Exam 3 - Complicated Diabetic Patients Flashcards
what are some long term potential complications that need to be managed for diabetic patients?
DKA - both dogs & cats
UTIs - both dogs & cats
cataracts - dogs
peripheral neuropathy - cats
what defines a complicated/problematic diabetic patient?
uncontrolled clinical signs related to hyperglycemia - excessive thirst, urination, & hunger
episodes of hypoglycemia - sleepiness, confusion, blindness, & seizures
maintain a suitable body weight - weight loss despite treatment
long term complications aren’t managed - DKA, UTIs, cataracts, & peripheral neuropathy
patient is not meeting these goals
what is the most important goal of managing diabetic patients?
a happy owner is most important!!! patient’s life line
what 4 questions do you need to answer when approaching a complicated diabetic patient?
- did the insulin have ANY effect?
- nadir (lowest BG value)
- duration of the EFFECT of insulin
- average BG concentration
what are the main 3 reasons we have for why diabetic patients become complicated?
- insulin related
- client related
- patient related - very complicated diabetic patient!!!
what kind of patient presentation for a diabetic animal would make you think that there is an insulin-related problem?
previously well controlled diabetic patient becomes suddenly unregulated!!!!
what are 3 reasons for how insulin can lose its effect?
- agitation - bottle should be ROLLED gently (vetsulin should be shaken)
- exposure to heat or extreme cold
- bacterial contamination - ALWAYS store in the fridge & follow the manufacturer’s instructions regarding shelf life
T/F: always discard a suspected bottle if a previously stable diabetic deregulates
true
what kind of patient presentation for a diabetic animal would make you think that there is an client-related problem?
newly diagnosed diabetic!!!
what are some ways in which a client may be making a mistake when giving their pet insulin? how can these mistakes be counteracted?
owner fails to expel air bubbles/owner draws the apparatus back while injecting
owner can’t see the markings on the syringe - need to use the smallest possible syringe, use an insulin syringe magnifier, switch to an insulin pen (more accurate especially at lower doses, easier to use, but more expensive)
owner may be injecting the insulin into the pet’s hair, intradermally, or ‘through and through’ - shave patches of hair so that they can see the needle, use an > 11 mm needle because ultra-comfort needles are too short
mismatch between U/ml of insulin & syringe
what is so very bad about U/ml & insulin syringe mismatch?
U40 insulin with a U100 syringe - SUBSTANTIAL UNDER DOSE
U100 insulin with U40 syringe - results in 2.5X overdose
how can you figure out if a complicated diabetic patient is having issues due to client-related issues?
watch the owner draw up insulin & give a test dose of saline to identify if the client is the issue
T/F: before considering patient-related issues, you need to consider insulin & client-related issues first as these are easier to identify & fix
true
what do you need to look at for patient-related problems in complicated diabetics?
BG data!!!!!!!!!
need to know if insulin has any effect, nadir, average BG, & duration of effect
what are the 3 categories that patient related problems are divided into for complicated diabetics?
- episodes of hypoglycemia
- short or unpredictable duration of effect of the insulin
- insulin resistance
what does the somogyi overswing effect look like? when do we commonly see it?
looks like insulin resistance, but in fact, the patient is OVERDOSED!!!!!!!!!
happens when insulin is increased based on spot checks of BG
what are some reasons that we may see episodes of hypoglycemia in a diabetic animal with patient-related problems?
current insulin dose is too high
cat or post-diestrus female dog is going into diabetic remission
irregular exercise program - unaccustomed exertion will cause problems so clients need to keep pets on a regular schedule (20 minute walk after meals ideal for dogs)
consider other hypoglycemic disorders - addison’s, insulinomas, large liver tumors, & beta blocker administration
what are some reasons that we may see short or unpredictable duration of insulin effect in a diabetic animal with patient-related problems?
insulin isn’t a good choice for the patient - lente in a cat or PZI for a dog
insulin is erratically absorbed from SQ space - repeated use of the same site can cause problems
intestinal disease - may impact nutrient absorption (secretion of key gi hormones, incretins, may be impacted & alter glucose homeostasis & response to food intake)
how does repeated use of the same injection site for insulin potentially cause problems for diabetic patients? how is this fixed?
the animal can get an inflammatory reaction at the injection site
have the owner rotate sites to avoid causing this problem
what defines insulin resistance in diabetic dogs & cats?
dogs - BG stays > 300 mg/dl despite getting 1.5 U/kg dose
cats - BG stays > 300 mg/dl despite 5 U/kg
what is the somogyi overswing?
acute hypoglycemia (insulin dose too high) triggers counter-regulatory hormones that can cause a persistent hyperglycemia for up to 24 hours
what are the categories that we use for classifying insulin resistance?
