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Questions after dog's death - was there medical error
Q: I lost a diabetic cushings dog 4 days after surgery for hind leg parlysis due to disk injury (not known if from natural circumstances or injury). I am looking for info on dopamine loss and adverse reaction drugs. Has anyone done any scientific research on any of the following drugs which were given together(at the same time): Reglan(a dopamine antagonist), Ranitidine(HCL), Sulcralfate, Baytril ,Valium and increased insulin(dog wasn't eating,but there was vomiting and diarrhea after drug medications).After the first drug combination the dog also experienced seizure like activity and later at night what appeared to be a grand mal seizure and was given valium.The following morning all drugs (except Valium) and increased insulin were given again.The dog became comatose and remained so until I arrived and asked for corn syrup (approx.1.00 -1.30 p.m. I brought him around and asked for water .He was extremely thirsty but had difficulty getting it as his mouth was stiff and pointed. I got him sitting up but he was extremely weak and did everything possible to try sitting.He was like he was drunk.His head was flattened on one side from lying on it and the eyes were wide open with an upward stare. He had gone from 8k down to 1.8k over the 4 days.(no food ,but lots of drugs and vomiting and diarrhea.) An hour later he tried to take a few sips of clear soup but was too weak. He took a fit and I asked a student to get the vet because he appeared very still and lifeless.He was dead.
I have read info with regard to Reglan being toxic in an animal pretreated with an MAO inhibitor and have also found a warning on the internet about giving it to small children.There are precautions in drug books also. I always found his blood glucose elevated after Baytril.When the hospital gave him Baytril his glucose went up to 22 and they increased his insulin even though he wasn't eating .They also had changed the type of insulin.He was on a 40 i.u.before admittance and they changed it to a 100 i.u. insulin(which when previously tried on him made him lethargic).They also thought that they were giving him one half of his regular dosage. I do not believe that 3.5 of a 100i.u. insulin is the same as one half of a 40 i.u. insulin which he was receiving at home. They were also jumping from one insulin to another(NPH,Lente and Ultralente) The medical society has informed me that drugs given were within acceptable standards. Due to the severity of his case they had to try to stablize him. It is my felling that they did not treat his cushing's disease and gave him the incorrect insulin. By doing what they did I feel that they gave him drugs that increased the cushing's disease symptoms , increased his ACTH which drove his glucose higher causing increased vomiting, diarrhea and eventual seizure , coma and death. Since there was no food intake I also feel that he was living on his body's toxic fat which also contributed to the enormous weight loss and toxicity . His reports show his tests after drugs on the third . Many of the cushing disease symptoms appear there. I would like to get any info on anything relating to this type of case. I also would not want anyone else to experience this trauma. E.
A: Evelyn- I am sorry to hear of the loss of your dog. I don't think I can answer all of your questions but can help with some of them.
Enrofloxacin (Baytril Rx) will react in some cases with sucralfate but in this instance the sucralfate interferes with absorption of the enrofloxacin and lowers the antibiotic's blood concentration. I have not heard of an interaction between enrofloxacin and blood glucose levels but this does occur with some antibiotics and falsely elevated levels appear in some instances when antibiotics are present in serum being tested for glucose. We have had difficulty with this problem in evaluation of diabetes when using cephalexin in diabetic pets.
Sucralfate is not absorbed well from the digestive tract, so most of its actions occur at the local level in the GI tract. It can decrease the absorption of several medications (including Baytril) so it is usually used several hours before or after administration of these medications.
Metoclopramide (Reglan Rx) is used for its ability to stimulate intestinal activity and to decrease vomiting. The method of action for the decrease in vomiting is probably dopamine antagonism. It may cause extreme hypertension in patients with pheochromocytoma (this is a cancer that is an unusual cause or concurrent problem in some cases of Cushing's disease in dogs) but patients with this problem seem to be prone to sudden death even without drug interference. It is very difficult to tell if pheochromocytoma is present (it is an adrenal gland tumor) without computerized tomography (CT) or magnetic resonance imaging (MRI). Metoclopramide may increase the absorption of diazepam (Valium Rx) from the small intestinal tract but probably not sufficiently to cause toxicity problems. It is also possible that metoclopramide would enhance the sedative effect of diazepam (or vice versa). Despite this, I can not find any warnings in the pharmcological references about using these medications concurrently.
I had a hard time following two parts of your note. It seems almost impossible for him to lose 6kg (13 lbs) of body weight in four days but that was the only interpretation I could make of the change from 8k to 1.8k. Perhaps I am misinterpreting this.
On the insulin dosing, if 0.35cc of U100 insulin was given, that would be 35 units. If 0.5cc of U40 insulin was given, that would be 20 units. If there was this much difference in the dosing then insulin shock does seem like a possible problem but there may be labwork supporting the need for the change or suggesting that it did not have an effect since you didn't mention low blood glucose in the labwork. I don't understand dosing with differing types of insulin except that changing from U40 to U100 of the same type of insulin should have no effect if the dosage is adjusted so the units are the same.
If you continue to believe that there was a medical error the best advice I can give is to contact your state board (I am not good with internet addresses -- I am hoping you live in the U.S.). They have the authority to review these cases and to take action if it seems appropriate. It is also a good idea to take your concerns to your vet and discuss them, if this is a feasible option. Ultimately, everyone gains if the research and discussion leads to a deeper understanding of the situation and it may help prevent problems for someone else or help you to resolve your concerns which would also be a good and important outcome.
Mike Richards, DVM
Last edited 08/30/02
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