The E tube can be in place as a temporary support measure or can be used long-term as an indefinite support measure. As you get used to using the tube, feeding will come to be a simple process and part of your regular pet routine.

To Feed your Pet

Have everything ready before beginning. You will need:

• A syringe full of the liquid food in the appropriate amount. The diet should be warmed but not hot. Do not microwave the diet, or you may get hot spots that are too hot. To warm the food, microwave a tall glass of water and insert the syringe of food in the warm water and let it sit until the food is at least room temperature, and ideally close to body temperature.
  
• A small glass or cup of tepid (lukewarm) water.
• Any medication you should be giving at this time.

Clear the tube by squirting 6 ccs of tepid water through it to be sure it is not clogged. Next, hook up the food syringe and slowly deliver the food to the patient. It is tempting to just blast it all in there but for patient comfort, try to take several minutes or so and take your time. Follow the food with a chaser of 6 ccs of tepid water to clear the tube. Liquid medicine can be given through the tube as long as the tube is cleared with 6ccs of tepid water before and after each time. Do not put pills in the tube as it could clog. Pills can be crushed and given through the tube only if they are well dissolved in liquid. Any caking of pill powder has the potential to clog the tube, so be sure to flush the tube with tepid water after use.

You will need to clean the stoma (the opening of the skin where the tube enters) daily with a baby wipe or moist tissue, otherwise discharge and/or crusting will accumulate there. Periodically the wraps will need changing. A special type of collar may be helpful in keeping the tube neat and comfortable.

Be sure to allow time for digestion between feedings. How much time depends on your pet’s feeding plan.
Be sure you understand the amount for each feeding and the feeding schedule provided by your veterinarian.

• If these two solutions do not work, the tube may have slipped too low inside the esophagus. If the tube is dipping into the stomach, the patient may vomit. The doctor can take an x-ray to see if this is the case and then easily reposition the tube. If none of these things seem to be happening, the patient’s primary disease may be progressing. Your veterinarian will need to evaluate your pet more comprehensively.

Tube clogged?

A clogged tube can be a challenge. First, try to force 6 ccs or so of tepid water through the tube by pushing. If the clog does not give way, try hooking up a syringe of 6 ccs or so of water and alternately push and pull back, creating a “toilet plunger” effect. Continue fairly rapid push-pull action until the tube is cleared.

Note: some people feel that incubating 6 ccs of cola soda in the tube overnight is helpful in dissolving a clog. Whether or not this works is somewhat controversial, but it may be worth a try, as the tube will be useless if it cannot be unclogged.

Crusting or pus at the tube exit site?

The patient’s body does not like having a foreign body sticking out of it and frequently there is some inflammation at the exit hole. True infection is unusual, and most of the time simply cleaning the area with gauze or a moist tissue is sufficient to solve the problem.

Esophagostomy tubes can stay in place for months without needing to be replaced. Hopefully your pet’s condition will have resolved before that time. When the time comes, the tube’s anchoring sutures can be snipped and the tube pulled out. The hole left behind will simply heal on its own. If you have any questions about the tube or its care, your veterinarian will be happy to assist you.

What the Pancreas Normally Does

The pancreas is a small light pink glandular organ nestled under the stomach and alongside the upper small intestine. There are two types of pancreatic tissues to know about. The first tissue is the “endocrine” pancreas which is the part of the pancreas that secretes hormones involved in blood sugar regulation, such as insulin, (which you have probably heard about if you know anyone with diabetes mellitus). The “exocrine” pancreas produces enzymes we use to digest our food. These two parts of the pancreas are not in separate areas but instead these two different types of pancreatic tissues are all mixed together throughout the entire pancreas.

Digestive enzymes break down fats, starches and proteins into smaller units so that we can absorb them into our bodies. These enzymes are stored as inactive forms inside special granules in the exocrine pancreatic tissue (the “acinar cells”). The enzymes sit there harmlessly until a chemical signal tells the pancreas to secrete them down the pancreatic duct and into the intestine where the food is waiting.

Once nutrients are broken down into smaller molecules (i.e. they are digested), they can be absorbed down the entire length of the GI tract. Without an adequate amount of enzymes, we cannot break down/digest our food. If we cannot digest the food, we cannot absorb the food. We get skinny, have especially nasty, rather greasy diarrhea, or both. Often, pets will develop a dry, dandruffy coat from their inability to absorb dietary fats and can be anemic from a vitamin B12 deficiency. Difficulty in clotting blood (vitamin K-related coagulopathy) can result as well.

Exocrine Pancreatic Insufficiency (also called Maldigestion)

About 70% of dogs with exocrine pancreatic insufficiency are German Shepherd dogs and 20% are Rough Collies.

Recently a juvenile onset form of exocrine pancreatic insufficiency has been described in the Greyhound, however, because this breed is primarily used in racing, sickly puppies are commonly euthanized thus keeping the condition from being recognized in the pet population.

In cats, chronic pancreatitis is the usual cause of exocrine pancreatic insufficiency. There does not appear to be a genetic concern; though, rarely, cats that eat grasshoppers may get infected with a pancreatic fluke carried by grasshoppers (Eurytrema procyonis). This fluke, similar to a very small worm, can cause enough inflammation to cause pancreatitis or enough general pancreatic damage to cause exocrine insufficiency. Fluke infection is rare, as mentioned, but feline pancreatitis is actually very common especially in older cats. There is frequently a link to chronic intestinal disease. 

Diagnosis Requires Specific Tests

A dog or cat with EPI will have almost no serum trypsin-like immunoreactivity in the bloodstream. The patient must be fasted for the test to be accurate, but only a single blood sample is needed to make the diagnosis. The feline version of this test often requires that the sample be sent to a university laboratory and generally a week or so is needed to get results but the canine test can be run in just a few days.

Other Tests

Another popular diagnostic is the fecal protease test, where a stool sample is tested for protein digesting enzymes. Fasting is not necessary and any fecal sample will do; however, three consecutive samples are needed to get a consistent result as there is tremendous variability in fecal enzyme activity over the day. Sometimes soybeans are given to dogs to help stimulate release of pancreatic protein digestion enzymes and get a more accurate test.

The fecal elastase test (elastase is another digestive enzyme) is the newest test and it is only available for dogs. A single fecal sample is needed but the problem is that sometimes normal dogs will test negative for elastase. This means that EPI can be ruled out when the elastase test is positive but not confirmed when the elastase test is negative.

Treatment

Dietary supplementation with digestive enzymes is an effective therapy for EPI even though most of the supplement given is digested in the stomach along with other dietary proteins. The little bit that survives the acid bath of the stomach and the patient’s own protein-digesting chemicals turns out to be enough to stop the diarrhea and enable the patient to actually gain some weight. Powdered enzymes (Viokase-V, Pancrezyme, PanaKare, and other brands) seem to work the best; tablets are available but do not seem to break down consistently. If the pet finds the taste of the enzymes objectionable, a compounding pharmacy can fill gel capsules with the powder. Again, enteric-coated tablets simply do not seem to work well.