- infection
- inflammation
- concurrent endocrinopathies/metabolic disorders
- medications
- anti-insulin antibodies
what are some examples of infections that can lead to insulin resistance in diabetic patients?
oral cavity - dental issues can cause substantial insulin resistance, so you need to address a bad mouth early
UTI - urine sediment exam may miss an infection due to DM
pneumonia
what are some examples of inflammatory conditions that can lead to insulin resistance in diabetic patients?
pancreatitis - can wax/wane, diagnose with PLI or ultrasound
stomatitis
IBD
OA
how can hypothyroidism cause insulin resistance in a diabetic dog?
patient gains weight despite poor diabetic control - uncontrolled DM will affect testing & will drive down total T4
how can hyperadrenocorticism cause insulin resistance in a diabetic dog?
signs of HAC overlap with poorly regulated DM - uncontrolled DM will affect testing & be a difficult diagnosis to make
how can acromegaly cause insulin resistance in a diabetic dog?
seen in diestrus females - progesterone triggers the release of GH from mammary tissue & antagonizes the effects of insulin
how can hyperthyroidism cause insulin resistance in a diabetic cat?
uncontrolled DM will drive down total T4 - measure free T4 in equivocal cases
when would you consider acromegaly as the cause of insulin resistance in a diabetic cat?
consider this if the cat gains weight despite poor diabetic control! these cats need huge insulin doses
usually male cats
how is acromegaly diagnosed in a diabetic cat? what is required to be done prior to testing?
measure IGF-1
patient needs to be on insulin for 6 weeks before measuring!!!!
how can hyperadrenocorticism cause insulin resistance in a diabetic cat?
uncommon but strongly associated with DM - use a LDDST to make this diagnosis
how can obesity cause insulin resistance in a diabetic dogs & cats?
adipokines impact insulin responsiveness
what concurrent medications may cause insulin resistance in diabetic patients?
glucocorticoids (topical & systemic) & synthetic progestins (megestrol acetate)
what is the theoretical issue of anti-insulin antibodies causing insulin resistance in diabetic patients?
antibodies bind insulin at the injection site & then affect its release
theoretical issue - very little data to suggest it’s an actual issue
what are the 10 steps to working up an insulin resistance diabetic dog?
- review history & physical exam
- thorough review of concurrent medications
- check sexual status, do an OHE if intact female
- routine cbc, chem, UA
- urine culture
- thyroid panel - especially if patient is gaining weight
- consider cushings - shave hair & re-evaluate growth, LDDST/ACTH stim
- consider spec cPLi particularly if appetite is variable
- consider dental cleaning if oral exam is supportive
- more extensive search for occult systemic disease (serum folate/cobalamin, thoracic radiographs, & abdominal ultrasound)
what are the 11 steps to working up an insulin resistance diabetic cat?
- review history & physical exam
- thorough review of concurrent medications
- routine cbc, chem, UA - measure free T4 if total T4 is at the upper end of normal
- urine culture
- consider spec fPLi particularly if appetite is variable
- consider serum cobalamin measurement particularly if appetite is variable
- consider running fTLi - if stools are soft
- consider dental cleaning if oral exam is supportive
- consider acromegaly - particularly if cat is gaining weight & measure IGF-1
- consider hyperadrenocorticism - particularly if skin changes are noted, run LDDST
- more extensive search for occult systemic disease (thoracic radiographs & abdominal ultrasound)
what is the best option for glucose measurements in complicated diabetic patients?
best done at home for cats
hand held glucometer or interstitial glucometer
serum fructosamine concentrations
what is the target nadir for diabetic patients? how often should you take blood glucose readings on cats managed with glargine?
target 100-150 mg/dl
every 3-4 hours
what are some common causes of the somogyi response?
spot check done at anticipated nadir
BG checks are > 2 hours apart
connecting the dots on a curve & not spotting a gap
how long do we aim for insulin to last in dogs?
aim for 10-12 hours
what is the average blood glucose level we aim for in diabetic patients?
<250 mg/dl
when does diabetic remission often occur in cats?
usually occurs within the first 3 months
how do you address inappropriate insulin metabolism in complicated diabetic patients?
inappropriate insulin metabolism - change the insulin type
for a diabetic dog, what insulins may you choose & why?
BID intermediate insulins are a good choice - lente, NPH/isophane, detemir - dogs have substantial post-prandial hyperglycemia!!!
avoid PZI - unpredictable kinetics & variable absorption
for a diabetic cat, what insulins may you choose & why? why not lente?
glargine & PZI - need a long acting insulin because cats have a very long post prandial phase because they are designed to snack & not meal feed
lente insulins are too short acting & the fast acting portion can drive down BG
how would you verify hypothyroidism in a diabetic dog? what would you expect to see?
thyroid panel
free T4 - should be low
TSH - should be high
TSH stimulation test - flat line
