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Endocrinopathies of Dogs and Cats Diabetes Mellitus (DM)

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Endocrinopathies of Dogs and Cats Diabetes Mellitus (DM) Endocrinopathies of Dogs and Cats Diabetes mellitus (DM) dr. Ákos Máthé Department of Internal Medicine Classification of DM ~ Action of insulin Blood glucose (>7.5 mmol/l) • Pathophysiologic ~ IDDM: insulin secretion ~ NIDDM: insulin secretion or , but insulin is less effective • Pathogenetic ~ Primary DM (pancreatic disease) – Autoimmune destruction of islets (dogs) – Islets amyloidosis (cats) – Pancreatitis, (neoplasia) ~ Secondary DM – Excess of counterregulatory hormones (GH , glucocorticoids ) – Obesity (reduced receptor binding of insulin) Consequences of extracellular BG glucose excess Glycosuria Hypokalemia (Polyuria) Hyponatremia Dog: BG >10 mmol/l Hypophosphatemia Cat: BG >14 mmol/l Intracellular dehydration Hyperglycemic coma Lens cataract Retinopathy Glycation of proteins Peripheral neuropathy Glomerulosclerosis Consequences of intracellular lack of glucose Ketonuria Lipolysis Ketonemia Acidosis Weight loss Ketoacidotic coma Hyperlipemia Fatty liver Gluconeogenesis Weakness Protein synthesis Poor wound healing Susceptibility to infections Diabetes Mellitus in the Dog I. • Signalment ~ Common disease ~ Middle-aged and old dogs ~ Intact females are predisposed ~ Poodle, Dachshund, Terriers, Beagle, Puli, Labrador, Retrievers, (English cocker spaniel, Rottweiler) Diabetes Mellitus in the Dog II. • Clinical manifestations in uncomplicated DM ~ Signs may appear 1-2 months after estrus ~ History with (possible) pancreatitis +/- ~ PD/PU, weight loss, (PP) ~ Dehydration, hepatomegaly, dull hair coat, flaking skin, cystitis, glycos- / ketonuria and hyperglycemia ~ Chronic cases: cataracts / retinopathy, proteinuria +++, (paresis) Cataracts, dehydration, weight loss Urine strip and BG measurement Diabetes Mellitus in the Dog III. • Clinical manifestations in complicated DM See above, and: ~ Diabetic ketoacidosis – Lethargy, weakness, anorexia, vomiting, coma, Kussmaul’s respiration, odor of acetone in the breath ~ Hyperglycemic hyperosmolar syndrome (HHS; BG >33 mmol/l) – Restlessness, ataxia, nystagmus, convulsions ~ Pancreatitis – Lethargy, vomiting / diarrhea, abdominal pain ~ Exocrine pancreatic insufficiency – Poorly digested feces, sour smell, flatulence ~ Signs of Cushing’s syndrome, acromegaly Diabetes Mellitus in the Dog IV. • Laboratory and instrumental findings ~ WBC , PCV ~ ALT , ALKP (SIAP?) , BUN / creatinine , K+ or , amylase / lipase , cholesterol , lipemia ~ Metabolic acidosis ~ Progesterone , cortisol , GH ~ (Fructosamine, glycosylated hemoglobin, IV glucose tolerance test) ~ Bacteriuria: sediment and culture ~ Abdominal US: diffuse hepatomegaly, pancreatitis +/-, enlarged adrenal(s) +/-, nephropathy +/-, cystitis +/-, ovarian / uterine cysts +/- Diabetes Mellitus in the Dog V. • Treatment in uncomplicated DM ~ The owner should be informed about prognosis, (lifelong) insulin therapy, dietary management, controls, costs ~ Oral antidiabetic drugs are ineffective ! ~ Insulin therapy: – Caninsulin A.U.V.: 30% amorphous, 70% crystalline zinc insulin suspension – 0.5 (BW >25 kg) – 1 (BW <15 kg) IU/kg/12h SC ~ Ovariectomy – Reduces (risk of) insulin resistance insulin demand (if DM manifested within three weeks, complete recovery is possible) Diabetes Mellitus in the Dog VI. • Diet ~ Amount and composition should be constant ~ Rich in protein, high fibre content, complex carbohydrates –Hill’s r/d, w/d, i/d, R.C. Weight Control Diabetic, Eukanuba Glucose Control etc. –Home prepared: 70% meat, 25 % rice, potatoes or pasta, 5% vegetables, cereals ~ 10-50 g/kg/24h divided into 4 equal