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5 tips to stop stressing over diabetic patient monitoring
Mrs. Smith is hypervigilant and Mr. McKinley is laissez faire. Your veterinary team can manage these pet owners' expectations with these five fairly simple steps for more effective home monitoring without the frustration.
It's natural for pet owners to feel distressed when your veterinarian diagnoses their pet with diabetes mellitus. And it can be more challenging for very conscientious owners if we don't appropriately manage their expectations from the outset. Often it seems that either the owner wants to do more than the pet needs to control the diabetes-or not enough when it's actually indicated. Both these situations pose challenging management scenarios for the veterinary team.
Similarly, pet owners may also be stressed when their diabetic dog or cat is more difficult to regulate or suffers from additional health problems, because these pets may require more frequent monitoring and rechecks-which also costs more money. The following tips can help pet owners take an active role in helping to monitor their pet's diabetes and improving your veterinary team's case management:
1. Urine monitoring at home
Urine dipsticks are a great way for owners of diabetic animals to feel involved with their pet's care. The urine strips should include a glucose pad and a ketone pad (Ketodiastix), and pet owners can buy these online or from a local pharmacy (Figure 1). Treated diabetic animals should have some amount of glucose in their urine-the amount does not matter since this is a crude representation of blood glucose-but never have any ketones. In sick animals, complicated diabetics or animals with a history of diabetic ketoacidosis, owners can check daily at first and keep a log they can bring to rechecks.
As time passes and owners feel more comfortable with managing their diabetic pet, they can taper off in frequency. But if the animal ever shows subtle behavioral or medical changes they know how to check themselves at home for ketones. Catching and checking urine can be much more challenging in cats. Cat owners who are interested can purchase special litter boxes that will catch the urine in a pan below. They can also use fine fish gravel in the litter box rather than litter as an alternative.
2. Weight and clinical signs
Figure 2Keeping track of a patient's weight and clinical signs is often one of the most telling and useful ways to monitor a diabetic pet. Dogs and cats that are relatively well controlled will maintain their weight-or even gain weight-and have improved to almost normal drinking and urinating on appropriate insulin therapy. It's important to weigh the pet at every veterinary visit and get a thorough history of the pet's drinking, eating and urinating habits. If necessary, the owners can directly measure water intake by measuring the water in the bowl at the beginning of a 24-hour period and again at the end of the 24-hour period (Figure 2).
3. Blood glucose curves and serum fructosamine concentration measurements
Ultimately, the best way to confirm how well a diabetic patient is controlled is with objective data, including blood glucose curves or a serum fructosamine concentration measurement. Blood glucose curves can be an invaluable diagnostic tool that give information about how long the insulin is lasting, how quickly the insulin peaks, how low the blood glucose concentration dips and how high it goes.
This information is particularly important if the patient doesn't seem well regulated for some reason. Blood glucose curves do require all-day veterinary visits and blood draws every two hours, so serum fructosamine concentration measurements are a good tool for fearful or difficult-to-handle animals. Serum fructosamine concentrations give a more general sense of what the average blood glucose concentration has been over the last two to three weeks. So it doesn't give as much information as a glucose curve, but it can be very helpful.
4. At-home glucose monitoring
Figure 3Some owners ask about learning how to do blood glucose curves at home. Generally, this is best reserved for the most compliant owners, as many owners tend to spot check blood glucose concentrations-rather than performing a whole curve-and change insulin based on a single reading. Also it requires purchasing a glucometer for home (Figure 3), which can be somewhat expensive up front, and for the owner to learn how to get a blood sample from their pet. Usually, pricking the ear margin with a lancet is the least invasive and easiest way for owners to get a blood sample (Figure 4).
Ultimately, many owners are interested in trying this method but then can't actually perform the repeated blood sampling required. At-home blood glucose curves can be a great tool for some owners and pets, but only if it's done correctly.
5. Routine rechecks with the veterinarian and veterinary team
Figure 5While this tip may seem intuitive, owners tend to only visit the veterinarian when something seems wrong. Sometimes, waiting until the pet owner notices behavioral or medical changes in their diabetic dog or cat can make it difficult to tease out new problems versus minor issues with diabetes management. Owners who are diligent with following recheck instructions, even if the pet seems to be doing well, are more likely to catch issues earlier, and you may achieve long-term diabetic control more readily (Figure 5).
Plan on rechecks at least every four to six months with a blood glucose curve and any blood work and complete urinalysis when indicated. This helps keep your veterinary team involved and familiar with the case, track weights, monitor any eye problems and catch new problems or impending problems earlier. Best of all, this leads to a happier owner and patient.
Jessica Midence, DVM, DACVIM, is a veterinarian at CARES, an Animal Specialty and Emergency Hospital in Langhorne, Pennsylvania.