Diabetes in Dogs
What is diabetes mellitus?
Diabetes is a disease of carbohydrate management in the body. In a normal dog, insulin is released from special cells called the beta cells in the pancreas. Insulin regulates the dog's blood sugar levels, helping to shuttle glucose, the fuel used by the body's cells into the cells as needed. In a diabetic dog, insulin is either not produced in sufficient quantities, or the cells no longer recognize insulin. This causes the blood sugar to rise much higher than is normal. Although the blood sugar is very high, the cells do not get any glucose, so your dog may eat more than normal but lose weight. Excessively high blood sugar is eliminated in the urine in a diabetic pet. When there is a lot of sugar in the urine, the body must excrete more water than normal, as the high sugar content pulls more water into the urine. As a result, your dog will drink and urinate a lot more than normal.
Dogs with diabetes can live normal healthy lives.
Types of Diabetes
There are two forms of diabetes in dogs: diabetes insipidus and diabetes mellitus. Diabetes insipidus is a very rare disorder that results in failure to regulate body water content. Your dog has the more common type of diabetes, diabetes mellitus. This disease is seen on a fairly regular basis, usually in dogs 7 years of age or older. Keeshond, puli, miniature pinscher, cairn terrier have a genetic predisposition to DM. The poodle, dachshund, miniature schnauzer, and beagle breeds are possibly at higher risk. Simply put, diabetes mellitus a failure of the pancreas to regulate blood sugar. The pancreas is a small but vital organ that is located near the stomach. It has two significant populations of cells. One group of cells produces the enzymes necessary for proper digestion. The other group, called beta-cells, produces the hormone called insulin.
In dogs, two types of diabetes mellitus have been discovered. Both types are similar in that there is a failure to regulate blood sugar, but the basic mechanisms of disease differ somewhat between the two groups.
1. Type I, or Insulin Dependent Diabetes Mellitus results from total or near-complete destruction of the beta-cells. This is the most common type of feline diabetes. As the name implies, dogs with this type of diabetes require insulin injections to stabilize blood sugar. Most dogs have Type I diabetes.
2. Type II, or Non-Insulin Dependent Diabetes Mellitus is different because some insulin-producing cells remain. However, the amount produced is insufficient, there is a delayed response in secreting it, and the tissues of the dogs body are relatively resistant to it. These dogs may be treated with an oral drug that stimulates the remaining functional cells to produce or release insulin in an adequate amount to normalize blood sugar. Alternatively, they may be treated with insulin. Dogs with NIDDM may ultimately progress to total beta-cell destruction and then require insulin injections.
What are the signs of diabetes?
How is diabetes caused?
Diabetes can have a variety of causes, ranging from destruction of the beta cells from pancreatitis or viral infection, to idiopathic causes (meaning the etiology is unknown) Corticosteroid use may also predispose dogs to DM. Obese dogs have an increased risk of developing diabetes, so keeping your dog slim will go a long way in keeping her healthy.
How is diabetes treated?
Most diabetic dogs are treated with twice daily injections of insulin. The exact type and dose of insulin varies greatly from dog to dog. Some dogs regulate very quickly, while others take a longer time finding their dose. Dogs can fluctuate in their insulin needs depending upon their general health and their stress levels.
Injecting your dog with insulin is a lot scarier than it sounds. Insulin needles have very small and thin needles, making the injection virtually painless. Many people couple the injection with a tasty treat, and these dogs quickly learn to accept their insulin injections.
How is diabetes mellitus diagnosed?
The normal level of glucose in the blood is 80-120 mg/dl (3.9-6.1 mmol/L). It may rise to 250-300 mg/dl 13.8-16.5 mmol/L) following a meal or when the dog is very excited. However, diabetes is the only common disease that will cause the blood glucose level to rise above 400 mg/dl (22 mmol/L). Some diabetic dogs will have a glucose level as high as 800 mg/dl (44 mmol/L), although most will be in the range of 400-600 mg/dl (22-33 mmol/L).
