0 0.0 - 0.2 mg/dL Cholesterol 366 82 - 218 mg/dL H Triglyceride 2766 20 - 90 mg/dL H Amylase 1317 520 - 2060 U/L Lipase 308 10 - 195 U/L H Creatine Kinase 575 64 - 440 U/L H Hemolysis Index ABN Lipemia Index ABN Spec fPL > 50.0 ug/L or = 3.5 ug/L - Serum Spec fPL concentration is in the normal range. It is unlikely that the cat has pancreatitis. Investigate for other diseases that could cause observed clinical signs. 3.6 - 5.3 ug/L - Serum Spec fPL concentration is increased. The cat may have pancreatitis and Spec fPL should be reevaluated in two weeks if clinical signs persist. Investigate for other diseases that could cause observed clinical signs. > or = 5.4 ug/L - Serum Spec fPL concentration is consistent with pancreatitis. The cat most likely has pancreatitis. Consider investigating for risk factors and concurrent diseases (e.g. IBD, Cholangitis, Hepatic Lipidosis, Diabetes Mellitus). Periodic monitoring of Spec fPL may help assess response to therapy. Urinalysis Collection CYSTOCENTESIS Color YELLOW Clarity CLOUDY Specific Gravity 1.060 pH 6.0 Protein 2+ (200-300 mg/dL) Glucose 3+ Ketones NEGATIVE Blood / TRACE Hemoglobin Bilirubin NEGATIVE Urobilinogen NORMAL White Blood 0-2 Cells 0 - 5 HPF Red Blood Cells 2-5 0 - 5 HPF Bacteria NONE SEEN HPF Epithelial Cells NONE SEEN HPF Mucus PRESENT Casts NONE SEEN HPF Crystals NONE SEEN HPF Other LIPID DROPLETS PRESENT Protein test is performed and confirmed by the sulfosalicylic acid test. Endocrinology Total T4 0.4 0.8 - 4.7 μg/dL RESULT VERIFIED BY REPEAT ANALYSIS Interpretive ranges: 0.8 Subnormal 0.8-4.7 Normal 2.3-4.7 Grey zone in old or symptomatic cats >4.7 Consistent with hyperthyroidism Cats with subnormal T4 values are almost exclusively euthyroid sick or overtreated for their hyperthyroidism. Older cats with consistent clinical signs and T4 values in the grey zone may have early hyperthyroidism or a concurrent non-thyroidal illness. Hyperthyroidism may be confirmed in these cats by adding on a free T4 or by performing a T3 suppression test. Following treatment with methimazole, T4 values will generally fall within the lower end of the reference range (0.8 - 2.3). **End Lab Results for 1/12/13** Transfer to local ER for continued supportive care through the weekend (Sat night through Monday AM) 1/12 - 1/14 (at ER) did okay, still not wanting to eat, they started to syringe feed her A/D - said that it went well but not eating on her own. Unsure of amount fed. Temp still 102-103.3 Continued Famotidine 5mg PO SID, started Amoxi 100mg PO BID, Buprenex 0.03mg/kg TM BID, Cerenia SC SID BG's every 2-4 hours were between 104 and 177 until next morning dose of Lantus. Lantus given 1.5 units in AM SC PlasmaLyte continued - Reglan CRI started Baytril 22.7mg (1/2 PO SID) started. BG's increased to 300-350 mg/dL towards end of weekend, so she was increased to 3 units Lantus SC SID AUS by certified sonographer, read by Sonopath - signif pancreatic changes "Enlarged with mottled echogenic appearance - prominent left limb, hyperechoic appearance of mesentery and fat" All other structures were WNL 1/15/13: Transfer back to our hospital from ER - Lantus still at 3units SID AM Temp 103.0 Still anorexic - would act like she was interested in food (smell it) but no intake. Drinking water okay. Normal urination in litter box. Tx - continued IVF support, baytril, famotidine, amoxi, cerenia (day 4), Buprenorphine. Started Vit K BID x 3 dose in prep for E-tube. Mirtazipine 3.75mg PO Ate WELL overnight! about 50% of her daily caloric value! Offered A/D, DM dry and canned. 1/16/13: No changes in meds (see above) or insulin - well controlled at 3units SID in AM Again, ate well overnight (when no one is around) - about 40% daily caloric req. Overall looking a little brighter, very friendly, walking around cage and wants to come out to walk around. 1/17 - Hiding now, vomit small pile of liquid. Temp 102.1 All meds are same. Recheck Lab Work (In hospital - Abaxis machines) MUCH RESOLVED! ALKP 40 (90) ALT 75 (100) Tbil 0.4 (0.6) Amy 760 (1100) Na 145 (142-164) K 4.5 (3.7-5.8) Still WNL Bun, Creat CBC: WBC Normal 5.86 (5.5 - 19.5) Lymph LOW 0.1 (1.5-7) Lymph LOW 10.4% (20-55%) HCT 33.7% RBC 6.96 Normal (5-10) PLT Normal 406 1/18/13: Started BID insulin - her 4pm insulin curve chck was 241 - so now Lantus 2units AM, 1 unit PM Ate small amt overnight, and ate again in the afternoon - total about 50% of caloric req for the day. **Pulled IVC - sent home on meds in hopes of more comfort there and continued progress** 1/19 - 1/20 - ER again on Sunday- very lethargic, no water or food intake since leaving the hospital. Recheck AUS - pancreas now more involved with single lymph node enlargement. "This still looks like acute on chronic smoldering pancreatitis and likely gastritis given the mildly enlarged but uniform epigastric ln. The image done at 1:58:34 demonstrates left limp panc but early pancreatic carcinoma and pancreatic lsa or dry fip can do this as well and wax and wane clinically. I would start by fna of the exemplary hypechoic part of the pancreas but may need full thickness bx gi ln and panc to get the dx. If he is not turning the corner in 24 hours this is what I would do if he were my cat. In the meantime pain manage aggressively, zithromax metronidazole, feeding tube if need be and gi protice along with fluids fluids fluids." 1/21/13 - back to our hospital - Temp has Normalized consistently now to 101.4 - 102.0 continued supportive care with IVF, baytril, flagyl PO, famotidine, Lantus bid, buprenorphine bid (changed to SC b/c TM was making her hypersalivate) Rechecked Lab Work: (Idexx Senior Profile with spec fPL) Glucose 198 REST is WNL!!! (values can be provided if needed or requested) spec fPL also Normal at 3.8 But she continues to do So-So. Not really matching her much improved lab work. 1/22 - 1/24 - Eats well overnight - she still is about 40-50% of her daily caloric needs - still on IVF Stop PO meds, transition to injectables b/c she becomes nauseous and hypersalivates. Started the 3 dose protocol for Vit K - planned E-tube 1/25 1/25/13 - E-tube placed - red rubber 12 french. ICS 8, confirmed with xray post-placement, negative pressure before feeding. She is getting A/D gruel through (IAMS max Cal is on the way!) - calculated RER - 70 x BW (superscript) 3/4. which is about 249 kcal/day. Started today at 30% total - she did very well with feeding. Seems very comfortable during and after. IVF discontinued - her legs cannot tolerate any more cephalic iv's - and I sent her home with her e-tube instructions to hopefully become comfortable in her own surroundings and show improvement in general activity and behavior. Also , we stopped checking BG's, her 12-hr curves were between 110 - 250. So she stays at 1unit sc BID. ( I changed this dose on 1/23 b/c her BG curve was dipping lower on the 2 units AM/1 unit PM) I had been hoping that the resolution of her pancreatitis may give resolution of DM, so had been checking curves daily. 1/27/13 TODAY: Just talked to O - Rosemary is doing kind of BLAH - laying downstairs but did come out to lay on sofa with them just recently. Overall water intake is down, no BM yet in litter box - still normal urinations. Tired all of the time, sleeping a lot. Just seems to not be doing as well as I would have hoped after now giving her 100% of her calories for 2 days. Maybe it takes a bit longer to see the normalcy back in her eyes - but in the back of my mind I think: 1. Do I need to aspirate this pancreas to definitely r/o neoplasia? Since this would drastically affect our px - I am thus far trying to manage and treat acute pancreatitis with DM. 2. Did Depo bring this whole thing to life? Or just a contributing factor? O thinks she may have been pu/pd in basement for a little while but we just can't be sure...the vomiting may have been underestimated as well. Regardless the depo absolutely made this problem so much worse. 3. What else can I do for this girl? In your experiences, does severe acute pancreatitis carry a guarded px? The studies show a varied px given the signs, some are mild, some are more severe- and to me hers are pretty dismal at the moment. 4. I am rechecking lab work tomorrow and possibly a pancreatic aspirate on Wed to r/o neoplasia. Chest films btw are fine. I am so sure I forgot some details, but I hope I have covered the high points. Thanks again for sticking in to the end of this - and thanks for the help!

Or waste of time and i just go for a biopsy?

Was there a risk of exposure between 2009 and now that could have spread fiv (cat fights)?

