SAM 1 - Endocrine: Diabetes Mellitus

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PLAY
What is the #1, 2 & 3 endocrine DZ in the dog (in order)?
Hypothyroid
DM
Cushings
What is the #1 & 2 endocrine DZ in the cat?
Hyperthyroid
DM
What is special in terms of glucose to these organs/systems:
CNS
Liver
RBCs
Lens of the eye
PCT cells
Beta cells of the pancreas
Don't need insulin for cells to uptake glucose
What can chronic pancreatitis, immune mediated processes or deposition of amyloid do to Beta cells of the pancreas?
Degenerate (Lose insulin)
Peripherally, cells can be insulin resistant secondary to __________.
Inflammation
Insulin deficiency results in:
FAT = ________ w/ increase _____ ______ and ______ ______ production
Lipolysis, fatty acid, ketone body
Insulin deficiency results in:
______ catabolism
Protein
Insulin deficiency results in:
____________ due to decreased glucose uptake and increased ______________.
Hyperglycemia, gluconeogenesis
Insulin deficiency results in:
DECREASED tissue utilization of _____, _____ ____ and _____ ______.
Glucose
Fatty acids
Amino acids
What are 3 common c/s of a patient with DM?
Hint: Think eye, breath and weight
Leucoconia (Glucoconia)
Acetonemia (fruity breath)
Overweight
What breed exhibits congenital/developemental DM related cataracts?
Border collies
Why do DM patients get cataracts?
Increased _______ causes an increase in the ________ pathway, which is highly osmolar and draws fluid into the lens.
Glucose; sorbitol
How else may a DM patient get cataracts (besides an increase in sorbitol?)
Inflammation (Uveitis, Glaucoma or a flare with normal iris)
Acetonemia: What is your main DDX?
Diabetic Ketosis (sometimes Acidosis too)
Will an animal appear healthy if it is a Diabetic Ketotic animal or if it is a Diabetic Ketoacidotic animal?
Diabetic Ketotic
These are many DDX for _______:
Spay
High caloric intake
Insulin resistance
HYPOTHYROID
Obesity
Of the DDX for obesity, which will you also see alopecia?
Hypothyroid
If you suspect a DM patient maybe Hypothyroid, should you test it to be sure?
NO (Euthyroid sickness will give you a false positive since it is currently sick)
What type of Diabetes?
*Most common form in DOGS
Beta cell destruction -> insulin deficiency
Usually cell-mediated autoimmune
TX: Insulin injection
"Type I" diabetes in humans
Insulin dependent diabetes mellitus
What type of Diabetes?
*Most common form in CATS
Impaired insulin secretion
Insulin resistance
Triggered by obesity, genetics, insulin amyloid deposition
"Type II" diabetes in humans
Non-insulin dependent diabetes mellitus
What type of Diabetes?
Meds interfere with insulin action
Antagonistic DZs: Pancreatitis, Cushings and Acromegaly cause insulin antagonism
Glucose intolerance results
Type III
What type of Diabetes?
Gestational DM
Type IV
DOG signalment of DM:
Age
7-9 years
DOG signalment of DM:
Sex
Females
CAT signalment of DM:
Age
>8 years
CAT signalment of DM:
Breed
Burmese (Australia)
CAT signalment of DM:
Sex
Neutered males
DOG signalment of DM:
2 risk factors
Obesity
Pancreatitis
C/S for DM:
4 most common presentations
PU (Glucosuria)
PD (PU)
PP (Satiety center needs insulin to take up glucose)
Weight loss (Lots of kilocalories lost with glucose)
In a DOG, what is the renal tubular capacity of glucose?
>200 mg/dL
In a CAT, what is the renal tubular capacity of glucose?
>300 mg/dL
Why can DOGS occasionally be blind?
Cataracts (Sorbitol increase)
Why can CATS present with Diabetic Neuropathy and have a plantigrade stance or "dropped hocks" like a rabbit?
Axonal degeneration (Motor mostly)
In general, how may a DM patient look?
Normal
Why may a DM animal have an enlarged abdomen?
Hepatomegaly (Subclinical hepatic lipidosis)
How may the haircoat of a DM patient look?
Sparse, dry, brittle, lusterless with some __________
hyperkeratosis
DDX for ____________ with ______ _______:
DM
Hyperthyroid (CATS)
Polyphagia; weight loss
What 6 parameters are a definitive DX for DM?
PU
PD
PP
Weight loss
Fasting hyperglycemia
Glucosuria
What would you add to a DM patient if it were a Diabetic ketoacidotic patient? ________ in urine.
Ketones
Stress hyperglycemia usually does NOT contain ______ in ________.
Glucose, urine
Renal glucosuria has a ________ BG level.
Normal
With c/s, a definitive DX can be achieved with an _______ _______ containing:
PCV
Total protein
BG
Azostix
Urine dipstick
Emergency panel
A _____ ________ contains (in a reading):
Glucose
Ketones
Protein
Blood and
Bilirubin?
Urine dipstick
A BG between ___________ & ++ glucose on a urine dipstick = DM
200-250
In dogs, is DM curable?
