Hi everyone, my name's Sophie McMurra. I'm a registered veterinary nurse and a veterinary technician specialist in small animal internal medicine. I work at North West Veterinary Specialists where I'm a medicine nurse.
I'm also the author of an endocrine chapter of a BSAVA textbook, and I'm a recover rescuer. And I'm here to talk to you today all about canine diabetes mellitus. We'll start off with a normal glucose regulation recap.
I think it's always useful to have a brief recap, even if you remember some of it before you go diving into the the depths of a disease. So our bodies require energy or glucose in order to survive. Glucose is absorbed when we eat food through the GI tract and then it's released from the liver and also the skeletal muscles.
The activation of glucose in the liver is called gluconeogenesis, and the tissue cells need to absorb glucose because we require energy to live. Insulin is required in order to utilise that glucose and take it from the bloodstream into the cells, and this allows you to use it as energy at the time, or also to store it for later use. The insulin is produced and secreted by the beta cells of the pancreas in response to the glucose level in the blood.
And the amount of insulin that is produced is proportional to the the glucose concentration in the bloodstream. So hyperglycemia is classed as anything above 8.5 millimoles per litre.
And if your glucose does go above the renal threshold, then you will start to see glucose in your urine as well, called glucoseuria. Now this is a talk about canine diabetes. However, the one point I will make about about cats or felines is that they can have a stress hyperglycemia of up to 18.
Depending on what textbook you read, the renal threshold sits around between 12 and 15, so you may well see glucosuria from stress hyperglycemia in the cat. However, we know that dogs don't get stress hyperglycemia, so if you do get glucosuria alongside a hypoglycemia in the dog, then it may well indicate diabetes. Now, when glucose sits in our urine, it has a very high osmotic pressure.
So that osmotic diuresis is, it promotes the activation of thirst centre in the brain, and that osmotic diuresis causes a polyurea, and then the first centres are activated which cause a rebound polydipsia as well. So that's where you get your PUPD symptoms from. And patients can also have a mild hypoglycemia from other diseases such as hyperadrenal corticism or Cushing's disease, or the use of exogenous glucocorticoids.
And just to briefly mention why that happens, you've got glucocorticoids. The clue is in the name gluco. It has a hypoglycemic effect, and that's because it promotes activation of glucose or gluconeogenesis in the liver.
So if you have excess levels of glucocorticoids, it will be promoting excess levels of glucanogenesis or activation of glucose in the liver and therefore may increase your glucose in your bloodstream slightly. So diabetes in dogs is multifactorial. So it could be a multitude of things contributing to to the onset of diabetes.
This could be a whole list of different things. So female female sex hormones when they're in season, it could be immune mediated, they could have pancreatitis, which has caused some some damage to the beta cells. It could be a genetic factor.
It could also be due to infection. We know that infections can cause insulin resistance. It could be some of the drugs that they're on.
We've just mentioned glucocorticoids, so if they're on steroids for their skin potentially. Or for any other reason, obesity is also something which causes insulin resistance or anything else that causes an ins insulin antagonist, such as different diseases or drugs. Many of these factors could lead to irreversible beta cell destruction or damage.
Some conditions such as prolonged untreated hyperadrenal corticism or pancreatitis could could cause beta cell exhaustion. Which may, if treated early enough, may repair and the beta cells may start functioning again. But otherwise, many of these different causes can contribute to beta cell destruction and damage, which is a permanent change, and it causes an absolute lack of insulin production, which in turn leads to a loss of glycemic control and therefore diabetes.
So diabetes mellitus in dogs is always treated with insulin, so it's classed as an IDDM, so insulin dependent diabetes mellitus. So which patients are likely to get diabetes, so this kind of care in any patient, any breed. The more common breeds that we see are the Bon frise, the Samoids, the schnauzer, or terrier breeds.
Females are twice as likely to get diabetes mellitus than males. And it can occur at any age, but it's most common between 7 and 9 years old. So the classic clinical signs of diabetes mellitus, PUPD, polyphasia, and weight loss.