In the past, it was suggested that incubating the enzymes in the patient’s food would help initiate the digestion process in the food bowl but this has not been found to be true; the enzymes can be fed immediately mixed with the patient’s regular pet food. Some patients respond best when an H2 blocker-type antacid (such as famotidine) is given concurrently with the enzymes.

It is important to thoroughly mix the enzyme powder into the food, because if it is sprinkled on top, it can be abrasive and lead to ulceration in the pet’s mouth. If ulceration has already occurred in this situation, incubating the food with the enzymes can help resolve the problem. A six-hour incubation at room temperature should suffice. If the food is to be refrigerated, a 24-incubation has been recommended. 

Raw beef or lamb pancreas can also be used as a possibly inexpensive form of enzyme replacement but the problems with raw foods include parasite and bacterial contamination. Cooking the pancreas relieves these concerns but inactivates the desired digestive enzymes. Raw pancreas can be stored frozen without losing digestive enzyme activity.

Generally a high-digestibility diet is the best choice for an EPI patient. These foods are low in fiber and may be especially helpful for patients with trouble gaining weight. Many animals simply use enzymes mixed with their regular food if prescription diets prove too expensive.

EPI patients commonly have an overgrowth of bacteria in their intestines, which means that the unabsorbed nutrients in the tract have fed the bacteria living there, instead of the patient, and an over-population of bacteria has occurred. This results in a vitamin B-12 (also called cobalamin) deficiency as the bacteria consume the vitamin instead of the patient getting his share. Periodic injections of vitamin B-12 and blood test monitoring have been recommended for patients with EPI. The B-12/cobalamin deficiency is a particularly big problem for cats with EPI, who typically require injections every couple of weeks for life. Folate deficiency is also common in cats and supplements are required for the first month of therapy. Regular cobalamin and folate blood levels important for cats with EPI. Supplementation with the fat soluble vitamins (especially vitamin K and vitamin E) are not usually needed.

Treatment is for life and without enzyme supplementation, all the unpleasant symptoms will recur. The good news is that a response to therapy is generally seen within a week of beginning it. Response can be excellent but approximately one dog in five will simply not respond well. Many do not ever regain a normal amount of weight. 

What if Results Are not as Rapid as Expected? 

Most pets respond in a matter of days to enzyme supplementation but if a week or so goes by and results are underwhelming, here are some tips to consider:

1. Use more enzyme powder with each meal. 
2. Check the powder’s expiration date. Consider a different brand of powder.
3. Be sure to supplement vitamin B12 by injection. Many pets will not get better until this deficiency is corrected
4. Treat the bacterial imbalance. Some patients will not get better without a course of antibiotics.
5. Consider incubating the enzymes in the food. This is not supposed to matter but some pet owners feel that it does.
6. Consider a prescription diet if one is not already in use.

If all of these factors are already controlled and diarrhea still has not cleared up, it may be time to consider that a second disease is afoot. Discuss this possibility with your veterinarian.

Want more support online? Join an Exocrine Pancreatic Insufficiency Forum for dog owners.

Pathophysiology

Infection with Blastomyces occurs when a cat or dog inhales the fungal spores into the lungs. The incubation period is from 5 to 12 weeks. Some animals don’t show clinical signs for a long time after being infected, but those animals are not contagious to other animals and people. Blastomycosis organisms have a predilection for the respiratory tract, and pulmonary disease is the most common sign (88-94% of canine cases). Once the lung disease develops, yeast forms of the organism spread throughout the body. Organs typically affected include eyes, bones, skin, lymph nodes, subcutaneous tissues, brain, and testes. It can also be found in the nose, prostate, liver, mammary glands, and heart, but those locations are less common.

Dogs appear to be much more susceptible to infection than other species. Although the disease does occur in both people and cats, the incidence is much lower than in dogs. Dogs are ten times more likely to contract the disease than are people, and 100 times more likely than are cats. The incubation period in dogs is also shorter than in people. The reason dogs are more susceptible is unknown, but immune-deficiency may play a role. Annual prevalence in dogs in endemic areas is estimated at 1-2%. Many infected animals live within 0.25 mile of water. An increased number of cases can occur after periods of unusually heavy rainfall. Historically, young (i.e. 1-5 years), male, large-breed (e.g. hounds, pointers) dogs have had the highest risk of infection. (This is probably because these animals would tend to have more contact, due to hunting activities, with the organism’s geographical area.) However, any age, breed, or sex of dog can be infected.

Clinical Signs

The signs of illness will depend on what organs are infected. Some dogs will have eye problems, and some will have neurological signs (seizures, head tilt, etc.). Lameness may occur, if the infection is in the bones. Owners of dogs in the specific geographic areas should watch for coughing, difficulty breathing, eye inflammation, enlarged testicles, fever, swollen lymph nodes, ulcerated/draining skin lesions, bloody urine, difficulty urinating, nasal cavity signs (including bloody nasal discharge), and lack of appetite. (Weight loss occurs because of the decreased appetite.) Infections in the nasal passages may result in skull damage, and lead to infection of the brain. Large skin abscesses and neurologic signs are more common in cats than in dogs, while bone lesions are more common in dogs than in cats. Hypercalcemia can occur in dogs, although it’s rare in cats and non-domestic feline species.

Diagnosis

Diagnosis involves physical exam, blood tests, imaging (radiography, ultrasonography, CT, etc.), urinalysis to look for Blastomyces yeast, cultures, serology, and biopsies of affected organs. Fungal serology, to look for antibodies, is not always accurate and has been known to produce false negatives. The enzyme immunoassay (EIA) for B. dermatitidis galactomannan antigen appears to have a high sensitivity in urine (93.5%) and serum (87%). The EIA assay is commercially available; cross reactions with Histoplasma capsulatum, Coccidioides immitis, and Penicillium marneffei can occur with this assay. The definitive diagnosis is finding the fungus in the tissues.

Treatment

Treatment involves various antifungal medications, including itraconazole, ketoconazole, fluconazole, amphotericin B, and some combination therapies. These medications usually need to be taken for a long period of time; how long depends on the specific case. Treatment usually can be done at home, unless the disease is severe. Pets with respiratory involvement should be on restricted activity. In severely ill dogs, intravenous fluids, oxygen, antibiotics for secondary infections, and pain medication may be necessary. Skin lesions may require wound cleaning and debridement.

Eyes that are severely affected may not respond well to the treatment because the medication does not penetrate eyes very well. Ocular blastomycosis cases may need systemic and topical corticosteroid therapy, topical anti-glaucoma medications, etc. Significantly affected eyes may require enucleation (removal of the eyeball).

