Diabetes Mellitus Flashcards
Obj: know and understand the clinical features of diabetes mellitus in dogs and cats
- Dogs:
- PU/PD, polyphagic, weight loss, blindness from cataracts
- Cats:
- PU/PD, polyphagic/inappetance, weight loss
- depressed/lethargic
- rear limb weakness and platigrade stance
Obj: know and understand the clinical use of insulin in diabetic dogs and cats
- Controls glucose fluctuations
Obj: understand the rationale and routine protocols for monitoring the efficacy of therapy in diabetic dogs and cats
- establish control
- evaluate patient’s and client’s progress
- Protocols:
- Clinical signs - resolve symptoms = control
- Urine glucose (dogs) - measure several times a day
- helps understand response to insulin
- Serum fructosamine - establish if hyperglycemia has been present for 3-4 days vs random event
- Blood glucose curve - see effectiveness, onset of action, time to peak effect, peak effect, and duration of action
- snapshot in time (can be severely affected by routine changes)
- Monitoring Glucodynamics - simpler, can be done at home
- snapshot in time (can be severely affected by routine changes)
- Continuous Glucose Monitoring - collects large amount of data over a 2 week period get good idea of patient’s average response
Obj: Know and understand diabetic ketoacidosis as it occurs in diabetic dogs and cats especially emergency management
- Acidosis is caused by the accumulation of ketone compounds - acetone, acetoacetic acid, beta hydroxybutyric acid
- Ketonuria - diabetic ketosis
- Acidemia w/hyperglycemia and hyperketonemia = ketoacidosis
- Regular insulin to manage
What is Diabetes Mellius?
- A disorder of the endocrine pancreas
- Characterized by severly impaired carbohydrate and lipid metabolism
What are the types of diabetes mellitus?
- Type 1 - Insulinopenia
- reduced or absent insulin production
- Type 2 - Insulin resistance
- reduced or absent insulin action
What type of diabetes affects dogs?
- Insulinopenia (Type 1) is main feature
- Histology shows islet damage w/ loss of functional mass
What are the potential factors in canine DM athophysiology?
- Genetic susceptibility is present for some breeds
- Autoimmunity
- Pancreatitis (40% of dogs w/ DM also have pancreatitis)
What is Feline DM?
- Insulin resistance (Early)
- Insulinopenia (Later)
- Histology shows islet amyloid deposition / loss of beta cells
- same in human type 2 DM
What are the potential factors in feline DM pathophysiology?
- Genetic component suspected in some breeds
- Others:
- Pancreatitis
- endocrinopathy (acromegaly)
- Diabetogenic medications (glucocorticoids)
- Diestrus / pregnancy
What is the classical triad of clinical signs associated with DM?
Polydipsia, Polyuria, Polyphagia
What are the other signs of DM? (outside Triad)
- Weight loss
- Cataracts (dogs)
- Neuropathy (cats)
- Asymptomatic hyperglycemia
Where does the glucose in DM come from for cats and dogs?
- (Usually) not dietary
- From the liver - increased hepatic glucose production
- glycogen, gluconeogenesis, etc
What defines DM?
persistent fasting hyperglycemia - (not clinical signs)
What are the challenges of diagnosing DM in the lab?
- Glucose in early or mild DM overlaps with normal range
- Stress hyperglycemia occurs in dogs and cats
- glucosuria - rarely present but possible
- ketonuria - never
What CBC findings are common with DM?
variable, no consistent abnormalities
What results are common on a biochemistry panel for DM?
- Hyperglycemia - should be repeatable finding
- Hyperketonemia
- Elevated liver enzymes (ALP and ALT)
- Increased serum triglycerides
- Increased cholesterol
- Electrolyte abnormalities (Na, Cl, K, Mg)
- usually decreased w/ uncomplicated DM
- Variable in complicated DM
What findings are common on a urinalysis with DM?
- Glucosuria
- Ketoneuria
What determines inpatient vs outpatient treatment for DM?
- Stable diabetic - outpatient
- routine signs, normal appetite, hydrated, unremarkable lab results
- Sick diabetic - inpatient
- severe clinical signs, appetite loss, dehydration, electrolyte disturbances
What are the treatment goals for DM?
- Eliminate clinical signs
- Address concurrent disorders and contributing factors
- Control hyperglycemia
- Aoid hypoglycemia
What are the different routes of controlling hyperglycemia?
- Insulin - treatment of choice
- Diet - not a sole therapy
- Weight loss / exercise - not a sole therapy
- Oral hypoglycemic drugs - usually ineffective
What are the different formulations of Insulin used in Vet Med?
- U 40 Insulin
What is the difference between U-100 and U-40 insulins
- U = unit
- indicates the insulin concentration in units/ml
-
U-100 (100 U/ml)
- most human insulins - HumulinN (NPH), HumulinR (regular) Lantus, many others
-
U-40 insulins (40 U/ml)
- only vet products (ProZinc (PZII), Vetsulin (lente
Why is it important to match the syringe type and the insulin type?
