Exam 4 - Canine Diabetes Mellitus

Question 1

what is the general characterization used to describe diabetes mellitus?

Answer 1

persistent hyperglycemia, resulting from defective insulin secretion, insulin action, or both

Question 2

what is the most common cause of canine diabetes mellitus?

Answer 2

immune-mediated beta cell destruction - results in absolute insulin deficiency (strong similarities to type 1 diabetes in people)

Question 3

what are the 4 causes of canine diabetes mellitus?

Answer 3

1. immune-mediated beta cell destruction
2. secondary to chronic pancreatic disease
3. diestrus diabetes
4. drug-related

Question 4

what is the pathogenesis of chronic pancreatic disease causing canine diabetes mellitus?

Answer 4

persistent inflammation of the exocrine pancreas damages the islets

islet loss results in essentially zero insulin secretion

Question 5

what is the pathogenesis of canine diestrus diabetes?

Answer 5

aka - canine acromegaly

progesterone in the diestrus phase triggers the release of growth hormone by mammary tissue which is a powerful antagonist to insulin (post-receptor effect)

DM may be reversible if the dog is spayed ASAP

Question 6

what is the pathogenesis of drug-related disease causing canine diabetes mellitus?

Answer 6

cyclosporine has been associated with DM in dogs - damages beta cells & impacts insulin sensitivity

Question 7

T/F: similar to people, dogs get obesity related diabetes mellitus (type 2)

Answer 7

false - they don’t!! cats & people do!

Question 8

T/F: sudden pu/pd/pp with rapid weight loss is the hallmark sign of canine DM

Answer 8

true

Question 9

why do clinical signs start so suddenly in patients with diabetes mellitus?

Answer 9

as soon as bg levels are > than the renal threshold (160-200 mg/dl), we see increased urine production

secondary increase in water intake due to fluid loss through urine

lack of insulin causes dramatic feelings of hunger & polyphagia

lack of insulin results in mobilization of reserves & rapid weight loss

Question 10

what is seen upon physical exam of a patient with diabetes mellitus?

Answer 10

often unremarkable except for weight loss

cataracts may be noted at the time of diagnosis - but rare

look for evidence of diseases that may complicate management - other endocrinopathies (check skin & hair coat) & systemic illnesses

Question 11

what is seen on urine analysis of a dog with diabetes mellitus?

Answer 11

glucosuria (very few other differentials for this - renal tubular injury/dysfunction, or spurious)

+/- ketonuria - some may be noted in newly diabetic dogs, but does not indicate DKA!!!

urine specific gravity impacted by glucosuria - often > 1.020 despite severe pu/pd

evidence of UTI - rbc, wbc, bacteria, may be subclinical

Question 12

T/F: like cats, dogs also get stress hyperglycemia

Answer 12

false

Question 13

what lab changes are seen on a chemistry panel of a dog with diabetes mellitus?

Answer 13

hyperglycemia usually >300 mg/dl

hypercholesterolemia/hypertriglyceridemia

elevated ALP activity - vacuolar change due to lipid mobilization

hyponatremia - partially dilutional due to hyperglycemia, some increase in urinary loss of sodium

Question 14

what changes may be seen on a cbc of a diabetic dog?

Answer 14

stress leukogram is expected

anemia is not expected!!! suggests concurrent disease

Question 15

what is the current consensus on subclinical UTI therapy in diabetic dogs?

Answer 15

not to culture or treat unless the dog has actual signs of a UTI

Question 16

why do a PLI test on a diabetic dog?

Answer 16

elevation supports concurrent pancreatitis - may impact dietary recommendations

Question 17

what are the 6 goals of treatment for a diabetic dog? which is the most important?

Answer 17

1. resolve pu/pd - minimize signs of hyperglycemia
2. avoid hypoglycemia
3. avoid DKA
4. optimize weight, activity level, & BCS
5. minimize complications (uti, cataracts)
6. satisfied owner - most important!!!!!! owner is life support system for the dog

Question 18

why are porcine or human insulins preferred for use in diabetic dogs?

Answer 18

canine insulin is identical to porcine insulin & very similar to the human molecule

Question 19

what is the only FDA approved pork insulin?

