Glucose Curves Wendy Blount DVM Wendy Blount

Glucose Curves Wendy Blount, DVM

Wendy Blount, DVM • DVM TAMU 1992 • Private Practice Houston 2 years – Westbury Animal Hospital • Small Animal Internal Medicine Residency – TAMU 1994 -1997 • Private Practice 1997 -present – Nacogdoches and Lufkin, TX – See appointments at 3 practices – CE for groups and in-house

Wendy Blount, DVM drblount@vonallmen. net www. wendyblount. com Handouts and Power. Points for these Presentations: www. talkoftheinternet. com/tomball

When Do You Do a Glucose Curve? When a Diabetic is not well regulated Signs of poor regulation? 1. Weight loss 2. Poor haircoat quality 3. Polyuria-Polydipsia • >water intake 100 ml/kg/day 4. Repeated infections, illness 5. Episodes of hypoglycemia • • • Lethargy Vomiting, poor appetite Neurologic signs, progressing to coma

Diabetic Rechecks Every 3 -4 months • weight • Urinalysis • exam Every 6 months • Weight, UA, exam • CBC, panel electrolytes • Urine culture • fructosamine • Blood pressure

Testing for Regulation Fructosamine • Average blood glucose levels over the past 10 -14 days • In house – HESKA Spotchem – Control is a healthy cat or dog • Or send out Glycosylated Hemoglobin (HA 1 c) • Average blood glucose levels over the past 2 -4 weeks • Not as reliable as fructosamine in dogs and cats • Send out

Testing for Regulation Fructosamine High • Significant period of hyperglycemia • Not enough insulin • Too much insulin – Hypoglycemia, rebound hyperglycemia Fructosamine normal range (200 -400) Fructosamine Low • Mild to moderate hypoglycemia • Not enough to cause Smoygi effect • Decrease insulin by 10 -15% Do glucose curve if fructosamine high

Glucose Curve Protocol • • • Owner feeds and gives insulin Bring pet to clinic within 2 hours Glucose (& fructosamine) on arrival Glucose every 2 hours when >100 Glucose every hour when <100 – Can miss nadir (low point) if you don’t do this • • Continue until you get 2 values 2 hours apart that are upwardly trending Usually can be completed in a business day, but not always – Some require 12 -24 hours – Have owners finish at home or take to E-clinic

Home Glucose Curves • • Really are better than “in clinic” Stress increases glucose – Especially in cats • • • Most owners can learn to do it It’s very helpful for owners to be able to check blood sugar in an emergency Entire curve does not have to be finished the same day

Home Glucose Curves 1. Warm the ear or area to be pricked • • • Lateral ear vein in cats Dog lip Foot pad, elbow callus 2. Apply vaseline if area is haired 3. Prick with human lancet • • Can use 27 gauge needle Use roll of gauze inside the ear for cats 4. Use low volume glucometer Resources Feline Handout Canine Handout

Spot Checking Diabetics Quiz – Spot glucose checks at insulin time What Would you do? 1. 2. 3. 4. 250, 260 350, 335 245, 265 200, 200

Spot Checking Diabetics • Which values in a glucose curve are used to determine dose? – Nadir (lowest glucose values - insulin peak) – Lowest glucose value should be around 100 • Which values on a glucose curve are used to determine interval and insulin type? – Peak glucose values (insulin nadir) – If glucose nadir is ideal, and glucose peaks are too high, then you need to give insulin more often, or you need a longer acting insulin • Ideally, a majority of the time, glucose should be between 100 and 200 – Never go lower than 80 -90

Spot Checking Diabetics Interpreting glucose curves 1. Duration of curve – – If your curve is 12 hours or less, you need to give insulin BID, not SID 2. Glucose range – If all values are 100 -200, leave it alone – Consider the same if 100 -250, if clinical signs are controlled

Spot Checking Diabetics Interpreting glucose curves 3. Glucose nadir – If < 90 -100, reduce the insulin dose – If >100 -150 and glucose peak too high, increase insulin dose – If >100 -150 and glucose peak <250, leave dose alone 4. Glucose peak – If nadir OK and peak too high, change to longer duration insulin – NPH – shortest – Then Vetsulin (Lente) – Then PZI – Lantus longest (not for most dogs)

Spot Checking Diabetics If you were only allowed two glucose checks in every 24 hour period, when would you want to take them? At Insulin Time? 5 -7 hours after insulin? One of each?

