Narudee Kashemsant, D.V.M. Ph.D. Kasetsart University Veterinary Teaching Hospital Faculty of Veterinary Medicine Kasetsart University

Transcription

1 Narudee Kashemsant, D.V.M. Ph.D. Kasetsart University Veterinary Teaching Hospital Faculty of Veterinary Medicine Kasetsart University

2 Glucose curve: definition A useful tool in the stabilization and monitoring of diabetic animals An accurate assessment on which to base changes in insulin therapy and are vital in investigating the unstable diabetic Help to determine insulin effectiveness

3 Glucose curve: Strategies Treatment protocol Preferably dose of insulin that is enough to maintain plasma glucose in acceptable range Acceptable glucose level Renal threshold Dog 100 and 250 mg/dl mg/dl Cat 120 and 350 mg/dl 200 to 280 mg/dl

4 Key of success Insulin Glucose Vet

5 Glucose curve: Strategies Glucose curve Same time of meal and insulin Same dose of insulin Same portion and type of meal Same activity and behaviour Consistency of blood collection interval Pass nadir time

6 Glucose curve: protocol Hospitalize Follow pet owner s lifestyles. This includes insulin injections, portion, type and timing of meals and exercise routine. Take a blood sample prior to insulin injection: many animals eat better at home and can be fed prior to bringing to the hospital.

7 Glucose curve: protocol Administer the insulin after eating except long acting insulin Consistently interval blood taken If possible for 24 hours but at least until the concentration has crossed back above the renal threshold: More frequent blood sampling (e.g. hourly) may be required if Somogyi effect is suspected and difficult to identify. Be careful not to take too many large blood samples in small dogs and cats. Blood glucose concentrations are measured and plotted against time to produce a blood glucose curve

8 Glucose curve: protocol meal Insulin meal Insulin

9 Insulin administration Type Latent time (hr) Peak effect (hr) Effecting time (hr) regular intermediate Glargine 2-4 N/A :

10 Before starting glucose curve Asking about time, volume of insulin Asking about type, portion, timing of meal If everything is right, let s start

11 Let s starting glucose curve

12 Let s starting glucose curve

13 Before starting glucose curve Asking about time, volume of insulin Asking about type, portion, timing of meal If everything is right, let s start

14 Can we start glucose curve? Same time of meal Same time of insulin Same dose of insulin Same portion of meal Same type of meal Same activity and behaviour

15 Whether It is going down too fast (>50mg/dl/hr, 20-40mg/dl/hr) Glucose at nadir point is in acceptable glucose level nadir point is at expected nadir time? Overall curve is in acceptable range?

16 During doing glucose curve: How we can fix if it is not what we want. Whether it is.. Going down too fast (>50mg/dl/hr, 20-40mg/dl) Will deal with Somogyi effect How to correct this problem Bolus glucose 50% 2cc/kg and terminate the curve Monitoring until consistently hyperglycemia Do it again next day with the reduced dose

17 During doing glucose curve: How we can fix if it is not what we want. If it is.. Glucose at nadir point is not in acceptable glucose level Higher than acceptable level Too low insulin increase another 10% next injection Lower than acceptable level Too much insulin reduce 10% next injection

18 During doing glucose curve: How we can fix if it is not what we want. If the nadir point is.. not at expected nadir time? Before nadir time, keep eye on somogyi effect After nadir time, keep eye on dehydration

19 12 yr FS poodle 3 kg BCS 2/5 spgr on prescription diet 1.2 RER ( ideal BW) q 12 hr 30:70 intermediate insulin 0.3 unit/kg q 12hr right after meal Time Glucose Time Glucose

20 12 yr FS poodle 3 kg BCS 2/5 spgr on prescription diet 1.2 RER ( ideal BW) q 12 hr 30:70 intermediate insulin 0.3 unit/kg q 12hr right after meal Time Glucose Time Glucose

