Diabetes Mellitus Flashcards
(31 cards)
IDDM pathophysiology
insulin secretion ⬇️
NIDDM pathophysiology
insulin secretion ↔️ or ⬆️, but
insulin is less effective
Primary DM
(pancreatic disease)
– Autoimmune destruction of islets (dogs)
–Islets amyloidosis (cats)
–Pancreatitis, (neoplasia)
Secundary DM
– Excess of counterregulatory hormones
(GH ⬆️, glucocorticoids ⬆️)
– Obesity (reduced receptor binding of insulin)
What are the consequences of EC glucose excess (BG)
- glucosuria -> polyuria, hypokalaemia, hyponatremia, hypophosphatemia
- IC dehydration -> hyperglycemic coma (blood sugar over 30-40, hyperosmolar hyperglycemia)
- glycation of proteins -> lens cataract, retinopathy, peripheral neuropathy, glomerulosclerosis
Blood glucose levels dog, cat
Dog: BG >10 mmol/l
Cat: BG >14 mmol/l
–> leads to glucosuria!
What are the consequences of lacking IC glucose?
Need another way to get energy for the cells! DM is a catabolic state!! + immunosuppr. (Protein synth)
🔺 Lipolysis (Fe!)
➡️ weight loss
➡️ hyperlipemia > fatty liver
➡️ ketonemia > ketonuria, acidosis, ketoacidotic coma
🔺GNG
➡️ protein synthesis decr > weakness, poor wound healing, susceptibility to infections incr
Signalment/history of DM
~ Common disease ~ Middle-aged and old dogs ~ Intact females are predisposed ~ Poodle, Dachshund, Terriers, Beagle, Puli, Labrador, Retrievers, (English cocker spaniel, Rottweiler)
Clinical manifestations in uncomplicated DM
(The first signs hasn´t caused secundary issues yet)
~ Signs may appear 1-2 months after estrus (lutheal phase - high P4 - mamm. Growth - high GH - insulin resistance)
~ History with (possible) pancreatitis +/-
~ PD/PU, weight loss, (initial polyphagia)
~ Dehydration, hepatomegaly, dull hair coat, flaking skin, cystitis,
glycos- / ketonuria and hyperglycemia
~ Chronic cases: cataracts / retinopathy, (uveitis if lens capsule ruptures - immune system can detect!), proteinuria +++, (paresis)
Clinical manifestations in complicated DM
Seen when not treated with insulin in time! See last card, and additionally:
🔺 Diabetic ketoacidosis
– Lethargy, weakness, anorexia, vomiting, coma, Kussmaul’s respiration,
odor of acetone in the breath (aromatic smell)
🔺 Hyperglycemic hyperosmolar syndrome (HHS; BG >33 mmol/l)
– Restlessness, ataxia, nystagmus, convulsions, low ketone!!
🔺 Pancreatitis (persistent high TG)
– Lethargy, vomiting / diarrhea, abdominal pain
🔺 Exocrine pancreatic insufficiency (persistent high TG)
– Poorly digested feces, sour smell, flatulence
🔺 Signs of Cushing’s syndrome, acromegaly
Laboratory and instrumental findings in DM
~ WBC⬆️, PCV⬆️
~ ALT ⬆️, ALKP (SIAP?) ⬆️, BUN / creatinine ⬆️,
K+ ⬆️ or ⬇️, amylase / lipase ⬆️, cholesterol ⬆️, lipemia
~ Metabolic acidosis
~ Progesterone ⬆️, cortisol ⬆️, GH ⬆️
~ (Fructosamine, glycosylated hemoglobin, IV glucose tolerance test)
~ Bacteriuria: sediment and culture
~ Abdominal US may give suspiscion: diffuse hepatomegaly, pancreatitis +/-, enlarged adrenal(s) +/-, nephropathy +/-, cystitis +/-, ovarian / uterine cysts +/-
Treatment in uncomplicated DM
🔺 The owner should be informed about prognosis, (lifelong) insulin therapy, dietary management, controls, costs
🔺 Oral antidiabetic drugs are ineffective ! Only work in Hu
🔺 Insulin therapy: 2x/day!
– Caninsulin AUV,
- 30% amorphous, 70% crystalline zinc insulin suspension
– 0.5 (BW >25 kg) – 1 (BW <15 kg) IU/kg/12h SC
🔺 Ovariectomy
– Reduces (risk of) insulin resistance. Always for intact female, to decr P4 source. Lutheal phase risk of severe insulin resistance!!!