To keep the body from losing its needed glucose, the kidneys do not allow glucose to be filtered out of the blood stream until an excessive level is reached. This means that dogs with a normal blood glucose level will not have glucose in the urine. Diabetic dogs, however, have excessive amounts of glucose in the blood, so it will be present in the urine.
What are the implications for my dog and me?
For the diabetic dog, one reality exists: blood glucose cannot be normalized without treatment. Although the dog can go a day or so without treatment and not get into a crisis, treatment should be looked upon as part of the dog's daily routine. Treatment almost always requires some dietary changes. Whether an individual dog will require oral therapy or insulin injections will vary.
As for the owner, there are two implications: financial commitment and personal commitment. When your dog is well regulated, the maintenance costs are minimal. The special diet, the oral medication, insulin, and syringes are not expensive. However, the financial commitment is significant during the initial regulation process and if complications arise.
Initially, your dog will be hospitalized for a few days to deal with the immediate crisis and to begin the regulation process. The "immediate crisis" is only great if your dog is so sick that it has quit eating and drinking for several days. Dogs in this state, called ketoacidosis, may require a week or more of hospitalization with quite a bit of laboratory testing. Otherwise, the initial hospitalization may be only for a day or 2 to get some testing done and to begin treatment. At that point, your dog goes home for you to administer medication. At first, return visits are required every 3-7 days to monitor progress. It may take a month or more to achieve good regulation.
The financial commitment may again be significant if complications arise. We will work with you to try and achieve consistent regulation, but some dogs are difficult to keep regulated. It is important that you pay close attention to our instructions related to administration of medication, to diet, and to home monitoring. Another complication that can arise is hypoglycemia or low blood sugar; if severe, it may be fatal. This may occur due to inconsistencies in treatment or because some dogs can have a spontaneous remission of their disease. This will be explained in subsequent paragraphs.
Your personal commitment to treating this dog is very important in maintaining regulation and preventing crises. Most diabetic dogs require insulin injections twice daily, at about 12 hour intervals. They must be fed the same food in the same amount on the same schedule every day. If you are out of town, your dog must receive proper treatment while you are gone. These factors should be considered carefully before deciding to treat a diabetic dog.
What is involved in treatment?
The best one word answer to that question is consistency. Your dog needs consistent administration of medication, consistent feeding, and a stable, stress-free lifestyle. To best achieve this, it is preferred that your dog live indoors. Although that is not essential, indoor living removes many uncontrollable variables that can disrupt regulation.
The first step in treatment is to alter your dog's diet. The ideal composition of the diet for diabetic pets has not been determined, and research continues in this area. However, many vets recommend a special diet that has a higher fiber content than commercially available foods. These special diets usually contain a greater amount of soluble fiber. Research in humans and in some animal studies shows that soluble fiber slows the absorption of glucose from the digestive system. This helps prevent a rapid rise in the blood glucose after a meal. You will see this referred to as postprandial (after eating) blood glucose. Several special diets are available by prescription from your veterinarian. Hills w/d is a commonly used prescription diet. Purina, Eukanuba, and other pet food manufacturers also make prescription diets.
Your dog's feeding routine is also important. The preferred way is to feed twice daily, just before each insulin injection. If your dog is currently eating on a free choice basis, please try to make the change. However, if your dog will not change or if you have several dogs that eat in a free choice fashion, you may find that this change is not practical. If a two-meals-per-day feeding routine will not work for you, it is still very important that you find some way to accurately measure the amount of food that is consumed.
Oral hypoglycemic therapy with drugs such as glipizide or glyburide is generally ineffective in dogs and not attempted as treatment. Most dogs have Type I diabetes and these drugs are ineffective in this situation.
The preferred form of treatment is insulin injections. Many people are initially fearful of giving insulin injections. If this is your initial reaction, consider these points.
