Monday, November 1, 2010

Diabetes Emergency Preparedness as Important as Insulin

Diabetes Emergency Preparedness as Important as Insulin
via Veterinary Practice News

Owners often are shell-shocked when they hear their pet has diabetes. But a veterinarian’s optimistic attitude can help a client successfully manage the disease.

“It’s usually a traumatic piece of information for an owner when a veterinarian tells them their pet has diabetes,” says Randy Lynn, DVM, a technical service veterinarian with Intervet Schering-Plough Animal Health of Summit, N.J.

“If the owner is handling the news well, you can discuss the emergency situations that may occur in a diabetic animal. If you’re speaking to them and their eyes gloss over, you might want to send them home with written information, and then have the owner return in a day or two once they’ve processed everything.

“It’s a delicate balance that the veterinarian has to weigh. If you tell them too much on day one, you could tip them over the edge.”

Dr. Lynn says a diabetes diagnosis gives veterinarians a “chance to shine,” noting that owners will rely heavily on them for information on choosing insulin, injecting insulin and monitoring the animal.

Besides hearing the diabetes news, distressed clients also have to be warned about hypoglycemia, the No. 1 emergency concern of veterinarians who deal with diabetic patients. The likelihood of hypoglycemia occurring in an animal is greater in the early weeks after diagnosis.

“When veterinarians have the emergency talk with owners, they must tell them specific signs of hypoglycemia and not speak in generalities such as ‘If the animal is acting strange, do this.’ Give examples,” says Audrey K. Cook, BVMS, MRCVS, Dipl. ACVIM, Dipl. ECVIM (companion animals). “Tell them an animal may stare into space, have tremors, walk like it’s drunk, run into walls or lean into furniture or even become unconscious.”

What to Do

Though all the contents may never be utilized, Ruth MacPete, DVM, of Del Mar Heights Veterinary Hospital in Del Mar Heights, Calif., says owners should have a diabetes kit. The kit should contain glucose testing supplies, syringes, ketone test strips, Karo syrup and what Dr. Cook calls “a junky kind of food.”

“Tell owners to keep a junky, fun-to-eat food on the shelf just in case,” says Cook, a clinical associate professor at Texas A&M University. “Some corn syrups are better than others for this, so tell owners a specific type and brand. If the animal is able to eat, giving food would be the first step, but if not, reach for the Karo and get the animal to the veterinary office.”

Another option for initial hypoglycemia treatment and an item for the emergency kit is Glucose RapidSpray.

“Glucose RapidSpray is basically sugar water,” says Arnold Plotnick, DVM, Dipl. ACVIM, Dipl. ABVP (feline), the owner of Manhattan Cat Specialists in New York City. “Four or five pumps of the spray on the gums should do the trick, and then the owner needs to get the animal to the veterinarian.”

Clients should monitor a diabetic pet’s appetite, water intake and urine output, Dr. MacPete says.
“Owners should record this information in a log and bring it with them to veterinary visits. They should alert their veterinarian immediately if they notice any changes,” MacPete says.

Why Hypoglycemia Occurs

Hypoglycemia has several causes, but one of the most avoidable is giving the wrong insulin dose.

“Insulin comes in different strengths,” Dr. Plotnick says. “U40 and U100 must be used with their corresponding syringes. When a client runs out of syringes, they might go to a local pharmacy or get leftover syringes from a friend whose pet had diabetes. Make sure clients are aware that syringe substitutes will not work and they should always buy their diabetes supplies through the prescribing veterinarian.”

During the hypoglycemia discussion, veterinarians should tell clients that only one person in the household should give insulin injections, authorities agree. This avoids potentially deadly confusion over missed or additional injections.

“Give insulin at the same time every day,” Plotnick says. “Since insulin is usually given every 12 hours, tell the owner to choose two 12-hour time frames in which they know they’ll be home. One of my clients gives his cat an injection at 3 a.m. and one at 3 p.m.”

Veterinarians might be tempted to start a cat on two units twice a day, according to Plotnick. This can lead to hypoglycemia.

“We gradually make our way to finding a patient’s correct insulin level,” Plotnick says. “Start with one unit twice a day, increasing it by an additional unit twice a day, if needed, after two to three weeks at the initial rate.”

Watch the Food

Diet is an important component in regulating an animal’s diabetes and preventing hypoglycemia, experts say.

“Although veterinarians are aware of the importance of diet, they have to convey that to the client,” Cook says. “I think about it in my mind like a teeter-totter—balance food and exercise with insulin.”

Maintaining proper weight plays a large role in diabetes regulation, Intervet’s Lynn says. This means the obligate carnivore cat needs a high-protein, low-carbohydrate food. Dogs also can benefit from a special diet.

“Altering a cat’s diet can have a huge impact on its diabetes status,” Lynn says. “Thirty to 80 percent of diabetic cats can become non-diabetic through diet and insulin therapy. Dogs are more omnivores, and we attribute their diabetes status more to bad genetics rather than obesity level, which is often the case with cats.” And watch the treats.

“With diabetic dogs, the big diet upset is giving snacks,” Cook says. “Changing the habit of giving diabetic dogs extra treats is an immediate need.”

Diabetic Ketoacidosis

Another emergency situation for diabetic cats is diabetic ketoacidosis (DKA). Experts say this occurs less frequently in diabetic animals than hypoglycemia but needs to be part of the early discussion with owners.

“An animal being treated for diabetes will suffer from DKA most frequently because there is a concurrent disease that counteracts the insulin being given,” Plotnick says. “The animal will vomit, stop eating and show distinct signs of not feeling well. Increased thirst, increased urination, weight loss despite a good appetite and sudden blindness can also occur.

“In this scenario, owners need to know they should immediately take the animal to their veterinarian.”

Two factors cause DKA. If an animal is given the required amount of insulin, the inability of the B-cells to secrete sufficient insulin gives rise to an absolute deficiency. An increased insulin requirement may lead to an inability to produce sufficient extra insulin, which is called a relative deficiency. This is an important distinction.

“If an animal appears particularly difficult to regulate despite being on an appropriate treatment regimen and the client is being compliant, the veterinarian should evaluate for the presence of medical conditions that may be making the regulation of diabetes more challenging, like an occult infection or other medical conditions,” MacPete says.

Cook says concurrent Cushing’s disease or immune mediated anemia can make regulating insulin very complicated.

Non-Stop Monitoring

Cook says diabetic emergencies can be avoided when owners are educated, motivated to monitor their pet at home and know when to take action.

“There are devices to help with this process,” she says.

Charles Wiedmeyer, DVM, Ph.D., Dipl. ACVP, adapted the human MiniMed continuous glucose monitoring device to minimize the stress of drawing blood and avoid emergencies. Dr. Wiedmeyer, an assistant professor of clinical pathology at the University of Missouri, says the device can be used with dogs, cats, horses and cows.

“Cats especially can get stressed during blood draws,” Wiedmeyer says. “This monitoring device is only a couple of centimeters in diameter and is inserted under the skin with a 22-gauge needle. The probe stays in the animal for three days, sending real-time data to a laptop that will graph the animal’s glucose rate.

“This would be used most in newly diagnosed diabetic patients.”
Wiedmeyer says the reusable monitoring device, from Medtronic Inc., costs about $1,200. One-time-use probes cost $35.

The company is considering directly marketing to the veterinary industry.

“An important part of educating pet owners about diabetes is preparing them for possible diabetic emergencies,” MacPete says. “Complications can occur and they need to know how to recognize the signs and symptoms and how to treat them.

“The more educated a client is about potential diabetic emergencies, the better.”
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