Small Ani. Med- Endocrine 5

wilsbach's version from 2016-05-01 21:42

DM ctd

Question Answer
***Diagnosis of DM: what is the huge sign she emphasized? how will the numbers differ between cat an dog?*****PERSISTANT *FASTING* HYPERGLYCEMA (this means you need to do PERSISTANT measures), The renal threshold for glucose is 180-220 so you will see concurrent glucosuria. With dogs, if the BG is >200mg/dL. with CATS though, they are stressballs and their BG can spike in response to that by just existing (severe stress hyperglycemia) so if the BD >300 mg/dL OFTEN (so need mult measurements) and glucosuric, then is DM
most common endocrinopathy of cats?ITS HYPERT...NOT DM. LOLOLOLOLOL.
what additional test must you do which might not feel like it relates to DM?THYROID TESTING!!! because the CSs between hyperT and DM are similar (although the cats will physically appear different--still check) for CATS: for all cats >6 years old, do a total T4 (bc middle aged to older is hyperT age too, that's the most common endocrinopathy of cats, mean age 13 years). for DOGS: might have low T4 due to euthyroid sick because of the DM, must do free T4 and TSH
what will chem look like with DM?dehydration, azotemic (bc dehydrated), elevated TP (cells think theyre starving, break down protein), elevated cholesterol and triglycerides (cells think they're starving, mobilize fat)--> these elevated fats can indicate DM, OR hypoT (thyroid hormone induces lipid metabolism, dec lipid receptors means it build up in the blood), or cushings (bc mobilizing fat due to catabolism), and there is also LOW SODIUM because there is so much glucose= glucose related hyperosmolarity, so to try to keep the osmolarity down the body dumps sodium. Their K and P are normal BUT the total body stores are kinda low *important to know when tx ketoacidotic animals
So diabteic animals can be dehydrated from their PU/PD (glucose=osmolar diuretic) and ketoacidotic from the ketones building up in their body (since cells cant utilize glucose, fat is being utilized) you want to give them fluids, but must be careful. things to consider?So the glucose is high and hyperosmolar, so they are dumping Na to exchange. Need Na. Also, they are acidotic from the ketones, so H+ is getting pushed into cell and K+ is getting pushed out, and then the K+ can get peed out too (body stores are low). but the blood levels are fairly normal/slightly high, so then you decide to give fluids without K which dilutes out the K they have even more. SO IF YOU ARE GIVING FLUIDS, YOU NEED TO suppliment K and MONITOR FREQUENTLY bc if you dont the K will plummet as you give non-K fluids and they will start rupturing RBCs
why is there PUPD in cushings? DM? hyperT?In hyperT, it is because the inc in BP causes inc GFR--> PU. in DM its bc osmolarity of glucose in urine works like a diuretic. In cushing's, it is catabolic and causes inc glucose, which once again can cause osmotic diuresis AND ALSO CORTISOL INTERFERES WITH ADH bc too much cortisol suppresses the pituitary where the ADH is formed...dec ADH= pee more
what will U/A look like with DM?GLUCOSURIA (threshold is 180-220 and the BG is above that), ketonuria (lots of ketones being formed from fat bc glucose not being utilized) and on sediment you may see inc inflammatory cells/bact (if peeing so much, even a few can be significant)
why more UTIs/bact/inflammatory cells in diabetic urine?BC NEUTROPHILS DONT WORK WELL WITH TOO MUCH GLUCOSE AROUND. this inc risk of infection not only in urine, but low grade infections everywhere else too (minorly: the glucose is good medium for bact to grow with)
***why should you ALWAYS culture a diabetics urine?PU can dilute out a sig amount of bact/inflammatory cells and you might miss the infection- culture to not miss it. glycosuria facilitates bact growth, inc glucose means dec neutrophil function
what are the 3 ketoacids? which is most common? what is a problem with trying to detect these?there is acetoacetate, acetone, and beta-hydroxybutyrate, BHB IS THE MOST COMMON, AND ALSO THE ONLY ONE NOT DETECTED WITH THE URINE DIPSTICK
how do you detect BHB ketone?facilitated by hydrogen peroxide
what is serum fructosamine/what is it used for?NOT A DX TEST. good for monitoring and baseline-- basically if glucose levels high enough, they complex with proteins--> fructosamine. KEEP IN MIND: if ur a cat and have been in shealter for 2-3 weeks--chronically hyperG bc stress---so can just be long term stress. so not dx but good for monitoring, esp if under tx. when in doubt-- NEED TO DO GLUCOSE CURVE.
what is Glycosylated Hemoglobin?similar to fructosamine but over 2-3mo-- but this isnt very clinically relevant.
glucotest (litter box strips)- explain these, what are they good for?Most useful for monitoring and evaluation in complicated cases. It's basically just a bunch of the little square on the dipstick for detecting glucose. Sprinkle in litter. if turn blue, need to do glucose curve, then change meds based on glucose curve. *****dont make adjustments based on stuff of urine tho!!
need to assess for concurrent dzs bc affects outcome of tx- look out for..dehydration, renal failure, pancreatitis, hyperA, hyperT in cats (esp if >6yr)
which body weight do you use to calculate insulin dose?DOSE ON LEAN BODY MASS (you might underestimate just a tad but better than hypoglycemia which can kill them)
