Diabetes Mellitus Flashcards
(61 cards)
1
Q
Obj: know and understand the clinical features of diabetes mellitus in dogs and cats
A
- Dogs:
- PU/PD, polyphagic, weight loss, blindness from cataracts
- Cats:
- PU/PD, polyphagic/inappetance, weight loss
- depressed/lethargic
- rear limb weakness and platigrade stance
2
Q
Obj: know and understand the clinical use of insulin in diabetic dogs and cats
A
- Controls glucose fluctuations
3
Q
Obj: understand the rationale and routine protocols for monitoring the efficacy of therapy in diabetic dogs and cats
A
- 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
4
Q
Obj: Know and understand diabetic ketoacidosis as it occurs in diabetic dogs and cats especially emergency management
A
- 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
5
Q
What is Diabetes Mellius?
A
- A disorder of the endocrine pancreas
- Characterized by severly impaired carbohydrate and lipid metabolism
6
Q
What are the types of diabetes mellitus?
A
- Type 1 - Insulinopenia
- reduced or absent insulin production
- Type 2 - Insulin resistance
- reduced or absent insulin action
7
Q
What type of diabetes affects dogs?
A
- Insulinopenia (Type 1) is main feature
- Histology shows islet damage w/ loss of functional mass
8
Q
What are the potential factors in canine DM athophysiology?
A
- Genetic susceptibility is present for some breeds
- Autoimmunity
- Pancreatitis (40% of dogs w/ DM also have pancreatitis)
9
Q
What is Feline DM?
A
- Insulin resistance (Early)
- Insulinopenia (Later)
- Histology shows islet amyloid deposition / loss of beta cells
- same in human type 2 DM
10
Q
What are the potential factors in feline DM pathophysiology?
A
- Genetic component suspected in some breeds
- Others:
- Pancreatitis
- endocrinopathy (acromegaly)
- Diabetogenic medications (glucocorticoids)
- Diestrus / pregnancy
11
Q
What is the classical triad of clinical signs associated with DM?
A
Polydipsia, Polyuria, Polyphagia
12
Q
What are the other signs of DM? (outside Triad)
A
- Weight loss
- Cataracts (dogs)
- Neuropathy (cats)
- Asymptomatic hyperglycemia
13
Q
Where does the glucose in DM come from for cats and dogs?
A
- (Usually) not dietary
- From the liver - increased hepatic glucose production
- glycogen, gluconeogenesis, etc
14
Q
What defines DM?
A
persistent fasting hyperglycemia - (not clinical signs)
15
Q
What are the challenges of diagnosing DM in the lab?
A
- Glucose in early or mild DM overlaps with normal range
- Stress hyperglycemia occurs in dogs and cats
- glucosuria - rarely present but possible
- ketonuria - never
16
Q
What CBC findings are common with DM?
A
variable, no consistent abnormalities
17
Q
What results are common on a biochemistry panel for DM?
A
- 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
18
Q
What findings are common on a urinalysis with DM?
A
- Glucosuria
- Ketoneuria
19
Q
What determines inpatient vs outpatient treatment for DM?
A
- Stable diabetic - outpatient
- routine signs, normal appetite, hydrated, unremarkable lab results
- Sick diabetic - inpatient
- severe clinical signs, appetite loss, dehydration, electrolyte disturbances
20
Q
What are the treatment goals for DM?
A
- Eliminate clinical signs
- Address concurrent disorders and contributing factors
- Control hyperglycemia
- Aoid hypoglycemia
21
Q
What are the different routes of controlling hyperglycemia?
A
- Insulin - treatment of choice
- Diet - not a sole therapy
- Weight loss / exercise - not a sole therapy
- Oral hypoglycemic drugs - usually ineffective
22
Q
What are the different formulations of Insulin used in Vet Med?
A
- U 40 Insulin
23
Q
What is the difference between U-100 and U-40 insulins
A
- 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
24
Q
Why is it important to match the syringe type and the insulin type?
A
- 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)
25
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
26
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
27
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
28
What does the Treatment/Monitoring Timeline for animals with DM look like?
* El
29
What are Indirect monitoring methods for animals with DM?
* Subjective:
* Clinical signs
* Physical examination
* Objective
* Blood hemoglobin A1c
* Serum fructosamine
* Urine glucose measurement
30
What are the direct monitoring methods for animals with DM?
* Glucose Curve
* Continuous Glucose monitoring
* Spot glucose determination
31
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
32
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
33
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
34
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
35
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
36
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
37
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
38
How can monitoring glucodynamics be utilized as a monitoring technique for patients with DM?
* **Glucose Curve** - BG sampled intermittently
* Continuous Glucose monitoring
39
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
40
What are blood glycated proteins
* Proteins that change in the presence of hyperglycemia
41
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)
42
What is “spot glucose" monitoring
* Blood glucose
* Urine Glucose
* Should NOT be used to:
* infer glycemic status (except hypoglycemic)
* Adjust insuline dose
43
What is the benefit of blood glucose spot monitoring?
useful to detect or confirm hypoglycemia
44
What is the benefit of urine glucose spot monitoring?
* represents accumulation over time
* May detect large changes in glucosuria or onset of ketonuria
45
What conditions can complicate DM?
* Diabetic Ketosis (DK) / ketoacidosis (DKA)
* Hyperosmolar Hyperglycemic State (HHS)
46
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)
47
What is Diabetic ketoacidosis?
* Results from insulin deficiency
* Ketones produced by impaired FA metabolism
* Ketones are metabolic acids
* Requires insulin for resoution
48
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)
49
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
50
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
51
What is the overall treatment for complicated DM?
* Fluid replacement
* Restore Euglycemia
* Correct Metabolic Imbalances
* Systemic support
* Address any concurrent disorders
* Monitor
52
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
53
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
54
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
55
What are the goals of insulin therapy?
* Control hyperglycemia
* Stop ketogenesis
56
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
* 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
57
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-
58
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
59
What systemic support can be needed for complicated DM cases?
* Systemic Support
* Body temperature (warming)
* Oxygen support
* Nutritional support
60
What concurrent disorders may need to be addressed in complicated cases of DM?
* Pancreatitis
* Bacterial infection (UTI, pneumonia)
* Other endocrinopathy
61
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