No (Require insulin injections BID forever!)
Which species is likely to go blind with cataracts?
Dogs
What can cure a dog with cataracts due to DM?
Phacoemulsification
How could you identify cystitis, pyelonephritis and pancreatitis in an animal with DM?
Abdominal ultrasound
What 2 CBC findings may you find in an animal with DM?
Stress leuk
Increased WBC (concurrent infection)
What 2 liver enzymes maybe increased secondary to hepatic lipidosis or pancreatitis?
ALT
ALP
What can result due to increased lipolysis and lipogenesis?
Hypercholesterolemia
Hyperlipidemia
_________ can occur with anorexia or DKA
Ketonuria
_____ are very common b/c glucose acts as a good growth media, decreased bacteriostatic media of dilute urine and maybe impaired immunity.
UTIs
In CATS, what should you screen older animals for, esp. if you have problems regulating the DM.
Hyperthyroid
What syndrome may the animal also be if it has DM that could cause a low total T4?
Euthyroid sick
What imaging tool do you use to find hepatomegaly due to lipid accumulation, pancreatitis, and emphysematous cystitis?
Abdominal radiographs
What imaging tool do you use as a good screening tool for pancreatitis?
Abdominal ultrasound
What is the goal in TX DM in DOGS? In other words, what main c/s are you trying to eliminate?
PU/PD (Due to hyperglycemia)
In CATS, the goal is to prevent further damage of the remaining _______ cells of the ____________ to avoid DM.
Beta; pancreas
TX with insulin using short, intermediate or long acting insulin?
Hospital setting (vet med)
Immediately prior to eating (humans)
Short
TX with insulin using short, intermediate or long acting insulin?
Dogs who have normal post prandial rise in BG after eating
Intermediate
TX with insulin using short, intermediate or long acting insulin?
Cats who have delayed rise in post prandial BG by 4-6 hours
Long
What species is 1 amino acid different from beef's insulin?
Cat
What species' insulin has an identical amino acid sequence to pork and one different from humans?
Dog
Are anti-insulin antibodies currently considered a problem in Vet med?
No
What insulin source is identical to the human a.a. sequence?
Recombinant
Animal originating insulin is ground up _______
Pancreas
This synthetic/analog of insulin is a new a.a. sequence that differs from human insulin - glycine and 2 arginines make it longer acting or peakless.
Glargine
What concentration should you give insulin?
?????
PZI (Long) and NPH (Intermediate) have __________ added to increase their duration of effect.
Protamine
Lente insulins have _____ to increase it's duration.
Zinc
Client education:
____ don't shake insulin.
Roll
Client education:
How do you store insulin?
Refrigerate
Client education:
If a pet does not eat well, what should you do with the upcoming insulin dose?
Skip it
Client education:
What do you do if you have to skip 2 insulin doses due to the animal still not looking well (c/s of hypoglycemia)?
Call the vet
C/S of __________:
Anorexia
Vomiting
Lethargy
*Ataxia
*Seizures
*Coma
Hypoglycemia (* = worse of the c/s)
Client education:
If their animal is undergoing a hypoglycemic crisis, instruct them to put _____ _______ on ___ and feed a ____ ______ (DO NOT GIVE INSULIN!)
Karo syrup, gums
Small meal
Initial TX of an uncomplicated diabetic:
Dog #1 =
Insulin (NPH or Vetsulin)
Initial TX of an uncomplicated diabetic:
Cat #1 =
Insulin (PZI or glargine)
For __________, glucose should be monitored at home at least 3-5x/day in the first 3 days to monitor hypoglycemia.
Glargine
When TX CATS with DM, what site of insulin injection should you AVOID?
Scruff of neck (Poor blood flow, fibrosis can occur with repeated injections)
Client education:
Where should you inject insulin?
Lateral thorax and abdomen (Daily)
Oral hypoglycemic agent:
Sulfonylureas =
Glipizide (Glucotrol)
What drug promotes secretion and secondarily improves tissue responsiveness to insulin?
Glipizide
Glipizide:
Used when owners decline to use _________
Insulin
Glipizide:
Successful in ______ term for 15%
Short
Glipizide:
Con to using this instead of insulin - unlikely to have transient DM, now progression to =
IDDM
Diet and Exercise:
Goal to get rid of _________ and minimize ______ _______ glucose spikes.
Obesity
Post prandial
Diets for CATS with DM:
First choice =
Protein (Canned carbohydrate restricted diets)
Diets for DOGS with DM:
First choice =
Complex carbs (Multiple meals to allow a gradual BG curve instead of glucose spikes)
Diets for DOGS with DM:
Ideally, how long BEFORE THEIR MEAL should you give insulin?
30 minutes
Monitoring DM:
Anytime you start or change insulin therapy, let the animal equilibrate for ________ at home before you assess their BG.
7 days (EXCEPTION: Monitor for hypoglycemia within the first 1-2 days)
Can you eventually stop insulin therapy for DOGS?
NO (Only cats can resolve, dogs can only decrease dose)
What is more dangerous, hyper or hypoglycemia?