You can get other signs later on, such as cataracts, lens induced uveitis, poor hair coat, lethargy dehydration, and also hepatomegaly. So just briefly before we talk about the diagnosis, just put in a slide about the treatment goals of diabetes. So 3 main things to think about when we're treating diabetes mellitus.
So we want to resolve clinical signs, we want to prevent complications, and we also want to improve the quality of life, both for the pet and the owner. And if you remember those three things, then it will help you along the journey of the, the monitoring in the long term management of these patients. To resolve clinical signs, as we mentioned before, the PUPD, polyphasia, and weight loss, so they're the ones we need to monitor, and they're the ones that we also need to make the owner aware to monitor as well.
You may ask if they're not aware to look out for any of these signs, you may ask them, Oh, how's the drinking. They haven't paid attention to it, so they won't be able to answer those questions effectively. So alert them and educate them.
Use your nurses to educate your the the clients. There's a lot to take in when it comes to diabetes and a newly diagnosed patient, but the more they are involved, the more successful the treatment will be. So even if you don't educate them on the first, the first consult, you can drip feed the information as you go along with all of the the the communication that you have with the owner.
So PUPD polyphagia and weight loss, the main clinical signs to monitor, prevent complications. So by that we mean DKA, diabetic ketoacidosis or hypoglycemia. Sorry, that should say hypoglycemia.
And improve the quality of life, both for the pet and the owner, and we'll talk about that in a little bit more depth in a moment. So when it comes to the the diagnosis of diabetes mellitus, we need a fasting hyperglycemia. Consistent clinical signs, which we've just mentioned, and glucose urea.
Fructosamine is a glycosylate protein, which reflects the glycemic state of the patient over around 2 to 3 weeks. So this is usually elevated with a diabetic patient. Underlying causes of diabetes should also be investigated just in case there is a concurrent disease or something which you could treat like Cushing's disease, which may well reverse the the diabetes.
This should include also a full biochemistry, haematology, urinalysis, including culture and sensitivity, and pancreatic lipase insufficiency to check for EPI as well. So there are different insulins available. We have the short acting insulin, which is usually known as neutral insulin.
This can be given IV IM as a bolus or as a CRI if you're in a hospital setting, more commonly used with DKA patients and it's effective within 30 minutes and lasts between 2 to 4 hours. We then have our medium acting insulin, porcine insulin, known as most commonly peninsulin, licenced for use in both dogs and cats, and they do also have these useful vet pens if you have an owner who prefers the vet pen. It's given subcutaneously and it lasts up to 12 hours in the dog, but it does last significantly shorter in cats.
And then we have our longer acting insulin, so protamine zinc or prozinc or glargine. So your Prozinc is licenced for cats. It's given subcutaneously and it lasts around 12 hours.
Lantus is not licenced in cats, but we do use it. It's given again subcutaneously and lasts a bit longer, so between 12 and 24 hours depending on the individual. And again, the treatment goals of diabetes is to resolve those clinical signs, prevent complications, and improve the quality of life.
So the treatment of diabetes includes many different factors, and it also includes a lot of teamwork. So the vet, the nurse, and the owner. The vet can't manage them alone, the owner can't manage them alone, and neither can the nurse.
But together, you are more likely to have a more successful outcome and a longer prognosis for the patient. So treatment of diabetes mellitus is achieved with drugs, insulin, diet, weight loss if the patient is overweight, an exercise regime, and control of any contributing factors which may be antagonising the insulin or causing a resistance. So we tend to start dogs on peninsulin, 0.25 to half an international unit per kilo, subcutaneously twice a day.
This is given at the same time as their daily, half of their daily requirements. So at the same time of food, or if you have a picky eater, I tend to say make sure they've eaten at least half of their food before you give in the insulin so that they can carry on and you can give the insulin while they're eating. It's important to store the insulin correctly, don't freeze it, don't leave it out at room temperature.
Store it in the centre of a fridge, ideally in a little tub where it's not gonna be affected by other things around it, it's not gonna be pushed to the back where it may freeze. And the recommendations say to change the bottle around every 28 days. Owners should also ideally keep a diabetic diary.
