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Treating Pet Diabetes

Tactical presentation can greatly influence client compliance.

By Lou Anne Epperley, DVM For Veterinary Practice News

Posted: November 14, 2013, 2:30 p.m. EDT

When it comes to giving advice on pet health issues, remember that clients will pick up on your attitude, demeanor and concern, just as their pets reflect theirs. How many times have "helpful” clients locked their dogs or cats in a death grip, while tersely informing you that Fluffy doesn’t like her feet touched as you move in for a quick cephalic blood draw?

Client anxiety travels like electricity down a leash and charges the entire room. But you can turn this phenomenon to your advantage. It’s all in the presentation.

Presentation and Addressing Challenges
"Diabetes is a lifetime disease for dogs, and how well they do depends on how strictly clients follow the prescribed protocol,” said Patty Lathan, VMD, Dipl. ACVIM, assistant professor of small animal internal medicine at Mississippi State University’s College of Veterinary Medicine. "The animals can’t have a very good quality of life if [the client does] just a few things.”

When giving a client the news that "Moses is diabetic,” he or she may hear: "This is a disappointing diagnosis that will mean a lifetime of giving him painful daily injections, countless trips to our clinic for checkups and expensive prescription food”—whether you say it or not. Your choice of words and body language speak loud and clear.

Moses is depending on you, because the tone you set can give his owner the confidence needed to be your partner in managing his disease.

How about: "We treat a lot of diabetic patients at our veterinary hospital, and if you follow some basic diet and medication guidelines, Moses likely will have a good quality of life for quite a while. He’ll feel better, and you’ll be proud of yourself for learning home nursing skills. I know you can do this.”

"Diabetes is difficult for owners,” said Cynthia R. Ward, VMD, Dipl. ACVIM, professor of internal medicine at the University of Georgia College of Veterinary Medicine. "I tell them, for most animals, we will get their blood glucose regulated in four to six weeks. Some owners have visions of going to the veterinary hospital every week for the rest of the animal’s life.

"A bottle of insulin will last six months in the refrigerator,” added Dr. Ward. "I try to make treating them as easy as I possibly can.”

Another positive perspective to offer owners of diabetic cats is the possibility of remission after initial treatment.

While the cat still needs periodic monitoring, the days of insulin injections could well be numbered. Lathan said the earlier in the disease process a cat is diagnosed, the greater the likelihood of a permanent remission.

Diabetic Treatment Options
Ward and Lathan said the number of human diabetic patients increases the likelihood that some veterinary clients are familiar with home glucose monitoring and insulin injections. Home blood checks are convenient for the owner and present the most accurate picture of the animal’s condition because traveling and hospital stress are eliminated.

Experts recommend the ear pinna and the non-weight-bearing metacarpal pad on the front paw as client-friendly venipuncture sites for blood glucose monitoring. The ear should be rubbed and warmed for a few minutes before the blood draw.

Ward said a user-friendly lancet is made by Becton, Dickinson, and others cited the lancet provided with the AlphaTRAK glucose meter by Abbott. If the ear is not a practical site, Lathan said to try the non-weight-bearing metacarpal pad at a point between the haired and non-haired skin.

Encourage clients to make their pet his own notebook, with a log of glucose measurements, clinical signs and other diabetic-pertinent information.

When teaching clients to give insulin injections, project your 100 percent confidence in their ability and reassure them that as long as they get the insulin dose correct, it’s probably harder to do it wrong than to do it correctly.

The key is putting them at ease, and several veterinary clinics have made YouTube videos on how to perform this procedure. Using the phrase, "giving dog insulin shot” will pull up several thousand video shorts. While you can’t control what people watch, you can select a few credible ones to recommend.