Answer 19

vetsulin

Question 20

T/F: almost all available insulins are now based on the human molecule

Answer 20

true

Question 21

what components of insulin make up the type when selecting one for therapy?

Answer 21

rate of onset

duration of effect

potency

Question 22

what are engineered insulins?

Answer 22

scientists have altered the amino acid chain of the human insulin molecule to change its behavior - these are more predictable & stable than the older types of insulin

referred to as “insulin x”

insulin glargine u-100 (lantus)

Question 23

what should be considered for insulin cost when making a decision on which option to use therapeutically?

Answer 23

consider how much of a bottle will be used

dose

stability after opening

syringes needed - U40 syringes, used for prozinc & vetsulin, are more expensive

Question 24

what does U40 mean? what does U100 mean?

Answer 24

U40 - 40 units/ml

U100 - 100 units/ml

Question 25

what insulin type is used for managing all species with DKA? how long does it last? how is it given? what syringe is used?

Answer 25

regular!!! lasts 4-6 hours if given SQ can be given IV/IM/SQ U100 syringe used

Question 26

what insulin type is used for diabetic cats but is unpredictable in dogs? how long does it last? how is it given? what syringe is used?

Answer 26

prozinc!!! 12 hours, sometimes longer SQ only U40 syringe

Question 27

what insulin type requires the use of an insulin pen for dosing in unit increments? how long does it last? how is it given? what syringe is used?

Answer 27

glargine U-300 more than 12 hours IV/IM/SQ U300 syringe (insulin pen)

Question 28

what insulin type is used for diabetic dogs that are bigger or failed to respond to lente/nph? how long does it last? how is it given? what syringe is used?

Answer 28

detemir - levemir, very potent lasts 10-12 hours IV/IM/ SQ U100

Question 29

what insulin type is routinely used in cats that gets good control? how long does it last? how is it given? what syringe is used?

Answer 29

glargine!! lasts > 12 hours IV/IM/SQ U100 syringes

Question 30

what are your 3 suitable first choices for insulin in diabetic dogs?

Answer 30

1. lente - vetsulin 2. NPH 3. insulin detemir

Question 31

how is lente (vetsulin) used for starting insulin therapy in diabetic dogs?

Answer 31

U40 porcine insulin product - starting dose is 0.25 U/kg twice daily - okay to round up to 0.5 U/kg in small dogs comes with a pen system - easier for the nervous owner & more accurate with small doses than a syringe

Question 32

how is NPH used for starting insulin therapy in diabetic dogs?

Answer 32

starting dose is 0.25 U/kg twice daily

Question 33

how is insulin detemir used for starting insulin therapy in diabetic dogs?

Answer 33

starting dose is 0.1 U/kg twice daily (very potent) - U100 syringe hard to dose in small dogs

Question 34

what is the initial approach that should be used when beginning insulin therapy in a diabetic dog?

Answer 34

administer the first insulin dose & feed in the morning (use 11 mm needles - too short may stay intradermal) measure BG every 2 hours over 8-12 hours if bg remains > 150 mg/dl, send home on this dose! may increase the dose by 10% if possible if bg is >250 mg/dl if bg goes < 150 mg/dl, decrease the dose by 10-25% (round to nearest unit) & if possible, hospitalize the dog to monitor response to the lower dose repeat blood glucose curve in one week

Question 35

what dietary strategies may be used for a diabetic dog?

Answer 35

feed a complete & balanced diet that is low in simple sugars - a 'special' diabetic diet has little benefit feed enough to optimize body weight feed equal sized meals twice daily at the time of insulin injection - consistency is key!! can use the pet nutrition alliance website to get help for creating a diet plan

Question 36

T/F: acute exertion in a diabetic dog can result in hypoglycemia

Answer 36

true

Question 37

what can be done to improve insulin efficacy after a dog finishes their meal?

Answer 37

15 minute walk after each meal

Question 38

what is the benefit of using a freestyle libre as a send home monitoring treatment for a diabetic dog? what are the disadvantages of it?