Pets with severe lung disease may get worse at the beginning of treatment because the fungal organisms are dying; the mass death of organisms can cause severe respiratory problems.

Patients may not appear to improve for one to two weeks after the start of treatment. Close monitoring should be done for the first two weeks, and then rechecks are usually scheduled on a monthly basis. Rechecks may involve blood tests, biochemistry profiles, and imaging, if appropriate.

Prognosis

The prognosis for many pets is good, especially if owners can afford to treat the pet for long enough. Approximately 50% to 75% of affected dogs recover when treated with itraconazole, fluconazole, or an amphotericin-ketoconazole combination. Prognosis is poor for dogs with severely affected lungs, but if the dog survives the first 7 to 10 days of therapy, the prognosis improves. However, mortality rates in dogs with Blastomyces dermatitidis can be as high as 41%.

The prognosis for the retention of vision, in animals that have eye disease, is variable.

Dogs with brain involvement often die. Seizures are common upon death of the organism and may be uncontrollable.

Prognosis is also poor when at least 3 body systems are involved.

Relapses are most likely to occur in dogs that had a severe case at onset, or dogs that were not treated long enough. Relapses are most common within the first 6 months after treatment. Dogs that recover from the disease are probably not immune to getting it again.

After discontinuing therapy, animals may be rechecked at 1, 3, and 6 months for evidence of relapse. In one study, relapse rates for itraconazole and fluconazole were 18% and 22%, respectively. Relapses are treated like a new infection.

There is no way to prevent your pets’ exposure to Blastomyces other than by keeping them away from affected geographic areas.

Zoonotic Potential

Blastomycosis is not considered to be a zoonotic disease. It is acquired by humans via inhalation or direct contact with infective conidia/spores. Risk of infection is higher for excavation workers, and for people working or playing in wooded areas with waterways. Blastomycosis cannot be spread between dogs and other animals, or between dogs and people. However, immunocompromised people should limit their contact with infected pets and should wear gloves when cleaning and treating draining lesions.

Be Careful with Seasonal Plants and Decorations

• Oh, Christmas Tree: Securely anchor your Christmas tree so it doesn’t tip and fall, causing possible injury to your pet. This will also prevent the tree water—which may contain fertilizers that can cause stomach upset—from spilling. Stagnant tree water is a breeding ground for bacteria, and your pet could end up with nausea or diarrhea should he imbibe.

• Avoid Mistletoe & Holly: Holly, when ingested, can cause pets to suffer nausea, vomiting, and diarrhea. Mistletoe can cause gastrointestinal upset and cardiovascular problems. And many varieties of lilies can cause kidney failure in cats if ingested. Opt for just-as-jolly artificial plants made from silk or plastic, or choose a pet-safe bouquet.
  
• Tinsel-less Town: Kitties love this sparkly, light-catching “toy” that’s easy to bat around and carry in their mouths. But a nibble can lead to a swallow, which can lead to an obstructed digestive tract, severe vomiting, dehydration, and possible surgery. It’s best to brighten your boughs with something other than tinsel.
  
• That Holiday Glow: Don’t leave lighted candles unattended. Pets may burn themselves or cause a fire if they knock candles over. Be sure to use appropriate candle holders, placed on a stable surface. And if you leave the room, put the candle out!
  
• Wired Up: Keep wires, batteries, and glass or plastic ornaments out of paws’ reach. A wire can deliver a potentially lethal electrical shock and a punctured battery can cause burns to the mouth and esophagus, while shards of breakable ornaments can damage your pet’s mouth and digestive tract.

Avoid Holiday Food Dangers

• Skip the Sweets: By now you know not to feed your pets chocolate and anything sweetened with xylitol, but do you know the lengths to which an enterprising pet will go to chomp on something yummy? Make sure to keep your pets away from the table and unattended plates of food, and be sure to secure the lids on garbage cans.
  
• Leave the Leftovers: Fatty, spicy, and no-no human foods, as well as bones, should not be fed to your furry friends. Pets can join the festivities in other fun ways that won’t lead to costly medical bills.
  
• Careful with Cocktails: If your celebration includes adult holiday beverages, be sure to place your unattended alcoholic drinks where pets cannot get to them. If ingested, your pet could become weak, ill, and may even go into a coma, possibly resulting in death from respiratory failure.
  
• Selecting Special Treats: Looking to stuff your pet’s stockings? Stick with chew toys that are basically indestructible, Kongs that can be stuffed with healthy foods, or chew treats that are designed to be safely digestible. Long, stringy things are a feline’s dream, but the most risky toys for cats involve ribbon, yarn, and loose little parts that can get stuck in the intestines, often necessitating surgery. Surprise kitty with a new ball that’s too big to swallow, a stuffed catnip toy, or the interactive cat dancer.

• A Room of Their Own: Give your pet his own quiet space to retreat to—complete with fresh water and a place to snuggle. Shy pups and cats might want to hide out under a piece of furniture, in their carrying case, or in a separate room away from the hubbub.
  
• New Year’s Noise: As you count down to the new year, please keep in mind that strings of thrown confetti can get lodged in a cat’s intestines if ingested, perhaps necessitating surgery. Noisy poppers can terrify pets and cause possible damage to sensitive ears. And remember that many pets are also scared of fireworks, so be sure to secure them in a safe, escape-proof area as midnight approaches.

In the host’s digestive tract, food passes from the mouth to the esophagus to the stomach to the small intestine to the large intestine to the rectum, and then to the outside world. This means the large intestine is one of the last stops for nutrients, and by this point in the journey, nutrients have largely been broken down and absorbed. The large intestine is the home of the whipworm. The adult worms bite the tissue of the intestine, actually embedding their heads inside, and suck blood there.

Eggs are laid inside the large intestine and pass with the stool. Once in the outside world, the eggs require about two-to-four weeks to form embryos and become capable of infecting a new host. (This means that contaminated soil is the source of infection, not fresh feces.)

The new host is infected by consuming the egg, usually during grooming. After the host eats it, the egg hatches in the host’s small intestine releasing a larva.

The larva dives into the local glandular tissue and, after about a week, emerges into the small intestine and is carried downstream into the large intestine with the digested food. Once in the cecum or large intestine, its permanent home, it embeds in the tissue there, and after a total of 74 to 87 days from the time the egg was swallowed, the young whipworm is ready to mate.

Signs of Infection

A few whipworms generally do not pose a problem for the host, but if large numbers of worms are embedding themselves in the large intestine tissue, tremendous inflammation can result, leading to bloody, gooey diarrhea. Usually, there is not enough blood loss to be dangerous, but diarrhea readily becomes chronic and hard to control. A second syndrome of infection has emerged but is not well understood: signs mimicking those of Addison’s disease (hypoadrenocorticism). Here, waxing and waning weakness with the inability to conserve salt ultimately creates a dehydration crisis. The syndrome mimics Addison’s disease in every way except that testing for Addison’s disease will be negative and deworming yields a complete recovery.

