March 2010, Issue 17. What's New at AMVS. In This Issue. 1 of 6 5/20/ :21 PM. 5 Practice Points for your Next Case. Dear Custom Field 1 Info,

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1 1 of 6 5/20/ :21 PM Having Trouble Viewing this ? Click Here You're receiving this because of your relationship with Aspen Meadow Veterinary Specialists. Please confirm your continued interest in receiving from us. You may unsubscribe if you no longer wish to receive our s. March 2010, Issue 17 Dear Custom Field 1 Info, What's New at AMVS Aspen Meadow Veterinary Specialists has a new face on Facebook! Please Click Here to view us on facebook. Our page has great information for both clients and veterinarians, and links to other resources you can use for your own practice. Why Facebook? Facebook is a free social networking site which allows users to: participate in group settings, track friends, send messages and IMs, update personal profiles and statuses, and keep groups, networks, and individuals abreast of what you are doing both personally and professionally. In This Issue 5 Practice Points for your Next Case Complications of Diabetes Mellitus- Hypoglycemic Crisis Laura Higgins, DVM Emergency Veterinarian Social online networking is happening more and more, and through a wide variety of vehicles. While facebook has been adopted significantly by Generation X and Y, it is actually women ages that comprise the largest bracket of users for facebook. AMVS made the strategic move to communicate/educate community and industry members on facebook in an effort to become more visible, gain online presence, and increase community involvement. The old adage, "If ya can't beat 'em, join 'em" truly applies. As a practice owner, you may find that many of your clients are already using social networking sites, and are receptive to participating in yours. You can Click Here to go directly to facebook. If you do not

2 2 of 6 5/20/ :21 PM already have a page, create one! Once you have located the Aspen Meadow Veterinary Specialists group page, simply click the icon next to our name that says "Become a Fan" and you are set. Just like our veterinary voice, we are always happy to receive your comments, feedback, and suggestions on facebook. We hope you enjoy the following article on Complications with Diabetes Mellitus-Hypoglycemic Crisis. Remember to use the Practice Points at the beginning of the article for your next case! Please contact us with any questions that you may have, and enjoy Veterinary Voice! Be sure to give us feedback so we can publish future issues to meet your needs. Please click the link below to forward this along to others at your practice! Practice Points for Your Next Case Complications of Diabetes Mellitus-Hypoglycemic Crisis 1). Recognized complications of Diabetes Mellitus include Hypoglycemic Crisis, Diabetic Ketoacidosis, Hyperglycemic Hyperosmolar syndrome, and more recently, idiosyncratic glipizide toxicity. 2). Cats receiving greater than 6 units insulin per dose are at greater risk of developing clinically significant hypoglycemia. 3). Obese diabetic patients are at greater risk of developing hypoglycemia. 4). The Somogyi Effect is a common phenomenon that may lead to insulin overdosing and subsequent hypoglycemia. 5). The duration of hypoglycemic state varies and is not necessarily dependent on insulin dose or type. Complications of Diabetes Mellitus- Hypoglycemic Crisis Complications of Diabetes Mellitus (DM) in veterinary

3 3 of 6 5/20/ :21 PM patients constitute a relatively common complaint to the emergency room. The 3 common emergency situations seen in diabetics include a Hypoglycemic Crisis, Diabetic Ketoacidosis (DKA), and Hyperglycemic Hyperosmolar Syndrome (HHS). Hypoglycemic crisis are seen in diabetics currently receiving insulin therapy. DKA and HSS, are often undiagnosed diabetics, however can certainly become a problem in patients currently being managed for diabetes as well. One less commonly appreciated complication of DM management is an idiosyncratic glipizide toxicity. For those patients taking glipizide to manage their DM, a toxicity unrelated to dosing may result in a hepatopathy that resolves with supportive care and discontinuation of the drug. The focus of this article will be on Hypoglycemic Crisis. Hypoglycemic patients present with neurologic symptoms such as weakness, ataxia, disorientation, and/or seizures. Generally the owners are well-educated on their pet's disease and therefore know exactly what symptoms to look for and seek immediate treatment. While both cats and dogs can develop a hypoglycemic crisis, cats are more commonly affected than dogs. Additionally, cats that are receiving greater than 6 units of insulin per dose are also more likely to become hypoglycemic, regardless of size or degree of insulin resistance. Obese diabetics are also at greater risk of developing hypoglycemia. Common causes of hypoglycemia in these patients include a history of anorexia or vomiting without adjustments in insulin dosing, spontaneous remission in transient diabetic cats, incremental insulin overdosing, and administration error. In November of 2009, the FDA released an alert regarding Intervet/Schering-Plough's Vetsulin, stating that the amount of crystalline insulin in the product was not stable and therefore for any given dose a patient may receive too much or too little insulin. Both the FDA and Intervet/Schering-Plough recommend those patients currently taking Vetsulin be transitioned to other insulin products in order to avoid unpredictable difficulties with glucose regulation, including hypoglycemia. The Somogyi Effect, a phenomenon in which a rebound hyperglycemia results from a subclinical hypoglycemic episode is another common problem in diabetic patients. This effect is secondary to incremental insulin overdosing when a diabetic presents for regularly scheduled blood sugar "spot" testing, and the result is high. An elevation in

