1.The GP hook

A GP-vet, RVN and owner‑centred guide to canine diabetes, drawn from Episode 33 with Dr Stijn Niessen. Diagnosis without drama, pragmatic insulin choices, ketones without panic, and how to keep clients on board when life and salsa classes collide.

2.The GP View

Canine diabetes is a classic GP problem: common, emotive and logistically demanding. We meet these dogs at messy, real‑life moments — middle‑aged or older, drinking the bowl dry, losing weight, owners worried about urine in the house or sudden cataracts. The medicine isn’t the only challenge; the management is. Owners have jobs, kids, travel, and not all dogs read the guidelines.

Textbooks can often assume time, tech and perfect compliance. GP reality is different. We may not have acid–base analysers; owners can’t always do “exactly 12‑hourly forever”; and rigid protocols can push people towards euthanasia for a very treatable disease. This article keeps the science intact but starts where our day-to-day decisions live: what’s sick vs stable, how much testing is “enough” to confirm diabetes, what insulin schedule this owner can actually run, and how to use CGMs to give flexibility without risking hypos. We also include Dr Stijn Niessen’s perspective on once‑daily options in some dogs and what future therapies might look like — with appropriate caveats.

What follows aims to get more diabetic dogs safely treated in first opinion, and more owners confident enough to stick with it.

3.Diabetes in dogs — what we’re actually treating

Sudden cataracts can be a presenting sign. If an “old dog” is “just a bit clumsy”, look hard for bilateral cataracts and then ask about thirst, appetite and night‑time urination.

Dog vs cat diabetes — at a glance (to orient your thinking)

  • Diabetes mellitus is a pathological elevation of glucose rather than a single disease. Causes in dogs vary.
  • Most canine cases are thought to be immune‑mediated destruction of pancreatic beta cells, leading to insufficient insulin action and persistent hyperglycaemia.
  • Other recognised canine variants include:
  • Dioestrus/progesterone‑related insulin resistance in entire females (via mammary growth hormone).
  • Diabetes associated with hyperadrenocorticism (Cushing’s) or exogenous steroids.
  • Obesity: association does not prove causation in dogs. Stijn highlighted that shared genetic predispositions may link obesity and diabetes without obesity causing the diabetes. Obesity is still undesirable for many other reasons.
  • Diet: evidence for “diabetic dog” diets is weak. In an emaciated newly diagnosed dog, a balanced diet alongside insulin may be preferable over low‑carb restrictions so the body can rebuild.
  • Dogs: usually insulin deficiency (immune‑mediated beta‑cell loss). Lifelong insulin typically required.
  • Cats: often insulin resistance; remission is possible with tight control and weight management.

4.From suspicion to confirmation — the calm, GP‑proof path

Common presenting pattern

Confirming diabetes in dogs — practical steps

When to broaden the work‑up

Not all hyperglycaemia in dogs is diabetes, and not all glucosuria is diabetes. Repeat a borderline glucose, interpret urinalysis in clinical context, and lean on fructosamine when the story doesn’t quite add up. And make sure the history and symptoms line up with diabetes.

What would you do next?

A nine‑year‑old dog drinks the bowl dry, is ravenous yet losing weight and has started urinating at night. In-clinic glucose is high and urine shows glucose.

Answer after Section 3.

  • Polyuria/polydipsia, polyphagia with weight loss, urinary accidents, plus or minus cataracts and deteriorating vision.
  • DKA variants will present sick (vomiting, off food, dehydrated, lethargic)
  • Clinical signs consistent with diabetes + pathological hyperglycaemia.
  • In dogs, stress hyperglycaemia is rare (but can occur). A repeat blood glucose can help if in doubt.
  • Add urinalysis for glucosuria. Be mindful that renal insults can cause glucosuria without diabetes, especially in very unwell dogs.
  • Fructosamine can support the diagnosis, particularly when the picture isn’t clear.
  • Stijn referenced an international consensus on diagnostic language (Project ALIVE via ESVE) with pragmatic cut‑offs and emphasis on combining clinical signs with pathological hyperglycaemia. Owners tend to find “we’re following international guidelines” reassuring.
  • If the dog is unwell, consider checks for pancreatitis (e.g., CPLI) and imaging as appropriate.
  • Always do urinalysis; insulin resistance and UTIs can coincide. Treating bacteriuria is nuanced — align to sediment findings and clinical signs in your practice.
  • A) Start insulin today with a plan for home monitoring
  • B) Repeat glucose on another day before deciding
  • C) Add fructosamine and proceed once results confirm the picture
  • D) Admit for fluids and abdominal ultrasound

5.Sick or stable? Admission decisions you can stand behind

The unwell diabetic

The well-but-diabetic

Admit if any of the following: not eating or persistent vomiting, marked lethargy/obtundation, clinically significant dehydration, abdominal pain (concurrent pancreatitis suspected), cardiovascular compromise, or you cannot safely start/monitor insulin at home.