I encourage you to get comfy, and thank you so much in advance for any guidance, advice, or critique you can spare. This is my office manager's cat so of course we are headed to the land of complication. If anything, much will be learned! My goal was to provide lab results in some kind of non-nauseating and confusing form. I hope I succeeded! Rosemary 9.5 yr FS DSH BCS 7/9 12.7lb Eats Blue Buffalo Indoor Formula, Indoor only cat. Hx of allergic dermatitis and occasional vomiting food (1 time/month) Treated with low dose prednisolone at 0.25mg/kg PO SID as needed (usually 7 day course)- symptoms resolved during tx and would not return again until months later. 1/4/13: One depo medrol injection at 20mg given (regretfully) when she had scabs on face on neck and very pruritic, O could not give any PO meds. 1/11/13: lethargy, vomiting, anorexia, staring at water bowl. T 103.5 cranial abd pain, listless but responsive. BG 548 mg/dL Urine dipstick Glucose 3+, Ketones negative Blood work sent out to Idexx - serum was very lipemic - strawberry milkshake color and consistency Tx - lantus 1 unit SC, cerenia SC, sc fluids, ate readily in clinic. Admitted to hospital for IVF and supportive care. Dx - Diabetes Mellitus, Poss pancreatitis (steroid induced vs idiopathic) 1/12/13: Supportive care continues, appetite is decreased to 10% normal, picking at DM canned and dry offered. Tx - BG q2h, ampicillin IV q8h, famotidine sc sid, Lantus SC SID, cerenia SC SID BG: 8a - 113 mg/dL 10a - 96 mg/dL 12p - 98 mg/dL BW results: Panel/Profile: Senior Profile with Spec fPL® -Feline RBC 11.74 6 - 10 M/μL H Hematocrit 62.9 29 - 45 % H Hemoglobin 19.5 9.5 - 15 g/dL H MCV 54 41 - 58 fL MCH 16.6 11.0 - 17.5 pg MCHC 31.0 29 - 36 g/dL % Reticulocyte 1.2 % Reticulocyte 141 3 - 50 K/μL H Reticulocyte WBC 2 4.2 - 15.6 K/μL L % Neutrophil 79.3 35 - 75 % H % Lymphocyte 8.4 20 - 55 % L % Monocyte 5.9 1 - 4 % H % Eosinophil 6.4 2 - 12 % % Basophil 0.0 0 - 1 % Neutrophil 1.586 2.5 - 12.5 K/μL L Lymphocyte 0.168 1.5 - 7 K/μL L Monocyte 0.118 0 - 0.85 K/μL Eosinophil 0.128 0 - 1.5 K/μL Basophil 0 0 - 0.1 K/μL Auto Platelet 390 170 - 600 K/μL Remarks SLIDE REVIEWED MICROSCOPICALLY. Glucose 637 70 - 150 mg/dL H BUN 35 15 - 34 mg/dL H Creatinine 1.6 0.8 - 2.3 mg/dL BUN / Creatinine Ratio 21.9 Phosphorus 5.1 3.0 - 7.0 m g/dL Calcium 9.1 8.2 - 11.8 mg/dL Sodium 138 147 - 156 mmol/L L Potassium 4.5 3.9 - 5.3 mmol/L Na / K Ratio 31 Chloride 102 111 - 125 mmol/L L TCO2 14 13 - 25 mmol/L Anion Gap 27 13 - 27 mmol/L Total Protein 7.8 5.9 - 8.5 g/dL Albumin 3.7 2.3 - 3.9 g/dL Globulin 4.1 3.0 - 5.6 g/dL Alb / Glob Ratio 0.9 0.4 - 0.8 H ALT 135 28 - 100 U/L H AST 106 5 - 55 U/L H ALP 107 0 - 62 U/L H GGT 5 0 - 6 U/L Bilirubin - Total 0.0 0.0 - 0.4 mg/dL Bilirubin - Unconjugated 0.0 0 - 0.3 mg/dL Bilirubin - Conjugated 0.0 0.0 - 0.2 mg/dL Cholesterol 366 82 - 218 mg/dL H Triglyceride 2766 20 - 90 mg/dL H Amylase 1317 520 - 2060 U/L Lipase 308 10 - 195 U/L H Creatine Kinase 575 64 - 440 U/L H Hemolysis Index ABN Lipemia Index ABN Spec fPL > 50.0 ug/L or = 3.5 ug/L - Serum Spec fPL concentration is in the normal range. It is unlikely that the cat has pancreatitis. Investigate for other diseases that could cause observed clinical signs. 3.6 - 5.3 ug/L - Serum Spec fPL concentration is increased. The cat may have pancreatitis and Spec fPL should be reevaluated in two weeks if clinical signs persist. Investigate for other diseases that could cause observed clinical signs. > or = 5.4 ug/L - Serum Spec fPL concentration is consistent with pancreatitis. The cat most likely has pancreatitis. Consider investigating for risk factors and concurrent diseases (e.g. IBD, Cholangitis, Hepatic Lipidosis, Diabetes Mellitus). Periodic monitoring of Spec fPL may help assess response to therapy. Urinalysis Collection CYSTOCENTESIS Color YELLOW Clarity CLOUDY Specific Gravity 1.060 pH 6.0 Protein 2+ (200-300 mg/dL) Glucose 3+ Ketones NEGATIVE Blood / TRACE Hemoglobin Bilirubin NEGATIVE Urobilinogen NORMAL White Blood 0-2 Cells 0 - 5 HPF Red Blood Cells 2-5 0 - 5 HPF Bacteria NONE SEEN HPF Epithelial Cells NONE SEEN HPF Mucus PRESENT Casts NONE SEEN HPF Crystals NONE SEEN HPF Other LIPID DROPLETS PRESENT Protein test is performed and confirmed by the sulfosalicylic acid test. Endocrinology Total T4 0.4 0.8 - 4.7 μg/dL RESULT VERIFIED BY REPEAT ANALYSIS Interpretive ranges: 0.8 Subnormal 0.8-4.7 Normal 2.3-4.7 Grey zone in old or symptomatic cats >4.7 Consistent with hyperthyroidism Cats with subnormal T4 values are almost exclusively euthyroid sick or overtreated for their hyperthyroidism. Older cats with consistent clinical signs and T4 values in the grey zone may have early hyperthyroidism or a concurrent non-thyroidal illness. Hyperthyroidism may be confirmed in these cats by adding on a free T4 or by performing a T3 suppression test. Following treatment with methimazole, T4 values will generally fall within the lower end of the reference range (0.8 - 2.3). **End Lab Results for 1/12/13** Transfer to local ER for continued supportive care through the weekend (Sat night through Monday AM) 1/12 - 1/14 (at ER) did okay, still not wanting to eat, they started to syringe feed her A/D - said that it went well but not eating on her own. Unsure of amount fed. Temp still 102-103.3 Continued Famotidine 5mg PO SID, started Amoxi 100mg PO BID, Buprenex 0.03mg/kg TM BID, Cerenia SC SID BG's every 2-4 hours were between 104 and 177 until next morning dose of Lantus. Lantus given 1.5 units in AM SC PlasmaLyte continued - Reglan CRI started Baytril 22.7mg (1/2 PO SID) started. BG's increased to 300-350 mg/dL towards end of weekend, so she was increased to 3 units Lantus SC SID AUS by certified sonographer, read by Sonopath - signif pancreatic changes "Enlarged with mottled echogenic appearance - prominent left limb, hyperechoic appearance of mesentery and fat" All other structures were WNL 1/15/13: Transfer back to our hospital from ER - Lantus still at 3units SID AM Temp 103.0 Still anorexic - would act like she was interested in food (smell it) but no intake. Drinking water okay. Normal urination in litter box. Tx - continued IVF support, baytril, famotidine, amoxi, cerenia (day 4), Buprenorphine. Started Vit K BID x 3 dose in prep for E-tube. Mirtazipine 3.75mg PO Ate WELL overnight! about 50% of her daily caloric value! Offered A/D, DM dry and canned. 1/16/13: No changes in meds (see above) or insulin - well controlled at 3units SID in AM Again, ate well overnight (when no one is around) - about 40% daily caloric req. Overall looking a little brighter, very friendly, walking around cage and wants to come out to walk around. 1/17 - Hiding now, vomit small pile of liquid. Temp 102.1 All meds are same. Recheck Lab Work (In hospital - Abaxis machines) MUCH RESOLVED! ALKP 40 (90) ALT 75 (100) Tbil 0.4 (0.6) Amy 760 (1100) Na 145 (142-164) K 4.5 (3.7-5.8) Still WNL Bun, Creat CBC: WBC Normal 5.86 (5.5 - 19.5) Lymph LOW 0.1 (1.5-7) Lymph LOW 10.4% (20-55%) HCT 33.7% RBC 6.96 Normal (5-10) PLT Normal 406 1/18/13: Started BID insulin - her 4pm insulin curve chck was 241 - so now Lantus 2units AM, 1 unit PM Ate small amt overnight, and ate again in the afternoon - total about 50% of caloric req for the day. **Pulled IVC - sent home on meds in hopes of more comfort there and continued progress** 1/19 - 1/20 - ER again on Sunday- very lethargic, no water or food intake since leaving the hospital. Recheck AUS - pancreas now more involved with single lymph node enlargement. "This still looks like acute on chronic smoldering pancreatitis and likely gastritis given the mildly enlarged but uniform epigastric ln. The image done at 1:58:34 demonstrates left limp panc but early pancreatic carcinoma and pancreatic lsa or dry fip can do this as well and wax and wane clinically. I would start by fna of the exemplary hypechoic part of the pancreas but may need full thickness bx gi ln and panc to get the dx. If he is not turning the corner in 24 hours this is what I would do if he were my cat. In the meantime pain manage aggressively, zithromax metronidazole, feeding tube if need be and gi protice along with fluids fluids fluids." 1/21/13 - back to our hospital - Temp has Normalized consistently now to 101.4 - 102.0 continued supportive care with IVF, baytril, flagyl PO, famotidine, Lantus bid, buprenorphine bid (changed to SC b/c TM was making her hypersalivate) Rechecked Lab Work: (Idexx Senior Profile with spec fPL) Glucose 198 REST is WNL!!! (values can be provided if needed or requested) spec fPL also Normal at 3.8 But she continues to do So-So. Not really matching her much improved lab work. 1/22 - 1/24 - Eats well overnight - she still is about 40-50% of her daily caloric needs - still on IVF Stop PO meds, transition to injectables b/c she becomes nauseous and hypersalivates. Started the 3 dose protocol for Vit K - planned E-tube 1/25 1/25/13 - E-tube placed - red rubber 12 french. ICS 8, confirmed with xray post-placement, negative pressure before feeding. She is getting A/D gruel through (IAMS max Cal is on the way!) - calculated RER - 70 x BW (superscript) 3/4. which is about 249 kcal/day. Started today at 30% total - she did very well with feeding. Seems very comfortable during and after. IVF discontinued - her legs cannot tolerate any more cephalic iv's - and I sent her home with her e-tube instructions to hopefully become comfortable in her own surroundings and show improvement in general activity and behavior. Also , we stopped checking BG's, her 12-hr curves were between 110 - 250. So she stays at 1unit sc BID. ( I changed this dose on 1/23 b/c her BG curve was dipping lower on the 2 units AM/1 unit PM) I had been hoping that the resolution of her pancreatitis may give resolution of DM, so had been checking curves daily. 1/27/13 TODAY: Just talked to O - Rosemary is doing kind of BLAH - laying downstairs but did come out to lay on sofa with them just recently. Overall water intake is down, no BM yet in litter box - still normal urinations. Tired all of the time, sleeping a lot. Just seems to not be doing as well as I would have hoped after now giving her 100% of her calories for 2 days. Maybe it takes a bit longer to see the normalcy back in her eyes - but in the back of my mind I think: 1. Do I need to aspirate this pancreas to definitely r/o neoplasia? Since this would drastically affect our px - I am thus far trying to manage and treat acute pancreatitis with DM. 2. Did Depo bring this whole thing to life? Or just a contributing factor? O thinks she may have been pu/pd in basement for a little while but we just can't be sure...the vomiting may have been underestimated as well. Regardless the depo absolutely made this problem so much worse. 3. What else can I do for this girl? In your experiences, does severe acute pancreatitis carry a guarded px? The studies show a varied px given the signs, some are mild, some are more severe- and to me hers are pretty dismal at the moment. 4. I am rechecking lab work tomorrow and possibly a pancreatic aspirate on Wed to r/o neoplasia. Chest films btw are fine. I am so sure I forgot some details, but I hope I have covered the high points. Thanks again for sticking in to the end of this - and thanks for the help!

