INTRODUCTION
Diabetes mellitus is a fairly common endocrinopathy in small animals.
This disorder, which is the result of a relative or absolute insulin
deficiency, is characterized mainly by high blood glucose levels so
that
the renal threshold will be exceeded.
As a result, glucose is excreted in the urine.
This osmotic action of glucose leads to polyuria and, through loss
of
fluid, to polydipsia.
In addition, metabolism is impaired so that the general condition of
the
animal deteriorates which finally leads to death. The factors
which play
a role in this process will be discussed in the chapter
"Symptoms of Diabetes Mellitus".
The prognosis of diabetes mellitus depends mainly on the cause, an
early
diagnosis and on an adequate therapy. Most forms of diabetes
can
successfully be treated with insulin. Besides insulin administration,
dietary adjustments and a regular life-style (daily exercise schedule)
play
important roles in the total treatment regime. Optimal communication
and
cooperation between veterinarian and owner is particularly important
in the
early stages of treatment. The attitude of the veterinarian largely
determines the owner's motivation and acceptance of the treatment.
INCIDENCE
Estimates of the occurence of diabetes mellitus range from 1:66 to
1:2000
in dogs and 1:800 in cats.
The disease mostly occurs in adult and elderly dogs and cats and
particularly in bitches and neutered male cats. A breed disposition
in
dogs has been reported with respect to several types of diabetes mellitus.
-in toy poodles, terriers, Cocker Spaniels, and Dachshunds, the disorder
generally occurs at a later age;
-large breeds such as Doberman Pinscher, Alsatian, Labrador and Golden
Retriever have a tendency to develop juvenile diabetes mellitus;
-inherited diabetes mellitus is suspected in several lines of Pomeranian
dogs and Golden Retrievers.
AETIOLOGY
The basic abnormality occuring in diabetes mellitus is a decreased
peripheral use of glucose. There are several types of diabetes mellitus:
1. Type I diabetes
Characteristics:
-insulin plasma level too low;
-impaired insulin response after glucose administration(glucose tolerance
test);
-good response to insulin treatment.
Potential diabetes mellitus is sometimes regarded as precursor type
I
diabetes. It involves impaired B cell function which results
in a slightly
increased blood glucose level, but one which remains below the renal
threshold
(10 mmol/l). This disorder is typically characterized by polyuria
and
polydipsia, but without signs of glucosuria.
Type I diabetes is the most common mainfestation of diabetes mellitus.
It occurs if the demand for insulin exceeds the ability of the B cells
of
the Islets of Langerhans to produce insulin. This situation can
be caused
by the following primary conditions:
Oestrus, pregnancy, obesity, stress and various disorders which stimulate
the release of hormones and other biochemical compounds which counteract
the interaction of insulin with the target cells. As a result,
the demand
for insulin will increase, eventually exhausting the B cells.
As long as the B cells remain intact, the condition will be reversible
and
the patient will recover after the primary cause has been eliminated.
Diabetes mellitus becomes irreversible when the B cells degenerate
due to
exhaustion over a long period.
PROGESTERONE
In view of the above, special consideration of the influence of
progesterone seems appropriate. Prolonged exposure to progesterone
is one
of the most common causes of diabetes mellitus. For this reason
elderly
bitches form a relatively large patient group.
Progesterone stimulates the release of growth hormone, resulting in
a
relative deficiency of insulin through counteraction of the insulin
effect.
In the early stage, diabetes mellitus is reversible but later the disorder
becomes permanent.
This mechanism can either be caused by constant exposure to endogenous
progesterone in elderly bitches left to cycle normally or by repeated
treatment with various progesterone derivatives used for oestrus control.
Type I diabetes mellitus in cats can also be induced by prolonged exposure
to progestogens used either for permanent or temporary oestrus suppression
or for treatment of skin conditions such as miliary dermatitis.
GLUCOCORTICOSTEROIDS
Another well-known primary cause of type I diabetes, in both male and
female animals, is an excess of circulating glucocorticosteroids.
Glucocorticosteroids act antagonistically to insulin by, for example,
stimulating gluconeogenesis. This will result in hyperglycemia
and if the
insulin release remains insufficient, diabetes mellitus. Here
also the
induced diabetes will initially be reversible.
50% of dogs with hyperadrenocorticism (Cushings's syndrome) are
hyperglucemic during periods of fasting. In 10% of such patients
this
condition will develop in to a clincial diabetes mellitus.