Answer to “What would you do next?”: In many GP contexts, A or C can both be defendable depending on confidence in the clinical picture and access to monitoring. Stijn’s group emphasises combining consistent signs with pathological hyperglycaemia; fructosamine adds weight when stress hyperglycaemia is a concern. If well and you can monitor (ideally via CGM), a carefully counseled outpatient start is reasonable.

  • Off food, vomiting/diarrhoea, painful abdomen, dehydrated, dull mentation — admit. If ketones are present and the dog is sick, manage as DKA until proven otherwise.
  • Bright, eating, PUPD/polyphagia/weight loss: outpatient start is reasonable in many cases.
  • Continuous glucose monitors (CGMs) can help you start earlier without overhospitalising, including over a weekend, if you give owners clear numeric thresholds and “phone us if…” safety nets. Several teams now fit CGMs on day 1 and start insulin conservatively.

6.Ketones without panic — and when it is DKA

Ketones ≠ DKA. Bright, eating and comfortable? Not DKA. Sick with GI signs/lethargy and ketones? Act for DKA while you confirm.

  • DKA requires three things: diabetes + ketones + acidosis. A well dog with ketones is not DKA.
  • If the dog is sick and ketotic, treat as DKA until proven otherwise. Many GP practices can’t measure acid–base; use clinical status to guide urgency.
  • Dogs don’t slip into ketosis as readily as humans on low‑carb diets, so ketones are a useful alert — but interpret in context.

7.First insulin choices and schedules — start with the owner, not the curve

Stijn’s core message: biochemical perfection fails if owners can’t live with the plan. Agree what’s doable first; then choose insulin accordingly.

“We can tailor insulin to your life as well as your dog’s needs. If your dog doesn’t eat, don’t give the usual dose — call us. If you’re ever in doubt, it’s safer to hold insulin and ring the clinic than to risk a hypo.”

  • Insulin is required for dogs. Stijn noted slight exceptions in steroid/Cushing’s‑related cases where off‑label strategies can exist — specialist advice recommended.
  • Licensed canine options discussed:
  • PZI (e.g., ProZinc): Stijn’s view is that a substantial proportion of dogs can be adequately controlled on once‑daily dosing. He cited figures ranging from 60% to 85% in the available literature/context, with the caveat that veterinary RCTs are limited.
  • Caninsulin: effective, often used twice daily in practice.
  • If BID is possible, biochemical control may be more likely — but consider owner life. CGMs can define an individual dog’s true duration of action and create safe “time windows” rather than rigid “exactly 12‑hourly” rules.
  • Stijn also noted that reliable owners facing one‑off disruptions can sometimes skip a dose safely; chronic unpredictability is different and unhelpful.

8.Starting at home: teaching, feeding, monitoring

Make injections unscary

Feeding

Monitoring that works at home

Follow‑up tempo

Build an RVN‑led diabetic start package: 1) injection lesson, 2) CGM fit and app setup, 3) water‑intake diary template, 4) owner “don’t inject if…” fridge card, 5) a booked phone check at 48–72 hours.

  • RVNs often teach this better than anyone. Hands‑on demos with saline in insulin syringes help owners feel the smallness of the injection.
  • Practical tip from Brendan: “Pull the skin onto the needle” can feel calmer than “thrusting” the needle.
  • Reassure: the needle length is short; you won’t hit anything dangerous if you place it subcutaneously with a sensible angle.
  • Double‑check syringe/insulin pairing (U‑40 vs U‑100) before anything leaves the building.
  • Aim for a diet the dog reliably eats when you put it down. Stijn cautioned that “diabetic dog” diets have weak evidence; an emaciated new diabetic may benefit from a balanced diet alongside insulin rather than carb‑restriction.
  • Brendan’s simple rule for owners: “If they don’t eat, don’t inject.” If they eat much less than usual, call the clinic for individual advice.
  • CGMs: game‑changers when they stay on and connect. Practical fit tips from Charlotte: surgical clip to very short hair, clean and dry the skin thoroughly, and consider a small amount of skin glue in addition to the applicator adhesive.
  • Remember: interstitial glucose (CGMs) can read lower than blood. If the number is low but the dog is bright, confirm before reacting.
  • Low‑tech wins: in single‑dog homes, daily water‑intake tracking is excellent. Combine with weight and demeanour.
  • Early rechecks often weekly in the first month, then extend. Costs and owner bandwidth matter — some teams prefer investing a little more in the first 4–6 weeks to stabilise faster and keep owners motivated.

9.When control won’t come — look for (and fix) the blockers

“Protocol perfection” can push clients towards euthanasia. Step the plan in over one to three consults, not all in one go. Keep the language permissive and problem‑solving, not punitive.

