Approach to Diabetes Mellitus

Question 1

what is diabetes mellitus

Answer 1

a state of chronic hyperglycemia caused by abnormalities of carbohydrate, protein and lipid metabolism which may be due to either an absolute lack of insulin or to factors that oppose its action

Question 2

what is the livers role in glucose metabolism

Answer 2

Involved in fatty acid synthesis

Glucose uptake

Glycogen synthesis

Gluconeogenesis

Ketogenesis

Question 3

what is the muslces role in glucose metabolism

Answer 3

Amino acid uptake

Protein synthesis

Glucose uptake

Question 4

what is the role of adipose tissue in glucose metabolism

Answer 4

fat synthesis

Question 5

what is the brains role in glucose metabolism

Answer 5

Insulin does not increase glucose uptake by brain or blood cells

Question 6

what are the factors that lead to insulin resistance (6)

Answer 6

1. growth hormone
2. glucose toxicity
3. auto-antibodies
4. cortisol

5. progesterone

6. obesity

Question 7

what are factors that can lead to islet cell exhaustion/destruction (4)

Answer 7

1. immune mediated destruction
2. pancreatitis
3. islet cell amyloidosis
4. insulin production increased

Question 8

what does islet cell exhaustion/destruction lead to

Answer 8

insulin production reduced relative to requirement

which leads to diabetes mellitus

Question 9

what is the signalment of uncomplicated diabetes mellitus (3)

Answer 9

1. any age (commoner in older animals)
2. either sex: females more likely
3. any breed: terriers?

Question 10

what are high risk breeds

Answer 10

Samoyed

Tibetan terrier

Carin terrier

Yorkshire terrier

Mini schnauzer

border terrier

mini poodle

border collie

CKCS

Question 11

what are low risk breeds

Answer 11

Cocker spaniel

Springer spaniel

Golden retriever

German shepherd

Boxer

Question 12

what are the clinical history of uncomplicated diabetes mellitus (7)

Answer 12

1. polyuria, polydipsia
2. weight loss
3. polyphagia
4. weakness/exercise intolerance
5. recurrent urinary tract infections
6. blindness (in dogs with cataracts)
7. recent estrus

Question 13

what are the clinical signs of uncomplicated diabetes mellitus (5)

Answer 13

1. bright and alert
2. thin
3. cataracts?
4. neuropathies (plantigrade posture in cats)
5. dermatopathies (hair coat may be sparse, hairs may be dry, brittle, and lustreless, scales from hyperkeratosis)

Question 14

what are the ddx for PUPD (7)

Answer 14

1. diabetes mellitus
2. chronic renal failure
3. hyperthyroidism (cats)
4. hyperadrenocorticism (dogs)
5. hepatic disease
6. pyogenic infections
7. hypercalcemia

Question 15

what are ddx for weight loss (9)

Answer 15

1. diabetes mellitus
2. chronic renal failure
3. neoplasia
4. hepatic disease
5. hyperthyroidism (cats)
6. chronic infections
7. maldigestion, malabsorption
8. cardiac cachexia
9. others

Question 16

how do you confirm diagnosis of diabetes mellitus (2)

Answer 16

1. urinalysis
2. serum biochem

Question 17

what is seen in urinalysis of a diabetes mellitus patient (2)

Answer 17

Urine specific gravity is typically > 1.025

Glycosuria

Variable ketonuria

Proteinuria

Bacteruria

Question 18

what is seen on serum biochem of diabetes mellitus (4)

Answer 18

1. Hyperglycemia: stress induced especially in some cats, some drugs
2. Hypercholesterolemia
3. Increased ALT
4. Increased ALP

Question 19

what is seen on hematology with diabetes mellitus

Answer 19

Typically normal

Neutrophilic leukocytosis, toxic neutrophils if pancreatitis or infection present

Question 20

what are glycated blood proteins

Answer 20

fructosamines are glycated proteins that result from an irreversible, non enzymatic insulin independent binding of glucose to serum proteins

The extent of glycosylation is directly related to the blood glucose concentration

The higher the average blood glucose concentration during the preceding 2-3 weeks the higher the serum fructosamine is

