There is No Sugarcoating It Managing the Canine Diabetic

Introduction

The host introduces the webinar and provides information about earning continuing education credits.

• The webinar is titled "Managing the Canine Diabetic" and is sponsored by BI and Covetrus.

• The host, Amy Bucher, welcomes participants to the live webinar on September 9th, 2020.

• Live participants can earn two continuing education credits for attending the one-hour webinar.

• Participants watching a recording of the webinar are not eligible for CE credit.

Participation Guidelines

The host explains how live participants can ask questions during the presentation and access a copy of the presentation slides.

• Live participants can ask questions at any point during the presentation by typing them into the questions pane of their GoToWebinar control panel.

• Questions will be answered during a Q&A session at the end of the lecture.

• A copy of the presentation is available in the handouts pane of participants' control panels. They can download it as a PDF.

Presenter Introduction

The presenter, Dr. Audra Fenimore, is introduced with her qualifications and experience.

• Dr. Audra Fenimore is an internal medicine specialist at VRCC Veterinary Specialty & Emergency Hospital in Englewood, Colorado.

• She graduated from Colorado State University (CSU) and completed her small animal internal medicine residency at CSU as well.

• Dr. Fenimore completed a Nestle Purina Internal Medicine Shelter Post-doctoral Fellowship at CSU after completing her small animal internal medicine and surgery rotating internship at Red Bank Veterinary Hospital in New Jersey.

• She is board certified by the American College of Veterinary Internal Medicine.

Presentation Overview

The presenter outlines what she will cover in this lecture on managing canine diabetes.

• The lecture will cover the diabetic etiology and clinical signs diagnosis.

• The majority of time will be spent discussing setting realistic treatment goals for diabetic patients and avoiding common treatment errors.

• The presenter will also discuss insulin options, including new products on the market.

• Participants are encouraged to refer to the 2018 AHA guidelines for managing diabetic dogs and cats as a resource.

Presentation Start

The presenter begins her lecture on managing canine diabetes.

• The presenter confirms that she is in presentation mode.

• She thanks BI and Covetrus for providing the virtual platform for this webinar.

• She introduces herself again and expresses excitement about sharing information with participants.

• The lecture will last 45 minutes, followed by a Q&A session.

Agenda Items

The presenter outlines the agenda items for this lecture.

• Etiology of canine diabetes mellitus

• Clinical signs diagnosis

• Setting realistic treatment goals

• Avoiding common treatment errors

• Insulin options

Canine Diabetes Mellitus Etiologies

The presenter discusses possible factors contributing to the development of diabetes in dogs.

• Canine diabetes mellitus is likely multifactorial in origin.

• Genetic predisposition may play a role in some cases, as certain breeds are more commonly affected than others.

• Examples include poodles, schnauzer terrier mixes, German shepherds, and boxers.

Diabetes in Dogs

In this section, the speaker discusses the etiology of diabetes in dogs and how concurrent disease processes can predispose dogs to developing diabetes.

Factors Contributing to Diabetes

• Certain breeds are more prone to developing diabetes than others.

• Concurrent disease processes such as pancreatitis, neoplasias of the pancreas, or Cushing's disease can predispose dogs to developing diabetes.

• Environmental factors may also contribute to the development of diabetes in dogs.

Diagnosing and Managing Diabetes in Dogs

In this section, the speaker discusses diagnosing and managing diabetes in dogs, including setting reasonable treatment goals and avoiding hypoglycemic events.

Diagnosing Diabetes

• Clinical symptoms that match with a diabetic patient include hyperglycemia and glucose uria.

• A good baseline physical exam, blood work, and history are important for understanding comorbidities that may complicate management.

Setting Reasonable Treatment Goals

• Resolution of clinical symptoms is a reasonable goal for treating diabetic patients.

• Avoiding hypoglycemic events is also important.

• Blood glucose numbers should not be prioritized over clinical symptoms.

Challenges in Managing Diabetic Patients

• Comorbidities such as chronic urinary tract infections or dental disease can make managing diabetic patients more challenging.

• It is important for veterinary professionals to set reasonable expectations with owners regarding what they can expect when treating their diabetic dog.

