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Diabetes Mellitus (특징 (Signalment (Aged dogs : 7~9yrs, F>>M, Aged…
Diabetes Mellitus
특징
Multifactorial : genetic; infection, insulin antagonistic dz and drugs, obesity, immune-mediated, pancreatitis → loss of beta cells → hypoinsulinemia
hyperglycemia, glucosuria, PU/PD, weight loss, ketoacidosis, vomiting, depression, dandruff
Signalment
Aged dogs : 7~9yrs, F>>M
Aged cats : 9~11yrs, CM>F
고양이는 품종 소인 없음.
Risk factors : obesity, recurring pancreatitis, hyperadrenocorticism(특히 고양이에서 주의)
Associated disorders : CKD, hyperlipidemia, systemic hypertension, bacterial infection, cataracts&blindness(dogs), peripheral neuropathy causing weakness and plantigrade(cats)
Complications : iatrogenic hypoglycemia, persistent or recurring PU/PD, weight loss, cataracts(dogs), bacterial infection(특히 UTI), recurring ketosis or ketoacidosis, systemic hypertension(dogs,), diabetic nephropathy
피부 문제
bacterial pyoderma; seborrheic skin dz(protein catabolism, abnormal lipid metabolism); thick and hypotonic skin(protein catabolism)
감염에 취약
Management
목표 : 임상 증상 해결, insulin-induced hypoglycemia 방지, 정상 생활 재개
Insulin
Never increase insulin dose more often than every 7~10 days. It takes about 7 days to see the full effect of the insulin. ← 7~10일 동안 기다린 후 반응을 보고 인슐린 용량 조절
Types(more potent, short-acting → less potent, long-acting) : insulin lispro or aspart, regular crystalline, NPH, Lente, protamine zinc, insulin glargine, insulin detemir
Short-acting insulin
high potency, rapid onset, duration 4~6 hours
regular insulin(R), insulin aspart
DKA나 응급 상황에서 사용
Intermediate/Long-acting insulin
Intermediate
NPH, Vetsulin
개와 고양이에서는 intermediate-acting까지 기대할 수 있음.
BID로 투여
Duration : 4~14 hours
Long
Protamine zinc(PZI), Prozinc, Glargine, Detemir
Duration : 6~24 hours
SID or BID
Healthy diabetic
처음에는 입원하는 것이 좋음.
절대 100점짜리 혈당 조절을 하려하지 말 것
Starting long-term insulin
Dogs : NPH; maybe detemir or glargine
Cats : Glargine; Prozinc, PZI; maybe NPH
SQ cervical area, lateral thorax
First dose is a test dose.
Avoid hypoglycemia.
Oral hypoglycemic agents
Do not work in dogs, seldom work in cats - overall, not recommended
May be considered in diabetic cats
보호자가 인슐린 투여를 거부할 때
ketonuria와 peripheral neuropathy가 발견되지 않았을 때
고양이가 상대적으로 건강한 경우
Diet
Dogs : increased fiber diet(Hills w/d, Royal Canin Diabetic, Purina DCO)
Cats : high protein/low carb diet; OR weight loss using high fiber diet
비만이 있다면 체중 감량(운동 추천)
Feed twice daily before insulin treatment, monitor appetite. Give usual dose of insulin if pet eats, half dose if not eating.
Client education
매우 중요! 당뇨는 평생 관리해야 하는 질병임을 알아야
diet, signs of hypo-/hyperglycemia, emergency care, glucose measurement, insulin administration, monitoring tools, exercise
혈당 측정 : ear margin, pisiform pad(상대적으로 쉬우나 아파함.)
주사에 실패한 경우, 억지로 다시 하려하지 말고 한번 건너 뜀.
Hyperglycemia isn't an immediate emergency, but pet may become sick if ketones develop.
hypoglycemia는 응급 상황 → 1~3 Tbsp corn syrup(Karo syrup) or honey → c/s(eg. 발작, coma)가 해결되지 않으면 emergency care(eg. IV dextrose)
Monitoring tools
Overview tests
Is there a problem?