Aspirate with what gauge needle?

How many usg reading were 1.008?

History as I know it: Sasha is a 12.5yr old FS husky who was previously diagnosed with diabetes and had been doing well for years. I first saw the dog at the beginning of October of last year. At that point, she was just shy of 42# which was a poor BCS (I rated it 3/9 at that point, that may or may not have been a little generous), If it was a less fuzzy breed I suspect ribs would have been showing. I was seeing the dog on a second opinion - had been going to another vet where she had been treated for both bowel and bladder infections - treated with cephalexin and nystatin. Owner got frustrated for a variety of reasons, but most pressing because she described the dog as having seizures and apparently was told to INCREASE the insulin dose. I'll post the full blood panel below, but a spot BG check on our catalyst panel showed a BG of 46. Talked with the owner further and she had been feeding the dog 3/4cup r/d BID with only occasional veggie treats. At this point I decided to pretend it was a newly diagnosed diabetic and started back at square one with the insulin (calculated to start at 10U BID), and switched the dog over to w/d for a slightly more healthy weight on the dog. Dog came back a few weeks later, spot glucose was 436 but mom was more concerned as she felt the dog was showing more signs of low BG at home. Got her to bring the dog in for a curve - owner gives insulin at 8am/pm, so the first BG at 9 was 374 , the next 2 at 2 hour intervals were both above 400, UA (unfortunately sucked off the kennel floor because we missed the brief window of having a bladder to get a cysto on) showed 3+ glucose (run at Idexx). Increased insulin to 12U BID. There were a few back and forth visits, eventually we settled on 13.5U twice daily and the dog was doing well for the most part but was having varying problems with the bowels - it'd be loose, we'd treat symptomatically then the owner felt it would get too hard for the dog and there'd be a back and forth between the problems. Fecal ova/parasites and giardia elisa were negative. Mid December, about a month after increasing to the 13.5, owner came back in because Sasha was getting "stumbly" again. Spot BG was 45. Couldn't get a urine sample (owner doesn't wait in the lobby with the dog for whatever reason so was walking outside just prior to the appointment and voided my sample into some wood chips). Treated for a suspected UTI and decreased insulin to 11U, did some VIN reading and was going to treat for a month with amoxicillin (ended up at ~12mg/kg BID). Came and saw my colleague on my day off at the start of the new year for some disorientation, tremors, wasn't eating well so stopped the antibiotic. spot BG was 402, up to 46# (rated by him at 3/9 so was told to go to 13U on the insulin. Recheck 1 week later with my colleague, starting to have bowel control issues. I had at one point recommended pumpkin which did help the hard stools but had made some fecal incontinence worse so owner cut back on the pumpkin but started having accidents with harder and sometimes crumbly stools. Decreased insulin to 12U and discussed trying to get pumpkin or metamucil at the right balance in the stool (suspected some degenerative or cognitive dysfunction contributing). Saw the dog back last Friday. Dog has been very disoriented all week. She's almost 47# now. The day of the exam, had been seeming weak and so she gave her a handful of her other dog's food (beneful) and that seemed to perk her up. She's having some difficulty eating (owner has been feeding small amounts at a time because too much at once caused regurg) but now seems to have more difficulty swallowing. Has been scratching at the face for the past few weeks but now the left eye had discharge and seemed painful. Still having the hard/crumbly stools. Spot BG was 334, didn't change any insulin as was unsure with the history if this was real, rebound, or due to beneful being fed at a weird time. Was able to get a cysto sample - 3+ glucose, pH 5.5, SG 1.037, some non crystalline debris, and no growth on culture. Positive stain uptake in the eye (straight line mid cornea). Started topical treatment for the ulcer and would discuss further treatment/diagnostics after we got the urine culture back. Owner has previously given cooked liver to her dogs for bowel issues (she's had huskies on/off for years and has also previously had wolf hybrids). Since Sasha now refuses to eat any food tainted with pumpkin, gave the OK to try that to see if we can't get that part under control. Before I do anything with the insulin, I want another curve to figure out what's actually going on. I may also see if the owner would be able to check BG at home - may do an in-home curve or at least be able to check when she gets "stumbly" to prove we are dipping low at that point (feeding brings her out of it but would be nice to know that it isn't just a coincidence). Is there anywhere else I should look for some reason why every few weeks she's bottoming out on her BG? In the beginning I was honest with the owner that it was going to be a difficult and long haul as she had such poor body condition and had apparently had really bad juju going on prior to my first seeing her. Thanks.

What kind of insulin are you using?

In the meantime, how is he feeling clinically?

I have an emergency case, so pardon me if I am somewhat brief. I have a 12 year old Male Intact West Highland White Terrier that has had ongoing bouts of diarrhea with blood since January 14th. We noted that he had a 2 pound weight loss at that time. Other abnormalities noted were the following: Appearance: BAR ***Oral Cavity: Significant dental tartar and gingival recession - no change ***Abdomen: Slightly tense on cranial abdominal palpation; ***Gastrointestinal: Diarrhea with blood Integument: Several small epidermal scabs, but overall improved (Chronic skin case) ***Peripheral Lymph Nodes: Within normal limits and Submandibular lymph node were prominent Treated with Metronidazole, Proviable and i/d diet = patient recovered unremarkably.... NOTE: This patient has chronic skin issues and 5/18/12 we did an ACTH (Cushing's suspect) which was positive Cortisol baseline of 3.4 and Post ACTH of 21.0. Started him on herbal meds for Cushings versus Trilostane at this time. To be re-evaluated in 6 months to 1 year. Anyhow, the diarrhea came back and the weight loss continued. Owner brought in last night - At this time, we found that right testicle was firm and warm to the touch. - radiographs: Radiographs from last night: Liver 1" past 13th rib, Lungs are clear, Normal gas pattern in the intestine with increased gas pattern in the large intestines; Spleen noticeable, but not enlarged; No obstructive pattern; Severe Spondylosis T4-6 and Significant spondylosis of T13 - L4 Labs just returned at exact same time as patient arrived in lateral recumbency - Elevated Potassium 5.6 (3.6-5.3) - BUN 156.9 CH - Creatinine 5.7 Phosphorus 16.9 (2.2-6.6) ALP 602 (always elevated in this patient) br/lase 2,042 Lipase 1,067 (78-765) Slight anemia HCT = 35.6 with normal WBC Urinalysis normal except Urine SG = 1.011 i-stat today - pH, PCO2 and HCO3 are all low with Sodium low of 131 and Potassium high at 5.0 Recheck of Calcium is normal If I hadn't done an ACTH, I would highly suspect addisonian, but for sure, we have acute renal failure...right? Any thoughts on getting the phosphorus down? I started on NaCL with 50% Dextrose and gave 1 unit of Humulin-N; Famotadine Any thoughts? Could the testicle be related with the renal failure.....? Dixie

Is the dog diabetic or hypoglycemic?