- Insulin syringes come in 2 sizes U-100 and U-40
- IF:
- syringes match (U-100i +U100u, etc) then dose = 100 units
- syringe mismatch:
- U-100i + U40s = OVERDOSE 25 (units)
- U-40i + U100s = UNDERDOSE (4 units)
What is the important key of dietary management in DM?
- Consistency:
- diet type and composition - feeding times, amount fed should e consistent
- Optimal body weight should be goal
- Diet should not be the sole therapy
What should the diet for a canine DM patient be?
- Complete / balanced diet will work for most dogs
- Dietary fiber - insoluble / soluble fiber may improve glycemic control
- High fiber commercial diets / supplemental=ed with fibber
- FFIber sources - canned pumpkin, cooked green bens, commercial supplements
What should the diet of feline DM patient be?
- High protein (>40% ME) and low carbohydrate content
- Canned food preferred - potion control, lower Caloric density, increased water intake
What does the Treatment/Monitoring Timeline for animals with DM look like?
- El
What are Indirect monitoring methods for animals with DM?
- Subjective:
- Clinical signs
- Physical examination
- Objective
- Blood hemoglobin A1c
- Serum fructosamine
- Urine glucose measurement
What are the direct monitoring methods for animals with DM?
- Glucose Curve
- Continuous Glucose monitoring
- Spot glucose determination
How can clinical signs be utilized as a monitoring technique for patients with DM?
- If clinical signs are not resolved early on the insulin dose is too low
- If patient is on 1x day and experiences signs (PU/PD) during the evening, dose needs to be changed to 2x day
- If patient is on a high dose of insulin, and has episodes of hypoglycemia, but still is PU/PD, a lower dose is recommended
How can Urine glucose monitoring be utilized as a monitoring technique for patients with DM?
- Dogs Only
- check urine glucose several times a day
- If values are high - possible hyperglycemic and needs a dose escalation
- if values are low/negative - possibly adequate control
- Monitoring can be diminished to several times a week for the pets life
How can serum fructosamine be utilized as a monitoring technique for patients with DM?
- Normal range 195 - 400 mg/dl
- increases w/ hyperglycemia for longer than 3-4 days
- cats with stress hyperglycemia will have normal serum fructosamine - unless hyperglycemic for >3-4 days
- DM - 500+ mg/dl - if clinical signs have been present for >3-4 days
What is Serum fructosamine?
- a complex of glucose and albumin (or other serum proteins)
- Form by a non-enzymatic, insulin-independent, amadori reaction in the presence of prolonged hyperglycemia
- Reflects the mean blood glucose level for the preceeding 1-3 weeks
What is Glycalated Hemoglobin?
- a complex of glucose and hemoglobin
- formed by a non-enzymatic, insulin-independent reaction
- longer half-life = reflects glycemic control over the previous 5-9 weeks
How can Blood glucose curve be utilized as a monitoring technique for patients with DM?
- Gold standard
- 12 hr curve is adequate for most patients (24hr may be performed)
- after breakfast & insulin blood glucose is drawn at time of arrival and every 2 hrs after that.
- Can see insulin effectiveness, onset of action, time to peak effect, peak effect, and duration of action
What are some problems of blood glucose curve?
- Cats that are easily stressed in the hospital usually do not have a curve that reflects at home response
- Some animals may fail to eat in the hospital
- activity level in the hospital is altered from home
- there is an expected normal daily variation in any animal’s glucose curve
How can monitoring glucodynamics be utilized as a monitoring technique for patients with DM?
- Glucose Curve - BG sampled intermittently
- Continuous Glucose monitoring
How can Continuous glucose monitoring (CGM) be utilized as a monitoring technique for patients with DM?
- Frequent measurement of glucose over an extended time
- becoming more popular as flash glucose monitoring technology is available
What are blood glycated proteins
- Proteins that change in the presence of hyperglycemia
Guidelines for Glycated protein test interpretation
- Therapeutic targets are not clearly defined
- Trends over tie provide the most useful information
- Tests can distinguish non-diabetic state from diabetic state
- Unaffected by transient hyperglycemia (stress hyperglycemia)
- Relatively insensitive to hypoglycemia, especially if episodic
- Affected by concurrent disorders (hypoalbuminemia, anemia)
What is “spot glucose” monitoring
- Blood glucose
- Urine Glucose
- Should NOT be used to:
- infer glycemic status (except hypoglycemic)
- Adjust insuline dose
What is the benefit of blood glucose spot monitoring?
useful to detect or confirm hypoglycemia
What is the benefit of urine glucose spot monitoring?
- represents accumulation over time
- May detect large changes in glucosuria or onset of ketonuria
What conditions can complicate DM?
- Diabetic Ketosis (DK) / ketoacidosis (DKA)
- Hyperosmolar Hyperglycemic State (HHS)
What is Hyperosmolar hyperglycemic State?
- Results from relative lack of insulin
- Hyperglycemia induces osmotic diuresis
- Lack of fluid (water) intake
- Hyperglycemia and hypernatremia cause Hyperosmolarity (may be severe)
What is Diabetic ketoacidosis?