4 4 of 6 5/20/ :21 PM blood glucose may be interpreted as the need for an increase in insulin dosing, however it is important to keep in mind that the Somogyi Effect may be responsible for this rise. Other causes of glucose elevations noted when spot testing include stress, and an increase in counterregulatory hormones secondary to underlying disease. Continuing to increase the insulin dose can eventually result in the patient no longer being able to effect a rebound hyperglycemia, and consequently may develop a hypoglycemic crisis in the future. The most common way to avoid this misinterpretation of hyperglycemia is to admit patients for a blood glucose curve (8 to 12 hours of blood glucose testing every 2 hours), and/or to submit blood work for fructosamine levels. Fructosamine levels allow the veterinarian to gain an understanding of the diabetic patient's blood glucose regulation over a period of 2-3 weeks, rather than relying upon values that may be bouncing around throughout the day. Interpretation of fructosamine levels can be challenging in some cases as frequent Somogyi events in a diabetic patient can also result in misleading elevated fructosamine levels. In effect, a patient receiving too much insulin may in fact have elevated fructosamine levels. Fructosamine levels are best interpreted in light of the clinical picture (i.e., is the patient PU/PD) and are more valuable when done in conjunction with a blood glucose curve. Treatment of a hypoglycemic crisis includes initial stabilization and control of neurologic symptoms. Owners may be instructed to apply Karo syrup, maple syrup, or honey to the gums/tongue of a symptomatic patient at home. It is still important that owners then bring the patient in to the hospital for more thorough treatment as oral sugar alone is typically not sufficient to stabilize the patient. In-hospital stabilization is typically done with IV dextrose bolus(es), given at a dose of 1 ml/kg of 50% dextrose, diluted to 25% in saline over 5 minutes. These patients require minimally 12 hours of IV dextrose therapy at 2.5% to 5%, added to an appropriate extracellular fluid replacement such as Normasol R or Lactated Ringers. 5% dextrose in water is not a preferred fluid choice for these patients due to resultant electrolyte abnormalities. Once stable, blood glucose levels are checked every 1-2 hours initially, and additional boluses may be needed. If a CRI of greater than 5% dextrose, or intermittent boluses are not enough to keep blood glucose levels within normal range, a central line may need to be placed in order to run a dextrose CRI at greater than 5%. An additional

5 5 of 6 5/20/ :21 PM advantage of placing a central line is the ability to more easily draw blood for frequent blood glucose rechecks. Pricking the ear for a small sample to place on a glucometer is another good option for compliant patients. Once the hypoglycemia is resolved, the patient can be restarted on insulin therapy. The recommended dose of restarting insulin therapy is 0.5 Units/kg. It is ideal to do this while they are in-hospital so that blood glucose levels can be monitored. In addition, it is essential that the patient be eating and drinking at this point. Once the patient is stable and owner error (or problems with the insulin itself) has been ruled-out as a possible cause of hypoglycemia, the patient is ready to go home. A recheck blood glucose curve is indicated 10 to 14 days after the insulin dosing has been changed. For some patients and their owners, at-home glucose testing may be a valuable tool for managing diabetics and may help to prevent hypoglycemic episodes. The AlphaTrack Blood Glucose Monitoring system by Abbott Veterinary is specifically designed for dogs and cats and is user friendly for most pet owners. One method of at-home monitoring is to check blood glucose levels twice daily, then dose insulin based on a scale designed by the veterinarian. While this method does seem to work well for many veterinarians and their patients, little research as to the effectiveness of this method has currently been published. Alternatively, some internists will recommend using at-home monitoring systems in order to have regular blood glucose curves performed in the patient's own environment. While at-home blood glucose monitoring has the distinct advantage of avoiding stress hyperglycemia from skewing spot blood glucose checks in the hospital, it is still recommended that patients are seen for in-hospital blood glucose curves and calibration of their AlphaTrack systems. Unfortunately, urine glucose testing is not a particularly useful method of at-home monitoring due to problems with false interpretation of glucosuria. At-home monitoring may seem overwhelming for some pet owners, and indeed for some noncompliant patients it would not be a viable option. However, with the guidance of their veterinarian,

6 6 of 6 5/20/ :21 PM many families will find at-home BG monitoring relatively simple and a great way to improve blood glucose control. Hypoglycemic episodes are a dangerous complication of DM that can often be avoided with careful and regular blood glucose monitoring. As a diabetic patient's needs for insulin change, it is important to couple those changes with thorough blood glucose monitoring such as in-hospital blood glucose curves, fructosamine monitoring, and/or at-home blood glucose monitoring. For some patients hypoglycemic episodes are an unavoidable complication of DM and owners should not only be trained to recognize the symptoms, but also encouraged to seek immediate treatment in these cases. Laura Higgins, DVM Emergency Veterinarian *If you wish to contact Dr. Higgins about any of the above information, you can reach her at lhiggins@aspenmeadowvet.com.* Thanks for your continuing support! -Aspen Meadow Veterinary Specialists- 104 S. Main Street Longmont, CO (p) (f) Info@AspenMeadowVet.com (e) Forward Marketing by This was sent to info@aspenmeadowvet.com by info@aspenmeadowvet.com. Update Profile/ Address Instant removal with SafeUnsubscribe Privacy Policy. Aspen Meadow Veterinary Specialists 104 South Main Street Longmont CO 80501