You used 0.01 mg/kg dex iv?

I have an emergency case, so pardon me if I am somewhat brief. I have a 12 year old Male Intact West Highland White Terrier that has had ongoing bouts of diarrhea with blood since January 14th. We noted that he had a 2 pound weight loss at that time. Other abnormalities noted were the following: Appearance: BAR ***Oral Cavity: Significant dental tartar and gingival recession - no change ***Abdomen: Slightly tense on cranial abdominal palpation; ***Gastrointestinal: Diarrhea with blood Integument: Several small epidermal scabs, but overall improved (Chronic skin case) ***Peripheral Lymph Nodes: Within normal limits and Submandibular lymph node were prominent Treated with Metronidazole, Proviable and i/d diet = patient recovered unremarkably.... NOTE: This patient has chronic skin issues and 5/18/12 we did an ACTH (Cushing's suspect) which was positive Cortisol baseline of 3.4 and Post ACTH of 21.0. Started him on herbal meds for Cushings versus Trilostane at this time. To be re-evaluated in 6 months to 1 year. Anyhow, the diarrhea came back and the weight loss continued. Owner brought in last night - At this time, we found that right testicle was firm and warm to the touch. - radiographs: Radiographs from last night: Liver 1" past 13th rib, Lungs are clear, Normal gas pattern in the intestine with increased gas pattern in the large intestines; Spleen noticeable, but not enlarged; No obstructive pattern; Severe Spondylosis T4-6 and Significant spondylosis of T13 - L4 Labs just returned at exact same time as patient arrived in lateral recumbency - Elevated Potassium 5.6 (3.6-5.3) - BUN 156.9 CH - Creatinine 5.7 Phosphorus 16.9 (2.2-6.6) ALP 602 (always elevated in this patient) br/lase 2,042 Lipase 1,067 (78-765) Slight anemia HCT = 35.6 with normal WBC Urinalysis normal except Urine SG = 1.011 i-stat today - pH, PCO2 and HCO3 are all low with Sodium low of 131 and Potassium high at 5.0 Recheck of Calcium is normal If I hadn't done an ACTH, I would highly suspect addisonian, but for sure, we have acute renal failure...right? Any thoughts on getting the phosphorus down? I started on NaCL with 50% Dextrose and gave 1 unit of Humulin-N; Famotadine Any thoughts? Could the testicle be related with the renal failure.....? Dixie

What is the tpr, glucose and wbc?

Lymphoma since 2009?

Hi Shelby is a SF 14 yo Beagle that presented two weeks ago for bumps on the ears and abdomen, urinating in the house, increased appetite and weight loss, and coughing at night. Physical exam: O: Bright, alert, and responsive. Food: n/a Amount: 2 cups HWP: n/a Flea control: n/a Ears: Normal Eyes: Mild cloudiness in lenses Lymphatics: Normal Skin: subcutaneous lesions (firm) on head and neck, not attached to deeper muscle layers. Subcutaneous lesions on sternum and ventral abdomen, not attached to deeper muscle layers and soft. Heart: grade 4/6 murmur heard on both sides of the thorax, PMI is left cranial thorax. Lungs:Normal Gastrointestinal: Normal Genitourinary: possible polyuria? Musculoskeletal: Very stiff in the rear legs, walking peg legged. Pain: 5-8/10 Dental:Moderate dental tartar and gingival inflammation BCS: 3/5 Neurological: Normal T: 101.6 P: 136 R: pant CRT 2s, mm pink/moist. A:Acquired heart murmur --valvular disease --DCM Polyuria --al disease --endocrine disease --diabetes Periodontal disease Arthritis Recommended to run lab work and take chest radiographs to see what was going on with the heart. Owner elected to do lab work which showed a UTI and abnormalities consistent with cushings or addisons. Superchem Total Protein 7.4 5.0-7.4 g/dL Albumin 4.1 2.7-4.4 g/dL Globulin 3.3 1.6-3.6 g/dL A/G Ratio 1.2 0.8-2.0 Ratio AST (SGOT) 31 15-66 U/L ALT (SGPT) 60 12-118 U/L Alk Phosphatase 163 5-131 U/L HIGH GGTP 6 1-12 U/L Total Bilirubin 0.1 0.1-0.3 mg/dL Urea Nitrogen 18 6-31 mg/dL Creatinine 0.7 0.5-1.6 mg/dL BUN/Creatinine Ratio 26 4-27 Ratio Phosphorus 4.5 2.5-6.0 mg/dL Glucose 99 70-138 mg/dL Calcium 11.7 8.9-11.4 mg/dL HIGH Magnesium 2.1 1.5-2.5 mEq/L Sodium 147 139-154 mEq/L Potassium 5.9 3.6-5.5 mEq/L HIGH Na/K Ratio 25 Chloride 107 102-120 mEq/L Cholesterol 441 92-324 mg/dL HIGH Triglycerides 393 29-291 mg/dL HIGH Amylase 974 290-1125 U/L Lipase 580 77-695 U/L CPK 182 59-895 U/L Comment Hemolysis 1+ No significant interfece. CBC WBC 11.8 4.0-15.5 103/mL RBC 6.86 4.8-9.3 106/mL Hemoglobin 15.7 12.1-20.3 g/dL Hematocrit 47.9 36-60 % MCV 70 58-79 fL MCH 22.9 19-28 pg MCHC 32.8 30-38 g/dL Platelet Count 588 170-400 103/mL HIGH Platelet EST Increased Adequate Diffetial Absolute % Neutrophils 8024 68 2060-10600 /uL Bands 0 0 0-300 /uL Lymphocytes 2832 24 690-4500 /uL Monocytes 472 4 0-840 /uL Eosinophils 472 4 0-1200 /uL Basophils 0 0 0-150 /uL Total T4 T4 0.5 0.8-3.5 ug/dL LOW Note new Canine refece range The Total T4 result is less than 1.0 mcg/dl. A Free-T4 by equilibrium dialysis may be helpful in supporting the diagnosis of hypothyroidism in patients demonstrating clinical signs compatible with hypothyroidism.Please use test code 9816 for this additional testing. Urinalysis Collection Method Natural Voiding Color Yellow Appearance Cloudy *Clear Specific Gravity 1.020 1.015-1.050 pH 5.5 5.5-7.0 Protein 3+ Neg HIGH Urine protein:creatinine ratio testing is recommended (if the sediment is inactive) to help determine the clinical significance of proteinuria. Glucose Negative Neg Ketone Negative Neg Bilirubin Negative Neg To 1+ Blood Trace Neg WBC 4-10 0-3 HPF HIGH RBC 2-3 0-3 HPF Casts None Seen LPF Crystals None Seen HPF Bacteria Rods >100 None HPF Squamous Epithelia 0-1 0-3 HPF Urine Microalbumin (Canine) Microalbuminuria >30 2.5 mg/dL HIGH I wanted to treat the potential UTI and recheck the urine in two weeks as well as do radiographs to assess the organs, but a LDDS was done and the results are sort of on the cusp of abnormal.... Time 1 Baseline Time 2 4Hr Time 3 8Hr Cortisol Sample 1 5.0 mg/dL Cortisol Sample 2 Dex 1.0 mg/dL Cortisol Sample 3 Dex 1.5 mg/dL So technically, she is Cushingoid, but I didn't get the urine yesterday (which owners are coming back for). General guidance requested...I've been doing primarily cats for the past five years!!! Thanks,

Is it a lot of weight loss?

Ua results?