Therapeutic use of glucocorticosteroids only incidentally
induces diabetes mellitus.
It must be borne in mind that the effects of progestogesn and
glucocorticosteroids are additive. The risk is increased if a
patient is
exposed to both hormones.
OTHER CAUSES
Disorders of the pancreas can play a major role
in the aetiology of type I diabetes.
Examples of such disorders include: infections, auto-immmune diseases,
surgical trauma, tumours, ameloid dispositon and congenital dysfunction.
Degeneration of the Islets of Langerhans due to ameloid dispostion
has been
found in many diabetic cats.
JUVENILE DIABETES
Juvenile diabetes is caused by a congential dysfunction of the pancreatic
B
cells. This condition leads to an absolute deficiency of insulin
which
results in hyperglycemia and diabetes mellitus.
This form of type I diabetes has been sporadically diagnosed, although
its
aetiology is still unknown.
Juvenile diabetes is clincally seen in young dogs of certain breeds(see
incidence) under one year of age.
2. Type II diabetes
Characteristics:
-normal or increased insulin plasma level
-no insulin response after glucose administration
-poor response to insulin treatment.
A relative shortage of insulin, due to the action of certain insulin
antagonists or as the result of insulin insensibility of peripheral
tissue
(particularly fatty tissue), occurs (insulin does circulate, but cannot
act) whereby the blood glucose level becomes too high.
This type of diabetes is very rare in dogs and cats. It is extremely
difficult to regulate patients suffering from this type of diabetes.
SYMPTOMS OF DIABETES MELLITUS
Insulin deficiency impairs the uptake of glucose by cells. The
organism
has to deal with a complex situation, e.g. extracellular hyperglycemia
and
intracellular glucose deficiency at the same time. The consequences
of
this are reflected in the following scheme:
Energy shortage intracellular
conversion of fatty tissue------>increase in fatty acids in plasma---->
ketosis-------->keto-acidosis ketonuria-------> acidotic coma
Energy shortage intracellular
increase in gluconeogenesis---------->increase in urea
roduction---->uraemia
Energy shortage intracellular
increase in gluconeogenesis---->decrease in protein
synthesis-cachexia/lethargy-polyphagia-increased susceptibilty to
bladder
infections--impaired wound healing--poor coat condition
Hyperglycemia extra-cellular
hyperosmotic plasma--->dehydration of cells--->hyperglycemic coma
exceed of the renal threshold--->glucosuria--->high specific gravity
exceed of the renal threshold-->glucosuria-->polyuria
osmotic diuresis-->polydipsia--->hypodelaemia hyponatriaemia
Polyuria, polydipsia and polyphagy in combination
with loss of body weight, poor coat condition and letargy
are the most common, directly observable clinical symptoms.
A diagnosis of diabetes mellitus must be confirmed
by blood and urine tests.
Normal values for the blood glucose level
in the dog range from 3.9 to 5.0 mmol/l (70.27 to 90.1)
and in the cat from 3.4 to 5.7 mmol/l(61.26 to102.7) (fasting).
In cases of potential diabetes mellitus, the value is 5 - 7mmol/l.
(90 to 126).
The renal threshold is 10 mmol/l.(180.2 for conversion)
Blood glucose levels which exceed this threshold result
in excretion of glucose in the urine(glucosuria).
In cases of clinical diabetes mellitus, blood glucose
levels of 10 mmol/l(180) and higher are found.
Temporary hyperglycemia can occur in cats under stress(for example in
cases
of urethra obstruction, but also during blood sampling). Glucosuria
will
be seen if the renal threshold is exceeded.
Since diabetes mellitus is not implicated in these cases(also indicated
by
the history), treatment with insulin in contraindicated.
The terminal phase of diabetes mellitus is often characterized by
keto-acidosis or hyperosmolaric non-ketotic coma(see scheme).
Symptoms of polyuria and polydipsia are often reported by the owner
to
persist for a long period.
Generally, keto-acidosis develops more rapidly. Symptoms such
as severe
depression, anorexia, vomiting, oliguria or anuria and hyperventilation
can
be observed. Sometimes even a stong acetone odour to the patient's
breath
is noticeable.
A patient in hyperosmolaric, non-ketotic coma has usually been ill
for a
longer period. The animal is very lethargic but non-keototic.