The injection technique is as follows:
About Insulin
Insulin comes in an airtight bottle that is labeled with the insulin type and the concentration. Before using, mix the contents. It says on the label to roll it gently, not shake it. The reason for this is to prevent foam formation which will make accurate measuring difficult. The type of insulin used in dogs has a strong tendency to settle out of suspension. If it is not shaken properly, it will not mix well, and dosing will not be accurate. Therefore, the trick is to shake it vigorously enough to mix it without creating foam. Since bubbles can be removed (as described later), it is more important to mix it well than to worry about foam formation.
Insulin is a hormone that will lose its effectiveness if exposed to direct sunlight or high temperatures. It should be kept in the refrigerator, but it should not be frozen. It is not ruined if left out of the refrigerator for a day or two, although this is not advisable. Insulin is safe as long as it is used as directed, but it should be kept out of reach of children.
Drawing up the Insulin
Have the syringe and needle, insulin bottle, and dog ready. Then, follow these steps:
Before injecting your dog with the insulin, check that there are no air bubbles in the syringe. If you get an air bubble, draw twice as much insulin into the syringe as you need. Then withdraw the needle from the insulin bottle and tap the barrel of the syringe with your finger to make the air bubble rise to the nozzle of the syringe. Gently and slowly expel the air bubble by moving the plunger upward.
When this has been done, check that you have the correct amount of insulin in the syringe. The correct dose of insulin can be assured if you measure from the needle end, or "0" on the syringe barrel, to the end of the plunger nearest the needle.
Injecting the Insulin
The steps to follow for injecting insulin are:
It is neither necessary nor desirable to swab the skin with alcohol to "sterilize" it. There are four reasons: 1)Due to the nature of the thick hair coat and the type of bacteria that live near the skin of dogs, brief swabbing with alcohol or any other antiseptic is not effective. 2) Because a small amount of alcohol can be carried through the skin by the needle, it may actually carry bacteria with it into the skin. 3) The sting caused by the alcohol can make your dog dislike the injections. 4) If you have accidentally injected the insulin on the surface of the skin, you will not know it. If you do not use alcohol and the skin or hair is wet following an injection, the injection was not done properly.
Although the above procedures may at first seem complicated and somewhat overwhelming, they will very quickly become second nature. Your dog will soon learn that once or twice each day it has to sit still for a few minutes. In most cases, a reward of stroking results in a fully cooperative dog that eventually may not even need to be held.
» Illustrated guide of how to give an injection
Why is insulin so important?
The role of insulin is much like that of a gatekeeper: it stands at the surface of body cells and opens the door, allowing glucose to leave the blood stream pass inside the cells. Glucose is a vital substance that provides much of the energy needed for life, and it must work inside the cells. Without an adequate amount of insulin, glucose in unable to get into the cells. It accumulates in the blood, setting in motion a series of events which can ultimately prove fatal.
When insulin is deficient, the cells become starved for a source of energy. In response to this, the body starts breaking down stores of fat and protein to use as alternative energy sources. As a consequence, the dog eats more; thus, we have weight loss in a dog with a ravenous appetite. The body tries to eliminate the excess glucose by eliminating it in the urine. However, glucose (blood sugar) attracts water; thus, urine glucose takes with it large quantities of the body's fluids, resulting in the production of a large amount of urine. To avoid dehydration, the dog drinks more and more water. Thus, we have the four classical signs of diabetes: increased eating, increased drinking, increased urination and weight loss.
Does hypoglycemia occur in dogs?
Hypoglycemia means low blood sugar. If it is below 40 mg/dl (2.2 mmol/L), it can be life-threatening. Hypoglycemia occurs under three conditions:
The most likely time that a dog will become hypoglycemic is the time of peak insulin effect (5-8 hours after an insulin injection). When the blood glucose is only mildly low, the dog will be very tired and unresponsive. You may call it and get no response. Within a few hours, the blood glucose will rise, and your dog will return to normal. Since many dogs sleep a lot during the day, this important sign is easily missed. Watch for it; it is the first sign of impending problems. If you see it, please bring in your dog for blood testing.
