Veterinary Medicine - September 2007 - (Page 612)

Diabetes management O P E E R - R E V I E W E D If the patient is doing clinically well, fructosamine assays can be performed in place of serial glucose measurements (Figure 4). Serum fructosamine reflects average serum glucose concentrations for the previous three weeks. If the fructosamine concentration is elevated, a glucose curve is necessary before dose adjustments are made. It is not safe to arbitrarily increase the insulin dose, as patients receiving too much insulin may have elevated fructosamine concentrations secondary to the Somogyi effect (in which acute hypoglycemia results in severe and often prolonged hyperglycemia). for feeding schedules and food type to remain consistent. I recommend offering food immediately before insulin administration to ensure the patient is interested in eating. In addition, for patients receiving Vetsulin, the first peak of activity provides an excellent buffer against postprandial hyperglycemia. Diabetic cats are quite different because dietary formulation may facilitate reversal of the diabetes.13,14 Lowcarbohydrate and high-protein diets are recommended (e.g. Purina Veterinary Diets DM—Nestlé Purina, Pre- scription Diet m/d—Hill’s), although other medical problems such as kidney disease may limit dietary manipulations. As cats can be finicky, finding a well-tolerated and palatable balanced diet is the most important consideration. Canned food tends to be lower in carbohydrates than dry food, but dry kitten chow is an acceptable option if a cat declines one of the therapeutic diabetic diets. It isn’t necessary to mealfeed cats receiving PZI or glargine, as both are well-suited to their natural tendency to eat small amounts freTABLE 2 Insulin resistance Patients requiring more than 2 U/kg/dose of insulin are regarded as being insulin-resistant. The most common causes of poor glycemic control are concurrent diseases or problems with the storage or administration of the insulin (Table 2). Watching the client give a dose to the patient can be informative. Some people shake the bottle vigorously, causing damage to the molecules, or inadvertently draw air into the syringe. When handling issues have been addressed, it is necessary to look for other health problems that may affect the body’s response to insulin. It is also worthwhile to make sure the patient isn’t receiving any other medications (including topical corticosteroids) that may antagonize the effect of insulin. A Stepwise Approach to Evaluating Patients with Insulin Resistance Evaluate the storage and administration of the insulin. • Verify that the insulin is kept refrigerated and out of direct light. • Make sure the bottle is gently rolled, not shaken, before use. • Discard the insulin if it is discolored or flocculent. • Discard any vial opened more than 30 days earlier. • If in doubt—throw it out! Start a new vial if storage or handling is questionable. • Verify that the correct syringes are being used if a U-40 insulin product is being given. • Watch the owner draw up and administer a dose. Ask the owner about other medications, including topical products. • Corticosteroids may affect the response to insulin. Perform a thorough physical examination to look for concurrent disease. Perform a complete blood count, serum chemistry profile, and urinalysis. • A urine culture is necessary to rule out infection. Perform additional tests to rule out concurrent disease: Dogs Cats Hyperthyroidism—Evaluate a T4 concentration; if the results are borderline, evaluate a free T4 concentration by equilibrium dialysis. Acromegaly—Measure IGF-1 concentrations; consider pituitary imaging (computed tomography, magnetic resonance imaging). Hyperadrenocorticism—Perform an ACTH stimulation test and ultrasonographic examination of the adrenal glands. Dietary considerations The impact of dietary formulation on canine diabetes appears to be modest. A recent study evaluating the effect of dietary fiber on postprandial glycemia did not demonstrate a significant effect on blood glucose concentrations, 10 although other studies have indicated improved fructosamine concentrations in diabetic dogs fed high-fiber diets.11,12 A palatable balanced diet is essential, but therapeutic diets may not provide substantial clinical advantages over commercial dog food. It is more important Hypothyroidism—Evaluate T4, free T4 (by equilibrium dialysis), and thyroid-stimulating hormone concentrations. Hyperadrenocorticism—Consider an ACTH stimulation test or a low-dose dexamethasone suppression test. Chronic pancreatitis—Measure the canine pancreatic lipase immunoreactivity concentration or image the pancreas. 612 September 2007 VETERINARY MEDICINE

Table of Contents Feed for the Digital Edition of Veterinary Medicine - September 2007

Contents Letters Leading Off The Veterinary Medicine Interview: Dr. William J. Kay Idea Exchange Practical Matters Salivary Mucoceles in Cates: A Retropspective Study of Seven Cases Hyperlipidemia in Dogs and Cats Purina Insert The Latest Management Recommendations for Cats and Dogs with Nonketotic Diabetes Mellitus CE Form Product Preview Advertiser Index Marketplace/Classifieds Mind Over Miller

Veterinary Medicine - September 2007

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