Managing difficult-to-control diabetic patients (Proceedings)

1. The Cushingoid Diabetic Dog

     a. Common endocrinopathies

     b. Occur simultaneously

     c. Similar clinical signs

     d. Diagnostic tests affected by disease

     e. Treatment of one disease will affect treatment of the other

     f. Concurrent disease

          i. treat DM first - loose control

          ii. diagnostic testing for HAC

2. When to suspect your diabetic is also Cushinoid

     a. Insulin Resistance

     b. dose of insulin >1.5 U/kg per injection

     c. outdated/mishandled insulin

     d. poor insulin administration technique

     e. improper insulin dosing

     f. decreased insulin absorption

     g. Concurrent endocrinopathies

          i. Hypothyroidism

          ii. Hyperadrenocorticism

          iii. Inflammatory disease

          iv. Infections

          v. Diestrus or pregnancy

          vi. Drugs

          vii. Obesity

          viii. Clinical suspicion

               1. insulin resistance

               2. clinical signs and clinicopathologic findings suggestive of HAC persist with insulin treatment

3. How do you prove your Diabetic is a Cushinoid

     a. Glycemic control-blood glucose 100-350 mg/dl

     b. Not in ketoacidotic patients

     c. ACTH Stimulation Test is the adrenal axis test to use

     d. Adrenal Function Testing in the Dog with DM

          i. Feed and give insulin as usual

          ii. Blood glucose measurement-100-350 mg/dl

          iii. ACTH Stimulation Test

          iv. 5 mg/kg cortrosyn IV (IM)

          v. pre-injection cortisol level

          vi. 45-60 minute post-injection cortisol sample

          vii. ACTH Stimulation Test – interpretation

               1. HAC: post-stimulation >22 mg/dl

               2. Gray area: 18-22 mg/dl

               3. No HAC: < 18 mg/dl

          viii. Pituitary vs Adrenal

4. Treatment of the Diabetic Cushingoid

     a. PDH

          i. o,p'-DDD (Lysodren)

          ii. Trilostane (vetoryl)

     b. Adrenal tumors

          i. Surgery

          ii. trilostane

5. Treatment considerations

     a. decreasing endogenous glucocorticoids

     b. removing insulin antagonism

     c. administered insulin increased potency

     d. precipitate hypoglycemic crisis

          i. Initial Treatment

               1. Lysodren/trilostane induction

               2. Decrease insulin dose 25-35%

               3. Mild hyperglycemia (250-300 mg/dl)

               4. glucose curve 5-10 days after change to check

               5. Urine glucose - 1-2 times per day

                    a. if negative > 3 times in a row; stop Lysodren/Trilostane

                    b. give 1/2 dose of insulin at next dosing interval

                    c. Urine ketonee - Call if positive

               6. Prednisone - 0.2 mg/kg q.d.

                    a. Physiological + dose

                    b. prevent hypoadrenocortical/hypoglycemic crisis

               7. Close owner monitoring

6. Monitoring and adjustments

     a. ACTH stimulation test

          i. feed and administer usual insulin dose

          ii. perform simultaneous glucose curve

          iii. goal

          iv. pre- and post-ACTH plasma cortisol levels in normal range

          v. control of HAC with preservation of adrenal glucocorticoid reserve

7. HAC and Insulin Therapy

     a. Evaluate glucose curve with ACTH stimulation test

     b. HAC under control - attempt tight glycemic control (100-250 mg/dl)

     c. HAC not well-regulated - keep slightly hyperglycemic (200-300 mg/dl)

8. Maintenance

     a. HAC controlled

     b. maintenance Lysodren dose: 35- 50 mg/kg divided twice per week

     c. Continue trilostane

     d. tight glucose regulation

     e. glucose curve performed to identify appropriate insulin and dosing requirements

9. Monitoring

     a. Urinary tract infections

          i. repeat urine cultures

          ii. appropriate antibiotic therapy

     b. Skin infections

          i. Treat these promptly

10. Take Home Messages

     a. Attempt some glycemic control before adrenal axis testing

     b. ACTH-stimulation test is the most accurate in a Cushingoid diabetic

     c. Do not attempt tight glycemic regulation with insulin until HAC is well-controlled

Hyperlipidemic Diabetics

1. Additional Problems

     a. Insulin resistance

     b. Increased osmolality from lipidemia

     c. Precipitates pancreatitis

2. Screen for Underlying Cause:

     a. Hypothyroidism - T4, fT4, TSH

     b. Cushing's Disease - ACTH-stimulation test

     c. High fat diet

3. Hyperlipidemia – treatment

     a. Low fat diet

     b. Omega-3 fatty acids

     c. Hyperlipidemia

     d. Gemfibrizol (fibric acid derivitive)

          i. Stimulates lipoprotein lipase activity

          ii. Decreases FFA concentration

          iii. 200 mg/day (dog)

          iv. 10 mg/kg q 12 hr (cat)

          v. Side Effects

               1. Vomiting

               2. Diarrhea

               3. Abdominal pain

               4. Abnormal liver function tests

     e. Statins

          i. HMG-CoA reductase inhibitors

          ii. Suppress cholesterol metabolism

          iii. Atorvastatin (Lipitor) 5 mg/kg/day (dogs)

     f. Niacin

          i. Reduces FFA release from fat cells

          ii. 100 mg/day/dog

Monitoring the Diabetic Cat and Dog

1. General Guidelines

     a. 4-6 weeks for control

     b. 7-10 days for animal to adjust to insulin

     c. Insulin requirements will be higher at home

     d. No need to hospitalize if stable

     e. Adjust therapy to owner

          i. Frequency of insulin administration

          ii. Frequency of monitoring

2. Monitoring Parameters

     a. Ketodiasticks

     b. Home Blood Glucose Monitoring

          i. Blood sampling sites

               1. Ear pinnae

               2. Foot pads

               3. Gums

     c. Fructosamine

     d. The Glucose Curve

          i. Type of insulin

          ii. Dose of insulin

          iii. Difficult to regulate patients

          iv. Suspected cases of insulin resistance

          v. Suspected Samogyi effect

          vi. 7-10 days after insulin change

          vii. May need at 48 hrs to get an accurate curve

          viii. Post-insulin overdose (hypoglycemia)

          ix. Sampling catheters

          x. Home generated

          xi. Interstitial Glucose Monitoring