Diabetes MellitusBrad Green

Internal Medicine ServicePuget Sound Veterinary

Referral Center

CGMS = continuous glucose monitoring system

Measures interstitial glucose every 5 minutes for 72+ hours

There was little correlation between days. Even consecutive days at home.

At the end of this talk, I will come back to these and how they can be useful.

So if measuring glucose every 5 minutes for 72 hours wasn’t helpful, how helpful is measuring glucose every hour for 12 hours?

Still the best practical tool that we have. Most helpful to ensure that

hypoglycemia is not occurring. Therefore, it is necessary to check BGs q 1

hours when doing BG curve

A reflection of mean glucose

Most helpful to determine how much time is spent in the range of hyperglycemia.

• Remember Somogyi but also remember it is rare

Weight gain suggests good control Weight loss suggests poor control PU/PD suggests poor control or

concurrent disease Resolution of PU/PD is highly supportive

of good control (or an inobservant owner)

Valuable when done correctly

Seldom done correctly

Nearly always leads to owner and veterinarian frustration

Often results in worse control of diabetes

Can be difficult to get owners to pay for your interpretation and recommendations Which results in self directed dosing

changes

Somewhat useful Can be done at home Should not be over-interpreted; should

not be used alone to adjust insulin dosing

Negative urine glucose can mean ideal control but it can also mean that insulin dose is too high and patient is experiencing hypoglycemia

Affected by renal tubular flow

Often owners of newly diabetic cats will say, I could give an injection once daily but not twice daily.

This is an opportunity to explain that good diabetic control up front – which requires BID insulin – may result in not having to use any insulin long-term. Many owners will realize twice daily injections aren’t so

bad Glargine is not an SID insulin

Diabetic cats should be fed a high-fat, high-protein, low-carbohydrate diet. Purina DM, Prescription Diet M/d Kitten food is an alternative if a prescription diet is cost-

prohibitive.

70% of diabetic dogs will develop cataracts within 1 year.

To prevent cataracts and to slow their progression, tight glycemic control is the goal.

Other complications are uncommon Once cataracts have developed and

have been surgically removed, control does not need to be quite as stringent

We are not going to have your pet’s glucose perfectly controlled.

We will have it adequately controlled to prevent most complications except cataracts.

I have only seen one dog with perfectly controlled diabetes. The owner was a nurse for diabetic people and

managed her dog as she would her patients: She gave lente insulin BID then gave a sliding-scale dose of regular insulin based on BG levels with meals.

This owner was exceptional. I do not recommend this.

Continuous glucose monitoring glucose devices and insulin pumps would likely work well.

Insulin doses are determined by body weight, glucose levels, fructosamine levels, and clinical signs.

Glucose levels (and hence insulin doses) are affected by many factors: steroids (endogenous or exogenous), epinephrine, glucagon, insulin

Insulin dosing will change over time It may even occur that at some point, we

need to start over

10 year old, male neutered, Siamese cat

Presents for PU/PD of 2 to 3 weeks duration

Chemistry panel: BG = 302; mild elevations of ALT and alk phos.

UA: 2+ glucosuria; no ketones

Insulin options: Glargine or ProZinc

Glargine starting dose: Usually 1 unit BID but may start lower on cats

< 4 kg May start higher on very large or very

hyperglycemic cats U-100 syringes

Insulin options: Glargine or ProZinc

ProZinc starting dose: 0.25+ units/kg BID This insulin and the above dose are intended to

be administered via U-40 syringes. However, I find that dosing adjustments are easier with U-100 syringes since the units are smaller. 1 unit with U-40 equals 2.5 units with U-100 .

For a 4 kg cat, I will write instructions as give 3 units with a U-100 syringe (or 1 unit with a U-40) every 12 hours.

DIET IS VERY IMPORTANT IN CATS High fat High protein Low carbohydrates Purina DM, Prescription Diet M/d, etc. Kitten food is an alternative when cost

prohibits use of prescription diet.

REEVALUATIONS It is important to remember and to

educate owners that many diabetic cats can be returned to the non-insulin dependent state.

This seems to be more likely if treatment is aggressive early.

There is a theory that prolonged hyperglycemia is toxic to the beta cells.