Remission possible in diabetic cats

By Lou Anne Epperley, DVM
For Veterinary Practice News

Many diabetic cats can go into remission and remain there, veterinary experts say.
Increased understanding of diabetes mellitus in cats has uncovered the optimistic fact that if discovered early and treated properly, remission is possible.
"For a cat to go into remission, you have to get rid of glucose toxicity,” said Patty Lathan, VMD, assistant professor of small animal internal medicine at Mississippi State University’s College of Veterinary Medicine. Most cats present with Type 2 diabetes, in which pancreatic beta cells produce an inadequate amount of insulin to keep up with insulin resistance, she said.
The protein amylin, which has insulin-like properties, can deposit as amyloid on beta cells and damage them. Meanwhile, the cat becomes persistently hyperglycemic, which also causes an inhibitory effect on insulin secretion termed "glucose toxicity,” explained Lathan, a diplomate of the American College of Veterinary Internal Medicine.
Caught early enough, glucose toxicity can be managed with insulin. Some 90 percent of newly diagnosed cats can become normoglycemic and go into remission after four to six months of insulin therapy, according to internationally recognized expert Jacquie Rand, BVSc, of the School of Veterinary Science at the University of Queensland in Brisbane, Australia.
Dr. Rand has spoken extensively on diabetes to the American College of Veterinary Internal Medicine and the World Small Animal, Federation of European Companion Animal and British Small Animal Veterinary associations.
The long-acting insulins glargine and detemir provide better glycemic control and reduced risk of clinical hypoglycemia when given twice daily and combined with a low-carbohydrate diet, Rand told the ACVIM.
In the early stage of treatment, Lathan’s protocol is to perform a weekly glucose curve, and then a curve every two weeks until the patient is regulated. "If they’re going to achieve remission, they usually do so within three to four months,” she said.
Once remission is achieved, Rand recommends that owners continue the cat on a strict low-carbohydrate diet and do once-weekly home blood glucose testing, with veterinary rechecks every six months.  Lathan added that another home option for clients is urine glucose monitoring.
While 25 percent to 40 percent of cats in remission will relapse and require insulin again, better glycemic control with smaller insulin doses is achievable, and a second remission more likely, Rand said.
Many predisposing factors, including obesity, chronic pancreatitis and systemic diseases such as hyperthyroidism, can contribute to insulin resistance in cats.
Urinary tract infections can also complicate insulin regulation in diabetic patients, noted Cynthia Ward, VMD, internal medicine professor at the University of Georgia College of Veterinary Medicine.
"Urinary tract infections are the most common thing I see. These can be clinically silent, so I always do a urine culture now in evaluating diabetic patients,” she said. "If an animal is failing to regulate on insulin therapy, that’s the first thing I check.”

 

Insulins available for veterinary use
These are insulin products currently used in veterinary medicine, listed by name, manufacturer, type, duration of action, and common use.
Source is  Mark E. Peterson, DVM, Dipl. ACVIM, "New developments in the use of insulin mixtures and analogues for the problem diabetic.” Proceedings. ACVIM Forum, Seattle, June 4-7, 2013.
1. Vetsulin (USA), Caninsulin (other countries). Merck Animal Health. Porcine lente zinc suspension; intermediate duration of action; twice-daily dosing in dogs; use U-40 syringes for most accurate dosing.
2. Humulin R (Eli Lilly), Actrapid (Novo Nordisk). 100 percent regular crystalline recombinant human insulin; short duration of action; management of diabetic ketoacidosis and ketosis in dogs.
3. Humulin N (Eli Lilly), Novolin N (Novo Nordisk). Recombinant human isophane (NPH) insulin; intermediate duration of action; twice-daily dosing in dogs; not recommended for cats.
4. Humulin 70/30, Eli Lilly. Combination of 70 percent isophane (NPH) and 30 percent regular insulin; premixed combination of 30 percent short-acting and 70 percent intermediate-acting duration; twice-daily dosing in dogs. May work for dogs that don’t respond well to Humulin N insulin.
5. ProZinc, Boehringer Ingelheim; recombinant human protamine zinc insulin; FDA-approved for use in cats. Efficacy comparable to that of discontinued PZI-VET insulin; use U-40 syringes; not recommended as first-choice therapy for dogs because effective dosage is higher than other products.
6. Humalog; Eli Lilly. Lispro insulin, short-acting insulin analog; alternative to regular insulin for treatment of diabetic ketoacidosis in dogs.
7. Lantus; Sanofi-Aventis. Glargine insulin, long-acting synthetic insulin analog; efficacious for long-term treatment of diabetic cats; twice-daily dosing. Can be used in place of short-acting regular insulin in cats with diabetic ketoacidosis. Efficacy in dogs not as predictable, so not generally used in them.
8. Levemir; Novo Nordisk. Detemir insulin, long-acting synthetic insulin analog; similar action/duration profile in cats as glargine. In dogs, it is very potent and long-lasting, and works much better than glargine. Twice-daily dosing, and dog dose is typically one-quarter that of NPH or Vetsulin.
L.A.E.

 

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