Because female whipworms only periodically lay eggs (whereas other female worms lay eggs continuously), a fecal sample tested may easily be negative for eggs. This makes confirmation of a whipworm infection a challenge. It is common to deworm whipworms if the symptoms are suggestive of their presence, even if the fecal test is negative. Most common deworming agents do not work on whipworms, so something special must be selected. The most common products are fenbendazole (Panacur®), and febantel (Drontal Plus®).

Thanks to the long maturation cycle of young worms, a second deworming some 75 days or so after the first deworming is needed to fully clear the infection (easy to forget). Often another deworming in between these doses is recommended to further control the whipworm numbers.

Products Effective against Whipworms

More recently, regular heartworm prevention products have been developed to remove and control whipworms: Milbemycin-based heartworm preventives (such as Sentinel®, Interceptor®, and Trifexis®) will cover whipworms, and their regular use covers the second deworming as well. Moxidectin based heartworm preventive, such as Advantage Multi® and similar products, will also cover whipworms. 

Soil contaminated by whipworm eggs is contaminated for years. It is virtually impossible to remove the eggs from the soil or kill them. This potential for environmental contamination is concerning, but while there are scattered reports in the medical literature supporting human infection, the Companion Animal Parasite Council does not consider the canine whipworm to be transmissible to humans until there is stronger evidence.

Feline Whipworm Infection

Pruritus, or itching, in dogs and cats, can involve scratching and licking, chewing, or biting the skin. Pruritus is the most common symptom of skin disease in veterinary medicine. Many conditions can cause pruritus, including allergies, fleas, and other skin parasites. Some skin problems are more common in younger animals, while others are diagnosed more often in older pets. 

Medications are available to manage pruritus, but unless the underlying cause of the pruritus is diagnosed and addressed, it will return once the medication is stopped. Some anti-pruritic medications, such as steroids, can result in other health issues. Providing your dog or cat’s medical history can sometimes help your veterinarian determine the cause of the itching. 

A lack of response to some medications can help your pet’s veterinarian narrow down the possible causes. Additionally, some medications can actually cause itching.

When Did the Pruritus Start?

It can be helpful to know when the itching started. If allergies cause itching, it is beneficial to know if the problem is worse at different times of the year.  

Other Health Problems 

Sometimes, skin conditions develop secondary to another health problem. Your veterinarian will ask questions about other symptoms that could point to a specific cause of pruritus. For example, pets with food allergies may have frequent bowel movements or soft stools.

Location of Skin Lesions

Some pruritic skin conditions cause skin lesions more commonly in one body region than another.

Type of Skin Lesions

Although most pruritic skin conditions look the same to pet owners, there are actually many types of skin lesions, and some skin lesions occur more commonly with specific skin conditions. However, if the pruritus has become chronic, many pruritic skin conditions look similar to each other. Your veterinarian may need to run some tests to help determine the cause of the pruritus.

What Tests are Used to Diagnose the Cause of Pruritus?

Below is a list of some common tests for diagnosing the cause. Your veterinarian will select tests based on your pet’s medical history and examination findings. 

Skin Scrapings

To look for skin parasites, a scalpel blade is used to gently scrape the skin layers to collect cells and any skin mites. The sample is then examined under the microscope.

Skin Cytology

To look for bacteria and yeast organisms, skin cells and debris samples are collected and placed on a glass slide for examination under the microscope. This test can also help determine what types of cells are in the skin.

Parasite Therapy Trial

For some parasites, the only way to determine if they are the cause of the itching is to treat the parasites. A decrease in pruritus after the anti-parasite therapy would be consistent with the parasite causing the pruritus.

Ringworm Testing

To determine if a dog or cat’s skin is infected with ringworm (a disease caused by a fungus called a dermatophyte, not actually a worm), your veterinarian may start by examining your pet under a special ultraviolet lamp called a Wood’s Lamp. If the hairs glow (fluoresce), this may mean your pet has ringworm  Those hairs are collected for further testing. In a fungal culture, hair and skin samples are placed on a fungal culture plate. If a dermatophyte grows, the dog or cat is diagnosed with ringworm. In a dermatophyte PCR test, (a test that looks for viral diseases) the hair and skin samples are checked for dermatophyte DNA. 

Food Trial

A prescription or home-cooked diet is fed for several weeks with no other foods or treats to diagnose food allergies. Unfortunately, there is no reliable skin or blood test in dogs and cats to diagnose food allergies.

Allergy Testing

Skin or blood allergy testing is used in dogs and cats that have had other causes of pruritus ruled out through other tests. It is mainly used to select allergens for a type of allergy treatment called allergen-specific immunotherapy. There are no reliable hair or salivary tests to diagnose allergies.

Skin Biopsy

A sample of skin can be obtained through minor skin surgery. Skin biopsy is especially helpful for diagnosing some less common causes of pruritus, such as skin cancer. However, a skin biopsy cannot be used as an allergy test and cannot diagnose the cause of a pet’s allergies.

(Dry eye is formally known as keratoconjunctivitis sicca or KCS)

Why Tears are Good

Tears consist mostly of water, but also of oil and mucus secreted by their respective eyelid glands. The water portion of tears is secreted by two lacrimal glands in dogs and cats: one just above the eye and another in the third eyelid (or so-called nictitating membrane).

“Conjunctivae” are the moist pink membranes of the eye socket. “Itis” means inflammation and “sicca” means dry. Keratoconjunctivitis sicca, abbreviated KCS, means there is an inflamed, dry cornea and conjunctiva. It occurs when there is a deficiency in the water portion of the tear film, which normally accounts for 95% of the tear volume. Without water, one is left with oil and mucus; hence, the gooey yellow eye discharge characteristic of this condition.

Why do Eyes Become this Dry?

There are many causes of dry eye. Some are:

• Canine distemper infection attacks all body interfaces with the environment including the eyes. Dry eye is part of the constellation of symptoms that can occur with canine distemper infection. 
• In cats, herpes upper respiratory infection can lead to chronic dry eye (see more on herpes conjunctivitis).
• There could be a congenital lack of tear-producing gland tissue (as described in certain lines of Yorkshire terriers).
• Exposure to sulfa-containing antibiotics, such as trimethoprim-sulfa combinations, can lead to dry eye. It can be either temporary or permanent and occurs unpredictably.
• Anesthesia will reduce tear function temporarily (thus eyes are lubricated with ointment by the attending nurse).
• During surgery for cherry eye, removal of the third eyelid tear-producing gland, instead of replacing the gland in its proper location, can lead to KCS. So can too much damage to the gland prior to proper gland replacement.
• A knock on the head in the area of one of the tear-producing glands can lead to KCS.
• The most common cause of KCS appears to be immune-mediated destruction of the tear-producing gland tissue. We do not know what causes this type of inflammatory reaction but certain breeds are predisposed: the American Cocker Spaniel, the Miniature Schnauzer, and the West Highland white terrier.

