The latest management recommendations for cats and dogs with nonketotic diabetes mellitus - Veterinary Medicine
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The latest management recommendations for cats and dogs with nonketotic diabetes mellitus
A new type of insulin is well-suited for cats, and the advent of at-home glucose monitors for dogs and cats can help owners become more involved in the care of their diabetic pets.


In-clinic monitoring

Serial glucose assays provide the most detailed evaluation of a patient's response to insulin. Food and insulin should be given on the usual schedule, and blood should be drawn for glucose measurement every two hours. If the glucose drops precipitously, more frequent monitoring may be necessary to identify the nadir. For patients receiving once-daily insulin, the glucose curve should be continued for 24 hours; for patients receiving twice-daily therapy, it is acceptable to measure glucose concentrations over 10 to 12 hours. Checking the glucose concentration every four hours is generally sufficient in patients receiving glargine since glargine has a slow onset of action (Figure 3).

Ideally, blood glucose concentrations should stay within the normal range, but this rarely occurs. As veterinary patients do not suffer from the retinal, renal, and vascular complications seen in people, blood glucose concentrations do not need to be as rigidly controlled. However, even mild persistent hyperglycemia can cause cataracts (in dogs) and peripheral neuropathy (in cats). Hypoglycemia should be avoided, and prolonged or extreme hyperglycemia is undesirable. As a general rule, if the lowest blood glucose concentration recorded in the clinic is < 70 mg/dl, the insulin dose should be reduced by 25%. If the glucose concentration is more than 250 mg/dl on two or more readings, a 10% increase in insulin is appropriate. It is important to remember that acute and severe hypoglycemia can trigger rebound hyperglycemia (the Somogyi effect), so never use a single high glucose measurement as an indication to increase the insulin dose.

Figure 4: Are serum fructosamine assays sufficient to monitor glycemic control?
If the patient is doing clinically well, fructosamine assays can be performed in place of serial glucose measurements (Figure 4). Serum fructosamine reflects average serum glucose concentrations for the previous three weeks. If the fructosamine concentration is elevated, a glucose curve is necessary before dose adjustments are made. It is not safe to arbitrarily increase the insulin dose, as patients receiving too much insulin may have elevated fructosamine concentrations secondary to the Somogyi effect (in which acute hypoglycemia results in severe and often prolonged hyperglycemia).

Insulin resistance

Table 2: A Stepwise Approach to Evaluating Patients with Insulin Resistance
Patients requiring more than 2 U/kg/dose of insulin are regarded as being insulin-resistant. The most common causes of poor glycemic control are concurrent diseases or problems with the storage or administration of the insulin (Table 2).

Watching the client give a dose to the patient can be informative. Some people shake the bottle vigorously, causing damage to the molecules, or inadvertently draw air into the syringe. When handling issues have been addressed, it is necessary to look for other health problems that may affect the body's response to insulin. It is also worthwhile to make sure the patient isn't receiving any other medications (including topical corticosteroids) that may antagonize the effect of insulin.

Dietary considerations

The impact of dietary formulation on canine diabetes appears to be modest. A recent study evaluating the effect of dietary fiber on postprandial glycemia did not demonstrate a significant effect on blood glucose concentrations,10 although other studies have indicated improved fructosamine concentrations in diabetic dogs fed high-fiber diets.11,12 A palatable balanced diet is essential, but therapeutic diets may not provide substantial clinical advantages over commercial dog food. It is more important for feeding schedules and food type to remain consistent. I recommend offering food immediately before insulin administration to ensure the patient is interested in eating. In addition, for patients receiving Vetsulin, the first peak of activity provides an excellent buffer against postprandial hyperglycemia.


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