Diabetic Patient Management

In this section, the speaker discusses an app that can help owners manage their pet's diabetes. They also introduce a clinical scoring system to monitor diabetic patients objectively. The speaker then talks about avoiding common treatment errors in dietary management, insulin selection, and administration.

App for Diabetic Patients

• An app offered by the Royal Veterinary College helps owners manage their pet's diabetes.

• The app is user-friendly and allows clients to monitor their pet's blood glucose levels and medications.

• It provides a diabetic clinical scoring system to put a number on subjective parameters.

• Owners can report back with objective numbers during physical exam rechecks.

Dietary Management

• A high insoluble fiber diet creates satiety and prevents postprandial blood sugar spikes.

• Not every diet is perfect for every diabetic patient; some may need an ultra-low-fat diet.

• A well-balanced diet that's moderate in fiber should be fed consistently twice a day.

• Checking in with the owner regarding understanding of diet type, amount given per meal, and dietary history is important.

Insulin Selection and Administration

• Avoid compounded insulin formulations as they are not FDA-approved or standardized.

• Intermediate acting insulins like NPH are commonly used but have limitations.

• Longer acting insulins like glargine provide better glycemic control but require more monitoring.

• Consistency in insulin administration is key to managing diabetics.

Monitoring Errors

• Avoid errors in monitoring by using objective measures like the clinical scoring system discussed earlier.

• Monitor blood glucose levels at home using glucometers or continuous glucose monitors (CGMs).

• Ensure consistent timing of blood glucose measurements and insulin administration to avoid errors.

Compounded Formulations of Insulin

The variability behind compounded formulations of insulin and the importance of avoiding them when managing diabetic patients.

Compounded Formulations Study

• A study by Dr. Scott Moncrief in 2012 looked at 12 different compounded protamine zinc insulin preparations.

• Out of those 12 preparations, only one met USB specifications for adequate efficacy.

• This highlights the variability behind compounded formulations and the importance of avoiding them when managing diabetic patients.

Avoiding Treatment Errors

• To avoid treatment errors, it is important to rotate injection sites and mix insulin before drawing it back in the syringe.

• Even though there are differences between U40 and U100 insulin syringes, mix-up mistakes still happen.

• It is also important to ensure that owners are administering the correct amount of insulin and using the correct type of insulin syringe.

Insulin Dosing Errors

Common treatment errors related to incorrect insulin dosing.

Case Study: Jackson

• Jackson was hospitalized for severe pancreatitis which led to a DKA crisis.

• Detemir was used due to its potency as a longer-acting insulin.

• Starting dose was 2.5 units twice a day for a dog weighing over nine kilograms.

Incorrect Insulin Dosing

• Incorrect insulin dosing is a common treatment error that can occur even with lower starting doses like those used with Detemir.

• It is important to monitor glucose readings closely and adjust dosage as needed to avoid hypoglycemia.

Diabetic Patient Management

In this section, the speaker discusses how to avoid treatment errors when managing diabetic patients. They emphasize the importance of educating owners on proper insulin administration and monitoring patients for concurrent illnesses that may interfere with successful diabetic regulation.

Educating Owners on Insulin Administration

• The speaker emphasizes the importance of showing owners how to handle insulin and having them demonstrate their ability to administer it correctly.

• Insulin syringes are marked with the correct dose for each patient, and a few are sent home with owners as a reminder.

• Despite thorough education, mistakes can still happen, so it's important to go back to basics and be thorough in history taking.

Monitoring Diabetic Patients

• It takes several weeks for diabetic patients to become well-regulated, so increasing the dose too rapidly should be avoided.

• Concurrent illnesses that interfere with successful diabetic regulation should be screened for through clinical history, blood work, and physical exam findings.

• When treating concurrent endocrinopathies like hypothyroidism or Cushing's disease, backing off insulin dose 10-20% per injection becomes important to avoid hypoglycemia.

Case Study

Lexie - Uncontrolled Diabetes and Hypothyroidism

• Lexie is an older Jack Russell Terrier with uncontrolled diabetes and hypothyroidism.

• As concurrent endocrinopathies are treated, careful adjustment of insulin dosage is necessary to avoid hypoglycemia.

FDA Approval of Prozinc for Diabetic Canine Patients

The lecture discusses the recent FDA approval of Prozinc for diabetic canine patients, adding to the options available for treating diabetic pets.