Due to
hyperosmolaric dehydration, the cells of the CNS are impaired.
TREATMENT OF DIABETES MELLITUS
As mentioned previously, the treatment of diabetes mellitus can only
be
successful if several aspects are taken into account.
Not only the veterinary surgeon, but also the owner plays a major role.
It
is advisable to invest time in giving the owner complete information
on all
aspects of the treatment, including the importance of dietary regulation
and a regular exercise schedule.
Ovario-hysterectomy
If diabetes mellitus has been diagnosed in an entire bitch, immediate
spaying should be considered. The chance of complete recovery,
without the
need for life-long insulin treatment, increases as the period of clinical
symptoms becomes shorter. In animals in a condition permitting
surgery,
ovario-hysterectomy has to be performed under stringent
monitoring(intravenous fluid therapy). If the condition of the
patient is
critical(dehydration, anorexia, uraemia, severe hyperglycemia and
glucosuria) to the extent that surgery is contraindicated, the primary
steps to be taken include fluid and insulin therapy.
In case insulin therapy has been implemented, the insulin dose
has to be
reduced to 30% on the day of the operation(because of the pre-operative
fasting). It is even better to cease insulin administration and
to give
intravenous therapy to provide sufficient extra fluid.
After surgery, a regular check on blood glucose level is necessary.
The
insulin requirement may decrease rapidly after the source of progestogen
has been removed. Extra control needs to be continued until a
stable
situation has been regained.
In cases of completely reversible diabetes mellitus resulting from the
influence of endogenous progesterone, several weeks are sometimes needed
for full recovery of the B cells.
Although the b cells occasionally cannot regenerate completely, the
insulin
response of the tissue cells will often improve somewhat after
ovario-hysterectomy. While maintaining a check on blood glucose
levels,
the use of a lower dose of insulin might be appropriate.
Diet
Composition and quantity of meals must be similar
from day to day. Since
this is difficult to establish when feeding left-overs,
etc. It is better
to feed commercial pet food, unless this is not
accepted by the patient.
note:Queenie has been on a homemade diet and
has been a
diabetic since April 23rd, 1995
Cats often are very fussy in their choice of food.
In principle every type of food that the cat will accept will suffice(in
many cases canned prescription diets are well accepted.)
The amount of food should fulfill requirements of the animal depending
on
whether the weight has to be maintained, decreased or increased.
The treatment schedule is based on the biphasis activity of the most
suitable insulin preparation, a mixture of amorphous and crystalline
insulin.
See figure 1 ( this is not included . It is a graph showing when caninsulin
peaks the 30% and 70% parts)
The total daily amount of food must be divided into two meals, synchronized
with the maximum activity of insulin.
For example, the first meal to be given at 08:30 hours and the second
meal
7 1/2 hours thereafter, at 16:00 hours.
As a result, an acceptable constant blood glucose level during the
greater
part of a 24 hour period will be established.
If insulin is overdosed, hypoglycemia will occur at times of the day
during
which the animal can be observed, provided that insulin has been
administered in the morning.
It is safer, for both dogs and cats, to first observe the animal's appetite
before giving the insulin injection.
Administration of insulin can then be done during
or directly following the meal.
If the patient eats half the meal only, giving 50% of the dose in
indicated. If the animal has been vomiting the previous day,
it is
advisable to wait one half hour after feeding before injecting the
insulin,
so that retention of the food can be assured.
In the first phase of insulin regulation, the patient is sometimes
reluctant to eat due to hyperglycemia. In such cases, insulin
must be
administered and the food must be removed after one hour.
If cats continue to refuse to eat in the morning, the best method is
to
leave the food available so that the animal can eat when appetite
is
stimulated due to declining glucose levels after insulin administration.
If the patient is not willing to, or cannot eat(fasting, vomiting,
diarrhea
or illness) after regulation has been achieved, insulin administration
is
contraindicated. This situation of fasting and retention of insulin
can
safely be permitted to remain for 3 or 4 days, as long as the body-fluid
balance is ascertained.
However, hyperglycemia with polyuria and polydipsia may occur.
During the
recovery phase, uptake of food and insulin dose have to be increased
mutually (1/4 portion food-1/4 insulin dose, etc.).
Insulin Treatment
1. Insulin Preparations
Up to now, a variety of preparations developed for the human field
have
been used in veterinary practice. Nowadays, novel human insulins
are
produced by synthetic or biotechnological methods. This method
of
production is very expensive and has been developed in order to avoid
the
presence of foreign proteins in the final product.
