Approach to Diabetes Mellitus Flashcards
what is diabetes mellitus
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
what is the livers role in glucose metabolism
Involved in fatty acid synthesis
Glucose uptake
Glycogen synthesis
Gluconeogenesis
Ketogenesis
what is the muslces role in glucose metabolism
Amino acid uptake
Protein synthesis
Glucose uptake
what is the role of adipose tissue in glucose metabolism
fat synthesis
what is the brains role in glucose metabolism
Insulin does not increase glucose uptake by brain or blood cells
what are the factors that lead to insulin resistance (6)
- growth hormone
- glucose toxicity
- auto-antibodies
- cortisol
5. progesterone
6. obesity
what are factors that can lead to islet cell exhaustion/destruction (4)
- immune mediated destruction
- pancreatitis
- islet cell amyloidosis
- insulin production increased
what does islet cell exhaustion/destruction lead to
insulin production reduced relative to requirement
which leads to diabetes mellitus
what is the signalment of uncomplicated diabetes mellitus (3)
- any age (commoner in older animals)
- either sex: females more likely
- any breed: terriers?
what are high risk breeds
Samoyed
Tibetan terrier
Carin terrier
Yorkshire terrier
Mini schnauzer
border terrier
mini poodle
border collie
CKCS
what are low risk breeds
Cocker spaniel
Springer spaniel
Golden retriever
German shepherd
Boxer
what are the clinical history of uncomplicated diabetes mellitus (7)
- polyuria, polydipsia
- weight loss
- polyphagia
- weakness/exercise intolerance
- recurrent urinary tract infections
- blindness (in dogs with cataracts)
- recent estrus
what are the clinical signs of uncomplicated diabetes mellitus (5)
- bright and alert
- thin
- cataracts?
- neuropathies (plantigrade posture in cats)
- dermatopathies (hair coat may be sparse, hairs may be dry, brittle, and lustreless, scales from hyperkeratosis)
what are the ddx for PUPD (7)
- diabetes mellitus
- chronic renal failure
- hyperthyroidism (cats)
- hyperadrenocorticism (dogs)
- hepatic disease
- pyogenic infections
- hypercalcemia
what are ddx for weight loss (9)
- diabetes mellitus
- chronic renal failure
- neoplasia
- hepatic disease
- hyperthyroidism (cats)
- chronic infections
- maldigestion, malabsorption
- cardiac cachexia
- others
how do you confirm diagnosis of diabetes mellitus (2)
- urinalysis
- serum biochem
what is seen in urinalysis of a diabetes mellitus patient (2)
Urine specific gravity is typically > 1.025
Glycosuria
Variable ketonuria
Proteinuria
Bacteruria
what is seen on serum biochem of diabetes mellitus (4)
- Hyperglycemia: stress induced especially in some cats, some drugs
- Hypercholesterolemia
- Increased ALT
- Increased ALP
what is seen on hematology with diabetes mellitus
Typically normal
Neutrophilic leukocytosis, toxic neutrophils if pancreatitis or infection present
what are glycated blood proteins
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
how are diabetic patients stabalized
- diet
- exercise
- insulin
what are the requirements of the success in managing diabetes mellitus
- owner compliance: the owner administers the treatment
- vet support: team approach, flexibility, practice documentation
what are the available insulins
beef, pork, recombinant human
beef is closest to cat
pork is closest to dog
what concentrations of insulins are available
40 IU/ml
100 IU/ml
what are the types of insulins
soluble (short acting)
isophane
lente
PZI (long peak, long duration of action)
what are the energy requirements of diabetes mellitus
obese animals: 70% of calculated requirement for target weight
thin animals: 100% for optimal weight
normal: 100% of calculated requirement
what carbohydrates are in a diabetic diet
try to avoid simple sugars
complex CHOs: starches (slow digestion), dietary fibre (reservoir effect)
what is the % ME of energy for canine diabetes mellitus
50-55% ME from complex CHOs
what is the % ME of fat for canine diabetes mellitus
restricted <20% ME
what is the % ME of protein for canine diabetes mellitus
moderate 14-30% ME
what is the CHO content in feline diet for diabetes
Inefficient carbohydrate metabolism:
Glucokinase activity reduced
Preferential metabolism of glucose compared to fructose
Glucose is a weak stimulator of insulin secretion
what is the main source of glucose in cats
gluconeogenesis from protein catabolism
arginine is stimulator of insulin secretion
what is the % ME of protein in feline diabetes mellitus diet
50-55% ME protein
what is the CHO content in feline diabetes mellitus diet
no simple and reduced complex CHOs
limited ability to digest starches
dietary fibre reduces palatability
what is the one patient where you can potentially cure diabetes melllitus
intact female dog
should be spayed asap
at what dose of lente insulin would you worry about insulin resistance
> 2 IU/kg
how are clients to use urinalysis to monitor blood glucose levels
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
how can diabetes mellitus be monitored (5)
- home records: urine glucose, ketones
- urination, thirst, appetite, demeanour
- hyoglycemic episodes
- clinical exam: weight, eyes
- biochem: frutosamines, blood glucose? curves?
what are continuous glucose monitoring systems
How much glucose is in the skin is proportional to how much glucose is in the blood
what is HbA1c
Glycated hemoglobin A1 in dogs:
what would you do if DM dog isnt eating but is otherwise bright and happy
decrease insulin by 50%
if eats in next 2 hours can give remainder
remember the grazing do
if ill needs to come in
how would you manage DM in surgery
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
what are complications of DM
Failure to stabilize
Cataracts (dogs)
Ketoacidosis
Hypoglycaemia
Neuropathies (cats)