Serum fructosamine is not affected by acute increases in the blood glucose concentration as occurs with stress, excitement etc

Question 21

how are diabetic patients stabalized

Answer 21

1. diet
2. exercise
3. insulin

Question 22

what are the requirements of the success in managing diabetes mellitus

Answer 22

1. owner compliance: the owner administers the treatment
2. vet support: team approach, flexibility, practice documentation

Question 23

what are the available insulins

Answer 23

beef, pork, recombinant human

beef is closest to cat

pork is closest to dog

Question 24

what concentrations of insulins are available

Answer 24

40 IU/ml

100 IU/ml

Question 25

what are the types of insulins

Answer 25

soluble (short acting) isophane lente PZI (long peak, long duration of action)

Question 26

what are the energy requirements of diabetes mellitus

Answer 26

obese animals: 70% of calculated requirement for target weight thin animals: 100% for optimal weight normal: 100% of calculated requirement

Question 27

what carbohydrates are in a diabetic diet

Answer 27

try to avoid simple sugars complex CHOs: starches (slow digestion), dietary fibre (reservoir effect)

Question 28

what is the % ME of energy for canine diabetes mellitus

Answer 28

50-55% ME from complex CHOs

Question 29

what is the % ME of fat for canine diabetes mellitus

Answer 29

restricted \<20% ME

Question 30

what is the % ME of protein for canine diabetes mellitus

Answer 30

moderate 14-30% ME

Question 31

what is the CHO content in feline diet for diabetes

Answer 31

Inefficient carbohydrate metabolism: Glucokinase activity reduced Preferential metabolism of glucose compared to fructose Glucose is a weak stimulator of insulin secretion

Question 32

what is the main source of glucose in cats

Answer 32

gluconeogenesis from protein catabolism arginine is stimulator of insulin secretion

Question 33

what is the % ME of protein in feline diabetes mellitus diet

Answer 33

50-55% ME protein

Question 34

what is the CHO content in feline diabetes mellitus diet

Answer 34

no simple and reduced complex CHOs limited ability to digest starches dietary fibre reduces palatability

Question 35

what is the one patient where you can potentially cure diabetes melllitus

Answer 35

intact female dog should be spayed asap

Question 36

at what dose of lente insulin would you worry about insulin resistance

Answer 36

\> 2 IU/kg

Question 37

how are clients to use urinalysis to monitor blood glucose levels

Answer 37

Can be helpful in dogs that have problems with recurring ketosis or hypoglycemia to identify ketonuria or persistent negative glycosuria Client is instructed not to adjust daily insulin doses on the basis of morning urine glucose measurements except to decrease the insulin dose in dogs with recurring hypoglycemia and persistent negative glycosuria Many diabetic dogs develop complications because clients were mislead by morning urine glucose concentrations and increase the insulin dose which results in insulin overdosing, hypoglycemia and glucose counter regulation Persistent glycosuria throughout the day and the night suggests inadequate control the diabetic state and the need for more complete evaluation of diabetic control using other techniques

Question 38

how can diabetes mellitus be monitored (5)

Answer 38

1. home records: urine glucose, ketones 2. urination, thirst, appetite, demeanour 3. hyoglycemic episodes 4. clinical exam: weight, eyes 5. biochem: frutosamines, blood glucose? curves?

Question 39

what are continuous glucose monitoring systems

Answer 39

How much glucose is in the skin is proportional to how much glucose is in the blood

Question 40

what is HbA1c

Answer 40

Glycated hemoglobin A1 in dogs:

Question 41

what would you do if DM dog isnt eating but is otherwise bright and happy

Answer 41

decrease insulin by 50% if eats in next 2 hours can give remainder remember the grazing do if ill needs to come in

Question 42

how would you manage DM in surgery

Answer 42

Stabilize diabetes Day of surgery: 1/2 insulin dose: no food Operate early in day Dextrose infusion Feed 1/2 normal food as soon as able Monitor blood glucose

Question 43

what are complications of DM

Answer 43

Failure to stabilize Cataracts (dogs) Ketoacidosis Hypoglycaemia Neuropathies (cats)