  • Entire bitches: dioestrus insulin resistance is real. Stabilise on insulin, then spay once safe. After spay, insulin needs may drop significantly — monitor closely.
  • Pancreatitis: address pain and GI signs; these patients often need inpatient support before you can meaningfully stabilise diabetes.
  • UTIs: can contribute to insulin resistance; correlate treatment with sediment activity and clinical signs.
  • Cushing’s: can complicate control. Many of us first get the diabetes safer, then revisit testing (e.g., ACTH stimulation) when the dog is more stable.
  • Thyroid: low T4 in a sick dog isn’t automatically hypothyroidism — interpret cautiously.
  • Insulin adjustments: Brendan prefers starting low and moving meaningfully enough to keep owners engaged; too‑slow progress can demoralise. He emphasised not changing doses too frequently; give time for effects to settle. This is personal experience rather than a formal protocol.
  • Atypical or refractory cases: phone a referral service. Off‑label insulins (e.g., glargine) may enter the discussion with specialist guidance.

10.Hypos and “DKA‑worry”: owner micro‑scripts that land

Hypoglycaemia

DKA

  • If the dog is showing hypo signs and is conscious and can swallow: let them eat.
  • If unconscious or can’t swallow: apply something that absorbs via the oral mucosa (e.g., honey or a commercial glucose gel) while arranging urgent veterinary review.
  • If a CGM reads low but the dog is bright and normal, confirm before acting dramatically; interstitial readings can run lower than blood.
  • If sick and ketotic, treat as DKA until proven otherwise.
  • If well with ketones, that is not DKA; act to improve diabetic control and monitor closely.

11.The near future — and why we’ll still tailor to pets and people

Stijn’s horizon scan:

Tear‑out: Owner fridge card — “When to call us”

RVN call‑out: New diabetic nursing bundle

Print two things today: a one‑page “Don’t inject if…” owner card and a water‑intake diary. These two alone improve safety and signal that you’re on the journey with them.

  • Once‑weekly or once‑fortnightly insulin injections: companies have published on these; timelines depend on regulatory and commercial decisions.
  • Gene therapy: intramuscular delivery of genes (e.g., pre‑proinsulin) that turn muscle into a protein “factory” has proof‑of‑principle in dogs and is used in human haemophilia for other proteins.
  • Bio‑artificial pancreas: CGMs + insulin pumps already exist in humans; AI control algorithms outperform manual control. There are case reports in pets.
  • Stem cells: generating new beta cells from the patient may be the end‑game.
  • Adapt, don’t copy‑paste: human goals (decades‑long microvascular risk reduction) aren’t identical to companion animal goals. We should use advances intelligently while protecting the human–animal bond.
  • Not eating, or eats much less than usual
  • Vomiting or diarrhoea
  • Marked lethargy, weakness, collapse, “not themselves”
  • Signs of hypo (wobbly, staring, tremors, fitting) — offer food if they can swallow, otherwise apply honey/gel to gums and call immediately
  • Rapidly worsening thirst/urination after initial improvement
  • Any CGM reading you’re worried about, especially overnight
  • After spay/neuter or other major changes — insulin needs may shift
  • Teach injection technique; swap to owner’s hands before they leave
  • Confirm syringe/insulin pairing and storage
  • Fit CGM (if used) with clip–clean–dry–glue method; test pairing before discharge
  • Provide water‑intake and feeding diaries; book a 48–72 hr phone check
  • Rehearse “don’t inject if they don’t eat” and the hypo plan
  • Prepare owners for the first month: “It’s a learning curve; we’ll step it in together”

12.TAKE‑HOME POINTS

  • Confirm diabetes in dogs by matching consistent clinical signs with pathological hyperglycaemia; add urinalysis and, when needed, fructosamine. Lean on the ALIVE consensus wording for confidence.
  • Sick + ketotic = manage as DKA; well + ketotic ≠ DKA. Don’t over‑medicalise ketones in a bright, eating dog.
  • Start insulin in a way the owner can actually deliver. Once‑daily PZI works for a sizeable subset per Stijn; BID often gives more biochemical control. Use CGMs to personalise timing windows.
  • Use RVNs and simple tools (injection coaching, water diaries, CGMs) to reduce hospital time and owner anxiety, especially in week one.
  • Look for control‑blockers early: pancreatitis, UTIs, entire bitches (plan to spay), Cushing’s. Re‑check dose changes with patience but without losing momentum.
  • Owner scripts save lives: “If in doubt, don’t inject — call us.” “If they can swallow during a hypo, let them eat; if not, rub honey/gel on gums and call.”
  • Future therapies are coming, but today’s wins are owner‑centred routines and flexible, safe insulin plans.

13.THE LAST WORD

We save more diabetic dogs when we make the plan fit the household as well as the biochemistry. Give owners permission to live, teach the early safety moves, and use CGMs and nurse power to keep the first month calm. As Stijn put it, the details of what’s doable determine longevity more than our prettiest glucose curves.

14.Useful links from this episode

Keep the conversation going

Listen to the full episode for the discussion, context and the bits that made Charlotte and Brendan laugh.

Listen to Episode 33
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