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Diabetes Mellitus: Monitoring - Coggle Diagram
Diabetes Mellitus: Monitoring
Newly diagnosed DM pets do not need to be hospitalized if
stable
eating well
hydrated
Even if ketones are present!
Blood Glucose Curves
Perform an in‐hospital BG curve 7‐14 days after starting insulin
Recheck BG curve
1) 7‐14 days after any dose change
2) Clinical signs of unregulated DM
3) Clinical signs of hypoglycemia
4) Every 4‐6 months, even if doing well
Can sometimes use fructosamine in place of curves
Steps
Get a history
appetite
PU/PD
activity
Weigh the patient
Start curve within 1‐2 hrs of insulin
BG q2 hrs for dogs; q4 hrs for cats on glargine
Nadir (lowest value/peak insulin effect)
Ideally 80‐150 mg/dL and duration (12 hours)
If doing well, no change needed
If not, check fructosamine and evaluate for concurrent disease
If <80 mg/dL, drop dose by 25%
If >150 mg/dL and efficacy is poor, increase by 25%
Change by ½ or whole units, not less
Duration of effect
Amount of time with BG < 250 mg/dL
Ideally 10‐14 hrs
If <10 hrs + high nadir, increase dose
If <10 hrs + ideal nadir, longer acting insulin or TID
If >14 hrs, consider SID dosing
High nadir (232 mg/dL) and short duration (1‐2 hours)
Ensure proper insulin handling and administration
If no problems with handling, increase insulin dose by 25%
Ideal nadir (87 mg/dL) but short duration (4 hrs)
Cannot simply increase dose due to risk of hypoglycemia
Change insulin type (long‐acting) or consider TID
Dangerously low nadir (47 mg/dL) and extreme highs
Somogyi Phenomenon?
Hyperglycemia in response to insulin‐overdose
Hypoglycemia induces counter regulatory hormones
elevated BG and clinical signs
Suspected when
BG <60 mg/dL
and >300 mg/dL within 24 hrs
more often due to too short a duration
try reducing insulin dose by 25% before switching types
In hospital or at home?
Large variability day to day, regardless of place
Prioritize control of clinical signs over “perfect” curve
Home BG monitoring
can be performed with a glucometer
AlphaTrek
Ear
lip
foot webbing
FreeStyle Libre
affordable continuous glucose monitor
q15 minute measurements
similar accuracy to glucometers
Scanned with a reader or smart phone q8 hours
Can stay in place for up to 14 days
Serial fructosamine concentrations
can also be used for monitoring
Individual patient trends are more important than reported lab guidelines
Clinically significant change = 50 umol/L or more
High level can occur with under or overdosing
Interpretation
:dog: Dogs (μmol/l)
Prolonged hypoglycemia < 350
Excellent control 400 – 460
Good control 460 – 540
Fair control 540 – 620
Poor control > 620
:cat: Cats (μmol/l)
Prolonged hypoglycemia < 350
Excellent control 350 – 400
Good control 400 – 450
Fair control 450 – 500
Poor control > 500
Remission in cats
Diabetic cats have ~25% chance of remission
30% relapse by 9 months
Positive predictors of remission in diabetic cats:
Short duration of DM
Recent corticosteroid therapy
Negative predictors of remission in diabetic cats:
Hypercholesterolemia
Diabetic neuropathy
Diabetic ketoacidosis is NOT predictive
Insulin Resistance average insulin dose
:dog: ~0.8 – 1 U/kg BID
:cat: ~0.5 U/kg BID
Doses > 1.5 – 2 U/kg BID = possible insulin resistance
Counter‐regulatory hormones can cause insulin resistance
Hypersomatotrophism
Progesterone
Hyperadrenocorticism
Exogenous Steroids
Other causes
Infections and inflammatory conditions
UTIs
dermatitis
Chronic inflammatory diseases
Pancreatitis
Thyroid disease
Major organ failure
Anti‐insulin antibodies