Answer 38

continuous monitor that is fairly reliable - data for 10-14 days & lets you safely step up doses quicker & achieve control faster disadvantages - doesn't always work, may need to verify with alpha trak a few times a day & poor concordance if bg changes fast (venous versus interstitial reading)

Question 39

after the initial diagnosis of diabetes & start of insulin therapy, what should your recheck schedule look like?

Answer 39

recheck every 1-2 weeks for the first month if not using a libre - can do a bg curve at home or in clinic & adjust dose as indicated recheck bg within 2 weeks of a dose change encourage home monitoring once a month - more data & more accurate! intermittent use of a continuous interstitial glucometer recheck every 3 months if doing well! treat patient & not numbers!!!!! we use the curve data to make adjustments when needed, but don't chase the perfect curve

Question 40

how is at bg curve done at home?

Answer 40

check bg feed & administer insulin as usual feeding at home ensures that the pet east all food test bg every 2 hours until next insulin dose - repeat bg within 1 hour if any glucose value is <100 mg/dl

Question 41

how is at bg curve done in the clinic?

Answer 41

have the owner feed the dog & give insulin at home test bg every 2 hours until next dose of insulin - repeat bg within 1 hour if any value <100 mg/dl

Question 42

T/F: it is dangerous to increase an insulin dose without performing a curve or using a libre

Answer 42

true

Question 43

what is nadir for diabetic dogs? what are important considerations for this when doing a blood glucose curve?

Answer 43

100-150 mg/dl - not the actual lowest if we are doing it every 2 hours, but our best estimate!! very important to do our best to establish this value continuous monitors will allow us to identify nadir most reliably - timing is inconsistent, so you can't just do a spot check! failure to identify the nadir but increasing the dose based on a spot check is a classic mistake okay to get close to 80 mg/dl in a stable patient

Question 44

what is nadir in regards to a blood glucose curve?

Answer 44

the lowest a measurement will be during the procedure/curve

Question 45

what is the target goal for duration of a blood glucose curve? what about target average bg value?

Answer 45

10 hours - try to establish when the insulin has worn off, bg is > 80% of the pre-insulin value! average - < 250 mg/dl

Question 46

if nadir is <80 mg/dl in a stable patient after a blood glucose curve, what should you do?

Answer 46

decrease their insulin dose by 25%!!

Question 47

if nadir is >150 mg/dl after a blood glucose curve, what should you do?

Answer 47

increase insulin by 10-20%

Question 48

if nadir is 100-150 mg/dl after a blood glucose curve, & average blood glucose is <250 mg/dl, what should you do?

Answer 48

no change to insulin dose!

Question 49

if nadir is 100-150 mg/dl after a blood glucose curve, & average blood glucose is > 250 mg/dl, what should you do?

Answer 49

glucose nadir /= 10 hours after insulin, change to a shorter acting insulin

Question 50

T/F: it is okay to allow a client to decrease or skip a single insulin dose if they are concerned, but they are not allowed to increase the dose unless directed to do so by the veterinarian

Answer 50

true

Question 51

for client education, what does the owner need to know about hypoglycemia & hyperglycemia in their diabetic dog?

Answer 51

hypoglycemia is deadly but short term hyperglycemia is not!!!!

Question 52

what specific instructions should you give to the owner of a diabetic dog showing signs of hypoglycemia?

Answer 52

offer food if the dog is able to eat - carbs are ideal rub karo syrup on gums - 0.125ml/kg will raise bg by about 50 mg/dl & may need to repeat this while insulin does its thing

Question 53

T/F: regular insulin ["R"] is analogous to endogenous insulin from the pancreas & all current R insulins are human molecules

Answer 53

true

Question 54

what defines the type of insulin?

Answer 54

whatever chemical is attached to the insulin molecule

Question 55

what is the 2 peak formulation of lente insulin?

Answer 55

30% fast acting & 70% slow acting - designed to blunt post prandial rise in blood glucose levels

Question 56

why is detemir insulin so much more potent than lente?

Answer 56

4x more insulin molecules/unit

Question 57

what 3 key questions should you consider when doing a blood glucose curve?

Answer 57

1. did the insulin have an effect? 2. what was the lowest value? goal of 150-250 mg/dl for the first dose!! 3. did the insulin last about 10 hours? (nadir about 6 hours post dose)