21 12 yr FS poodle 3 kg BCS 2/5 spgr on prescription diet 1.2 RER ( ideal BW) q 12 hr 30:70 intermediate insulin 0.3 unit/kg q 12hr right after meal Time Glucose Time Glucose

22 12 yr FS poodle 3 kg BCS 2/5 spgr on prescription diet 1.2 RER ( ideal BW) q 12 hr 30:70 intermediate insulin 0.3 unit/kg q 12hr right after meal Time Glucose Time Glucose

23 12 yr FS poodle 3 kg BCS 2/5 spgr on prescription diet 1.2 RER ( ideal BW) q 12 hr 30:70 intermediate insulin 0.3 unit/kg q 12hr right after meal Time Glucose Time Glucose

24 12 yr FS poodle 3 kg BCS 2/5 spgr on prescription diet 1.2 RER ( ideal BW) q 12 hr 30:70 intermediate insulin 0.3 unit/kg q 12hr right after meal Time Glucose Time Glucose

25 12 yr FS poodle 3 kg BCS 2/5 spgr on prescription diet 1.2 RER ( ideal BW) q 12 hr 30:70 intermediate insulin 0.3 unit/kg q 12hr right after meal Time Glucose Time Glucose Continue?

26 12 yr FS poodle 3 kg BCS 2/5 spgr on prescription diet 1.2 RER ( ideal BW) q 12 hr 30:70 intermediate insulin 0.3 unit/kg q 12hr right after meal Time Glucose Time glucose Off insulin/add fluid/meal Short acting insulin if exceed renal threshold/ continue fluid continue fluid Increase rate of fluid/ diluted reg Nadir point later than nadir time expected :dehydration

27 What wrong with me? Day 2 : on prescription diet 1.2 RER ( ideal BW) q 12 hr 30:70 intermediate insulin 0.3 unit/kg q 12hr right after meal Time Glucose Time glucose Fluid ??? Insulin dose/ fluid Off insulin/add fluid/meal Fluid Short acting insulin if exceed renal threshold/ continue fluid Fluid Fluid Fluid Fluid

28 What wrong with me? Day 2 : on prescription diet 1.2 RER ( ideal BW) q 12 hr 30:70 intermediate insulin 0.3 unit/kg q 12hr right after meal Time (hr) Gluco se Time (hr) glucose Fluid Increase by 10% 0.33 unit/kg/ fluid (0.03 cc) Fluid continue fluid Fluid Off fluid Fluid Fluid Fluid Nadir time but too high : not enough insulin

29 What wrong with me? Next day : on prescription diet 1.2 RER ( ideal BW) q 12 hr 30:70 intermediate insulin 0.33 unit/kg q 12hr right after meal Time Glucose Time glucose Nadir time overall is happy

30 Take home message before moving on Check hydration status, type/timing/volume of insulin, type/timing/amount of diet before doing glucose curve Consistently interval of blood collection/ pass nadir time and stop when it s bad 24 hr check is excellent but stop when passing renal threshold is acceptable

31 Question before moving on If patient can maintain weight but glucose curve is not acceptable, what s the decision Primary and secondary DM Taking care DM when it has complication

32 Cat glucose curve Do the same way as doing in the dog but it is harder to interpret take cat body weight into an account on glucose curve interpretation curve is good if cat can maintain his weight

33 Cat and insulin administration Find appropriate time that cat like to eat if they were fed ad lib Night time is most preferable for cat Do it your best

34 Problem Uncontrolled glucose pets who get very high dose insulin might have the concurrent diseases Most cat need very high dose insulin, however it would be great if they was already ruled out hyperthyroidism or acromegaly

35 Take home messages Success client communication is the key for treating this disease Factor that can increase glucose including factor that can make insulin malfunction Factor that can reduce glucose Too high glucose at nadir point ( expected nadir time) and patient reduce weight means too low insulin

36 Take home messages Too low glucose at to fast nadir time mean too high insulin Too high glucose which can not find the nadir time follow by too low glucose some day, possibly means too high insulin (severe somogyi effect)

37 Questions and Thank you for your attention