portions ~ One portion few minutes before each insulin dose, one portion 3-4 hours later Diabetes Mellitus in the Dog VII. • Client instructions ~ Method of insulin administration must be taught in detail and tried by the owner ~ Reduction of insulin dose by half in case of anorexia or vomiting ~ Information about hypoglycemia – Signs: excitement, tremor, weakness, falling, convulsions, coma – Treatment: honey with spoon, extra meal, following insulin dose is skipped, consultation – If there is no improvement in 15 minutes, emergency treatment is required ~ Diet ~ Daily water intake (maximum 60-70 ml/kg) Instructions for owners Diabetes Mellitus in the Dog VIII. • Control examinations ~ On the first two weeks: weekly ~ After control is stable: every 3-6 months ~ Blood glucose 6 hours after morning insulin dose should be 4-9 mmol/l ~ Adjust insulin dose +/- 5-10% Diabetes Mellitus in the Dog IX. • Problems with insulin therapy and controls – Insulin activity and administration problems should be ruled out ~ Hypoglycemia – Anorexia, vomiting, unusual physical activity, (relative) insulin overdose – Client instructions, reduction of insulin, IV glucose administration ~ Somogyi effect (posthypoglycemic hyperglycemia) – BG <3 mmol/l adrenaline, glucagon, (cortisol, GH) BG – PD/PU, hyperglycemia – Serial BG measurements, reduction of insulin dose Continuous interstitial glucose monitoring Diabetes Mellitus in the Dog X. • Problems with insulin therapy and controls ~ Stress induced hyperglycemia at controls – No complaints at home, but hyperglycemia in the examination room – Measurement of BG at home ~ Short action of insulin – PD/PU and hyperglycemia a few hours before insulin – Longer acting insulin / dietary modification ~ Insulin resistance – Insulin dose >1.5 IU/kg is ineffective – Cortisol or progesterone / GH excess should be investegated and treated Diabetes Mellitus in the Dog XI. • Treatment of ketoacidosis ~ Volume repletion: – Ringer’s solution + 1 mmol KCl / 100 ml – 20 ml/kg in the first hour, thereafter rate may be reduced by half every hour, until 2.5 ml/kg/h ~ Regular insulin: Actrapid HMge – 0.25 IU/kg IM, thereafter 0.1 IU/kg repeated every hour, until BG stabilizes between 8-13 mmol/l 0.3-0.5 IU/kg Caninsulin SC ~ K+ replacement: mmol KCl = (4.5 - K+) x 0.6 x BWkg ~ Bicarbonate therapy if pH <7.1 Complicated DM Diabetes Mellitus in the Dog XII. • Prognosis ~ Uncomplicated cases have good prognosis, but –Regular control examinations are needed –Much depends on owner compliance ~ Complicated cases have poor prognosis Diabetes Mellitus in the Cat I. • Signalment ~ Relatively rare ~ More common in male cats • Clinical manifestations ~ Sudden onset of PD/PU ~ (Weight loss, PP) ~ Cataracts are rare ~ Neuropathy: plantigrade posture of hind legs Diabetes Mellitus in the Cat II. • Laboratory and instrumental findings ~ Hepatic lipidosis is more severe: TBr ~ Hypokalemia is common • Diagnosis ~ Hyperthyroidism: PP and weight loss dominates, goiter ~ Stress hyperglycemia is frequently found in healthy cats urine glucose at home (or: fructosamine) Diabetes Mellitus in the Cat III. • Treatment ~ Glipizide (Minidiab 5 mg tabl.) –5 mg/cat 2-3 times a day PO –Stimulates insulin secretion and effectiveness –Reduction in BG levels may need 1-2 months –Many cats will require insulin therapy because of unsatisfactory control ~ Less problems with insulin treatment than in dogs (Caninsulin, glargin insulin – Lantus) ~ Diet is difficult Diabetes Mellitus in the Cat IV. • Prognosis ~ Usually good ~ Some cats will recover after a few weeks / months of insulin therapy ~ Treatment of Cushing’s syndrome or acromegaly can cure insulin resistant DM Thank you for your attention !.
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