Clinical picture
History : 보호자가 제대로 하고 있는가, insulin dose
C/S : PU/PD, PP, weight loss, evidence of hypoglycemia
PE : weight loss, cataracts(dogs), diabetic neuropathy(cats)
Spot glucose concentration ← 일반적으로 권하지x
Fructosamine
marker of mean BG over 1~3 weeks
long-term glycemic control
Poor control : >500μmol/l
Excellent control : 350~400μmol/l
Prolonged hypoglycemia : <300μmol/l
Urine glucose and ketone
Negative urine glucose may indicate a problem(hypoglycemia).
Ketones are always a sign of a problem.
Trouble shooting tests
What is the problem?
Blood glucose curve
6, 12, 24 hours
intermittent blood sampling q 1~3h
CGMS(continuous glucose monitoring system) : 7일 정도 모니터링
장점
Gives a more detailed picture.
Identify problems : efficacy, onset of cation, duration of action, peak and nadir
단점
In-clinic
Stress is a confounding factor.
technically demanding
May not represent "real world".
At home : client training
variability day-to-day, day-to-night
Nadir : 80~130mg/dl
Preinsulin glucose level : 180~300mg/dl
Portable glucometer
아무 거나 쓰지 말 것
검증된 것 eg. AlphaTRAK, ACCU-CHEK, etc.
ACCU-CHEK : control 물질이 있어서 calibration 필요
진단
Healthy diabetic : history, PE, CBC, chemistry, UA, urine culture
Sick diabetic, DKA : 전해질, 산-염기 불균형 체크해야
Lab findings : hyperglycemia, hypercholesterolemia, glucosuria, ketouria, USG>1.025, UTI
Glycated proteins
Glycated Hb(HbA1c) ← 동물에서는 측정이 의미 없음.
FRA(Fructosamine) ← 치료 모니터링에도 사용(FRA가 떨어지면 치료 잘 한 것)
당화 단백질은 오랫동안 당이 높음을 보여줌. cf) 스트레스로 당이 올라간 경우에는 당화 단백질이 높지 않음.
Detection of ketones
Ketones : acetone, acetoacetate, β-OH-butyrate(임상적으로 더 중요)
합병증이 있는지 확인하기 위해 케톤 검사
요에 있는 케톤보다 serum에 있는 케톤 수치가 더 중요 → 혈장을 분리하여 dipstick에 떨어뜨림.
dipstick은 acetoacetate만 감지 ← β-OH-butyrate에 민감x
ketone meter 사용을 권장
유형
Type 1 : failure of pancreatic beta cells(99% of DM dogs; 50~70% of DM cats)
Type 2 : insulin resistance, and beta cell burnout over time(30% of DM cats)
transient or subclinical : ~20% of cats
Sick diabetic
emergency situation
hypoglycemia(인슐린 처치 잘못해서 발생), DM+ketosis, DKA(diabetic ketoacidosis), hyperosmolar non-ketotic DM
The healthy diabetic
persistent hyperglycemia & glucosuria
*Renal threshold for glucose : >290mg/dl in cats, >180mg/dl in dogs
*미니어쳐 슈나우저는 hyperlipidemia 잘 발생 → 췌장염, DM
*Hyperglycemia 원인 : DM, stress, postprandial, HAC, drug therapy, pancreatitis, dextrose-containing fluids, head trauma
*Glucosuria 원인 : DM, stress hyperglycemia, renal tubular dz, primary renal glucosuria, Fanconi syndrome
*Somogyi phenomenon : hypoglycemia or rapid decrease in BG regardless of nadir (any dose of insulin; >2U/kg especially) → stress로 작용하여 Epi, glucagon 분비 → hyperglycemia (insulin resistance)