As the result of these measurements, the risk of immunological side
effects
in human beings can virtually be excluded.
These expensive preparations do not appear to be necessary for veterinary
use, although products containing bovine insulin may sometimes induce
a
slight insulin resistance. This is due to the fact that bovine
insulin
differs in its amino acid structure from canine insulin at two sites.
The
consequence of this is that the dosage needs to be slightly increased
in
cases if insulin resistance. Furthermore, if the insulin therapy
is
converted from bovine insulin to purified porcine insulin, one must
be
aware of the fact that a decrease in dosage might be necessary.
Porcine
and canine insulin have an identical amino acid structure. For
this
reason, highly purified insulin derived from porcine pancreas is most
suitable.
Various solutions and suspensions are available, each one with a specific
duration of activity. Since one injection per day is desirable,
the use of
a preparation having a duration of 24 hours is preferred. An
insulin-zinc
suspension is very suitable for this purpose.
Caninsulin is an aqueous suspension of 40 I.U. highly purified porcine
insulin per ml, consisting of 30% amorphous and 70% crystalline zinc
insulin. The amorphous fraction will reach its maximum effect
approximately 3 hours following subcutaneous administration and the
total
useful effects lasts for about 8 hours. Thereafter, the effect
is taken
over by the crystalline fraction, having a slower onset with a maximum
effect ranging from 7 to 12 hours following injection. Afterwards,
the
effect gradually declines to zero at 24 hours after administration(see
Figure 1)(not Included in the email).
various other types of insulin preparations are available, but can
only be
used in exceptional situations. These types are less suitable
for routine
treatment of diabetes mellitus in dogs and cats
-Aqueous insulins can be used in critical cases of diabetic keto-acidosis.
After intravenous administration, the plasma half-life ranges from
5 to 15
minutes. The onset after sucutaneous injection is 30 minutes
with a
maximum effect after 2 hours.
-Compared to Caninsulin, the onset of a mixture of 25% aqueous and 75%
crystalline insulin is somewhat earlier, but the total useful effect
is
only 18 hours.
-100%Amorphous zinc insulins have an onset of 2 hours, and a total useful
effect of 12 hours only.
-100% Crystalline zinc insulins have a delayed onset and a total effect
of
26 hours(overdosing results in a long period of hypoglycemia!).
2. Starting Dosage
Caninsulin contains 40 I.U. per ml and should be injected by the
subcutaneous route. Intramuscular administration is also possible,
although resorption, onset and duration of action are different.
In
addition, intramuscular application might cause discomfort to the patient.
Therefore, the intramuscular route is not generally recommended.
In order
to obtain a homogenous suspension, shake the vial gently before use.
The
use of U40 insulin-syringes is advisable to ensure accurate dosage.
In July of 2008 vetsulin changed their recommended
starting doses.
I cannot find on caninsulin website if they
followed suit but I am going to assume they did.
New vetsulin recommended dosing can be found
on the beginner's page.
http://www.caninediabetes.org/beginners.html
Vetsulin has cut their recommended doses by HALF to avoid hypoglycemia.
The following are the old recommended doses
for vetsulin, click on the above link for new dosing recommendations.
I left the old chart(below) up to show
the drastic change in recommended doses
Dog
The starting dosage for dogs is 1 I.U. per kg body weight, plus
a
supplementary dose related to body weight.
| Body weight |
Dose supplement |
| <10 kg |
1 I.U. |
| approx. 10 kg |
2 I.U. |
| 12-20 kg |
3 I.U. |
| >20 kg |
4 I.U. |
Examples
| Body weight dose |
Starting Dose |
Dose Supplement |
Total |
| 7 kg |
7 I.U. |
1 I.U. |
8 I.U. |
| 10 kg |
10 I.U. |
2 I.U. |
12 I.U. |
| 15 kg |
15 I.U. |
3 I.U. |
18 I.U. |
| 35 kg |
35 I.U. |
4 I.U. |
39 I.U. |
Cat
The starting dose for cats is 2-4 I.U. depending on body weight.
Although it has been found that the majority of cats
eventually need 1 I.U.per kg body weight,
it is not without risk to start directly with such a
dosage, particularly in obese cats. It is preferable to increase
the dose
by steps of 0.5 I.U., guided by the plasma glucose level.