Hi Shelby is a SF 14 yo Beagle that presented two weeks ago for bumps on the ears and abdomen, urinating in the house, increased appetite and weight loss, and coughing at night. Physical exam: O: Bright, alert, and responsive. Food: n/a Amount: 2 cups HWP: n/a Flea control: n/a Ears: Normal Eyes: Mild cloudiness in lenses Lymphatics: Normal Skin: subcutaneous lesions (firm) on head and neck, not attached to deeper muscle layers. Subcutaneous lesions on sternum and ventral abdomen, not attached to deeper muscle layers and soft. Heart: grade 4/6 murmur heard on both sides of the thorax, PMI is left cranial thorax. Lungs:Normal Gastrointestinal: Normal Genitourinary: possible polyuria? Musculoskeletal: Very stiff in the rear legs, walking peg legged. Pain: 5-8/10 Dental:Moderate dental tartar and gingival inflammation BCS: 3/5 Neurological: Normal T: 101.6 P: 136 R: pant CRT 2s, mm pink/moist. A:Acquired heart murmur --valvular disease --DCM Polyuria --al disease --endocrine disease --diabetes Periodontal disease Arthritis Recommended to run lab work and take chest radiographs to see what was going on with the heart. Owner elected to do lab work which showed a UTI and abnormalities consistent with cushings or addisons. Superchem Total Protein 7.4 5.0-7.4 g/dL Albumin 4.1 2.7-4.4 g/dL Globulin 3.3 1.6-3.6 g/dL A/G Ratio 1.2 0.8-2.0 Ratio AST (SGOT) 31 15-66 U/L ALT (SGPT) 60 12-118 U/L Alk Phosphatase 163 5-131 U/L HIGH GGTP 6 1-12 U/L Total Bilirubin 0.1 0.1-0.3 mg/dL Urea Nitrogen 18 6-31 mg/dL Creatinine 0.7 0.5-1.6 mg/dL BUN/Creatinine Ratio 26 4-27 Ratio Phosphorus 4.5 2.5-6.0 mg/dL Glucose 99 70-138 mg/dL Calcium 11.7 8.9-11.4 mg/dL HIGH Magnesium 2.1 1.5-2.5 mEq/L Sodium 147 139-154 mEq/L Potassium 5.9 3.6-5.5 mEq/L HIGH Na/K Ratio 25 Chloride 107 102-120 mEq/L Cholesterol 441 92-324 mg/dL HIGH Triglycerides 393 29-291 mg/dL HIGH Amylase 974 290-1125 U/L Lipase 580 77-695 U/L CPK 182 59-895 U/L Comment Hemolysis 1+ No significant interfece. CBC WBC 11.8 4.0-15.5 103/mL RBC 6.86 4.8-9.3 106/mL Hemoglobin 15.7 12.1-20.3 g/dL Hematocrit 47.9 36-60 % MCV 70 58-79 fL MCH 22.9 19-28 pg MCHC 32.8 30-38 g/dL Platelet Count 588 170-400 103/mL HIGH Platelet EST Increased Adequate Diffetial Absolute % Neutrophils 8024 68 2060-10600 /uL Bands 0 0 0-300 /uL Lymphocytes 2832 24 690-4500 /uL Monocytes 472 4 0-840 /uL Eosinophils 472 4 0-1200 /uL Basophils 0 0 0-150 /uL Total T4 T4 0.5 0.8-3.5 ug/dL LOW Note new Canine refece range The Total T4 result is less than 1.0 mcg/dl. A Free-T4 by equilibrium dialysis may be helpful in supporting the diagnosis of hypothyroidism in patients demonstrating clinical signs compatible with hypothyroidism.Please use test code 9816 for this additional testing. Urinalysis Collection Method Natural Voiding Color Yellow Appearance Cloudy *Clear Specific Gravity 1.020 1.015-1.050 pH 5.5 5.5-7.0 Protein 3+ Neg HIGH Urine protein:creatinine ratio testing is recommended (if the sediment is inactive) to help determine the clinical significance of proteinuria. Glucose Negative Neg Ketone Negative Neg Bilirubin Negative Neg To 1+ Blood Trace Neg WBC 4-10 0-3 HPF HIGH RBC 2-3 0-3 HPF Casts None Seen LPF Crystals None Seen HPF Bacteria Rods >100 None HPF Squamous Epithelia 0-1 0-3 HPF Urine Microalbumin (Canine) Microalbuminuria >30 2.5 mg/dL HIGH I wanted to treat the potential UTI and recheck the urine in two weeks as well as do radiographs to assess the organs, but a LDDS was done and the results are sort of on the cusp of abnormal.... Time 1 Baseline Time 2 4Hr Time 3 8Hr Cortisol Sample 1 5.0 mg/dL Cortisol Sample 2 Dex 1.0 mg/dL Cortisol Sample 3 Dex 1.5 mg/dL So technically, she is Cushingoid, but I didn't get the urine yesterday (which owners are coming back for). General guidance requested...I've been doing primarily cats for the past five years!!! Thanks,

Does the dog look cushingoid on your physical exam?

Can you post the last few bg curves?

Hi there, Let me preface this message by saying that I've just come off of mat-leave, so I'm a little rusty! Ok, I have a 5 year old MN indoor DSH who has an approximate 4 month history of voluminous diarrhea with a concurrent insatiable appetite (diarrhea and appetite change started at roughly the same time). His weight over the past few years has gone up and down, so it is difficult to say if there has actually been a continuous weight loss, but currently he is down in weight from his previous visit, which was ~1 year ago. Diarrhea is described as chocolate pudding consistency and colour. Cat is otherwise in good condition; BAR, PE WNL. No recent changes in diet. No recent changes in life (i.e. move or board or travel) No pu/pd. I believe there is a dog in the house (don't have the file with me at the moment). My r/o's included hyperthyroid, diabetes, IBD, lymphoma, and after some reading, EPI. I ran a wellness including a T4, and everything is completely normal. I started him on a 3 week course of Prednisolone (I know, I know, probably should have done Metronidazole, please don't chew me out, I realize that this can mask a dx of GI lymphoma if we were to pursue that diagnostic route.... can't say why I chose pred, other than that I'm just back in the work force and was also just thinking about putting out the initial fire to bring the kitty some comfort). 2.5 mg PO SID x 7d, then EOD x 7 doses. Update on cat, after ~10 days of tx, is that there aren't any changes. They are coming to see me tomorrow. The next diagnostic steps I'm considering taking are sending out a fecal (for the regular stuff as well as Tritrich, giardia, etc), prophylactic deworming, and, if finances will allow, a TLI/folate/cobalamin and an abdominal u/s. I was just wondering if I should be thinking about any other diagnostics, and if there are any other r/o's that I may have missed. I realize that EPI is quite rare in cats, but it is the only thing that I can think of that ties the diarrhea to the voracious appetite. Any input would be appreciated. Thanks,

Would you characterized the diarrhea as larger or small bowel, and why?

Is his tail tone normal, and his anal tone?

I have a 16 year old MN DSH that presented for senior exam. The blood work was unremarkable but the potassium was low at 3.6 (3.9-5.3). The BUN was 25 (15-34) and the creatinine was 1.1 (0.6-2.3) Blood work done Oct. 2012 was also unremarkable (prior to dental procedure). The potassium was 4.1 Urine SG was 1.018. I assumed the cat had early renal disease and had the owner start tumil K at 2 mEq twice daily. Repeat potassium was done a month later and the result was lower at 3.5. I measured his blood pressure and it was 220 on the doppler. Previous BP measurements had always been in the 130 to 150 range. I ordered an aldosterone level from MSU and it was 2254 (194-388) Diagnosis is hyperaldosteronism. I tried to find the adrenals on U/S but couldn't find them definitely. My next step is CT. So, even this is an asymptomatic cat, I have to assume this is hyperaldosteronism and I just caught it before the potassium dropped to a clinically relevant level. Would you agree or am I missing something more common? Am I over-reaching for this?

Did ou call msu and chat with one of their endocrinologists about the case?

Alternatively, it's possible that the t4 was suppressed because the dog's diabetic (sick euthyroid)--did you do a free t4 and tsh level?

I have a 16 year old MN DSH that presented for senior exam. The blood work was unremarkable but the potassium was low at 3.6 (3.9-5.3). The BUN was 25 (15-34) and the creatinine was 1.1 (0.6-2.3) Blood work done Oct. 2012 was also unremarkable (prior to dental procedure). The potassium was 4.1 Urine SG was 1.018. I assumed the cat had early renal disease and had the owner start tumil K at 2 mEq twice daily. Repeat potassium was done a month later and the result was lower at 3.5. I measured his blood pressure and it was 220 on the doppler. Previous BP measurements had always been in the 130 to 150 range. I ordered an aldosterone level from MSU and it was 2254 (194-388) Diagnosis is hyperaldosteronism. I tried to find the adrenals on U/S but couldn't find them definitely. My next step is CT. So, even this is an asymptomatic cat, I have to assume this is hyperaldosteronism and I just caught it before the potassium dropped to a clinically relevant level. Would you agree or am I missing something more common? Am I over-reaching for this?

Is there a radiologist who could give another shot at finding the adrenals?

I'm wondering if there is some infection in the skin around the tube that could be flushed/compressed?