If you have a freestyle Libra in place, the Libra app is really, really useful. However, they're not going to have a freestyle Libra on at all times. So the other one that I like to use, I like to recommend is the RVC app.
And that's just a pet diabetic app made by the Royal Veterinary College, and it has a diary on there. And it also has quality of life tools, which I'll talk about in a moment. OK, so we've talked about insulin.
That's the mainstay treatment of diabetes. However, there are other parts as well. And if we just rely on insulin, then we're fighting an uphill battle really, because there are other contributing factors that we need to think about.
So diet, we know that our glucose comes from our diet. If they're not on an appropriate diet, again, we're fighting an uphill battle because the insulin is trying to bring the glucose down. They're on an inappropriate diet which is sending it up and it's gonna be a real struggle to get these patients under control.
Ideally, in the ideal world, we want a veterinary prescription diabetic diet. It's not always possible. If there's a patient with money constraints or the patient just doesn't like the diabetic diet that they're given, Chappy works very well and it's also nutritionally balanced and it's very cheap.
So diets should be low in simple carbohydrates, high in protein and high in fibre. So we know the carbohydrates cause that postrondy hyperglycemia spike because they're converted into sugars. So we need to reduce that carbohydrate level.
And that will just help prevent fluctuations in the blood glucose throughout the day. And fibre also slows carbohydrate absorption from the diet, which so the diet should have a minimum of 12% fibre content, and that will also help with your management and your glycemic control throughout the day. So diet is a vital part of this treatment.
Again, low carb, high protein, wet food is really good because of the high moisture content. We know the patients are become dehydrated quicker with diabetes, so the higher moisture content will certainly help with that. And it's absolutely vital that we stress the importance of measuring the food.
The owner can't free Paul, two different diets throughout the day. If they are given the exact same amount of insulin that they do every day, they need to give the exact same amount of food, because if they are given different amounts because they're free pouring and not measuring, then we are expecting a good glucose control. And we're just not going to achieve that.
We know that if we free port, it may be out by 10, 15%. So if they measure the food, you're much more likely to be safe and not cause a hypoglycemia, and we're much more likely to get that good glycemic control. So it is very, very important that they all weigh in that food.
We need to feed at the same time each day, and ideally have no treats because they use will spike blood glucose. And I've said ideally because in the ideal world, we want a textbook diabetic. We know that we don't live in an ideal world, and this is not always achievable.
And if you think of those three main aims of diabetic treatment is the reduction of your clinical signs, the prevention of complications, and also improve the quality of life. Now I think this is the one which affects the owner's quality of life, probably on a daily basis that they will, they will feel the quality of life has declined if they can't give the patient a treat. And if they need to give their their pet a meal 12 hours apart from each of them.
Owners seem to really struggle with that, and that's totally understandable. I couldn't have a meal and then wait 12 hours. It's a huge gap.
And also the patient, if they're older, they may be 1011 years old, they've had their food, their tea at 5 o'clock every night, and now you're asking them to wait another 3 hours. So yes, we want the ideal patient and the ideal diabetic control. But it may not always be possible.
And actually, if that small change can affect the quality of life, which means that that owner continues the treatment for this diabetic patient and doesn't opt for euthanasia because they feel like they're suffering, then that will lead to a more successful outcome. Providing you can get that glycemic control to a normal level to resolve the clinical signs and treat it effectively so that the patient is doing well and minimising complications, I think the odd treat here and there is not the biggest issue in the world. However, we need to make sure that they are appropriate treats, and we'll talk about that in a moment.
Now often these patients could come in obese, or they could come in with weight loss, depending how they've presented. Once they're back, once they're on this treatment plan, it's really important for us to keep an eye on that weight and how the weight is changing because it will be changing almost by the week. So reassess the weight regularly, whether they come into you, whether they go into their their other vets if you're in a referral centre, whether they weigh at home if they've got a small patient.
Weekly weigh-ins are really, really useful and it allows us to then tailor our treatment as well. So we know that obesity causes insulin resistance, so weight loss is key for an obese patient. And to put into figures some of the data that's out there, around 65% of dogs in the UK are classed as overweight or obese, and 37% of them were juveniles in a study by Alex Jer.