If your dog is slow to recover from this period of lethargy, you should give it corn syrup (1 tablespoon by mouth) or feed one packet of a semi-moist dog food. If there is no response in 15 minutes, repeat the corn syrup or the semi-moist food. If there is still no response, contact us immediately for further instructions. (Note: Diabetic dogs should not be fed semi-moist foods except for this situation.)
If severe hypoglycemia occurs, a dog will have seizures or lose consciousness. This is an emergency that can only be reversed with intravenous administration of glucose. If it occurs during office hours, come in immediately. If it occurs at night or on the weekend, call our emergency phone number for instructions.
Signs of hypoglycemia
Is continual or periodic monitoring needed?
It is necessary that your dog's progress be checked on a regular basis. Monitoring is a joint project on which owners and veterinarians must work together. The exact schedule of recheck examinations is decided on a case by case basis by your veterinarian.
Home Monitoring
Your part consists of two forms of monitoring. First, you need to be constantly aware of your dog's appetite, weight, water consumption, and urine output. You should be feeding a constant amount of food each day which will allow you to be aware of days that your dog does not eat all of it or is unusually hungry after the feeding. You should weigh your dog at least once monthly. It is best to use the same scales each time. A baby scale works well for this.
You should develop a way to measure water consumption. The average 10 pound (4.5 kg) dog should drink no more than 7 1/2 oz. (225 ml) of water per 24 hours. Since this is highly variable from one dog to another, keeping a record of your dog's water consumption for a few weeks will allow you to establish what is normal for your dog. Another way to measure water consumption is based on the number of times it drinks each day. When properly regulated, it should drink no more than four times per day. If this is exceeded, you should take steps to make an actual measurement.
Any significant change in your dog's food intake, weight, water intake, or urine output is an indicator that the diabetes is not well controlled. We should see the dog at that time for blood testing.
Monitoring of Blood Glucose
Determining the level of glucose in the blood is the most accurate means of monitoring. This should be done about every 3-4 months if your dog seems to be well regulated. It should also be done at any time the clinical signs of diabetes are present.
Timing is important when the blood glucose is determined. Since eating will elevate the blood sugar for several hours, it is best to test the blood at least 6 hours after eating. When testing the blood we want to know the lowest glucose readings for the day. The highest reading should occur just before an injection of insulin is given. The lowest should occur at the time of peak insulin effect. This is usually 5-8 hours after an insulin injection, but it should have been determined during the initial regulation process. To help us assess how well your dog's insulin dose is working, we measure the blood glucose during the peak of insulin effect. This means that we measure the blood glucose at about noon. Give your dog her normal breakfast and insulin dose at the time you normally do it the morning of any blood glucose checks.
Periodically we will also do another type of blood test called a fructosamine level. The fructosamine level gives a better idea of how the average blood glucose has been over time. Think of the mid-day blood glucose as a snap shot, while the fructosamine is a videotape of the same event. Both give different kinds of information that together are used to best manage your dog's diabetes.
This section contains general principles about home blood glucose testing for pets. The different techniques used to obtain a blood sample from cats and dogs are described. Detailed instructions are given for the ear and paw prick methods for cats, and the lip and leg-callous stick for dogs. Managing diabetes is very complicated. Blood glucose readings can change depending on food consumption, exercise, stress, and normal daily fluctuations. There may also be other diseases or conditions that are affecting your dog's health. Home blood glucose monitoring should be performed in consultation with your veterinarian.
Purpose of Home Blood Glucose Monitoring
Home blood glucose monitoring is a useful tool to help you and your veterinarian get your dog's diabetes regulated. It can be used to determine how well the current type and dose of insulin is controlling the diabetes. This determination is best done under typical daily conditions where the pet's feeding, exercise, and stress levels are normal. One common problem with doing blood glucose testing in the vet's office is that many pets, especially dogs, become severely stressed, refuse to eat, are confined to a cage for a long period of time, then restrained for a blood test. These are not normal conditions and the blood glucose values obtained at the vet's office may not accurately reflect what the blood glucose is doing on a typical day.
If your dog's diabetes is pretty well regulated, home blood glucose monitoring can be used to check the blood glucose on an occasional basis or to fine tune the control. You can perform a blood glucose test at any time, quickly and conveniently.