Insulin Options for Diabetic Patients

• Having multiple insulin options is important as no one insulin is perfect for every dog.

• Vetsulin and Prozinc are both U40 insulin suspensions with FDA-approved labels, providing confidence in their efficacy and safety.

• Other U100 insulin options include Novolin, Humulin, NPH insulins, detemir, and glargine insulins.

Factors When Choosing Insulins

• An FDA-approved label provides confidence in a product's efficacy and safety.

• Expense plays a significant role in decision-making, especially during times of financial hardship like COVID-19. Different insulin options at varying price points can be important.

• Accurate dosing is crucial; U40 insulin preparations and their respective syringes provide more accurate dosing in smaller veterinary patients.

• Concurrent diseases such as pancreatitis or chronic GI issues can make it harder to treat diabetes with certain insulins performing differently in these cases.

Understanding How Insulin Behaves Within the Body

• Understanding how insulin behaves within the body is crucial to managing diabetic patients successfully.

• The duration of action and onset of action determine whether or not patients will be controlled effectively with a particular type of insulin.

Insulin Types and Duration of Action

In this section, the speaker discusses different types of insulin and their duration of action in dogs.

Regular Insulin

• Regular insulin is a crystalline zinc insulin that's dissolved in a clear solution.

• It is in its soluble form, which allows for rapid absorption when given IV, IM or subcutaneously.

Intermediate Acting Insulins

• Intermediate acting insulins have a longer duration of action due to how the insulin is put into suspension.

• NPH is an example of an intermediate acting insulin that gets complexed with other things like protamine and zinc to form complexes that have to be degraded by enzymes within the subcutaneous tissue.

• 35% of NPH insulin is in a soluble form whereas 65% is in an insoluble form.

Longer Acting Insulins

• Longer acting insulins have a slower absorption from the subcutaneous space into the systemic circulation by different mechanisms.

• Prozinc has regular insulin but it's also complexed with zinc and protamine to form a crystalline complex.

• Glargine forms smaller complexes or micro precipitates in the skin to cause slow release while Dendomir binds to a fatty acid chain to albumin which gets dispersed throughout the body.

Importance of Duration of Action

• Historically, intermediate acting insulins have been recommended for canine diabetes treatment with a duration of action anywhere from 8 to 12 hours.

• However, some patients may require longer acting insulins where the duration of action is more like 12 to 24 hours for better control over blood sugar levels.

• If the duration of action is too short, dogs will experience high spikes in their blood sugar, extreme variability with their blood glucoses all over the place during the day and night, and uncontrolled clinical symptoms.

Prozinc

• Prozinc is an FDA-approved second U-40 insulin preparation that can be used for both dogs and cats.

• It has a duration of action anywhere from 16 to 24 hours and is labeled for once daily dosing, but some dogs may need twice-daily dosing.

Starting Insulin Doses and Monitoring Diabetic Patients

In this section, the speaker discusses starting insulin doses for diabetic patients and how to monitor them.

Starting Insulin Doses

• ProZinc is a veterinary preparation that can be given at a dose of 0.5-1 unit per kg once a day.

• The majority of dogs require half to 0.75 units per kg once a day.

• Vetsulin is more potent than other insulins, so lower doses are used.

Monitoring Diabetic Patients

• It can take weeks for diabetic patients to become regulated on insulin therapy.

• Owners should check their dog's urine with strips to see if there are daily glucose or ketones present.

• Rechecking fructosamine levels two to three weeks after starting insulin or making an insulin change is appropriate as long as the patient is stable.

• If clinically unstable or hypoglycemia is suspected, blood glucose levels should be measured using veterinary calibrated glucometers or interstitial glucose monitoring systems like Freestyle Libre.

At-home Glucose Monitoring

• Veterinary calibrated glucometers are great for use at home because stress doesn't play as big of a role in the home setting compared to the hospital setting.

• Freestyle Libre provides an incredible wealth of information but owners need to be reminded that it's merely a tool and not an end-all be-all.

Prescription Sensor

• Freestyle Libre is a prescription sensor that can be obtained from the human pharmacy.

Canine Diabetes Management

In this section, Dr. Fennimore discusses the use of interstitial sensors for monitoring blood sugar levels in dogs with diabetes.

