Endocrinopathies - III diabetes Flashcards
Overview/ definition of diabetes mellitus.
Syndrome associated with chronic hyperglycemia.
- Loss or dysfunction of insulin secretion by pancreatic beta cells
- Diminished insulin sensitivity in tissues
- Or both
Diabetes in dogs.
Beta cell loss due to immune-mediated destruction/vacuolar degeneration/pancreatitis.
Insulin-resistant effects of the diestrus phase in intact female dogs, transient or not.
Diabetes in cats.
Loss or dysfunction of beta cells due to insulin resistance/islet amyloidosis/chronic lymphoplasmacytic pancreatitis.
Remission is possible with diet and insulin.
Risk factors for developing DM for both dogs and cats include: (4)
Obesity
Certain diseases
- Acromegaly and kidney disease in cats, hyperadrenocorticism, hypertriglyceridemia and hypothyroidism in dogs, dental disease, systemic infection, pancreatitis, pregnancy/diestrus.
Medications
- Steroids, progestins, cyclosporine
Genetics
- Australian terriers, beagles, samoyeds, keeshonds, Burmese cats
Clinical signs of diabetes mellitus. (5)
PU/PD, PP (polyphagia) + weight loss
Lethargy, weakness, poor body condition
Cataracts in dogs
Impaired jumping and abnormal gait in cats (peripheral neuropathy)
Systemic signs of illness (DKA): anorexia, vomiting, dehydration, depression
Diagnosis of diabetes is based on what exams? (4)
Physical exam
Blood pressure
Blood analysis
Urinalysis
(complete blood count, chemistry with electrolytes, urinalysis with culture, urine protein:creatinine ratio (UPC), fructosamine!, triglycerides, blood pressure (BP), and thyroxine (T4); to confirm the diagnosis as well as to rule out other diseases.
- problems often associated with the disease (e.g., urinary tract infections, pancreatitis).
- conditions that may interfere with the patient’s response to treatment (e.g., hyperthyroidism, renal disease, hyperadrenocorticism).
Typical CBC findings in diabetes.
stress leukogram
Typical biochemical findings in diabetes.
Hyperglycemia:
- Glucosuria and clinical signs when blood glucose >11.1 mmol/L in dogs, >13.9-16,7 mmol/L in cats.
Increased cholesterol and triglycerides
Dogs: elevated ALP, ALT
Cats: variable ALP, elevated liver enzymes - rule out concurrent liver disease.
CPL - pancreatitis is common comorbidity
DKA: very elevated BG, azotemia, metabolic acidosis, hyperosmolarity
Typical urinalytical findings in diabetes. (5)
Glucosuria
Protein
Ketones
Bacteria
Casts
Always culture - UTI is common.
Diagnosis of diabetes requires: (4)
Persistent hyperglycemia +
glucosuria +
characteristic clinical signs
(+ elevated serum fructosamine in cats)
Reasons for Hyperglycemia without clinical signs (4)
Stress hyperglycemia (cats)
Corticosteroid administration
Concurrent insulin-resistant disease
- e.g. Hyperadrenocorticism, Obesity
Early stage of developing DM
Next,
rule out stress hyperglycemia: reassess blood and urine glucose, measure serum fructosamine
→ correct insulin-resistant diseases
→ discontinue drugs associated with impaired insulin release/sensitivity.
Treatment of diabetes and the 2 main goals.
Insulin + diet
Goals:
- Controlling BG below the renal threshold for as much of a 24 h period as possible - improves clinical signs of DM.
- Avoid clinically significant hypoglycemia.
Each patient requires an individualized treatment plan, frequent reassessment, and modification of that plan based on the patient’s response.
Goal of Treatment of diabetes in cats specifically.
Goal is remission.
+ Minimal/no clinical signs
+ Owner perception of good quality of life and favorable treatment response.
+ Avoidance/improvement of DM complications: DKA, peripheral neuropathy
+ Avoidance of hypoglycemia
Treatment of diabetes in cats using…
Insulin: glargine (Lantus), starting dose based on:
- Estimated ideal body weight.
- BG levels: 0.5 U/kg q12h if BG >20,
0.25 U/kg q12h if BG <20
- usually 1 U q12h, do not exceed 2 U per cat q12h.
Treatment of diabetes in cats.
Monitor BG on the first day of insulin treatment?
Yes, the goal is solely to identify hypoglycemia - do not increase insulin dose.
BG q2-4h for 10-12 h following insulin.
Decrease insulin dose 50% if BG is <8.3 mmol/L any time.