3. Control and Continuous Regulation
Therapy has to be monitored by means of urine glucose assessments and
since
this is often not sufficient on its own, by plasma glucose assessments.
The urine can by checked by the owner through the use of test strips.
In
the initial stage of therapy it is advisable to test three times per
day.
After regulation has been achieved, routine tests before the morning-meal
two to three times weekly will suffice.
The best times for carrying out urine glucose tests are
| 1. Directly before the morning-meal _08:00 hrs. |
| 2. Around the time of the 2nd meal _15:00-16:00 hrs |
| 3. In the evening when the insulin action declines
_21:00-22:00 hrs |
From the results of urine glucose assessments, the insulin dose can
be
adjusted.(for explanation, see 4: Results and complications during
regulation)
Here is the chart
Results
Time 1 |
Urine Glucose
Time 2 |
Assessment
Time 3 |
Adjustment of Dose |
| trace |
-negative |
-negative |
none:correct dose |
| trace |
-negative |
+positve |
none:correct dose |
| +positive |
-negative |
-negative |
none:correct dose |
| +positive |
+positive |
+positive |
+10%:dose too low |
| -negative |
-negative |
-negative |
-10%:dose too high |
| +positive |
-negative |
+positive |
-20%: Somogyi effect |
During the regulation phase, blood glucose assessment must be performed
in
addition to the urine test. This is particularly needed when
the results
of the urine test are near the detection level and the correct insulin
dose
has almost been reached. A positive urine result indicates only
that there
has been a moment of exceeding the renal threshold since the last time
of
urinating.
In addition, it is sometimes impossible for the owner to sample urine
three
times daily.
By means of blood testing, the reaction of the blood glucose level
to
administration of insulin and dosage enhancement can be assessed.
If the
glucose level remains below the renal threshold, the owner is not able
to
observe possible fluctuations. For instance, the glucose level
can either
be still sufficiently high or far below the renal threshold,
near severe hypoglycemia.
The preferred time for blood testing is 15:30 hrs, shortly before the
second meal. At this time it can be determined if the blood glucose
level
has declined excessively due to insulin given the same morning.
From these blood glucose assessments, the insulin dose can be adjusted
(for explanation, see 4:Results and Complications):
Result plasma glucose assessment
(initial value for ex. 20 mmol/l) |
Adjustment of dose |
| 5-9 mmol/l |
none, correct dose |
| 10-12 mmol/l after the first day |
none, repeat dose |
| 10 mmol/l after sluggish decline |
+10%, dose too low |
| 5 mmol/l |
-10%, dose too high |
4. Results and Complications during Regulation
If a correct dose of insulin has been administered, the morning blood
glucose level(before injection) is just above the renal threshold(trace
of
glucose in the morning urine). After insulin injection, the level
declines
to the desired value of 6-8 mmol/l, but not lower due to feeding.
During
the night, due to a decreasing effect of insulin, the blood glucose
increases to a level slightly above the renal threshold. In case
the
glucose level declines rapidly after initializing the therapy, and
still is
(slightly) above the renal threshold at 15:30 hrs, a similar dose has
to be
given the next morning. Here increase in the dose by 10% can
be hazardous.
The glucose level remains above the renal threshold of 10 mmol/l for
24
hours in case of a too low insulin dose. As a consequence, the
patient
constantly suffers from glucosuria, polydipsia and polyuria.
The dose must
be increased by steps of 10%(cats 0.5 I.U.). If no effect can
be observed,
steps of 20% have to be considered. It is extremely ill advised
to
regulate the patient based on convenience so that the glucose level
always
will remain just above the renal threshold(no risk of over-dosage,
only
urine tests necessary). Such a method can have severe consequences
for the
eyes(cataracts) and kidneys (degeneration and infections).
In situations where the dose is far too high, hypoglycemia will occur.
This is a serious situation which may occur at any stage in diabetes
mellitus, even after stable regulation has been achieved (for example
due
to loss of appetite, vomiting, excessive exercise or unknown causes).
Symptoms are, in order of ascending severity, hunger, restlessness,
shivering, ataxia, disorientation, convulsions and coma. Immediate
oral
application of a glucose solution(1 gram per kg body weight) or corn
syrup
by the owner can alleviate this condition. The owner must be
fully aware
of the necessity of having glucose or corn syrup always available.