what are the ranges of BG you want dogs to be in? cats? explain why these levelsDOGS: want 80-200. CATS: want 80-300. However, remember we are treating for CSs not a number on a test!!!! So as long as some insulin on board, not gonna get ketoacidotic so not gonna die. DM pts die because of HYPOGLYCEMA. so if glucose goes high its not as important. worst owner is the diabetic person-- bc dont treat the same in dogs and cats as do in people. hyperglycemic not as much of a prb- need to avoid hypoglycemic!! we dont need it in a small range. also and dogs and cats dont respond to minute changes like ppl do. decide need to make a change, change insulin, do glucose curve after a wEEK will you see if it had some affect.
mainstay in management is insulin therapy. Goals of tx?Dec CSs, dec BG, rehydrate/dec osmolarity, monitor and correct electrolytes
dogs get which species of insulin? cats get which species of insulin??DOGS=porcine. CATS=cows ("cats cows puppies pig")
when is human insulin (called "REGULAR" insulin) used?ER KETOACIDOSIS ONLY! can give IV for ER.
very important to keep in mind with dosingTHERE ARE TWO DIFF KINDS OF SYRINGES (U-100 or U-40)
what is the insulin we really like for cats?GLARGINE- human type, extra long lasting
(i think we dont have to worry about this too much) vetsulin is what kinda insulin for who, things to keep in mindintermediate porcine, but can be used in cats or dogs. USES U-40 SYRINGES- so make sure owner doesnt get the wrong syringes. and dont use packaging dose.
what is nice about glargine?SUPER long lasting, good for use in cats, is "peakless" (can have peak but not very severe)
****ADJUSTMENTS OF INSULIN DOSE IS BASED OFF OF WHAT?? WHAT IS THE ONE EXCEPTION?****ALWAYS BASE INSULIN DOSE OFF THE NADIR (aka low point) OF BG CURVE!!!! The one exception is that with glargine you do it on pre-insulin BG levels AND nadir
if you have a newly dx DM cat-- what might you be able to do to put them into remission?start them on GLARGINE therapy right away- might get remission after a MINIMUM of 2wk therapy.
how might you know if they are going into remission with glargine therapy- what do you do?If pre insulin BG is <180 decrease to Q24h, if stays below 180, discontinue and monitor
important things to know about glargine storagecan be room temp for 6wk, or refrigerated for 3-6mo. need to be careful tho bc they are mult injection vials so BACTERIAL CONTAMINATION RISK. monitor for discoloration or cloudyness. *MAKE SURE THEY ARENT RESUING NEEDLES- CONTAMINATES VIALS AND BuRRING IS PAINFUL
how is it that remission can happen?hyperglycemia can inhibit Beta cells from releasing insulin. but if you fix this quick enough with the glargine, then the beta cells become uninhibited and then they can get better!
explain glucose toxicityPersistent hyperglycemia Inhibits release of insulin from B cells. If hyperglycemia resolves quickly enough B cells can regain function. SO, Must monitor cats on Glargine for remission
nutritional management of Dogs and cats with DM?FOR BOTH: MOST IMPORTANT IS JUST THAT THEY EAT!!! DOGS: high fiber might help-- don't do low fat if they have a low BCS. CATS: low carb/high protein, canned might be best (high water)
whats up with Oral Hypoglycemics for Cats?(she doesnt like them) 33% work...can reserve for owners who are scared of needles. but usually only a temp fix. Types are: Sulfonylureas (glipizide- can take months to work! and hepatopathy possible), Α -glucosidase inhibitors, acarbose, biguanides, metformin, Thiazolidinediones, Troglitizone, Transition metals (these all make cats puke- Vanadium and Chromium)
the kist of how much insulin you wanna give themJUST enough to not be ketotic- dont want them to die from hypoglycemia being overzealous
order of eating and insulin giving?always give after eating so you dont cause hypoglycemia if they decide not to eat
things to talk about with owner education(1) insulin: should be clear. (2) storage: depends on type, refrigerated, no direct light, 30d to 6mo. (3) handling: rolling not shaking (depends on type) (4) Syringes: APPROPRIATE SIZE! U40 vs U100 (5) have them practice, have owner show how they do everything
how long does it take to get it under control usually? how do you do follow up?takes weeks to control: Monitor BG Q2-4h for first 12 to 24 hours (in hospital), then BG curve in a week, curve 5-7d after any changes in insulin. If well regulated, every 6-8wk initially.
how much adjustment do you make with insulin? when do you check to see if change had effect?10-15% at a time, check 5-7d later to see if worked.
how is initial follow up particualr for cats?many go to remission on glargine within first mo, so Check pre-insulin and nadir BG *weekly for the first month. Decrease 50% or discontinue if hypoglycemic (<70) or pre-insulin BG is <180
how do you manage the ER ketoacidotic pt?give REGULAR (this is human for ER) insulin either CRI or IV q1h until BG <250. Monitor potassium frequently and supplement fluids!! (if K was normal when started fluid therapy- would add it bc fluids will dilute it and make K drop. Why might be Hyperkalemic ((or high end of normal)? bc acidotic-- H in and K out...but start fixing acid base status- goes back into cells, K plummets. So start supplementing once K gets in normal range. Make sure to give them fluids. Consider K+ stuff. RARELY need bicarb bc the fluids alone often tx it- and the bicarb can make osmotic stuff worse (consider if after fluids pH <7.1)