If your dog's diabetes is difficult to regulate, home blood glucose monitoring can be used to obtain the information that is necessary for your vet to determine the appropriate adjustments to the insulin therapy.
Will My Dog Hate Me?
Many owners are discouraged from doing home blood glucose monitoring because the vet suggests that the pricks may make the pet dislike the owner. None of the people I've spoken with who do home blood glucose monitoring have had this problem. Sure, this is not the pet's favorite activity, but it is relatively quick and painless. But not all pets will tolerate being restrained or having a prick performed. If you have a pet who hates being handled, lightly restrained, or is otherwise uncooperative, home blood glucose testing may not be appropriate for you and your dog.
Even if your dog is cooperative, you do not want to become "prick-happy". You and your vet can discuss the appropriate amount of home blood glucose testing for your dog. Some vets also believe that the home blood glucose meters are inaccurate - this is not true. These meters are relied on by human diabetics for their daily diabetes management, and for the the purposes of diabetes regulation in pets, these meters have adequate accuracy.
Will I Hurt My Dog?
Probably not. Some vets suggest that the ear can be seriously damaged doing an ear prick. Of course it is possible to cause a bruise, an infection, or a more serious injury that requires veterinary attention, but in over three years of corresponding with other owners, I have never heard of an owner having any problems with excessive bleeding, bruising, infection, tearing, or any other problems. By taking proper precautions, these methods can be safely used on your dog. If a problem does arise, contact your veterinarian for advice.
Which Meter Should I Purchase For My Dog?
There are several very good meters for use with pets. These meters require a very small blood sample and have test strips that use capillary action to "suck" the blood into the test chamber. Always be sure to read, understand, and follow the instructions provided with your meter and the test strips.
Where to Prick
Dogs and Cats
Clipping a claw too short in order to get blood is not recommended. This is very painful for the pet and can not be used on a regular basis.
Cats
The edge of the ear, or a paw pad works well. You will have to determine the best site for you cat. Some cats hate their paws being touched, while others hate their ears being played with. At first, we tried drawing blood from a front paw vein, but our cat was not cooperative. Unless you have a very cooperative cat, I would not recommend this method. You only need one drop of blood, and one of the prick methods usually works well.
For the ear prick, there is a small blood vessel that runs around the outer edge of the cat's ear. To locate the blood vessel hold a flashlight (or sit near a bright lamp) with the light shining into the inside of the ear. Look on the back (furry side) of the ear. You should see the a thin red line - this is the blood vessel that you will prick.
Dogs
Ear pricks usually do not work on a dog because they don't have the prominent marginal vein that cats do. Most dog owners who perform home blood glucose testing prick the inside of the upper lip. Have your dog lay on its side and gently lift the upper lip and roll it outward so you can work on the inside surface. The area near the canine tooth is often a good spot. Wipe the area with a clean cloth so all saliva is removed. Pricking towards the edge of the lip often works well. You will have to figure out the spot that works best for your dog. Dog owners who use the lip prick technique report it is very easy, and it does not hurt the dog. Some even do it while the dog is sleeping. Be careful that your dog will allow you to do this and you don't get bitten. Another owner has success pricking the outside of the lip.
Other sites that owners prick include: a paw pad, the calloused area on the leg, the chin area, a pinch of skin on the rump. Others have had their vet show them how to draw a tiny amount of blood from their dog's leg vein. An unused insulin syringe is perfect for this - it has a very tiny needle.
General Precautions
If you are pricking a cat's ear, it must be warm. It is very hard to get a drop of blood from a cold, or even cool ear. Warm the ear by massaging your dog's head and ears or use a warm washcloth inside a plastic bag or a rice bag you can heat in the microwave. Whatever you use, make sure it will not burn your dog.
If you are pricking a paw pad, it will also help if the paw is warm.
What The Numbers Mean
The blood glucose value tells how much glucose is in blood. Meters in the U.S. report the units in mg/dL - that is milligrams of glucose per deciliter of blood. Normal values are around 80-120 mg/dL.