Now, if you are already obese or overweight as a juvenile, you are going to live the rest of your life in that same manner. So it's really important to educate earlier on, and this is where all of that owner education in the early days comes into play. And then if you're listening from the USA, around 56% of dogs, so more than half of dogs are overweight or obese.
So when we are changing a diabetic patient's diet, the most important thing is that that patient eats. We cannot be given insulin to a patient who is not eating. So we need to make sure that we're doing it gradually, mix the food over 7 to 10 days.
And if they don't like the food, don't bother changing it yet. This can't have any dramatic changes if the pet is eating even a little bit less, that insulin could be detrimental. So just switch them back, wait, and then try a different food later on when you're ready.
If the patient has a concurrent disease, or maybe they have IBD as well, then choose the diet for the other condition over the diabetes. If we manage successfully manage the other conditions, we're less likely to see insulin resistance to the diabetes. So choose the other condition first over a diabetic diet.
I mentioned about the lack of treats and that huge 12 hour gap having a big effect on the quality of life, both for the owner. And also for the pet as well. So if you are going to, if this pet is, if this owner is phoning up saying, you know, I'm really struggling here, the my pet is barking at me, they usually have their tea at 5 o'clock and they're really struggling to wait until 8.
I now feel like they are suffering and are not enjoying their life with diabetes. I'm struggling, what can I do? Then you can recommend a few different things.
So if they have a small snack around that time, it could just be a few pieces of their own kibble. It doesn't have to be a treat. I would advise against treats because they are higher in sugar.
But if they can choose something that is low in sugar, like cucumber or cooked courgette in chunks, you'd be surprised how many cats and dogs like courgette. Then this is unlikely to cause a huge spike. So you can just give them a little snack just to tie them over, and that will then reassure the owner, make them feel better and also provide the patient with something .
Which is a little bit more comforting because it is a long, it is a long gap to wait 12 hours. Carrots is another one which often the owners will say they give, but it is quite high in sugar, so either their own kibble, cucumber or courgette would be my go to, and that's what I usually recommend to our owners if they feel they need to give a treat. Now, part 3 of the treatment is exercise.
So exercise is really important. It helps maintain normal glycemia, it also helps if we're on a weight loss journey. We know if we've eaten a food and we go and burn a load of energy by going on a walk, then it's gonna bring that glucose down because it's utilising the energy.
They do need to be gentle, frequent and consistent from day to day. So if it's one walk a day, that's fine as long as it's around a similar walk every day and they're not then going bonkers of a weekend. So it needs to be consistent because they need to be burning around the same amount of energy each day on each walk in order to get the same outcome from their glucose.
So I would say take caution when the owner phones and says it's OK, we're gonna be fine, we're going on holiday, I'm gonna spend a week on the beach. These weekends away or holidays away on the beach, we need to educate the owner that they can be detrimental and owner education is absolutely paramount. I've had owners phone me and say, oh, his glucose was a bit low, so I took him for a walk because I thought it would help.
Education is so, so important for these, for these cases because they need to be in control of their management. We're not there at all times, and if we can drip feed small bits of education to help them understand this disease process, it will prevent any detrimental things happening like the patient collapsing on the beach in Cornwall because they've gone away and spent 7 hours running around during the day. And if the owner is going on a walk, I always give them a tip of if you've got a handbag, if you've got a treat bag, if you go on regular car journeys, keep a tube, keep some of their own kibble, and keep a tube of honey or gluco gel in your handbag.
If your pet does have a low blood sugar while they're out, you have it to hand. Go for the most natural method first, give them a treat or give them some of the kibble to bring that glucose up. If that doesn't work or if they have gone past that point, you can use the honey on their on their gums.
This may be of particular importance if you do have a large breed dog and you walk frequently in fields. If you're out in the field, they've run around, they've gone hypoglycemic, there's nobody around for you to shout for help. You can't carry a 30 kg dog by yourself.