Following this emergency measure, food must be provided(related to
the
short duration of effect, 30-60 minutes, of the glucose solution).
Food
must be given repeatedly with intervals of 1-2 hours until the effects
of
the insulin has been eliminated.
In case the insulin dose is slightly too high, the Somogyi-effect may
occur. This is a chain reaction of the body to a sluggish decline
of the
blood glucose leve. If after insulin injection the glucose level
has
decreased to approx. 3 mmol/l, the patient will become hungry and restless
or lethargic. Due to a decling glucose level in the CNS, adrenaline
and
subsequently cortisol, glucagon and growth hormone will be released.
These
hormones will induce an increase of the blood glucose level(through
gluconeogenesis, release of glucose from hepatic glycogen and increase
in
the peripheral resistance to insulin). This results in a rapid
rise of the
glucose level shortly after the second meal. During the rest
of the 24
hour period, the blood glucose level further increases to 15-18 mmol/l
or
even higher. The urine glucose level is negative during the day,
but rises
in the evening and night and will become strongly positive in the morning.
Symptoms of polyuria and polydipsia will occur. This condition
bears the
risk that if guided only by the results of urine tests, the insulin
dose
will be increased. This is absolutely contraindicated since in
this way a
severe hypoglycemia will be induced. In contrast, the insulin
dose must be
decreased by 20%!
Alternatives
In the human field, medicines are available for treatment of various
types
of diabetes mellitus (for example tolbutamide). These compounds
stimulate
the release of extra insulin by B cells in the pancreatic Islets of
Langerhans. Since the aetiology of most types of diabetes mellitus
in dogs
and cats is related to excessive stimulation and thus exhaustion of
the B
cells(type I diabetes) it should be clear that these types of preparations
are strictly contraindicated for veterinary use.
Hence, veterinary alternatives for insulin are not available.
Prognosis of Diabetes Mellitus
As stated earlier, the prognosis for a diabetic patient depends completely
on the level and knowledge and dedication of the owner. These
are closely
related to the attitude and to the degree of explanation given by the
veterinary surgeon.
It must be said that treating diabetic patients is interesting, rewarding
and certainly not a complicated as is sometimes thought.
The majority of diabetic patients can be brought to a stable condition
within one week after intitial regulation.
Dogs
The survival time of regulate dogs depends on age and ranges on average
from 2 to 5 years. An unexpected sensitivity for insulin resulting
in
fatal hypoglycemia must always be taken into account.
Apart from this routine control of a regulated dog sometimes reveals
a
minor hypo or hyperglycemia. If all signs are normal(urine, appetite,
water uptake, general condition, etc.) it is advisable to check the
following day again before and adjustment of the insulin dose is
considered.
Cats
In many cases cats can be satisfactorily treated for years without
adjustments to the dose. However, it is not unusual that, after
several
months or years for instance, either sudden withdrawal of insulin or
major
increase in the dose is required. These occurrences always necessitate
concurrent monitoring of blood and urine.
It is sometimes seen that during initial regulation the blood glucose
level
fluctuates in such a way that stabilization cannot be achieved throught
dose adjustments. This situation can be dealt with by choosing
a dose
resulting in optimal clincal condition of the patient. It must
be borne in
mind that influenced by stress(visit to the veterinary clinic) major
fluctuations of the blood glucose level may occur. In such cases
it is
preferable to take action only if the experience of the owner indicates
the
necessity.
Final Remarks
After diagnosing diabetes mellitus, one must always try to find a primary
cause. In cases of Cushing's syndrome or progestagen therapy
specific
measurements have to be taken to remove or alleviate these primary
causes.
Very occasionally it may appear impossible to regulate a patient
by using
Caninsulin and by following the indicated schedule. For example,
it might
be that the patient either suffers from another type of diabetes mellitus,
rarely found in dogs and cats, or from another metabolic disorder.
It is
beyond the scope of this brochure to discuss these aspects extensively.
The vet's copy of Caninsulin was typed with permission from Intervet.
This is not to meant to take the place of advice from your vet.
This
brochure is available to your vet from intervet.
If you are using caninsulin or vetsulin
you do NOT have to use the large guage (29 guage) syringes that are produced
by intervet for caninsulin and vetsulin. Here is a conversion page
for using U100 syringes manufactured for human diabetics ( cheaper and
more comfortable)
because you can purchase up to 31 guage short)
http://www.caninediabetes.org/u40conversion.html |