How We Make the KCS Diagnosis

The moisture of the eye will wet the paper. At the end of the 60-second period, the length of the moistened area on the paper is measured. A length of 15mm or more is normal. A length 11 to 14mm is a borderline result. A height of less than 10mm is dry. A height less than 5mm is severely dry.

Cyclosporine is an immunomodulating drug used to prevent organ transplant rejection in people and treat certain immune diseases in dogs and cats. When applied as an eye drop or ointment, it suppresses the immune destruction that is the most common cause of KCS, and tear production is restored.

The success of this treatment plus its convenient dosing interval (1 -3 times daily) has made this medication the primary treatment for KCS.

Animal hospitals used to make their own cyclosporine eyedrops out of oral cyclosporine and vegetable oil, but this largely ended when Optimmune® eye ointment (containing 0.2% cyclosporine) came out. Occasional patients simply do not show a good response to cyclosporine ointment but will respond when the concentration is increased. Higher-concentration products can easily be formulated by compounding pharmacies or one of the alternative medications listed below can be used. Treatment is almost always required for the lifetime of the pet.

After beginning cyclosporine eye drops or ointment, a recheck in three to four weeks is a good idea to check for improvement. If the Schirmer tear test is still showing poor results, the dosing frequency can be increased to three times a day; similarly, if excellent results are seen, the medication can be dropped to once a day.  Periodic rechecks are needed for dose adjustment and some dogs take as long as three to four months to show a response. Dogs with Schirmer tear tests as low as 2 mm still have an 80 percent chance of responding to cyclosporine. This medication has been a miraculous breakthrough in the treatment of KCS.

Tacrolimus is another medication that is an immune modulator. No commercial products are available for use in the eye, so they must be obtained from a compounding pharmacy. It is often tried in cases that are unresponsive or poorly responsive to cyclosporine. It is used in a manner similar to cyclosporine and is generally similar in cost.

Pilocarpine is a cholinergic drug, which means it works on the autonomic nervous system (the part that controls automatic functions such as glandular secretion). This medication can be given for the particular form of dry eye known as neurogenic KCS. In these cases, neurogenic stimulation of the tear gland is absent, so the pilocarpine is given in an attempt to stimulate the gland. Although the drug comes as an eye drop, for KCS it is actually given orally at an increasing dose until side effects are seen (diarrhea, drooling, vomiting). If side effects are encountered, the dose is reduced to that which the animal tolerates. It is continued indefinitely or until the neurogenic KCS subsides, usually twice daily. Neurogenic KCS typically affects only one eye.

Artificial tear solutions, gels, and ointments can be purchased in most drug stores. These can be combined with other therapies and are soothing. Their use is particularly important early in therapy until cyclosporine or tacrolimus takes effect and in eyes that do not respond to these latter medications. Over-the-counter products may be recommended two-12 times daily, depending upon their formulation and the severity of the KCS.

Topical antibiotics are often needed, especially when starting treatment for KCS because secondary infections are common with inadequate tears. These products do not increase tear production but help relieve the thick discharge.

Topical steroids may be beneficial in decreasing the inflammation associated with KCS. Typically they are combined with topical antibiotics in the same solution or ointment, especially when given to dogs.

Surgical Solutions

Parotid duct transposition is a surgical solution to unresponsive, severe KCS, although it is a delicate procedure, usually done by a veterinary ophthalmologist. The parotid duct is the salivary gland on either side of the face/cheek. It produces saliva that is carried to the mouth via a long duct. This duct can be carefully dissected out and moved to the outer corner of the inside of the lower eyelid in order to deliver saliva to the eye. Saliva is a reasonable substitute for tears, although in time some mineral deposits may form on the eye surface. Mineralization of the cornea can range from mild to severe and there is no good way to predict whether mineralization will be a problem prior to the transposition of the duct. The eye may water uncontrollably when the dog is fed and facial wetting may be objectionable in some cases.

Ketoacidosis is one of the most extreme complications of diabetes mellitus that can be experienced. Unfortunately, most cases of ketoacidosis are in patients that were not previously known to be diabetic so the owner (and pet) must deal with two serious diagnoses: one acutely life-threatening and expensive and the other requiring ongoing commitment and daily treatment.

The diabetic patient has an insulin deficiency. To recap, there is a huge amount of glucose in the bloodstream but without insulin, none of it can get inside the cells that need it. It just circulates around uselessly. The tissues, some of which require glucose as their only food, are starving. Add to this some sort of second stressful condition such as infection or pancreatitis, and the tissue demand for food/fuel increases. The tissues, including the brain, become especially desperate and the body begins to frantically break down fat in order to liberate the small amount of carbohydrate (which can convert to glucose) contained therein.

Fat is able to convert to a biochemical called a ketone body. Ketone bodies can be used as an alternative fuel source by tissues that require glucose (brain, red blood cells, etc.). This will save the day in the short term but the problem is that ketone bodies do not “burn clean.” When ketone bodies are burned, pH and electrolyte imbalances ensue. These imbalances create dehydration, which in turn creates more pH and electrolyte imbalances. A metabolic disaster results if this state of glucose desperation persists.

Most patients in diabetic ketoacidosis are lethargic, depressed, and will not eat. They are dehydrated and frequently nauseated. Blood glucoses are extremely high and ketones can be detected in the urine. The goal is to gradually correct all the imbalances, get the patient out of the extreme fat-burning state, and establish some sort of initial regulation of the diabetes. 

Prognosis is generally fair as long as the complicating disease (the disease that is happening on top of the diabetes mellitus) can be resolved. That said, round-the-clock monitoring of electrolytes and blood sugars is needed to safely guide the patient through the crisis, and this kind of care has significant expense. Ketoacidosis involves potential disasters in potassium, phosphorus, pH, blood sugar, and sodium. All of these parameters must be controlled. The goal is to convert the complicated diabetic patient into an uncomplicated diabetic patient, but the patient will still be diabetic at the end of treatment.

What to Expect in the Hospital

The sooner the crisis is recognized, the faster treatment can be started. Because electrolytes can change moment by moment, blood testing is necessary throughout the day to keep track and keep the imbalances corrected. A facility that offers 24-hour care is ideal. Aside from the monitoring required to manage the ketoacidosis, testing to determine the precipitating stress is necessary as well.