It could be life saving if you've got that tube of honey or some kibble, or both, ideally, in the treat bag or in your handbag on those walks. And then the other part of the treatment to consider is infections. So, these patients are immunosuppressed, so they're more likely to develop infections.
The urinary tract infection is particularly common because of all the sugar in the bladder. It's a a breeding ground for bacteria. But they can occur anywhere, so it could be an ear infection, a skin infection, and infections can cause insulin resistance.
So it will make the insulin less effective and could actually contribute to the onset of a diabetic ketoacidosis episode. So if you do suspect that the patient has an infection of any kind, treatment is absolutely vital. Now to cover some of the management, water access has to be in there.
We have to teach the owner about water access because if the patient becomes dehydrated or doesn't have access to water, if they go to work and do a 10 hour shift and they forgot to forget to fill up the bowl. Then dehydration can be detrimental to a diabetic. Because of that osmotic diuresis, they're losing more water than the average patient, so they need to compensate by drinking more.
So hyper osmola syndrome could cause coma or death. And large water bowls are ideal or fountains as well, especially if you have cats. Even for cats, some of them like to, you know, they have strange habits.
They like to drink out of it at the last sort of cup or something random. Whatever they want, give it to them just so that they have enough water while the owner is out of the house. And then the management of these cases can be really interesting, but this is This is where your nurse comes in as well.
So diabetic nurse clinics are really, really useful. And they can do everything from advising how to inject, how to draw up all of the information that I've given so far. I'm a nurse that can be given by your nurses, the placement of freestyle Libras, which we'll talk about in a moment, and also the interpretation of the data of that freestyle Libra.
I often liaise with our clinicians. I'll have looked at the Libre results. I'll discuss it with them, and then I'll be the one who phones the owner.
They will, of course, come in and see the clinician maybe every 3 months or every 6 months, depending on how they're doing, but the rest of the care is over to me as the nurse. While I'm liaising with the clinician, so there is still a clinician in charge, but you don't need to be the person responding to the owner's emails, educating the owner and phoning up and dealing with all of this long term management. We are nurses and this is a perfect condition for us to really get our teeth into.
So, freestyle Libras are really good. We can place them and monitor the glucose from at the time of the first injection. Around 7 to 10 days, it can take about 7 to 10 days for the patient to adjust to the new insulin regime.
So try not to start with an insulin regime and then change it again after, say, 4 or 5 days because it may not be having its full effect for 7 to 10. The results can be reviewed weekly, especially if you do have a Libra, then you have access to it on the Lib review system in your practise, and I've got a picture of what that looks like in a moment. And we can review it weekly in order to up titrate the insulin dose.
This can take around 2 to 8 weeks to get your good glycemic control and the appropriate dose that the patient needs to be on. And when you're increasing the dosages, it should not be increased by more than 25% each time, just to make sure that we're increasing and we're staying within that safe range. Now we say that long-term management is really important, but what is the owner looking out for?
So what does a stable diabetic look look like? So it looks like a patient who has a good appetite, who is drinking a normal amount without excess volumes, urinating normally, maintaining a stable body weight. No signs of hypoglycemia.
And this can take months sometimes to achieve. But if we educate the owner that this is the goal, this is what they can achieve, hopefully, then they know what to look out for. And they also know signs to look out for if the patient becomes stable, but then they, it starts to creep back in.
So maybe the patient's developed a urinary tract infection and it starts to destabilise the diabetes and the glycemic control is not as as good. Or maybe the patient has developed a concurrent disease, or kidney disease, because it's an older patient, for example. If, if they are aware of what symptoms to look out for, they will notice if there is a decline, and they will also know that the patient can hopefully get to a normal way of life as, as it seemed before the diabetes.
Sometimes not always possible depending on the concurrent disease and whether we can manage the two alongside successfully. And again, it requires teamwork, so not just the owner, not just the vet, not just the nurse. It needs all three of us, and we all bring our own different qualities to in order to successfully manage the long term prognosis and the lives of these pets and the owner.
So there are other complications of diabetes, and these things are more of a More of a thing that I like to educate as we go along. So I won't tell the owner about these in the first clinic because I think there's a hell of a lot of information to take in. It's overwhelming.