Hypoglycemia
What is the goal of long term monitoring of therapy?
Resolution of c/s
If this c/s returns when the animal is on insulin therapy, call the vet immediately:
PU/PD
Monitoring long term TX of diabetes:
1) Owner feeds animal in the morning
2) Bring animal into hospital for insulin (given by vet)
3) Monitor BG _______ _______ until a duration of effects has been determined.
Every hour
Once glycemic control has been established the patient should be rechecked every ___________
4-6 months
The goal of insulin therapy is to maintain a BG between ___ - ____ mg/dl for 18-24 hours/day
80-200 (Normal range 80-120mg/dl)
Why wouldn't you keep the BG within normal range when trying to avoid PU/PD and other c/s when TX with insulin? What are you trying to avoid?
Hypoglycemia!
Glucose nadir:
If the BG is _____mg/dl, INCREASE insulin dose by 10-15% increments.
>120
Glucose nadir:
If the BG is _____mg/dl, DECREASE insulin dose by 10-15% increments.
<80
If giving insulin SID it's activity should be between ______ hours
20-24
If giving insulin BID it's activity should be between _____ hours
10-12
The effects of _______ should be considered in a CAT with an abnormal BG curve.
Stress (Better for owner to monitor BG at home)
Glycated protein levels reflect the mean BG concentration over the preceding weeks with _______ or months with ________
Fructosamine (weeks)
Hb (months)
Hb irreversibly bound to glucose =
Glycosylated Hb (reflected glucose levels from the past 8-12 WEEKS in the DOG and 5-6 weeks in the CAT)
Albumin irreversibly bound to glucose =
Fructosamine (reflected glucose levels from the past 5-8 DAYS)
Fructosamine or GHb?
Serum sample
Fructosamine
Fructosamine or GHb?
Whole blood in EDTA
GHb
What does it mean if there is a higher percentage of GHb or fructosamine in the blood? That there is ______ glycemic control.
Poor
Can stress affect a fructosamine or GHb test?
Yes! (Can't use these tests to DX DM)
Could you rely on a urine glucose test to adjust an insulin dose?
No (Well controlled diabetics can have normal glucose/no glucose in urine)
Can both insulin UNDERdose & OVERdose cause glucosuria?
YES (Too much can cause resistance)
Can you find a small or trace amount of ketones in a "healthy" diabetic's urine?
Yes
You should investigate a persistent glucosuria that lasts > __ ____ or one that is consistent with systemic signs.
3 days
If an insulin TX animal becomes hypoglycemic, TX with diluted ____________ bolus IV @ .5-1 ml/kg
50% dextrose (Then maintenance at 2.5% dextrose if needed)
If insulin's DOA is too short, change dose from SID to:
BID (Or switch to a longer acting insulin)
What EFFECT is seen with insulin induced hyperglycemia?
Somogyi (Insulin causes hypoglycemia, resulting in rebound HYPERGLYCEMIA)
Rebound hyperglycemia - Somogyi effect:
When BG<60 mg/dl the __________ senses it and affects the _______ nervous system to release _______ at the adrenal glands.
Hypothalamus
Sympathetic
Epi (Causes glucose to increase b/c catabolic)
Rebound hyperglycemia - Somogyi effect:
Low BG and Epi causes the release of ____ and ____, which also contribute to rebound hyperglycemia.
GH
GC
What EFFECT is demonstrated by a BG <60 followed by a BG >300mg/dl within a 24 hour period.
Somogyi (Morning BG levels usually high; 400-450)
Can you DX somogyi with a spot check of BG?
NO (Need to do a BG curve)
How do you TX a Somogyi patient?
______ insulin dose by _________, then reassess the BG profile.
Decrease 25-50%
What is the condition whereby a normal amount of insulin produces a subnormal biological response?
Insulin resistance (Suspect this if >1.5 U insulin/kg is needed to maintain glycemic control)
Insulin resistance:
What are the divisions of the types of causes of IR?
Pre-receptor
Receptor
Post-receptor
Insulin resistance:
Using inactive insulin, wrong dilution, wrong dose/dose interval, poor injection technique, scar tissue at injection site and anti-insulin antibodies are all examples of ___________ insulin resistance.
Pre-receptor
Insulin resistance:
Obesity or any concurrent DZ are examples of ________/____________ causes of IR.
Receptor
Post-receptor
CAT or DOG common concurrent DZ -> RI:
Cushings
Severe obesity
Ch. pancreatitis
Renal insufficiency
GC therapy*
Diestrus*
Oral/UTI*
Hyperlipidemia*
Dog
CAT or DOG common concurrent DZ -> IR:
Severe obesity
Ch. pancreatitis
Renal insufficiency
Oral infections
Cushings
Acromegaly*
Hyperthyroid*
Cat
What DZ?
GH-producing pituitary tumor
Pred: Old male cats
Acromegaly (GH - catabolic; HYPERGLYCEMIA)
ALL cats with Acromegaly are _______ and ________ _________.
Diabetic
Insulin resistant
What is the lifespan of an animal with DM?
2 years