In the case of a chronic disease such as canine diabetes, we have to do an excellent job of handling clients' concerns, or it may be the owners' misperceptions about canine diabetes rather than the diabetes itsels that results in the loss of a patient. David Bruyette, DVM, DACVIM, has developed a trouble-shooting top 10 list to help assure owners of newly diagnosed dogs that it's going to be OK.
"My dog has diabetes? What do I do?" For the last 24 years, I've heard dog owners ask these questions, often with great anxiety. As veterinarians, we're well trained in diagnosing and treating disease but not so in handling anxious—and at times overly concerned—clients. In the case of a chronic disease such as canine diabetes, we have to do an excellent job of handling clients' concerns, or it may be the owners' misperceptions about canine diabetes rather than the diabetes itself that results in the loss of a patient. Anything we can do to decrease owners' anxieties about the diagnosis of diabetes will likely contribute more to the long-term management of their dogs' disease than any discussion of the disease itself. I've developed a trouble-shooting top 10 list to help us assure owners of newly diagnosed dogs that it's going to be OK.
10. "But according to Uncle Billy Bob's Diabetic Pet website...."
The Internet should be like cable TV, but instead of parental controls, you should turn on veterinary controls. Not all websites are the best sources of information. Assemble a list of websites that you and your staff approve of and provide that to clients. A good website explains diabetes, discusses its clinical signs, explains how it's diagnosed and monitored, and reviews injection techniques. Many good websites originate from owners of diabetic dogs. See Helpful websites for my recommendations.
9. "I can't give my dog an injection! Isn't a pill easier?"
In general, no, it's not easier. While some owners are great at giving oral medications, most aren't and struggle with compliance. Many owners, after attempting to give pills at home, ask to switch to injections. There's also no question that insulin is the preferred treatment for diabetes in conjunction with dietary management. Oral medications used to treat diabetes are not as effective at controlling diabetic clinical signs as insulin injections are. You can teach clients how to give injections with minimal stress for both themselves and their dogs.
8. "The food costs how much?"
We should recommend the best diets available that have data to support their use for diabetic management. Evidence shows that in dogs high-fiber diets can help control diabetes; however, many commercially available high-fiber diets require a prescription or need to be purchased through veterinary clinics. This means they cost more than the average diet. I recommend high-fiber diets for diabetic dogs but recognize that owners may not be willing to spend the money.
Owners may say, "Sure doctor, I'll feed my dog any diet that you recommend." But that's not always true—food can be an uphill battle. As a fall-back position, try to have owners agree not to feed semi-moist foods (any diet in a foil pouch), which can result in postprandial hyperglycemia, and to continue their dogs' current diets and feeding schedules. Then the only variable we need to manage is the insulin dose.
7. "We're going out of town this weekend. It'll be fine to skip these insulin doses, won't it?"
While missing an occasional dose probably won't cause major diabetic complications, missing multiple consecutive doses can. We want owners to be able to live normal lives and feel that they have options when things arise that interfere with their dogs' care. In my opinion, most owners of diabetic dogs that are euthanized make this decision based on nonmedical reasons. So anything we can do to make the owners' lives easier can prolong their dogs' lives. Help owners arrange for a dog sitter, such as a technician from your clinic, to give injections in their absence or board the dog if necessary.
6. "Three units are the same as three ccs, right?"
It's amazing how much owners can forget between the clinic and home, so always give them information you discussed in a written form, such as discharge instructions or preprinted forms. When they have questions, they can refer to the discharge sheet or forms or to the list of pre-approved websites you provided during the consultation. Many people have problems using insulin syringes, so discuss using insulin pens as an alternative, as well as small syringes (1/3 cc) that make dosing easier and more accurate. When using U-40 insulins, such as Vetsulin, make sure the owners are using U-40 insulin syringes. It's a great idea to have owners demonstrate their preparation and insulin injection techniques with sterile saline in the clinic so you or your technician can ensure proper home administration.
5. "I'm giving Patches the insulin, but he hasn't eaten in three days."
It's important for owners to recognize that while their dogs are diabetic, they're still prone to the diseases that can afflict any nondiabetic dog. In general, if a dog isn't eating, it should receive half its insulin dose, and if it's still not feeling well by the time it is due for its next insulin dose, it needs to see a veterinarian. It's that simple. We also need to recognize and tell owners of diabetic dogs that things will go wrong. Some will be minor and annoying, such as accidents in the house—and others, such as seizures due to hypoglycemia, will be scary and can be life-threatening. You should also make clients aware of the potential for unexpected costs to arise, such as with urinary tract infections and pancreatitis.
4. "My neighbor, an astrologer, told me to treat Skippy with ground eye of newt and organic spinach, so I stopped the insulin. I wanted to try something natural."
While I have no problem with owners using nontraditional and complementary medications to treat their diabetic dogs, they must do so in conjunction with insulin, and their use of complementary methods must be done under the direction of a veterinarian who is educated in this field.
3. "I have diabetes, so I'll use my insulin. It'll be cheaper that way."
Many of our clients with diabetic pets are themselves diabetic, and because their insurance covers expenses for insulin and syringes, it's natural that they'd inquire about using their products on their dogs. However, it is not acceptable for veterinarians to write prescriptions for insulin or insulin syringes using the client's name. The prescription needs to clearly indicate the medication is intended for a dog or cat. Another frequent mistake that diabetic owners make is using their U-100 syringes for administering U-40 insulin. This can result in significant under-dosing of the patient. Owners need to purchase U-40 syringes from their veterinarian to avoid confusion.
2. "We gave our dog the insulin for about a month but then stopped. It didn't seem to work."
Frequently remind the owners that this is a lifelong treatment for a lifelong disease. Anytime something does not seem to be working, there is a problem. We can usually control the clinical signs of diabetes in dogs and cats. Unlike the situation in people with diabetes where strict control of blood glucose is necessary to prevent diabetic-related complications, that is not the case with pets. Our job is to stop clinical signs. If we can control polyuria and polydipsia, slow or delay the progression of cataracts, prevent hypoglycemic reactions, and maintain ideal body weight, we have done our jobs. And we can accomplish this not by strict glycemic control where the goal is euglycemia, but simply by keeping the blood glucose below renal threshold (180 mg/dl in dogs) for the majority of the day.
1. "I'm afraid Daisy won't do well with diabetes."
We need to make sure clients understand that they can manage chronic diabetes and that most dogs and cats do well with it. Having been the proud owner of a diabetic poodle for 10 years (Beau Bruyette), my approach to treating diabetes changed a great deal as I went from being a doctor to a client. Experiencing it from a client perspective allows me to help clients deal with their diabetic pets. Maybe all veterinarians should have a diabetic pet. We would all find it easier to convince clients that their pets can live long and healthy lives with minimal effort on their part. And after all, that is why we do what we do.
For knowledgeable support and practical resources for both you and your pet owners, visit www.vetsulin.com.