Your vet will help you interpret the blood glucose numbers and decide if any changes are needed in your dog's insulin dose, insulin type, or other aspects of the daily care routine.
Things To Remember
Conclusions
This is how some owners perform blood glucose tests on their pet. The ideas are for you to use or modify to best suit the needs of you and your dog.
Tips For The Glucometer Elite
This is a great meter for doing home blood glucose tests on pets. It is easy to use and requires a very small drop of blood. The test strip automatically pulls the drop of blood into the test chamber, so you don't have to try to drip the blood onto the strip. Also, you can move the meter up to the pet - you don't have to keep the meter laying flat on a table.
Partially insert the test strip before the pick, then fully insert it (you hear a beep) just before you are ready to do the prick. The meter beeps when the test strip is correctly inserted. After the beep, the meter allows 3 minutes to get a drop of blood. The 3 minute time is a battery saving function of the meter. The test strip is still good after 3 minutes.
If you can't get a drop of blood in 3 minutes, remove the test strip, wait a few seconds, and then re-insert the strip. This will give you another 3 minutes.
You must get the required amount of blood into the test strip all at once. The meter beeps when it has enough blood. If you try to get blood into the meter and the meter doesn't beep, you can NOT do another prick, then get more blood into the strip until it beeps. The blood glucose value may be invalid. If you don't get enough blood on the first try, discard the test strip, use a new test strip, and try again. One "fault" of the glucometer elite is that is can "beep" to tell you it has enough blood, when it really doesn't. Look at the test strip and compare it to the picture of a "full" test strip in the gluc. Elite users manual. If you question the validity of a test, try to repeat it. Also, be sure your meter is properly coded to the right "F code". A coding strip comes with each new box of test strips.
Bayer has a new meter, the "Dex". Some owners prefer this model because it has a wheel of test strips that stay in the meter, so you don't have to fuss with a test strip for each test. The Dex is more expensive than the elite, but both models work very well.
Other Sources Of Information
Your vet should be able to help with most questions about your technique.
If you have questions about the meter, read the instruction book or call the 800 phone number for the manufacturer. Many of the popular meters, the website, and users manual link are available at: http://www.sugarcats.net/sites/harry/bgtest.htm. Most manufacturers have an 800 number that you can call for questions.
Many members of the Canine diabetes E-mail list perform home blood glucose testing. If you would like to discuss the pros and cons of home testing with people who actually do it, they are a great source of information. There are also members who do not do home blood glucose testing, so you can get both sides of the story.
Urine Testing: Every morning you should test your dog's urine using the Keto-Diastik strips. If your pet is a male dog this is very simple because of their urinating habits. As he raises the leg or semi-squats simply catch a small amount of urine in a pie pan. A cup attached to a broomstick also works well. The pan works the best for the female dog. Another trick is to train the dog to urinate on concrete. The dipstick test can then easily be performed before you hose down the area.
There are 2 color pads on the end of the test strip. The top one measures sugar levels and is the most important. Note the color of the pad (after 30 seconds). Use the information provided to determine the amount of insulin your pet needs for the current day. The bottom color pad measures ketones. If this pad turns color (after 15 seconds) two days in a row you should notify the doctor, as changes in treatment may be needed.
USE THE FOLLOWING SCALE TO DETERMINE THE AMOUNT OF INSULIN YOUR PET NEEDS:
URINE GLUCOSE (color of top pad on strip) ADJUST DOSAGE OF INSULIN
NEGATIVE ------------------------------------> DECREASE 2 UNITS
1/10 %(TRACE)--------------------------------> NO CHANGE FROM YESTERDAY
1/4 % (1+)---------------------------------------> NO CHANGE FROM YESTERDAY
1/2 % (2+)---------------------------------------> INCREASE 1 UNITS
1 % (3+)----------------------------------------> INCREASE 2 UNITS
2 % (4+)----------------------------------------> INCREASE 2-3 UNITS
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