In dogs, the most common precipitating/concurrent conditions are pancreatitis, urinary tract infection, and Cushing’s disease. In cats, precipitating/concurrent conditions include hepatic lipidosis, kidney infection, pancreatitis, and cholangiohepatitis.

Intravenous Fluids

Fluid therapy is the key to treatment. The patient is invariably dehydrated from the high circulating blood sugar levels, which cause excess fluid loss in urine, as well as from vomiting or diarrhea, which are common in ketoacidosis. Aside from simply providing fluids, the IV fluid provides a vehicle by which other metabolic derangements can be repaired.

Insulin

Blood sugar must be controlled if treatment is to be successful but to prevent brain damage, blood sugar levels must be dropped slowly. To achieve this, “regular insulin” (typically Humulin R®) is used, given either as multiple intramuscular injections or as a continuous drip. This type of insulin is short-acting and wears off quickly, which allows it to provide small adjustments. It is not until the patient is eating and nausea has been controlled that maintenance insulins can be started.

Potassium

Patients in ketoacidosis are greatly depleted in potassium. While insulin is needed to control blood sugar, insulin makes the problem worse by driving potassium into the body’s cells and out of the bloodstream. Typically, high amounts of potassium must be supplemented in the intravenous fluid solution.

Phosphorus

Low levels of phosphorus also accompany diabetic ketoacidosis and if levels drop too low, the patient’s red blood cells will begin to burst and be unable to maintain integrity. Phosphorus is also supplemented through the intravenous fluid solution.

Blood pH

The term ketoacidosis implies that the blood pH is overly acidic. If the situation is severe enough, sodium bicarbonate must be added to the intravenous therapy.

All these aspects require regular monitoring, which means lab work perhaps four times daily or more. Patients in diabetic ketoacidosis require close monitoring and intensive care.

When urine dipsticks no longer test positive for ketones and the patient is eating well and in good spirits, he or she is able to go home and be managed as a regular diabetic. Diet, monitoring, insulin etc. will be on-going concerns. Ideally, Ketostix, obtainable from any drug store, will be used at home to monitor for ketones to head off problems before they become extreme in the future.

ake-Homes for Pet Diabetes:

1. Diabetes mellitus is caused by a deficiency of insulin. You will probably have to give insulin injections to correct the deficiency. (Don’t worry. It’s easier than you think.)
   
2. The main symptoms of diabetes mellitus are excessive urination, excessive thirst, excessive appetite, and weight loss. Treatment should control these symptoms. Watching for these symptoms is the best way to know how your pet is doing.
   
3. The starting insulin dose is going to be based on averages and will be tweaked based on trial and error, depending on both test results and control of the symptoms.
   
4. You can save a lot of money if you get your own glucose meter and learn to do blood sampling at home (it’s easier than you think).
   
5. Using too little insulin is a problem in the long term, but too much insulin is potentially an emergency in the short term. Be sure you know how to recognize hypoglycemia and what to do about it. See Summary, below.

What is Diabetes Mellitus?

In order to understand the problems involved in diabetes mellitus it is necessary to understand something of the normal body’s sugar metabolism.

The cells of the body require fuel in the form of fat or sugar to conduct their daily activities.  Some tissues can use either sugar or fat depending on circumstances, and some tissues (such as the brain and nervous system) depend almost exclusively on sugar as fuel. Diabetes mellitus mostly involves the metabolism of sugar (in particular, a sugar known as glucose), so we will focus on the sugar part of the situation. Glucose comes from the diet in the form of starches and sugars that we eat.

Tissues cannot absorb glucose without a hormone known as insulin. Insulin is produced by the pancreas as part of the body’s natural blood sugar regulation. Insulin can be considered to be a key that unlocks the door, allowing sugar in the bloodstream to enter the body’s cells. Once inside the tissues, glucose can be burned for fuel or stored, but without insulin, the sugar stays in the bloodstream and cannot be used by the body.

Ketones in urine for three days or more in a row warrant a visit to the veterinarian. 

The body’s tissues are starving and the bloodstream has plenty of glucose to feed them, but without insulin, the glucose is unavailable.

So What Symptoms Result from this?

Because there is no way to remove glucose from the bloodstream, blood sugar levels are astronomically high. Normally, the kidney is able to conserve the bloodstream’s glucose but its mechanisms are overwhelmed and glucose spills into the urine in high amounts. If we continue our food delivery analogy, all the undeliverable food must be dumped. In the body, glucose dumping happens in the kidney with extra glucose dumping in the urine. This process involves the use of a lot of water with the ultimate result being a lot of urine being produced to process all that glucose to dump. This translates into excessive thirst and urination.

The tissues of the body are unable to access any of the glucose they need for fuel and are basically starving. Fat is mobilized and muscle is broken down to help feed the tissues but it does not do much good without insulin to bring fuel inside the cells. The patient shows excessive appetite because his body is in a state of starvation. Because the body is rapidly breaking itself down, weight loss is also a classic sign.

All the sugar in the urine provides a desirable growth medium for bacteria, and urinary tract infection is a common finding in diabetes mellitus. 

In diabetic dogs (but not cats), a specific type of cataract rapidly develops in the eye when high amounts of glucose enter the lens. Glucose normally feeds the lens, but the amounts of glucose coming into a lens in the diabetic state are much higher. Excess glucose is converted to another sugar called sorbitol, which in turn attracts water. The excess water disrupts the clarity of the lens, creating a diabetic cataract, which leads to blindness in almost all diabetic dogs. 

The main symptoms of diabetes mellitus are:

• Excessive Thirst
• Excessive Urination
• Excessive Appetite
• Weight Loss

Is it like Human Disease? Will We Need to Give Insulin Shots?

Dogs: Diabetes is most likely permanent and yes on the insulin shots.

Cats: Diabetes might not be permanent. Yes on the insulin shots if you want a chance at remission.

Diabetes mellitus is a classical disease in humans and most of us have heard some of the terms used to describe it. In humans, diabetes is broken down into two forms: Type I and Type II. These are also referred to as juvenile-onset and adult-onset diabetes or insulin-dependent and non-insulin-dependent diabetes. In short, Type I is the type where the pancreas produces no insulin at all, and Type II is the type where the pancreas produces some but not enough. Many pet owners wonder if dogs and cats have similar categories for their diseases.

Virtually all dogs have insulin-dependent diabetes and must be treated with insulin. There is no way around it. Their condition is similar to the Type I diabetic human in many ways.

Treatment: Giving Insulin by Injection

Since deficiency of insulin is the problem, it’s not surprising that giving insulin is the solution. You will need to learn to give injections, which is daunting to some owners at first, but almost everyone quickly becomes an expert. 