Luthel phase huge decr of efficacy of treatment
➡️insulin demand ⬇️(if DM manifested within three weeks, complete recovery is possible)
(Must neuter in time, insulin deficient insulin dependant problem may develope)
Diet in DM
🔺 Amount and composition should be constant
🔺 Rich in protein, high fibre content, complex carbohydrates (fiber slows down starch digestion)
–Hill’s r/d, w/d, i/d, R.C. Weight Control Diabetic, Eukanuba Glucose Control etc.
–Home prepared: 70% meat, 25 % rice, potatoes or pasta, 5% vegetables, cereals
🔺 10-50 g/kg/24h divided into 4 equal portions
🔺 One portion few minutes before each insulin dose(to decide if give full dose or not dep on if dog eats), one portion 3-4 hours later
What is best to measure blood glucose, glucosuria, ketonuria
- Human dipstick for glucosuria is sensitive and reliable (not ketones!! Cannot detect betahydroxybuturate, the most common one)
- human glucometer to measure blood glucose.
(Continous interstitial glucose monitoring on neck - detection of insulin therapy problems, no stress, puncture..)
Fructosamine
Only increase in permanent hyperglycemia.
Its concentration represents the glucose average concentration in the 2-3 weeks period before sampling. Not influenced by short term hyperglycemia!
(Glycated haemoglobin - 2-3m average)
Important client instructions
🔺 Method of insulin administration must be taught in detail and tried by the owner (saline)
🔺 Reduction of insulin dose by half in case of anorexia or vomiting (OD - hypoglycemia)
🔺 Information about hypoglycemia/OD signs
– Signs: excitement, tremor, weakness, falling,
convulsions, coma (must be able to recog. NS symptoms!)
– Treatment: honey with syringe/spoon, extra meal, following insulin dose is skipped, consultation
– If there is no improvement in 15 minutes, emergency treatment is required
🔺 Diet
🔺 Daily water intake (maximum 60-70 ml/kg) - diary (glycemic control - PD disappear or not)
Control examinations
~ On the first two weeks: weekly
~ After control is stable: every 3-6 months
➡️ bwt, PD/PU, hypoglycemic events?
~ Blood glucose 6 hours after morning insulin should be 4-9 mmol/l
~ Adjust insulin dose +/- 5-10%
Hypoglycemia as a problem with insulin therapy
– Anorexia, vomiting, unusual physical activity,
➡️(relative) insulin overdose
– Client instructions, reduction of insulin,
IV glucose administration
Somogyi effect as a problem with insulin therapy
🔺 Somogyi effect (posthypoglycemic hyperglycemia)
–BG <3 mmol/l➡️
adrenaline, glucagon, (cortisol, GH)⬆️➡️ BG⬆️⬆️
– PD/PU, hyperglycemia
- insulin lowers your blood sugar too much, it can trigger a release of hormones that send your blood sugar levels into a rebound high –> insuline resistancy that may last for 3 days. Symtoms of reccurent diabetes seen - PD/PU, blood sample - resistance vs post resistance phase of body (adrenalin, gluc) -> serial blood test needed. For the correct insulin dose
– Serial BG measurements, reduction of insulin dose
What do you have to rule out before diagnosing problems with insulin therapy and controls
Insulin activity and administration problems should be ruled out
Stress induced hyperglycemia as a problem with insulin therapy controls
– No complaints at home, but hyperglycemia in the examination room
– Measurement of BG at home
Short action of insulin as a problem with insulin therapy
– PD/PU and hyperglycemia a few hours before insulin
– Longer acting insulin / dietary modification (should last 12h)
Insulin resistance as a problem with insulin therapy
– Insulin dose >1.5 IU/kg is ineffective
– Cortisol or progesterone / GH excess should be investegated and treated (as it may cause the resistance)
Treatment of ketoacidosis
🔺 Volume repletion:
– Ringer’s solution + 1 mmol KCl / 100 ml
– 20 ml/kg in the first hour, thereafter rate may be reduced by half every hour, until 2.5 ml/kg/h
🔺 Regular insulin: Actrapid HMge
– 0.25 IU/kg IM, thereafter 0.1 IU/kg repeated every hour, until BG stabilizes between 8-13 mmol/l
➡️ 0.3-0.5 IU/kg Caninsulin SC
🔺 K+ replacement: mmol KCl = (4.5 - K+) x 0.6 x BWkg ¨
🔺 Bicarbonate therapy if pH <7.1