Treatment of diabetes in cats.
Reevaluation (blood glucose curve):
Immediate reevaluation if any signs of hypoglycemia occur.
Need to avoid clinical signs suggesting hypoglycemia (<3.5 mmol/L):
lethargy, trembling, depression, ataxia, seizures, coma. Lethargy, anorexia, vomiting.
Otherwise, In 1-2 weeks after first initiating treatment with insulin - do not increase dose earlier than q1-2w!
Treatment of diabetes in dogs using…
Insulin: porcine lente (Caninsulin)
0.25 U/kg q12h rounded to the nearest whole U
Based on estimated ideal body weight.
Avoid symptomatic hypoglycemia.
Feed equal-sized meals twice daily at the time of each insulin injection.
Remission is rare.
OHE in intact diabetic dogs will support.
Insulin dose should not be increased more often than q1-2w!
Things to note about insulin and its practical use.
12 +/-2 h window and occasional missed doses are acceptable
Caninsulin shaken, other insulins rolled
Vial stopper wiped with alcohol prior to inserting needle
Do not freeze/expose to heat, store in refrigerator, use up to 3-6 months, new vial if change in appearance.
Oral hypoglycemic drugs
Oral hypoglycemic drugs are neither recommended nor considered appropriate for long-term use. Their use is considered temporary and only if combined with dietary modification if the owner refuses insulin therapy or is considering euthanasia for the pet.
e.g. “Bexacat” ingredient bexaglifoxin
mechanism of action of GLP-1 receptor agonist drugs
used primarily in the treatment of type 2 diabetes and, more recently, obesity. Their mechanism of action is based on mimicking the effects of the endogenous hormone GLP-1, which is naturally secreted by intestinal cells (L-cells) in response to food intake.
GLP-1 drugs enhance the secretion of insulin from the pancreas, but only when blood glucose levels are elevated. This glucose-dependent insulinotropic effect helps to lower blood sugar without causing hypoglycemia.
GLP-1 drugs inhibit the release of glucagon, secreted by alpha cells in the pancreas. Glucagon normally raises blood glucose
- Delay in gastric emptying and increased satiety.
- Reduction in postprandial blood glucose levels.
- Weight loss and potential cardiovascular benefits.
Describe how to do a blood glucose curve.
BG q2h (q3-4h with glargine) for 1 interval between injections (so a span of 12h if insulin q12h, span of 24h if its given 1q24h).
- but q1h when BG <8.3 mmol/L
Glucometer calibrated in dogs and cats.
Capillary blood from ear, gums, non-weight bearing/accessory foot pads, elbow callus.
Use normal insulin and feeding schedule.
Perform In hospital or at home.
blood glucose curve values to aim for
lowest acceptable
range
highest acceptable
Determine 1. nadir (lowest BG) and 2. duration of action of the insulin dose.
- Duration cannot be evaluated until the nadir is optimized.
Ideal nadir/lowest point is 4.4-8.3 mmol/L (80–150 mg/dL)
- Reduce dose if BG is ever <4.4 mmol/L (<80 mg/dL).
Highest BG should be close to 11.1 in dogs (200 mg/dL ), 16.7 in cats (300 mg/dL ).
BG should be successfully managed for as much of a 24 h period as possible.
Describe Continuous glucose monitoring system
Freestyle libre product
Measures interstitial glucose concentration q15min for up to 14 days.
Can be used in Dogs and cats
Hospitalized patients with DKA
which type of curve are we aiming for with insulin therapy?
which one represents the somogyi response?
green one id ideal curve
blue is somogyi
What test in addition to home-GLU testing can we suggest to owners?
urine dipstick for glucose and ketones.
If ketones are present, contact veterinarian.
monitoring blood glucose levels in cats and dogs algorithm
managing hypoglycemia in diabetic cats and dogs algorithm
Uncontrolled diabetic with concurrent disease may experience…?
insulin resistance
When,
- Dogs: insulin dose >1 U/kg/dose with no response or >1.5 U/kg fails to bring BG <16.7 mmol/L.
- Cats: insulin dose >5 U/dose.
Treatment of DKA.
hospitalization is required
fluid therapy immediately, balanced crystalloid with buffer
- supplement potassium
slightly later instigate insulin therapy
interpreting a glucose curve which glu value do you use?
the nadir aka the lowest value and apply to the attached algorithm.
even if some values are higher than ideal, use the nadir to make your maintenance decisions as to avoid inducing hypoglycemia with too high an insulin dose.
note that if your BGC values steadily creep up to over ref. values, consider increasing dose.