First, an insulin type and dose need to be selected. There are several types of insulins and it is not possible to know exactly how much insulin your individual pet will require; trial and error is needed. Your veterinarian will make a guess based on what works for other cats and dogs and what has been reported in the literature. Most pets require injections twice a day, approximately 12 hours apart, in conjunction with a meal. Because an overdose of insulin is potentially an emergency, it may be prudent to start with once-a-day insulin, just in case. If you like, discuss the pros and cons of each approach with your veterinarian. 

Insulin has traditionally been given by syringe in a shot, but insulin pens are proving more and more popular. The syringe method involves buying a box of syringes and a bottle of insulin, drawing up a measured amount of insulin, and giving a shot. The pen involves applying a needle tip to the pen, dialing a dose on the pen, sticking the tip into the pet’s skin, and pressing a button on the pen. Most people feel the pen method is much easier to perform but it may be difficult to find needle tips that are long enough for pet use as pet skin is much thicker than human skin.  In some situations, the pen is used as a dispenser for the syringe as the pen cartridges may be more cost-effective than bottles of insulin. Without video or first-hand experience with insulin pens or syringes, it may be hard to visualize the difference. See our section on insulin administration for more details. Not all pet insulins are available in a pen format. Your veterinarian will instruct you regarding options. 

Some insulins are available from the neighborhood pharmacy and some are available only through veterinary offices and veterinary pharmacies. Your veterinarian will either provide you with supplies or will give you the necessary prescriptions. If you are using syringes (instead of a pen) be sure the syringes and insulin concentration match. Insulin syringes are marked in insulin units (either U-100 syringes for 100 unit/cc insulins or U-40 syringes for 40 unit/cc insulins). Whenever you receive more supplies, always double-check these numbers.  

Never alter the insulin dose recommended by your doctor. To determine whether dose adjustments (or even a different type of insulin would be more appropriate), the pet will need a “glucose curve” where sugar levels are tracked over 10-24 hours. This can be done either by testing glucose levels with a glucose meter every 2 hours or so or by using a continuous monitor such as a FreeStyle Libre®. If a meter is used, it is best to test blood glucose in the pet’s own home and send the values to the vet but the curve can certainly be performed in the vet’s office. Note that stress and anxiety will alter blood glucose levels which means that values obtained at home will be more representative of the pet’s situation. 

Treatment: Oral Agents (Cats only)

Some cats will qualify for oral treatment of their diabetes. There are three medications that might be employed for this: bexagliflozin, velagliflozin, and glipizide.  

Bexagliflozin, an oral tablet medication, and velagliflozin, an oral solution (liquid), are options for some cats with diabetes mellitus where insulin injections are not practical.  Both of these drugs increase the kidneys’ ability to remove extra glucose from the bloodstream, keeping blood sugar levels in check. Lower blood sugar levels allow the pancreas to recover some and may alleviate many symptoms of diabetes. On the flip side, only certain cats will qualify for use, and there is potential for some very serious side effects. This includes diabetic ketoacidosis, a condition where insulin becomes so low that blood sugar cannot be used well in the body’s cells.  Following your veterinarian’s recommendations on proper monitoring is crucial. 

Finally, glipizide is a human medication used to reduce glucose levels by causing the pancreas’ beta cells to actually produce insulin.  In order for glipizide to have an effect, healthy beta cells need to be present. Glipizide is not as effective as bexagliflozin or velagliflozin in lowering blood glucose levels, so it does not include the intense monitoring or the same risk for complications as the others do. It is typically used for borderline patients or patients where insulin injections are simply not possible. Approximately 25% of cats will respond to this medication.

The various insulin formulations have different storage requirements. Check with your veterinarian for the proper storage of your pet’s prescribed insulin.

Diet and Feeding

Regulation can generally be worked out on whatever diet the pet is eating but there are some diets and feeding strategies that are helpful. For dogs, high-fiber/low-fat diets are preferred as they slow the absorption of sugars in the diet and help maintain a more regulated blood sugar level. Fiber also seems to make the body’s tissues more sensitive to insulin which also helps with regulation. Rewards are often employed to facilitate the insulin injection experience but these calories can add up and interfere with regulation so be sure your veterinarian is aware of all food items.  Diabetic dogs are best fed in two meals, approximately 12 hours apart. After they have been seen to eat their food, their insulin dose can be given.

For cats the strategy is different. First, cats seem to do best fed in multiple small meals daily so they should be allowed access to food at all times. Second, the high protein/low carbohydrate diets seem to be the most conducive to regulation. There are specific prescription diets, both canned and dry, for diabetic cats.

Learn more details on handling diets and feeding for cats and dogs.

What about Home Glucose Testing? 

Home glucose monitoring has many benefits: glucoses are monitored in the comfort of the pet’s own home without alterations from vet visit anxiety, a lot of money can be saved by monitoring at home, and questions about glucose status can be quickly answered and addressed. There are two ways to monitor glucoses at home: Continuous monitoring and a glucose meter.

Continuous Monitoring 

Continuous monitors have changed the way diabetic pets are monitored. A sensor with a tiny needle is implanted in the pet and paired wirelessly to either a phone or a reader. It reads tissue glucose levels constantly and reports its data to the device of your choice as well as to an internet portal where your veterinarian can access it. The sensor setup lasts up to 2 weeks and typically costs less than an in-house glucose curve run in the hospital. This is a fantastic option when it is time to get get a glucose curve. If one simply wants to spot-check a glucose level, one will need a glucometer and you will need to be able to take a blood sample from your pet.

Glucometer/Glucose Monitoring

 Many pet owners like to check glucose levels prior to insulin injections on a daily basis or simply want the ability to check a glucose level if there is a concern for hypoglycemia. For these situations, a glucometer is needed.  Human meters can be obtained at any drugstore, but we recommend getting a veterinary meter as the calibration is different. AlphaTrak is a popular brand, but there are presently several other brands available. 

The meter kit will contain measuring strips, solutions for calibration, and a spring-loaded lancet device for taking blood samples (usually from the ear margin). For details, please visit the Diabetes Monitoring section of this library. Taking single-drop blood samples turns out to be easier than you might think, and video links are provided in the monitoring section. Still, not every pet is amenable to blood sampling, and we do not want anyone getting bitten or scratched.

If you choose to use a glucometer at home, be sure to keep a log of when your pet was fed, when insulin was given, and what the glucose levels were that you found. (There are many phone apps to assist with this). Bring this log to your veterinarian when you come for checkups. Glucose levels obtained prior to the first insulin administration of the day are particularly useful. Your veterinarian will also be particularly interested in signs associated with poor regulation: excessive thirst, excessive urine production, excessive appetite, and weight loss

See the insulin administration guide for cats.