I have a 9 year old MC Chihuahua (very fractious/anxious) who was diagnosed with Diabetes mellitus on 7/28/12. At that time, he had had PU/PD for about a week and had lost about 2 lbs. Physical was unremarkable other than a lipoma and mild dental disease. BG was 552 on the glucometer and urine dipstick showed 3+ glucose. A Superchem/CBC/T4/UA was sent out at that time. ALP was 362 (5-131), Glucose 455, urine neg ketones, 3+ glucose. All else unremarkable. He was started on 3 units NPH SQ BID (pet was 15.6 lbs). Urine culture came back + for e.coli and was treated with simplicef x 21 days. BG was rechecked 1 week later (4-6 hrs after insulin) and was 252. PE hadn't changed except mild weight gain. Owners reported PU/PD had started to decrease 2 days prior. Insulin dose was not changed. BG checked another week later and was 442. Insulin dose was not changed because owner was not sure that he had gotten the full insulin dose that morning. The following week, BG was 384 and owner was confident insulin was being given appropriately. Insulin was increased to 4 units BID. urine strip at home was 4+ glucose, neg ketones. 2 weeks later, BG check = 289. Owner had just switched to insulin pen for ease of administration. Dose was not changed. 1 month later, BG rechecked and was 228. Owner had changed dose to 4.5 units at some point. Pet had lost 2 lbs and had developed cataracts which were not present previously. Another month later (11/4), still on 4.5 units BID and 1 more pound of weight loss. Still PU/PD at night. BG = 543. Full bloodwork/UA repeated and no real change. except ALP now 283 and Triglycerides 381 (29-291). UA WNL, no bacteria. Fructosamine was 709 (142-450). Insulin was changed to 5 units BID. 3 weeks later, (11/21), Another 1 lb weight loss BG = 425. PU/PD slightly better. Insuline increased to 6 units BID. 1 week later (12/1), BG = 278. Owner had reported that when they first gave 6 units, pet seemed woozy so they had done 5 1/2 for a couple of days and then he tolerated 6 units ok. Told owner to stay with 6 units BID. 2 weeks later, (12/21), BG = 347. Increased the insulin to 6 1/2 units BID. Now is on w/d food exclusively after several discussions about it. 2 weeks later, (1/7), BG = 489. Per owners, pet doing clinically well but weight dropped another pound. Increased to 7 1/2 units NPH BID. 2 weeks later (1/28), BG = 573. weight is stable, pet doing well clinically--eating well, no PU/PD At this point, the owners are getting frustrated and the pet is pretty fractious and stressed every time he comes in. Doing BG curves isn't necessarily practical for them. Should I increase the insulin to 8 1/2 or 9 units at this point (pet is currently 12.3 lbs)? Should I recommend internal medicine consult (they have been resistant to this in the past)? AUS? ACTH stim or LDDS? There have been extensive discussions to ensure that the insulin is being given correctly. I will ask to see if they are still using the same bottle as when the initial diagnosis was made. Any other suggestions? Thanks very much!

The owner is neither over- nor under-shaking the insulin (we scare them so much sometimes about not over-shaking it that they fail to reconstitute it well and inject diluent)--maybe in a pen, though, they don't need to reconstitute it?

How many calories/day does the cat currently get?

Hi, I need some advice. Boris is a 10yr old nm Devon Rex with DM. He has had a 1 yr history of weight loss (12lbs to 6.9lbs-current), chronic gi issues- vomiting projectile bile in large amounts every 2-3 days. littermate died of lymphoma last march. Boris was dx with DM in 10/12 with a glucose of 375 and trace ketones . At that time he weight 8.9lbs and I wanted to start on 0.5mg/kg (2 units) Lantus. O/ was a bit hesitant so we started on 1unit bid and DM canned diet. A curve was done 1 wk later. 11/5/12- 8am- fed dm can and gave 1 unit Lantus 9:20am- 353 11:30am-365 1:55pm=384 4:00pm-287 o/ had to pick up. dose was increased to 1.5units and curve was recommended to be rechecked in 2 weeks. 1/3/13-returned for curve 9am fed and gave 1.5 units Lantus 10am- 42, gave 1cc karo, fed 1/3 can dm 11am- 31, gave 3cc karo 12pm-64 1pm- 53, gave 1 cc karo 2pm- 48, gave 3cc karo 3pm- 83 4pm- 110 5pm- 111 dose was decreased to 0.5units sq bid, went over importance of feeding and giving insulin at same time. ua, urine culture, texas gi panel was done. panel-neg for pancreatitis, low cobalamine noted. started vit b12 injxns 0.25cc sq once weekly X 6 wks. ua showed infection-rods, culture came back negative. pet was started on orbax. started on cerenia for vomiting. 1/10/13- returned for curve 6:30am- fed and gave 0.5 units lantus sq 8:15am-237 10:00am-240 12:00pm- 128 1pm- 82 2pm- 68 4pm- 62 gave 1 cc karo o/ had to pick up. insulin was d/c. DM can continued 1/14/13- vomiting continued. cbc/chem/ua/t4 done- cbc- wbc=23 (2.8-17.0), neuts= 12.8 (1.4-10.2), eos=4.7 (0.17-1.57), basophils 0.46 (.01-0.26), chem= glucose=498, urine unremarkable, no ketones, no infection. t4 wnl. started back on Lantus 0.25units sq bid 1/30/13- returned for curve, drew ua and urine culture-both pending current diet DM 2 cans total per day, graze 6:30am- fed and gave 0.25units Lantus 8:45am- 419 9:45- 470 11:45am- 433 1:45pm- 270 3:45pm- 221 5:45pm- 163 6:30pm- 163-- recommend keeping overnight 7:45pm- 156- ate 1/3 can, normal bm overnight 9:45pm- 171 11:45pm- 267- ate 1/3 can DM 1/31/13- continued- 7:20am- 404 8:30am- fed and gave 1/2 can DM 10:25am- 465 so what to do at this point? it appears that the insulin is taking a long time to take effect. O/'s are frustrated and considering euthanasia. Declines referral. Im not sure where the vomiting fits in- related to diabetes, ibd, lsa? thanks for the advice

What is it exactly that makes the owner want to euthanize?

I am not sure the question in, "is there any evidence of mastocytosis occurring in dogs and may they somehow tie in with the extreme vasculitis that was occurring previously?" as for what do do in this case?

Hi, I need some advice. Boris is a 10yr old nm Devon Rex with DM. He has had a 1 yr history of weight loss (12lbs to 6.9lbs-current), chronic gi issues- vomiting projectile bile in large amounts every 2-3 days. littermate died of lymphoma last march. Boris was dx with DM in 10/12 with a glucose of 375 and trace ketones . At that time he weight 8.9lbs and I wanted to start on 0.5mg/kg (2 units) Lantus. O/ was a bit hesitant so we started on 1unit bid and DM canned diet. A curve was done 1 wk later. 11/5/12- 8am- fed dm can and gave 1 unit Lantus 9:20am- 353 11:30am-365 1:55pm=384 4:00pm-287 o/ had to pick up. dose was increased to 1.5units and curve was recommended to be rechecked in 2 weeks. 1/3/13-returned for curve 9am fed and gave 1.5 units Lantus 10am- 42, gave 1cc karo, fed 1/3 can dm 11am- 31, gave 3cc karo 12pm-64 1pm- 53, gave 1 cc karo 2pm- 48, gave 3cc karo 3pm- 83 4pm- 110 5pm- 111 dose was decreased to 0.5units sq bid, went over importance of feeding and giving insulin at same time. ua, urine culture, texas gi panel was done. panel-neg for pancreatitis, low cobalamine noted. started vit b12 injxns 0.25cc sq once weekly X 6 wks. ua showed infection-rods, culture came back negative. pet was started on orbax. started on cerenia for vomiting. 1/10/13- returned for curve 6:30am- fed and gave 0.5 units lantus sq 8:15am-237 10:00am-240 12:00pm- 128 1pm- 82 2pm- 68 4pm- 62 gave 1 cc karo o/ had to pick up. insulin was d/c. DM can continued 1/14/13- vomiting continued. cbc/chem/ua/t4 done- cbc- wbc=23 (2.8-17.0), neuts= 12.8 (1.4-10.2), eos=4.7 (0.17-1.57), basophils 0.46 (.01-0.26), chem= glucose=498, urine unremarkable, no ketones, no infection. t4 wnl. started back on Lantus 0.25units sq bid 1/30/13- returned for curve, drew ua and urine culture-both pending current diet DM 2 cans total per day, graze 6:30am- fed and gave 0.25units Lantus 8:45am- 419 9:45- 470 11:45am- 433 1:45pm- 270 3:45pm- 221 5:45pm- 163 6:30pm- 163-- recommend keeping overnight 7:45pm- 156- ate 1/3 can, normal bm overnight 9:45pm- 171 11:45pm- 267- ate 1/3 can DM 1/31/13- continued- 7:20am- 404 8:30am- fed and gave 1/2 can DM 10:25am- 465 so what to do at this point? it appears that the insulin is taking a long time to take effect. O/'s are frustrated and considering euthanasia. Declines referral. Im not sure where the vomiting fits in- related to diabetes, ibd, lsa? thanks for the advice

Is it finances?

The owner is only feeding at mealtimes, when the insulin is given, using a measuring cup and the amount is reasonable for a dog this size (sometimes when the weight is falling off of them they panic and start really over-feeding the dog---which means we have to chase after them with an ever-increasing amount of insulin) what does he currently weigh?