If we overwhelm them, they're more likely to think I can't deal with this and go for euthanasia. So tell them about the necessities in the first click the first clinic or the first week. Afterwards, when you're checking in.
You can then start to drip feed all of this information and give them a handout so that it's on there and they can read in their own leisure. And this is also where the quality of life tool comes in. So if you provide the patient, the owner with a with a quality of life tool, and they say, actually, I've managed a hypoglycemic episode now.
I feel fine with that and I feel confident in dealing with it, but I'm really concerned about the onset of cataracts later on. You can then tailor your next phone call to educate the owner. I can see that you have some concerns around the formation of cataracts.
Let me educate you about how well dogs and cats do when they, if they do become blind, especially with cataracts, it can be a gradual process. Blind patients, you don't even know that they're blind most of the time. They respond really well and they adapt.
It's very different to if it were to be a person. And you can just tailor your calls to what they may be worried about, because again, it then reassures them and improves the quality of life if it stops them being anxious and worrying about the long term prognosis. And the journey along the way.
Insulin resistance should be suspected if any patient has poor glycemic control, despite insulin dosages above 1.5 international units per kilo, or when the glycemic control is erratic. And the most common cause are CKD, obesity, pancreatitis, maybe the, the feline dog is in season, infections, or any drugs that may be causing an insulin resistance.
And then we'll move on to glucose monitoring, so hopefully, I mean some people may still be doing glucose curves. Most of us have hopefully moved away from glucose curves now with the introduction of the freestyle Libras which have shown to be really useful and successful. Educate the owner on what a normal blood glucose is.
That's one of the most common things I think we we forget to do because we know what's normal. We expect them to know what's normal as well. But how does the owner know if they're high or low?
What, what is the normal range to teach them that the normal range, what the normal range is. We can do fructosamines, which we mentioned earlier, and then the frequent the continuous glucose monitoring devices. So just to touch on these devices in case you have used them, but you're not fully sure on the difference between interstitial glucose versus blood glucose or the pros and cons, or maybe you haven't used them yet in your practise.
So I placed these as a nurse and I've also taught the owners to place them as well. They can get them from human pharmacies and they range dramatically in price. The cheapest I've seen them is a human pharmacy around 35%, 35 pounds going up to 75 pounds, and then sometimes they're up to about 200 pounds for the placement of one in a veterinary clinic.
So that's a lot of money, especially if the pet is not insured. So if they buy one for 35 pounds from a human pharmacist, they can come in for a nurse clinic, you can teach them how to place these and they can do it really successfully at home. And then as soon as they're on, once they're on your database, you instantly get access to all of their data, which is really helpful.
Now they are human sensors, and it's a small disc. I've got plenty of pictures which I'll show you in a moment. A small disc with a subcutaneous needle.
Now this does not measure blood glucose, it measures interstitial glucose. And they are not quite the same thing, but it gives you the same idea. So there is a slight lag between the interstitial between the blood glucose and the interstitial glucose, and we believe that delay is around 15 minutes.
So the way I describe it to owners is it's like train carriages, so that initial, the first train carriage is the blood glucose, and the train carriages following behind is the interstitial glucose. So if they have a hypoglycemic episodes, for example, the patient's still conscious, that they've given them the treat, they've eaten it well, but they're not going to see an instant change in that interstitial glucose on the sensor because although we've fed them and it's gone instantly into the bloodstream, it may not show for 15 minutes, and in which case they may think, oh, I need to give the honey. It's fine if they do.
Better to be safe than sorry, but just to educate the owner and the veterinary team that actually there's about a 15 minute delay. So go off clinical signs for things like a hypoglycemia as well is also useful. So yeah, there is just that slight delay which is worth being made aware of.
It links up to the owner's mobile phone app. And they just use their phone to scan the sensor. And it gives them the current glucose and then a trend of 8 hours and also an arrow whether the glucose is currently trending up or down, and that's useful if they are going into a hypoglycemic episode, because if it's, say, 4, for example, and it's still a rapid arrow down, that means it's dropping quickly.