Hypoglycemia and Other Things to Watch for

The most serious problem to watch for is hypoglycemia (low blood sugar). This results from a mismatch in food consumption and insulin dose. If the dose is too high, you can get hypoglycemia. If the pet doesn’t eat, you can get hypoglycemia.  Your pet may look simply tired, weak, or sleepy. If she is roused, she will seem drunk or may not be able to fully come to alertness. This can be an emergency and can progress to seizures, so it is good to know what to do at home to prevent disaster.

If your pet appears wobbly or drunken, the blood sugar level may have dropped too low. This occurs after an insulin overdose. First, try to get your pet to eat. If the pet will not eat, administer light Karo syrup, honey, or even sugar water at a dose of one tablespoon per 5 pounds. If no improvement occurs, immediately see your veterinarian for emergency treatment. When your pet is more stable, a glucose curve will be needed to determine why this happened and what a more appropriate insulin dose might be.

It is best to make sure that your pet has recently eaten before giving the scheduled insulin dose.

Other Reasons to Return to the Vet

Bring your pet in for a re-check exam and testing if you note any of the following: 

• the pet seems to feel ill.
• the pet is losing weight.
• the pet has a ravenous appetite or loses its appetite.
• the pet seems to be drinking or urinating excessively. 
• the pet becomes disoriented or groggy.

It is important for diabetic pets to have their teeth cleaned annually. Dental tartar seeds the body with bacteria and when blood sugar levels run high, infections in important organs can take root. The kidneys and heart are particularly vulnerable.

Some Pets are Difficult to Regulate

Your pet will probably require re-regulation at some point. There may be an underlying reason to sort out. If your pet seems to fit into this category, some reasons could be:

• Improper administration of insulin. If possible, have your doctor observe you giving the insulin to your pet. Another possibility is that your insulin may be out of date.
   
• Rapid insulin metabolism. Insulin wears off quickly in some animals. Your pet may require a different type of insulin or a second injection during the day, or even additional injections during the day.
   
• Insulin overdose may actually lead to elevated glucose levels (and clinical signs of diabetes mellitus). In this situation, too much insulin brings the blood glucose too low, and other hormones respond to bring it back up (and generally overdo it).  
  
• Steroid administration (such as prednisone, prednisolone, etc.) will interfere with insulin. 
    
• Progesterone, a female hormone, also interferes with insulin. Unspayed female diabetics should be spayed once they are sufficiently regulated.

For more details on trouble with regulation, read about hard-to-regulate cats.

Additional Information on Feeding a Diabetic Pet

Regulation is achieved via a balance of diet, exercise, and insulin. Realizing that therapeutic diets are not always attractive to pets, there are some ideal foods that should at least be offered.

The most up-to-date choice for cats is a low-carbohydrate, high-protein diet. These diets promote weight loss in obese diabetics and are available in both canned and dry formulations. For dogs, high-fiber diets are still in favor as fiber seems to help sensitize the pet to insulin. Talk to your veterinarian to select an appropriate choice for your pet.

Avoid soft-moist diets as sugars are used as preservatives. Avoid bread and sweet treats. If it is not possible to change the pet’s diet, then regulation will just have to be worked out around whatever the pet will eat.

In Summary:

1. Diabetes is caused by a deficiency of insulin. Diabetes mostly involves metabolizing sugar, particularly a sugar called glucose. You will probably have to give insulin injections to correct the deficiency. It’s easier than you think.
2. A body requires fuel in the form of fat or sugar. Glucose comes from a diet of starches and sugars. Tissues cannot absorb glucose without insulin, so the level of insulin affects the glucose level.
3. The main symptoms are excessive urination, thirst, appetite, and weight loss. Watching for these symptoms is the best way to know how your pet is doing.
4. Tissues are unable to access any of the glucose they need for fuel and are basically starving. Rather than going into tissues, unmetabolized glucose goes into the bloodstream but cannot be removed from there, so glucose levels become astronomically high. The kidney compensates by dumping glucose straight into the urine. The kidney needs much water to do that, so a larger volume of urine is made just for dumping, causing a cycle of excessive thirst and urination.
5. Your veterinarian will select the first dose of insulin based on glucose averages and will tweak it thereafter. You can use either a syringe or an insulin pen.
6. While using too little insulin (high blood sugar or hyperglycemia) can lead to problems, using too much insulin (low blood sugar or hypoglycemia) is potentially life-threatening in the short term. Low blood sugar creates listlessness and potential unconsciousness; the fix is to offer food immediately.
   • Extremely low blood sugar can cause tremors, seizures, weakness, collapse, and incoordination, in addition to other signs.
   • Extremely high blood sugar can cause seizures, circling, pacing, weakness, coma, and incoordination, among others.
   • Both are emergency situations, and you should see your veterinarian or an emergency hospital immediately.
7. Never alter the insulin dose without discussing it first with your veterinarian.
8. It’s easiest for your pet if you get a glucose meter, install a continuous monitor, and do blood sampling at home. That way, you can find out their glucose status right away and do something about it.
9. Some pets are difficult to regulate. Yours will probably require re-regulation at some point. Regulation needs a consistent balance of diet, exercise, and insulin.
10. The current choice of food for diabetic cats is a low-carbohydrate, high-protein diet. High-fiber diets are best for dogs. 
11. Dogs: Diabetes is most likely permanent, and they need insulin shots.
12. Cats: Diabetes might not be permanent. To have a chance of remission, they need insulin shots. Some cats might be able to take pills rather than shots.

Diarrhea is the frequent evacuation of watery stools. Vomiting is the forceful expulsion of stomach contents through the mouth. 

What to Do

1. Remove all food and water. 
2. Check for signs of dehydration. 
3. If diarrhea and/or vomiting continues or the pet acts ill, seek veterinary attention. 
4. If no vomiting occurs for 6 to 8 hours, begin to frequently give small amounts of clear liquids (water, Gatorade, Pedialyte, or other electrolyte solution).
   • A rule of thumb is to give 1 teaspoon per pound of body weight every 2 or 3 hours throughout the day and night. 
   • If your pet does not vomit the fluid, the following day offer small frequent meals of boiled hamburger and rice or boiled chicken and rice.
5. If your pet does not want to eat, starts to vomit, or continues to have diarrhea, see a veterinarian right away.
6. Isolate the sick pet from other pets.

Diarrhea and vomiting can quickly lead to serious fluid loss and electrolyte imbalance, especially in very young or old animals, and those with certain health issues.  Severely dehydrated animals may need to be hospitalized and receive IV fluids to recover.

What NOT to Do

• Do not administer any over-the-counter or prescription medications to your pet without talking to a veterinarian first.  
• Do not allow the pet to eat or drink anything until there has been no vomiting for 6 to 8 hours.

Most infections that cause diarrhea and vomiting are contagious, so it is wise to assume that other pets might be vulnerable if they are exposed. 

If your pet is not feeling well and has vomiting and/or diarrhea, see a veterinarian.