Hi, I need some advice. Boris is a 10yr old nm Devon Rex with DM. He has had a 1 yr history of weight loss (12lbs to 6.9lbs-current), chronic gi issues- vomiting projectile bile in large amounts every 2-3 days. littermate died of lymphoma last march. Boris was dx with DM in 10/12 with a glucose of 375 and trace ketones . At that time he weight 8.9lbs and I wanted to start on 0.5mg/kg (2 units) Lantus. O/ was a bit hesitant so we started on 1unit bid and DM canned diet. A curve was done 1 wk later. 11/5/12- 8am- fed dm can and gave 1 unit Lantus 9:20am- 353 11:30am-365 1:55pm=384 4:00pm-287 o/ had to pick up. dose was increased to 1.5units and curve was recommended to be rechecked in 2 weeks. 1/3/13-returned for curve 9am fed and gave 1.5 units Lantus 10am- 42, gave 1cc karo, fed 1/3 can dm 11am- 31, gave 3cc karo 12pm-64 1pm- 53, gave 1 cc karo 2pm- 48, gave 3cc karo 3pm- 83 4pm- 110 5pm- 111 dose was decreased to 0.5units sq bid, went over importance of feeding and giving insulin at same time. ua, urine culture, texas gi panel was done. panel-neg for pancreatitis, low cobalamine noted. started vit b12 injxns 0.25cc sq once weekly X 6 wks. ua showed infection-rods, culture came back negative. pet was started on orbax. started on cerenia for vomiting. 1/10/13- returned for curve 6:30am- fed and gave 0.5 units lantus sq 8:15am-237 10:00am-240 12:00pm- 128 1pm- 82 2pm- 68 4pm- 62 gave 1 cc karo o/ had to pick up. insulin was d/c. DM can continued 1/14/13- vomiting continued. cbc/chem/ua/t4 done- cbc- wbc=23 (2.8-17.0), neuts= 12.8 (1.4-10.2), eos=4.7 (0.17-1.57), basophils 0.46 (.01-0.26), chem= glucose=498, urine unremarkable, no ketones, no infection. t4 wnl. started back on Lantus 0.25units sq bid 1/30/13- returned for curve, drew ua and urine culture-both pending current diet DM 2 cans total per day, graze 6:30am- fed and gave 0.25units Lantus 8:45am- 419 9:45- 470 11:45am- 433 1:45pm- 270 3:45pm- 221 5:45pm- 163 6:30pm- 163-- recommend keeping overnight 7:45pm- 156- ate 1/3 can, normal bm overnight 9:45pm- 171 11:45pm- 267- ate 1/3 can DM 1/31/13- continued- 7:20am- 404 8:30am- fed and gave 1/2 can DM 10:25am- 465 so what to do at this point? it appears that the insulin is taking a long time to take effect. O/'s are frustrated and considering euthanasia. Declines referral. Im not sure where the vomiting fits in- related to diabetes, ibd, lsa? thanks for the advice

How many calories are in 2 cans of dm?

What has she been feeding up till now?

Hi, I need some advice. Boris is a 10yr old nm Devon Rex with DM. He has had a 1 yr history of weight loss (12lbs to 6.9lbs-current), chronic gi issues- vomiting projectile bile in large amounts every 2-3 days. littermate died of lymphoma last march. Boris was dx with DM in 10/12 with a glucose of 375 and trace ketones . At that time he weight 8.9lbs and I wanted to start on 0.5mg/kg (2 units) Lantus. O/ was a bit hesitant so we started on 1unit bid and DM canned diet. A curve was done 1 wk later. 11/5/12- 8am- fed dm can and gave 1 unit Lantus 9:20am- 353 11:30am-365 1:55pm=384 4:00pm-287 o/ had to pick up. dose was increased to 1.5units and curve was recommended to be rechecked in 2 weeks. 1/3/13-returned for curve 9am fed and gave 1.5 units Lantus 10am- 42, gave 1cc karo, fed 1/3 can dm 11am- 31, gave 3cc karo 12pm-64 1pm- 53, gave 1 cc karo 2pm- 48, gave 3cc karo 3pm- 83 4pm- 110 5pm- 111 dose was decreased to 0.5units sq bid, went over importance of feeding and giving insulin at same time. ua, urine culture, texas gi panel was done. panel-neg for pancreatitis, low cobalamine noted. started vit b12 injxns 0.25cc sq once weekly X 6 wks. ua showed infection-rods, culture came back negative. pet was started on orbax. started on cerenia for vomiting. 1/10/13- returned for curve 6:30am- fed and gave 0.5 units lantus sq 8:15am-237 10:00am-240 12:00pm- 128 1pm- 82 2pm- 68 4pm- 62 gave 1 cc karo o/ had to pick up. insulin was d/c. DM can continued 1/14/13- vomiting continued. cbc/chem/ua/t4 done- cbc- wbc=23 (2.8-17.0), neuts= 12.8 (1.4-10.2), eos=4.7 (0.17-1.57), basophils 0.46 (.01-0.26), chem= glucose=498, urine unremarkable, no ketones, no infection. t4 wnl. started back on Lantus 0.25units sq bid 1/30/13- returned for curve, drew ua and urine culture-both pending current diet DM 2 cans total per day, graze 6:30am- fed and gave 0.25units Lantus 8:45am- 419 9:45- 470 11:45am- 433 1:45pm- 270 3:45pm- 221 5:45pm- 163 6:30pm- 163-- recommend keeping overnight 7:45pm- 156- ate 1/3 can, normal bm overnight 9:45pm- 171 11:45pm- 267- ate 1/3 can DM 1/31/13- continued- 7:20am- 404 8:30am- fed and gave 1/2 can DM 10:25am- 465 so what to do at this point? it appears that the insulin is taking a long time to take effect. O/'s are frustrated and considering euthanasia. Declines referral. Im not sure where the vomiting fits in- related to diabetes, ibd, lsa? thanks for the advice

What exactly was the t4 value?

Is he on prednisone now?

Hi, I need some advice. Boris is a 10yr old nm Devon Rex with DM. He has had a 1 yr history of weight loss (12lbs to 6.9lbs-current), chronic gi issues- vomiting projectile bile in large amounts every 2-3 days. littermate died of lymphoma last march. Boris was dx with DM in 10/12 with a glucose of 375 and trace ketones . At that time he weight 8.9lbs and I wanted to start on 0.5mg/kg (2 units) Lantus. O/ was a bit hesitant so we started on 1unit bid and DM canned diet. A curve was done 1 wk later. 11/5/12- 8am- fed dm can and gave 1 unit Lantus 9:20am- 353 11:30am-365 1:55pm=384 4:00pm-287 o/ had to pick up. dose was increased to 1.5units and curve was recommended to be rechecked in 2 weeks. 1/3/13-returned for curve 9am fed and gave 1.5 units Lantus 10am- 42, gave 1cc karo, fed 1/3 can dm 11am- 31, gave 3cc karo 12pm-64 1pm- 53, gave 1 cc karo 2pm- 48, gave 3cc karo 3pm- 83 4pm- 110 5pm- 111 dose was decreased to 0.5units sq bid, went over importance of feeding and giving insulin at same time. ua, urine culture, texas gi panel was done. panel-neg for pancreatitis, low cobalamine noted. started vit b12 injxns 0.25cc sq once weekly X 6 wks. ua showed infection-rods, culture came back negative. pet was started on orbax. started on cerenia for vomiting. 1/10/13- returned for curve 6:30am- fed and gave 0.5 units lantus sq 8:15am-237 10:00am-240 12:00pm- 128 1pm- 82 2pm- 68 4pm- 62 gave 1 cc karo o/ had to pick up. insulin was d/c. DM can continued 1/14/13- vomiting continued. cbc/chem/ua/t4 done- cbc- wbc=23 (2.8-17.0), neuts= 12.8 (1.4-10.2), eos=4.7 (0.17-1.57), basophils 0.46 (.01-0.26), chem= glucose=498, urine unremarkable, no ketones, no infection. t4 wnl. started back on Lantus 0.25units sq bid 1/30/13- returned for curve, drew ua and urine culture-both pending current diet DM 2 cans total per day, graze 6:30am- fed and gave 0.25units Lantus 8:45am- 419 9:45- 470 11:45am- 433 1:45pm- 270 3:45pm- 221 5:45pm- 163 6:30pm- 163-- recommend keeping overnight 7:45pm- 156- ate 1/3 can, normal bm overnight 9:45pm- 171 11:45pm- 267- ate 1/3 can DM 1/31/13- continued- 7:20am- 404 8:30am- fed and gave 1/2 can DM 10:25am- 465 so what to do at this point? it appears that the insulin is taking a long time to take effect. O/'s are frustrated and considering euthanasia. Declines referral. Im not sure where the vomiting fits in- related to diabetes, ibd, lsa? thanks for the advice

Is the gi tract thickened on palpation?

What diet is being fed?

I have been managing this diabetic intact Schnauzer for 10 months. She initially presented after seeing another veterinarian with uroliths and pancreatitis. We worked her up and determined she also had diabetes. She has been doing well on w/d with some salmon/steak protein and NPH insulin at 6 units every 12 hrs. Her recent heat cycle was 3 weeks ago and the owner, who checks her urine at home that is showing glucose of 200 and ketones of 40. We increased her to 7 units NPH and her glucose level 1 week later is 414 with ketones still present in her urine. She is eating well and not vomiting. Thoughts? change insulin, ultrasound to assess liver... labs are pending superchem will post tomorrow. Can this all be related to her heat cycle? Thanks

Do you have any bg curves?

I'm a little confused by your description of ascites developing on the trilostane---but it doesn't sound like ascites was seen on the repeat ultrasound?

Dr I have a patient/client kitty that has had Irritable Bowel for years. Nothing has worked well for very long except prednisolone and the dose has to be increased from time to time which frightens the owner. We've tried food trials. The cat is doing as well as she ever has on a canned low carb high protein moderate fat diet but still has episodes. Owner asked me an interesting question I think you may know the answer to. She has seen somewhere that humans have taken DMSO orally for a variety of ailments. She knew I was using your DMSO mixture topically and asked me if there was a formulation of DMSO that could be given to cats for inflammatory bowel. I told her I would ask you about this and possibly minocycline as that has anti-inflammatory properties also. Thanks keith

Irritated bowel syndrome or ibd?