So the arrows are really useful. You can also set alarms for the owner on their phone or they can do it themselves, which alarms the owner if the pet, the pet goes hypoglycemic. So you can set that range and the alarm will go off.
I've had many owners say, oh, the alarm went off at 4 a.m. And now I'm really concerned if they don't have a Libra on, what happens, the pets?
I may not have been there and I was asleep, I wouldn't have noticed the hypoglycemia. So they are very important. They can also have information overload, but it's really useful for us to have a a freestyle Libra on, especially during the early stages of diabetes or any insulin dose changes or any areas of instability.
So glucose monitoring with these devices. It's absolutely a nursing skill. The average consultation time for vets in the UK is between 9 and 15 minutes.
You have so much information to tell the owner, even just talking about insulin alone will take more than that. So step away from the Libras, allow your nurses to get involved and place these and educate the owners if they want educating. And let the nurses place the freestyle laborbras.
They give you reasons every minute, and they can scan as frequently as they like, but it needs to be an absolute bare minimum of 8 hours. If they don't, fine, there'll just be a couple of hours gap if they're out at work, for example. Blood glucose curves can miss the peak or the naira, and this gives you a more detailed picture of what's going on.
Which in turn allows us to make easier treatment decisions because you can see every minute of that curve. And unlike some of the other monitoring devices like the Dexcom, which we used to use, which is again a great device. The calibration on that was incredibly long-winded and these don't need any calibration.
As soon as they're on, the owner scans it and within one hour it starts to read. They can last up to 14 days, not many of them do, because it's a human device, not made for animals. Animals are more agile.
And even if we clip that far by day 14, they will have a decent amount of growth back, not to mention them rolling on their back, pulling off the sensor, trying to use their their paws to get it off. So they don't always last that amount of time, so make sure you do educate the owner of that. And even if we get 4 days out of it, that's 4 days' worth of 24 hour around the clock data, which is way better than a blood glucose curve ever gave us.
And when it comes to the patient, there's also many advantages for the patient as well. So it prevents us having to stab the patient every hour. When a patient who is already gonna be stressed, those areas become painful.
The interference, especially if you are dealing with cats, just that interaction and pain will increase that glucose level. And Something else to be aware of is these are human devices, so they're, they just read as low, less than 2.2, they won't give you a reading.
Hopefully our patients won't go that low anyway. And it will just read as high for 27.8 and above.
We know that a lot of our patients start off above that. So your reading may just consistently say 27/8, which means that you're above that. Do you need to know that it's 30 or 35?
Or does it suggest that they may need to increase the insulin if you're on the 7 to 10 days of starting insulin? Yes, it has its limitations, but I I still think it gives so much information, which is really useful and helps us make educated decisions. If they do have any signs of hypoglycemia, check the, you can check the scanner, be aware of that lag.
So check with a glu glucose monitor. And if they do have an alpha track at home, so obviously they can't have these devices on forever, have an alpha track at home, take a glucose stick, reading and act accordingly. We're not talking about cats here, but they are useful when the cat is approaching remission because you can see that the patient is starting to become normal glycaemic despite a lack of insulin.
And early diagnosis, also when the owner goes on holiday. That's one of the contributing factors to a poor quality of life. The owner feeling like they can't go away or ever ever go on holiday with a diabetic because they have to leave somebody else to inject, or even if they're in kennels, if they have a glucose monitor on and somebody else is scanning it with their phone, they can log into that account and see the patients, .
The patient's glucose data while they're on home, so while they're on holiday. So another just extra security blanket. So once a freestyle is in place, this is a snapshot of the Lib review data that we can see in the veterinary clinic.
So many people, so many veterinary clinics place Libras and then don't know how to access the data, so they ask the vets to the owner to take screenshots and email it to them. You don't need to do that. You have so much more information than the owner will have.
And you just create a Libreview account. It's a practise account to sign up the owner, you just place the Libra or they place the Libra. All you need is their name and surname, their date of birth because it's a human device.