REEVALUATIONS Start with single blood glucose 6 to 8 hours after

insulin administration. BG curves would be ideal but be careful to AVOID

OWNER FATIGUE Recheck weekly. Slowly increase dose until BG <

225. If BG > 225, it is almost always safe to increase

insulin. Remember Somogyi but also remember it is rare

Once BG < 200-225, do BG curve and fructosamine 7 days later

Day 1: Glargine insulin and diet started

Day 7: BG = 242. Glargine increased to 2 units BID

Day 14: BG = 176. Continue 2 units. Day 21: BG curve

Possible interpretations: Diabetes is fairly well controlled but

not ideally controlled Diabetes no longer requires insulin

Fructosamine in fair range Diabetes is fairly well controlled but not

ideally controlled Increase insulin (to 2.5 units)

Fructosamine is in very good range Diabetes probably no longer requires insulin

There is some response to insulin but the high points may be attributable to stress

Decrease insulin (to 1 unit BID) and repeat curve in a week. *usually I don’t do curves more often than every 10 to 14 days but I am more aggressive here to ensure that this newly diagnosed diabetic does not relapse.

Day 1: Glargine insulin and diet started

Day 7: BG = 242. Glargine increased to 2 units BID

Day 14: BG = 230. Glargine increased to 3 units BID.

Day 21: BG = 116. Glargine increased to 4 units BID.

Day 28: BG curve

Fructosamine at border of fair and good ranges.

Interpretation: Diabetes is fairly well controlled but not

ideally controlled Control of diabetes can not be improved

with this insulin Changing dose does little to change shape of

curve

Options: Leave well enough alone Use a different insulin

Different insulin options: Switch from glargine to PZI (or vice-versa) Combine a shorter acting insulin with the

longer acting insulin Decrease glargine dose, add regular insulin This is similar to how diabetes is managed in

people

All of these curves look fine. The mean BG is best with 3 units

glargine + 2 units regular insulin. This curve is also “safer” since the nadir is not as low.

IS IT WORTH GIVING 2 INJECTIONS? Depends on the owner

Similar curves can be seen in dogs and a similar approach can be taken. However, in dogs it is a little easier in that it does not necessarily require two injections. There is a proprietary formulation that is 70% NPH and 30% regular insulin (Novolin 70/30). There used to be a Lente 70/30 that went off the market with Lente. I do not know if Vetsulin (a Lente insulin) and regular insulin can be mixed.

Presents for SEVERE PU/PD of several weeks duration. Good appetite. No vomiting.

PE: seemingly hydrated, no significant findings

CBC: stress leukogram UA: 4+ glucose, 3+ ketones Chem: alk phos=342; Na=132; K=5.2;

P=4.4; bicarb=11 To hospitalize or not to

hospitalize???

I do not hospitalize healthy ketotics but this is admittedly debatable. I would guess that it is 50:50 amongst internists to hospitalize or not.

Subcutaneus fluids: 0.9% NaCl with 20 mEq Kphos per liter; 50-60 ml/kg

Start long-acting insulin: 0.5 units/kg NPH or Vetsulin BID

Call the next day to hear the owners tell you how great Fritz is doing.

Recheck in 1 week as described for Poco.

This is a good product BUT it is poorly labeled. The manufacturer chose to have it labeled for

once daily usage with a starting dose of 1 unit/kg. This is not appropriate. Even in the study that was used for FDA approval, there were unexplained deaths.

Vetsulin is a BID insulin. When I have started it at 0.4 units/kg BID, I

have had no problems and have found it to work well.

Several years ago, I tried glargine in a dog It didn’t work

PZI label says that it is not for use in dogs but it doesn’t state that it doesn’t work.

Hospitalized for last 3 days for diabetic ketoacidosis.

Not previously known to be a diabetic No concurrent disease. Urine culture

negative Always do urine culture on new diabetics

Now eating and drinking

What is our immediate goal for this patient?What treatments are appropriate to

accomplish that goal?

What is our immediate goal for this patient now that she is eating and drinking? Get her home Medicate her in such a way that she will be

stable at home It is not a reasonable or appropriate goal to

send the patient home with the expectation that the diabetes will be controlled.

What treatments are appropriate to accomplish that goal? Sage is no longer a sick ketoacidotic patient.

At worst, she is a healthy ketotic like Fritz. She can be treated like a new diabetic that

has not been hospitalized for treatment of ketosis

Long-acting insulin: NPH or Vetsulin 0.4 to 0.5 units/kg BID

+/- subcutaneous fluids

What monitoring is appropriate to accomplish that goal?

It is ok to continue to check BGs but it must be remembered: The purpose should be to ensure that

hypoglycemia is occurring so check at the expected nadir

Hypoglycemia is unlikely at this dose particularly when there is up-regulation of epinephrine and cortisol

The diabetes will not be controlled at discharge That’s ok. Most importantly, 0.5 units/kg will prevent

ketosis is 99% of patients.

Continuous glucose monitors

Insulin pumps

Islet cell transplant

Any questions???