Interstitial Sensors

• The interstitial sensor is applied to the dorsum in the interscapular space.

• The Freestyle Libre sensor can last about 10 to 14 days and provides non-invasive information regarding blood sugars.

• A separate script for the reader or scanner is required which gets placed over the sensor to obtain glucose level readings.

• Owners can download the Freestyle Libre app on their iPhone and use it as a scanner.

Managing Diabetic Patients

• There are different insulin preparations available, but not one insulin is perfect for every diabetic patient that we treat.

• It takes time to manage diabetic patients, and it can take several weeks to achieve success.

• Human error can contribute to challenging diabetics. Going over with owners what type of insulin, syringe, and how they're administering insulin all play a role in successfully managing diabetic patients.

• Screening for underlying infection, inflammation or other concurrent endocrinopathies that may be contributing to lack of our patients' diabetic control is important.

• Doing good physical exams and running blood work helps understand all factors that go into our diabetic success.

Q&A Session

Urine Strips

• Keto strips measure ketones while urine strips measure both glucose and ketones.

• Online pharmacies carry urine strips that measure both glucose and ketones.

Common Treatment Errors

• Human error is incredibly common, and it is still so common to not give the correct amount of insulin.

Common User Errors in Diabetic Patients

In this section, the speaker discusses common user errors that can be avoided when treating diabetic patients. She emphasizes the importance of asking questions about insulin type, insulin syringe, and how it is given during every recheck exam.

Insulin Preparation

• Veterans are the only insulin that needs to be rigorously shaken.

• Other insulin preparations need to be gently rolled between the hands.

• These are common user errors that can be avoided by asking questions about what type of insulin is being used.

Comorbidities and Abnormal Albumin Levels

• In cases with hypo or hyperalbuminemia, the dose of dedemere may need to be adjusted.

• The speaker is judicious with her dose when starting out in a patient who has an abnormal albumin level.

• Glucose monitoring at home is necessary for these patients, and their insulin may need to be adjusted more rigorously due to comorbidities or abnormal albumin levels.

Applying Freestyle Libre Sensor

In this section, the speaker explains how to apply a Freestyle Libre sensor on a patient.

Application Process

• Clip an area and wipe it down with alcohol before applying the libre.

• Line up the mark on the sensor with the mark on the applicator and push down into place.

• Gently press down on the prepared area for 10 seconds before using hemostats to guide out from underneath applicator.

Tips for Keeping Sensor On

• Place surgical glue around sensor before applying it to skin.

• Place a t-shirt or mesh vest over the Freestyle Libre area to prevent it from getting caught on anything.

• Avoid placing it in an area where a halter will rub up against it.

Placing Freestyle Libre Sensor

In this section, the speaker discusses whether sedation is required when placing a Freestyle Libre sensor and shares her experience with using the sensor on cats.

Sedation

• No sedation is required when placing a Freestyle Libre sensor.

• It's almost like a sub-q injection and typically comfortable for dogs.

• Hemostats are used to gently guide the sensor out from underneath applicator.

Using Sensor on Cats

• The speaker has used the sensor on some cats but had to sedate one cat during placement.

• The benefits of using the sensor outweighed the need for blood glucose monitoring.

Cataracts Secondary to DM

In this section, the speaker answers a question about what can be done for cataracts secondary to DM.

Treatment Options

• The speaker does not provide any specific treatment options for cataracts secondary to DM.

Eye Inflammation and Diabetic Regulation

Dr. Fenimore discusses the importance of managing eye inflammation in diabetic dogs to ensure proper regulation of diabetes.

Eye Inflammation Management

• Eye inflammation can be a source of trouble in managing diabetics, especially if their eyes get really inflamed secondary to hyper-mature cataracts that can form.

• Ophthalmologists recommend using florboprofen eyedrops from the beginning, even if there's not a lot of inflammation associated with the eye, to keep the eye comfortable and suppress inflammation from cataracts that can interfere with diabetic regulation.

• Cataract surgery is an option for referral, but ophthalmologists may require getting diabetes under control first before considering it.

Conclusion

Dr. Fenimore emphasizes doing due diligence and working up diabetic patients by controlling inflammation anywhere in the body and infection to ensure proper regulation of diabetes.