Have you done recent cysto urine culture?

Hi, I would like to get an advice for a 5 1/2 years ols neutered male cat that I have been following for recurrent indolent ulcers since 2010. I have been treating his with Revolution for 3 consecutive months to eliminate the possibility of underlying skin parasites and doing 3 food trials (3 months with Hill's D/D Duck and potatoes, 3 months with RC Hypoallergenic HP and 2 months with Science Diet no grains). A stopped the later one since the cat seemed to get worse on it. The cat not only has an indolent ulcer to his upper left lip, but also has a lesion on his left elbow, left flank and right carpus from licking and bitting himself. He also removes the air on his belly. The cat is now up to 20 lb and I am afraid that he is going to become diabetic soon... Blood tests were normal 2 months ago. He had been on prednisolone and depo-medrol injections almost non stop in the past. I tried Atopica without improvment. I was thinking of trying Amitriptylline or Vanectyl-P... Do you have any suggestion to make this cat feel better without making him diabetic? Thanks a lot

Can you tell me how long you used the atopica and at what dose?

But, a random bg of 95 and a high fructosamine would make me want to do a whole curve (to make sure he doesn't go lower than this) and to see what the duration of insulin effect is...do you monitor with curves?

Hi, I would like to get an advice for a 5 1/2 years ols neutered male cat that I have been following for recurrent indolent ulcers since 2010. I have been treating his with Revolution for 3 consecutive months to eliminate the possibility of underlying skin parasites and doing 3 food trials (3 months with Hill's D/D Duck and potatoes, 3 months with RC Hypoallergenic HP and 2 months with Science Diet no grains). A stopped the later one since the cat seemed to get worse on it. The cat not only has an indolent ulcer to his upper left lip, but also has a lesion on his left elbow, left flank and right carpus from licking and bitting himself. He also removes the air on his belly. The cat is now up to 20 lb and I am afraid that he is going to become diabetic soon... Blood tests were normal 2 months ago. He had been on prednisolone and depo-medrol injections almost non stop in the past. I tried Atopica without improvment. I was thinking of trying Amitriptylline or Vanectyl-P... Do you have any suggestion to make this cat feel better without making him diabetic? Thanks a lot

Would the owner go for allergy testing and immunotherapy?

Some people advocate for hyperbaric oxygen for these cases too?

Hi. Pomie is 11y CM Pomeranian initially presented with thrombocytopenia, petechia, hematuria, and hematemesis. PLT 9000, HCT 20(fallen to 10 12hrs later) He was originally on prednisolone and Cyclosporine at the local vet but couldn't hold down anything. So when he was referred to our hospital we switched to dexamethasone IV 0.5mg/kg SID. Pomie was found to have concurrent IMHA and received few transfusions. It''s been 2 weeks sine he was on steroid, PLT is now 128000, HCT is 31(32 yesterday, retics count looking good) Vomiting has stopped and he's been on oral pred 2mg/kg and azathioprine 2mg/kg. While he was vomiting extensively, he was on 0.45% N/S + 2.5% Dex fluid. Glycosuria(2-3+) and slightly increased blood glucose(fasting BG around 140-160) were noticed and I thought it might be due to the fluids, however he's not on fluid anymore but fasting BG this morning was around 160 again and dip stick showed glucose 1+. I'm wondering if I should check his glucose curve and start him on insulin. I've been reading some threads and obviously steroid-induced diabetes won't be resolved. Could it still be reversible? BG at the moment doesn't seem too high to me. Thank you so much! Sarah DVM South Korea

I'd go back to cyclosporine---do you think the owner can afford it?

Are they new?

Hi. Pomie is 11y CM Pomeranian initially presented with thrombocytopenia, petechia, hematuria, and hematemesis. PLT 9000, HCT 20(fallen to 10 12hrs later) He was originally on prednisolone and Cyclosporine at the local vet but couldn't hold down anything. So when he was referred to our hospital we switched to dexamethasone IV 0.5mg/kg SID. Pomie was found to have concurrent IMHA and received few transfusions. It''s been 2 weeks sine he was on steroid, PLT is now 128000, HCT is 31(32 yesterday, retics count looking good) Vomiting has stopped and he's been on oral pred 2mg/kg and azathioprine 2mg/kg. While he was vomiting extensively, he was on 0.45% N/S + 2.5% Dex fluid. Glycosuria(2-3+) and slightly increased blood glucose(fasting BG around 140-160) were noticed and I thought it might be due to the fluids, however he's not on fluid anymore but fasting BG this morning was around 160 again and dip stick showed glucose 1+. I'm wondering if I should check his glucose curve and start him on insulin. I've been reading some threads and obviously steroid-induced diabetes won't be resolved. Could it still be reversible? BG at the moment doesn't seem too high to me. Thank you so much! Sarah DVM South Korea

Then in 48-72 hours, measure a trough blood level---can you get this done?

Were the samples sent to a commercial lab or run in-house?

Hi. Pomie is 11y CM Pomeranian initially presented with thrombocytopenia, petechia, hematuria, and hematemesis. PLT 9000, HCT 20(fallen to 10 12hrs later) He was originally on prednisolone and Cyclosporine at the local vet but couldn't hold down anything. So when he was referred to our hospital we switched to dexamethasone IV 0.5mg/kg SID. Pomie was found to have concurrent IMHA and received few transfusions. It''s been 2 weeks sine he was on steroid, PLT is now 128000, HCT is 31(32 yesterday, retics count looking good) Vomiting has stopped and he's been on oral pred 2mg/kg and azathioprine 2mg/kg. While he was vomiting extensively, he was on 0.45% N/S + 2.5% Dex fluid. Glycosuria(2-3+) and slightly increased blood glucose(fasting BG around 140-160) were noticed and I thought it might be due to the fluids, however he's not on fluid anymore but fasting BG this morning was around 160 again and dip stick showed glucose 1+. I'm wondering if I should check his glucose curve and start him on insulin. I've been reading some threads and obviously steroid-induced diabetes won't be resolved. Could it still be reversible? BG at the moment doesn't seem too high to me. Thank you so much! Sarah DVM South Korea

I also wonder about rickettsial disease...is he on doxycycline as well?

How long since the surgery?

Hello all, I have a 35lb, 14 year old FS Cocker Spaniel that has been pu/pd for the past 5-6 months. She has been on and off antibiotics several times for lower urinary tract infections. The two most recent urinalysis results were: 1/11/13 (void) SG 1.012 pH 6 1+ protein No blood, 1 wbc/hpf mild-moderate bacteria 1/31/13 (cysto) SG 1.016 pH 8 1+ protein 15-20 rbc/hpf, no wbc no bacteria culture was negative Bloodwork on the 26th showed a BUN/creat ratio of 31 (ref 4-27) and and increase in ALP (350) which I believe is age related. No other abnormalities. The dog is showing no signs of addison's, cushing's, cardiovascular disease that would indicate pheochromocytoma or any other illness (aside from the pu/pd). I know that an occult pyelonephritis can produce minimal changes on bloodwork and urinalysis and can sometimes culture negative. I posted a few ultrasound images of the kidneys on a different board and the responder didn't think it looked like pyelonephritis. I'm not sure where to go next. I had to push the owner a little bit to do the ultrasound and culture and she's probably going to be upset that it didn't yield any answers. Any suggestions? I've considered a DDAVP trial but I don't think the urine SG is low enough to indicate DI.

The lower urinary tract infections were culture proven or assumed?

Treatment...get rid of the feces with enemas and manual debulking?

Hello all, I have a 35lb, 14 year old FS Cocker Spaniel that has been pu/pd for the past 5-6 months. She has been on and off antibiotics several times for lower urinary tract infections. The two most recent urinalysis results were: 1/11/13 (void) SG 1.012 pH 6 1+ protein No blood, 1 wbc/hpf mild-moderate bacteria 1/31/13 (cysto) SG 1.016 pH 8 1+ protein 15-20 rbc/hpf, no wbc no bacteria culture was negative Bloodwork on the 26th showed a BUN/creat ratio of 31 (ref 4-27) and and increase in ALP (350) which I believe is age related. No other abnormalities. The dog is showing no signs of addison's, cushing's, cardiovascular disease that would indicate pheochromocytoma or any other illness (aside from the pu/pd). I know that an occult pyelonephritis can produce minimal changes on bloodwork and urinalysis and can sometimes culture negative. I posted a few ultrasound images of the kidneys on a different board and the responder didn't think it looked like pyelonephritis. I'm not sure where to go next. I had to push the owner a little bit to do the ultrasound and culture and she's probably going to be upset that it didn't yield any answers. Any suggestions? I've considered a DDAVP trial but I don't think the urine SG is low enough to indicate DI.

What clinical signs did she have?

Have you tried chlorpheniramine or amitriptyline?

I have a 3- year old, previously well-controlled diabetic kitty who belongs to an older woman on a fixed income. Long story short, she absolutely refuses to spend over $100 on a bottle of glargine. She used to get it through Canada, but that price has increased dramatically (she's actually using a bottle that is almost a year old, which appears to be part of the problem with his increased BG). The other recommended insulins are just as expensive- any suggestions on what to do? Thanks for any suggestions-

I assume she's feeding a low carb, high protein canned food?

Have you considered a gi workup (ultrasound, endoscopy, etc)?