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to the hospital and stabilized before long term insulin therapy is instituted. The most common concurrent diseases seen with diabetes mellitus include: urinary tract infections, concurrent endocrinopathies such as Cushing’s disease, hypothyroidism, and hyperthyroidism, pancreatitis, infections, and pregnancy.Initial evaluation of the diabetic animal should include a complete physical examination, CBC, chemistry profile, urinalysis, and T4 (cats). A urine culture should be considered even if urinalysis and sediment parameters are normal since up to 35% of urinary tract infections can be clinically silent
in animals with dilute urine. Abdominal imaging may
be pursued if clinically indicated. Concurrent medical conditions should be addressed aggressively so that the diabetes mellitus can be more easily controlled.
Diabetes mellitus can be frustrating, expensive, and time-consuming for owners to treat. Our goals of therapy should be correction of clinical signs, control of concurrent diseases, and avoidance of emergency situations such as hypoglycemia, ketosis, and hyperosmolality. It is beneficial to have an in depth discussion with the owner as to the time and effort s/he can realistically commit for diabetic control for the pet. It is important to establish a good rapport with diabetic owners since they will be asked to provide invasive (injections) and time-consuming (glucose monitoring) care for their pets. Stable cats with blood glucoses
less than 400 mg/dl may be treated initially with a diet change. Cats are very carbohydrate intolerant, and a low carbohydrate diet can result in euglycemia in some cats. Prescription diets are recommended; however, if the owners can’t or won’t commit to these diets, commercial diets can be used. Canned diets tend to be lower in carbohydrates and some websites include carbohydrate data on specific diets. Because of the deleterious effects of a hyperglycemic environment on the cat pancreas, diet change alone should not be tried for more than 2 weeks. If the cat has not become euglycemic over that time period, then insulin therapy should be instituted. Insulins recommended for cats include: ProZinc tm, glargine (Lantus tm), and Vetsulin tm. ProZinc insulin has an advantage in that it is labeled for veterinary use. Determir tm may also be used, although there is less experience with this insulin in cats. NPH insulin may be used but it does not have the duration of action in cats to allow bid treatment. Optimally NPH needs to be given tid-qid in cats. The starting dose of insulin (regardless of type) in cats is: 0.25 U/kg bid. The optimal diet for diabetic dogs is one high in insoluble fiber. This diet slows glucose absorption from the gut and postprandial hyperglycemia. Unlike cats, dogs will not usually revert to euglycemia
as a result of a food change. Newly diagnosed diabetic dogs should be started on insulin therapy. Appropriate insulins for use in the dog are: Vetsulin tm, NPH, Detemir tm, ProZinc tm, and glargine (Lantus tm). Dogs are initially
dosed at 0.5 U/kg bid except for Determir that should be started at 0.25 U/kg.
Dogs and cats should be fed twice a day when insulin is given. Many owners give insulin while the animal
is eating. This makes the insulin injection a pleasant experience for the pets and easier for owners to treat the animal. Some cats prefer to nibble food throughout the day. These grazers can often be well managed by allowing them free choice eating with insulin injections twice per day. Care should be taken to ensure that the cats are not receiving more than their caloric needs since extra weight should be avoided.
Exercise is beneficial to diabetics and serves to lower insulin requirements and provide better glycemic control. Daily walking for dogs and cat play can be effective ancillary treatments for diabetes mellitus. Average time for initial diabetic control is 4-6 weeks.
After insulin is started, the veterinarian should wait 7-14 days to monitor any effects since it takes this long for
the animal to adjust to insulin therapy. During that time period owners may measure urine glucose and ketones. They should call if there are more than 2 negative urine glucose readings or if the ketones are positive. If urine glucose is negative, one doesn’t know if the blood glucose is 40 or 200 mg/dl. Alternatively, the owner can use a portable glucometer and measure blood glucose directly. Insulin doses should not be changes as a result of readings, but owners should call if the animal is ketotic or hypoglycemic.
At the initial recheck, the veterinarian should question the owner about resolution of clinical signs. A physical exam and weight measurement should be completed.
In this way the veterinarian can evaluate the clinical response to insulin.Serum fructosamine levels have been advocated for use in monitoring insulin response. For fructosamine to be interpretable, the pet should have been on a stable insulin dose for at least 3 weeks before the fructosamine is taken. Fructosamine levels can be useful; however, it is inappropriate to use in unstable animals or those in which a hypoglycemic-hyperglycemic (Somogyi) response is suspected. For these patients, a glucose curve must be completed.
A glucose curve is the only way to truly evaluate the body’s response to insulin. Important information obtained from glucose curves includes the onset of action of the insulin, the duration of action of the insulin, the time of peak activity of the insulin, and how low the glucose goes (nadir). The first three parameters indicate whether the right type of insulin is being used; the last parameter gives information about the dose of insulin used.
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