- Results from insulin deficiency
- Ketones produced by impaired FA metabolism
- Ketones are metabolic acids
- Requires insulin for resoution
How can complicated diabetes be recognized?
- Insonsistent presentation
- May not have DM history
- Non-specific signs
- PU/PD
- Lethargy and weakness
- Inappetence
- Vomiting (diarrhea)
- Neurological abnormalities
- more pronounced in HHS
- Emaciation
- Recent illness/drug therapy
- Acetone Odor (DKA - from ketones)
What laboratory findings are common with complicated DM?
- Hyperglycemia / glucosuria
- Azotemia - pre-renal (common) or renal
-
Electrolyte abnormalities
- DKA - hyponatremia, hypochloremia, hypokalemia are common
- HHS - hypernatremia, hyperchloremia
- hypernatremia especially when glucose >600 mg/dl
- Hypophosphatemia, hypomagnesemia (common after insulin therapy)
- Metabolic acidosis (more pronounced with DKA)
- elevated AG
- Hypobicarbonemia
- Hyperketonemia / ketonuria
- Effective osmolality > 330 mOsm/L
- depends on electrolytes and glucose but does not include urea
What physical exam findings are common with complicated DM
- Dehydration - mild (5%) to severe (15%)
- Hypo- or hyperthermia
- Signs of hypovolemia and shock
- Tachycardia
- Poor pulse strength
- Poor perfusion
- Neurological abnormalities
- more pronounced in HHS
- Evidence of diabetes
- Signs of concurrent disorders
What is the overall treatment for complicated DM?
- Fluid replacement
- Restore Euglycemia
- Correct Metabolic Imbalances
- Systemic support
- Address any concurrent disorders
- Monitor
Describe the fluid replacement treatment for complicated DM
- Volume Replacement - Replace deficit over 6-12 hours
- Replace deficit due to volume loss/dehydration
- Replace ongoing losses
- Isotonic fluid - 0.9% NaCl or Lactated Ringers Solution (LRS)
- Hypovolemic shock
- Need to restore BP
- May need shock fluid dose
- Moderate to severe dehydration
- replace deficit
- Meet maintenance + losses
- Hypovolemic shock
How is Fluid Replacement for Hyperosmotic Hyperglycaemic State (HHS) approached?
- HHS - monitor the sodium level
- Hypernatremia usually associated with hyperosmolality
- Judicious use of fluids so that sodium is lowered slowly
- Monitor neurologic status
Describe how to restore euglycemia in complicated DM?
- Diuresis promotes renal glucose loss
- Insulin promotes glucose uptake
- Always use short-acting insulin preparation
- target Glucose is <250 mg/dl
- Use CRI or intermittent therapy
- CRI for regular and ultrafast insulin types
- intermittent therapy using regular insulin is suitable
- Always use short-acting insulin preparation
What are the goals of insulin therapy?
- Control hyperglycemia
- Stop ketogenesis
How are metabolic imbalances corrected in complicated DM?
- Metabolic imbalances:
- Electrolyte correction
- Acid / Base correction
- Na- and Cl- - replaced with NaCl-containing fluids
- K+ - add KCl supplement to crystalloid
- Other Electrolytes
- Phosphorous - important after insulin therapy begins
- signs when phos. < 1.0 mg/dL ⇢ weakness, hemolysis
- supplementation needed when Phos. < 2 mg/dL
- Magnesium -
- signs: cardiac, neuromuscular, and electrolyte disturbances
- Supplement when total Mg2+ falls below 1.0 mg/dL
- Bicarbonate - treatment of acidosis (not usually needed)
- Use if severe acidemia (pH < 7.1) persists after volume
- Phosphorous - important after insulin therapy begins
- Glucose supplementation:
- rationale - support blood glucose during insulin therapy
- Not usually needed
- If used: 2.5 - 5% glucose CRI to maintain BG
- Continue CRI insulin until ketones resolve
How are metabolic imbalances corrected in Diabetic Ketoacidosis?
Isotonic fluid (Lactated Ringers Solution or 0.9% NaCl) is used to replace volume deficit and Na+ and CL-
How are Metabolic imbalances corrected in a Hyperosmolar Hyperglycaemic State (HHS)?
- Isotonic fluid is used to replace volume deficit
- If hypernatremia persists following initial volume replacement, hypotonic fluid (0.45% NaCl or 5% Dextrose (D5W) is used to replace free water
What systemic support can be needed for complicated DM cases?
- Systemic Support
- Body temperature (warming)
- Oxygen support
- Nutritional support
What concurrent disorders may need to be addressed in complicated cases of DM?
- Pancreatitis
- Bacterial infection (UTI, pneumonia)
- Other endocrinopathy
What should be monitored in complicated cases of DM?
- Clinical parameters: body weight, urine output, blood pressure
- Serum glucose concentration
- Urine Ketone level
- Electrolytes
- Na and K are frequently monitored, monitoring of Phos and Mg
- Monitoring is essential when electrolytes are being supplemented
