Diabetes, Pt. 2 Flashcards
Types of insulin:
When should animals be started at the lower end of the dose range of insulin?
- hypoglycemia concerns
- mild hyperglycemia (<300 mg/dL)
How is insulin measured? What syringes are used?
units (U) = 1/100th of a mL
- U40 (ProZinc, Vetsulin) = 40 U/mL
- U100 = 100 U/mL
- U300 = 300 U/mL
What preparation of insulin is not recommended?
dilution, which can cause uncertainty with stability and pharmacokinetics - use pens or other insulin type
- do not dilute glargine ever
How does U100 syringes compare to U40? If a patient requires 10 U, how would filling up both syringes with 10 U compare?
U100 is 2.5x more concentrated
- U100 syringe+ U40 insulin = 4 units
- U40 syringe + U100 insulin = 25 units
What is the only insulin given IV? When is it most commonly used?
Regular
- emergency treatment of ketoacidosis
- hospitalized patients that need BGs lowered quickly while being monitored
What type of action is Lente (Vetsulin)? In what animals is it used? How is it used?
intermediate-acting (porcine)
FDA approved in dogs* and cats
- U40 syringes - not many pharmacists familiar
- can also use a VetPen
- must shake the bottle!
When should nadirs in dogs and cats be reached with Lente (Vetsulin)?
DOGS - 1-10 hrs with a duration of 10-24 hrs
CATS - 2-8 hrs with a duration of 8-14 hrs
What kind of action does NPH insulin have? What syringes does it use? In what animal is it most commonly used?
intermediate action
U100
dogs - economical in larger breeds
What kind of action does Prozinc have? What syringe does it use? In what animals is it most commonly used?
long-acting - can be used SID in dogs
U40
dogs and cats
What action does Lantus (Glargine) have? Why must it be carefully dosed? What syringes does it use?
ultra-long action —> peakless
U100
In what animals is Lantus (Glargine) most commonly used? What is it associated with?
cats - 1-3 U per cat BID
high rate of remission after a minimum of 2 weeks of therapy
How does insulin use compare in animals compared to humans?
much smaller dose = not used up as fast, can keep refrigerated longer than date on bottle —> has bacteriostat in it, monitor for discoloration or cloudiness
What is considered the most potent insulin? What action does it have? What syringes does it used?
Detemir/Levemir
long acting, similar to Glargine but requires lower dosing
U100
In what animal is Detemir/Levemir most potent?
dogs —> peakless, must be used cautiously
What insulin blend can be used? Why would it be used?
70/30 MPH/Regular (U100)
- intermediate/regular
allows for fine tuning
How is insulin stored? What must be done before its use? Which insulin has an exception?
refrigerated, no direct light
re-suspension - rolled
Vetsulin must be shaken
How is insulin administered?
- inject SQ over lateral thorax or between shoulders
- no air bubbles (already have such a small dose)
- if injected into fur/unsure if done correctly, do not readminister
- CONSISTENCY: same time, diet, and exercise
What is the treatment and monitoring timeline for diabetic patients?
- DIAGNOSIS: start insulin, monitor glucose/fructosamine
- 1 WEEK: monitor glucose, adjust if needed
- 1 MONTH (“control”): adjust if needed based on glucose of fructosamine
- 3 MONTH: clinical evaluation with glucose and fructosamine monitoring —> if controlled, monitor q 3-4 months
How long does it typically take to reach stable glycemic control with insulin? What is key control?
2-3 months —> lifelong regular re-evaluations necessary
owner observation of PU/PD and weight improvement - perfect control is not clinically important if patient is improving
When can insulin dose or type changes be considered? When can it be changed immediately?
give it a few days - need time for a fill response
if hypoglycemia results
What are the top insulin treatments for stable diabetic dogs? What are 2 other important aspects of treatment?
- VETSULIN
- ProZinc
- NPH
- Glargine
- Detemir
- high-fiber diet +/- prescription diabetic diet - CONSISTENCY
- promote general wellness regimen - healthy weight, control of infections, dental care, spay/neuter
What are the top insulin treatments for feline diabetics? What are 2 other important aspects of treatment?
- GLARGINE
- Prozinc
- Detemir
- high protein, low carb canned diet - CONSISTENCY
- promote general wellness regimen - healthy weight, control of infections, dental care, spay/neuter
What additional treatment is available for specific cats with diabetes?