Spot Checking Diabetics Correct Your Quiz 1. 250, 260 • Need to decrease insulin 2. 350, 335 • • Increasing insulin would probably make this dog or cat hypoglycemic Need to change insulins instead 3. 245, 265 • Need to increase insulin 4. 200, 200 • Insulin should not be changed

Nutrition for Diabetic Cats For many years, we fed diabetic cats high fiber, low fat diets, just like dogs & people • 2000 - Randomized, controlled crossover study • Improved glycemic control when fed 12% insoluble fiber • Both diets high in carbs (~35%) J Am Vet Med Assoc. 2000 Apr 1; 216(7): 1082 -8. Effect of dietary insoluble fiber on control of glycemia in cats with naturally acquired diabetes mellitus. Nelson RW, Scott-Moncrieff JC, Feldman EC, De. Vries-Concannon SE, Kass PH, Davenport DJ, Kiernan CT, Neal LA.

Nutrition for Diabetic Cats 2001 – ACVIM Abstract • Low carb-low fiber diet (canned Hill’s Feline Growth) compared to high carb-high fiber diet (canned W/D) • 31% fed LC diet were able to d/c insulin, and an additional 46% decreased insulin dose • None of the HC cats were able to reduce or discontinue insulin Comparison of a low carbohydrate versus high fiber diet in cats with diabetes mellitus. Bennet N, Greco DS. ACVIM 2001. 13 cats. J Feline Med Surg. April 2006; 8(2): 73 -84. 63 cats.

Nutrition for Diabetic Cats Since 2001 • Goal of treatment is remission rather than merely good control • Achieved by using low carb-high protein diets with long acting insulin (glargine - Lantus) • 1998 ACVIM article - median survival 2 years • Some papers have reported remission rate as high as 68% • Chances of remission increases four-fold by feeding low carb-high protein diet

Nutrition for Diabetic Cats Use of a High-Protein Diet in the Management of Feline Diabetes Mellitus. Vet Ther 2[3]: 238 -246 Summer'01 Clinical Study 14 Refs. G Frank; W Anderson; H Pazak; E Hodgkins; J Ballam; D Laflamme. The Effect Of High Protein, High Fat Or High Carbohydrate Diets On Postprandial Glucose And Insulin Concentrations In Normal Cats. ACVIM 2002. H A Farrow, J S Rand, G D Sunvold. Use of glargine and lente insulins in cats with diabetes mellitus. J Vet Intern Med. 2006 Mar-Apr; 20(2): 234 -8. KE Weaver, EA Rozanski, OM Mahony, DL Chan, LM Freeman.

Nutrition for Diabetic Cats Ideal diet for diabetic cats • >40% protein and <8% carbs, as % of calories • A little different from DM basis (fat is 2 x as calorie dense as protein & carbohydrate) • Only one dry diet on the market that fits the bill – Innova EVO (California Naturals - Natura) – Purina DM and Hill’s R Diet M/D dry - 15% carbs, protein OK • Many commercial canned diets fit the bill – Handout

Nutrition for Diabetic Cats Myth #1: Diabetic cats should be meal fed if they are to be well regulated • Fresh food BID – allowed to eat ad lib • Multiple small meals eaten throughout the day and night • 24 hour glucose curve done (q 2 h) • no correlation between blood glucose and the amount of food consumed over the previous 2 -h • overnight fast did not significantly alter morning blood glucose J Feline Med Surg. 1999 Dec; 1(4): 241 -51. Food intake and blood glucose in normal and diabetic cats fed ad libitum. Martin GJ, Rand JS.

Nutrition for Diabetic Cats Myth #2: You shouldn’t give insulin to pets who aren’t eating • If glucose >300 for any period of time, insulin needs to be given to prevent diabetic ketoacidosis • Dogs and cats with DKA will remain acidotic until they get insulin • If you are chicken, give small amounts only as needed • A small amount of insulin can do a great deal of good in a DKA patient

Nutrition for Diabetic Cats Flop • Day 0 – not feeling well, abscess on toe, Tx clindamycin PO BID • Day 3 – – still not feeling well, not eating UA shows ketones and glucose, blood glucose 298 Treated with IV fluids and IV antibiotics No insulin given because not eating • Day 6 – Very weak, vomiting blood – BUN 41, glucose 290, venous p. H 7. 035, K+ <2. 0, Phos 1. 6 – Diabetic ketoacidosis with pancreatitis

It takes less time to do things right than to explain why you did it wrong. --Henry Wadsworth Longfellow