SGLT2 inhibitors - Bexacat or Senvelgo
What needs to be done before any patient is started on diabetic therapy?
ensure they are stable and any concurrent problems are being addressed
- CBC
- biochemistry
- T4 when > 6 y/o
- urine/blood ketones
- UA/urine culture
- BP
- abdominal ultrasound
What cats are able to be started of SGLT2 inhibitors?
- healthy cats with good appetite, no lethargy, good PE
- newly diagnosed, never been on insulin
- no evidence of renal or hepatic disease
- no ketosis
- no lab results consistent with DKA (metabolic acidosis)
- fPL < 5.3 mcg/L (no pancreatitis)
What is not considered an appropriate way of monitoring diabetic patients? What use does this technique have?
spot BG checks
identifying hypoglycemia and severe hyperglycemia
What are the best ways of monitoring diabetic patients?
- blood glucose testing with glucometers at home
- continuous glucose monitors = curve
How do values achieved on urine glucose/ketone reagent strips be assessed?
- persistent high glucosuria = inadequate control
- frequent negative = insulin overdosage
- ketonuria = poor control and potential danger
(DO NOT adjust insulin based on urine glucose alone - some is normal, want patients to spill into urine)
What is important to consider with urine glucose/ketone reagent strips?
- summation of urine over a varying time period
- hydration and urine concentration impact results
- ketonuria is a DANGER SIGN if > trace
How are reagent strips used to determine glucose and ketone concentrations?
- hold stick under urine
- wait 15 s to read ketones
- wait 30 s to read glucose
(waiting too long can cause changes in results)
What are the expected results on glucose/ketone reagent strips on a well-regulated diabetic?
- some sugar is allowed - 100-500 is good; negative is BAD, blood sugar can be dangerously low
- negative ketones are good; any positive is a problem
What is fructosamine? What does it reflect? What does it not detect?
serum proteins that have undergone glycosylation - increases with severity and duration of hyperglycemia
glycemic control over the previous 2-3 weeks
hypoglycemic episodes
What fructosamine levels are expected in diabetic patients? When can it be an inaccurate measurement?
should be higher than normal because they are not expected to be persistently normoglycemic - trends given better information
if the patient is hypoproteinemic (hypoalbuminemia), anemic, or hyperthyroid
When are fructosamine measurements unaffected in suspected diabetic patients? What is it insensitive to?
transient hyperglycemia (stress hyperglycemia)
hypoglycemia, especially if episodic
What do continuous glucose monitoring devices measure? What are 4 advantages to this monitoring?
interstitial glucose - strange numbers can be caused by monitor
- 14 days of averages glucose
- real time ability to spot check when hypoglycemic concerns arise
- allows for more aggressive insulin changes
- more confidence given for decision making
What 3 ketones are normally produced? Which one is produced first? Why is this significant?
- beta-hydroxybutyrate (BHBA)
- acetone
- acetoacetic acid (can take time to get into urine)
BHBA - most sensitive test for BHBA, which is not a metabolite (like AA) tested for on urine test strips —> blood BHBA is a better measurement
What is the purpose of performing blood glucose curves?
- assess first dose
- assess change in dose after 5-14 days
- assess long term management q 3 months
- assess glucose when clinical signs recur (poor control)
- know how to adjust dose
- detect hypoglycemia
What are 3 advantages to performing blood glucose curves?
- adequacy of insulin dose and frequency of administration
- assesses discrepancies in clinical signs and fructosamine
- appropriate interpretation of persisting high fructosamine
What are 4 disadvantages to performing blood glucose curves?
- cost
- can result in anemia in small dogs of not careful (jugular draws not necessary!)
- in hospital is rarely reliable, especially in cats
- low repeatability
What monitoring is performed in the initial day of insulin therapy?
- feed pet and initiate treatment
- do a glucose curve to ensure that hypoglycemia does not occur the first day
- BG < 150 mg/dL at any time: decrease dose by 10-50% in dogs or by 0.5 U in cats, then re-curve the nect day until the nadir is > 150 mg/dL
- BG > 150 mg/dL all day = discharge and re-evaluate in 1-2 weeks
insulin should not be increased on day 1 no matter how high BG may be
How is a blood glucose curve done in hospital?
- feed patient and give insulin
- obtain a base BG
- get BG q 2 hours for 8-12 hrs
What places are used for blood draws for BG curves? How can it be done at home? Why is this done?
- jugular catheter (avoids repeated sticks)
- ear margin vein
blood sticks or continuous glucose monitors, like Free Style Libre or alpha-TRAK
stress in hospital for dogs and cats can play a large role in affect BG and change eating and drinking behavior