And their email address and every time that links to them and their account so every time they place another Libra later down the line and as soon as they scan it with their phone, it instantly gives you the data and all joins up together. So apologies, this image is a little bit grainy, but hopefully you can still make out what the numbers say. So down the left hand side here, the grey area, you can see these are all the different areas or ways of you looking at that data.
I personally prefer the, the daily log, which is what we're on here. And you can see this is the highest and the lowest that the glucose has been every hour. So this is given you hourly Hourly glucose readings, but they can go more frequently if this the owner has noticed it's going down and they've scanned every minute they can give you that much information if you want it.
But this will give you the highest and the lowest reading per hour, which personally I think is enough. And you can also see, I don't know if you can see my see if I can get a pointer up. Oh yeah.
So you can see here, so the, the pet has gone down to 11.6. There's a picture of an apple.
So that means that the patient has been fed and the owner's logged it, and she's also left a note here to say she's had 80 grammes of chicken, some chappy and some kibble. She's had cucumber, And Teddy has had his vaccination. Which the vet is OK.
So, we don't really need that information, but it's useful to see what they've eaten, that they've had their meal, and this here, the, the dark green is the insulin, so she's logged how much insulin has been given. So she's given 4.5 international units along with the food.
And then we can see the trend up here, if you prefer to look at that, and the numbers here as well for the next 12 hours. And then in the evening again, she's given some food, and she's given 3.5 international units because this patient has had a few hypo episodes during the night, so she has a slightly lower insulin dose at night.
And then if you come down to the next day, you can see here the red. She's gone down to 3.4.
So, the owner has logged here, so you can see, exercise. So she's been out for a walk and that's instantly told us that's likelihood the cause of the hypoglycemia. She's gone down to 3.4 and you can see the apple where she's given a snack.
And then she's also logged the snack. So walk, sorry, I thought it would be OK. I know you can't see this because my camera, but it says, I thought you'd be OK because the glucose was 16+.
And then you can also see how she's responded to, she's given some cucumber, some kibble, and then later on you can see this meal here, she's given chicken and chappy and kibble as well. So you can see the owner's given, taking the patients for a walk. She understands why the hypoglycemia has occurred, so your education is working.
She's then reacted to it successfully. She's given food, which has caused it to come back up, and then you can see the response for the rest of the day. So absolutely perfect.
It's giving you so much more information than we would have had previously. It allows me to then reassure and, you know, tell that owner that she's actually responded really well and say well done, a pat on the back to this owner because she's she's done really well to get that patient out of hypoglycemic episodes. She's likely to have been quite anxious about this.
So reassurance is always really important. And this is the beauty of the Libra. You can also look at all of these different bits of information, but the daily log, if you are going to get a practise account, the daily log is the most useful in my opinion.
And then we'll just touch briefly on the quality of life because it is a very important part. It makes up one of the three main points of the treatment of diabetes because after all, if the owner deems a poor quality of life, then we're much more likely to have an unsuccessful management and not a very long journey for the for this pet. So there are a few bits of data out there on the data of this the article which is stated down at the bottom.
Evaluates 748 questionnaires, and it's the title is Priorities on Treatment and Monitoring of Diabetic Cats from an owner's point of view. So these are an owner's point of view, it's not science, it's a point of view. So take it with a pinch of salt.
However, it's still useful for us to see how they are interpreting. Our response to their pets management. So some of the important things that I've pulled out is a diagnosis.
46% of vets discuss the signs of an unstable diabetic, and I'm often quite surprised how many owners come to us at a referral clinic for for these clinics, and they're not aware of the signs to look out for. Might be something that you think previously might think was irrelevant, but actually, It's so important to get the owners looking out for these signs, otherwise, how can we expect to take a full clinical history if they don't know what to look out for? 40% of vets told them about home glucose monitoring.
49% were supervised first drawing up and injecting, which absolutely blows my mind because only half of the pets have been shown or the owners have been shown how to draw up and inject. Get your nurses involved with these clinics. Your nurse can spend an hour with this owner until they are happy injecting.
Drawing up seems to be the most one of the most fiddly things for owners and actually it's second nature for us, but they've never even handled a needle and syringe in their life. So it's even just drawing up the insulin can be can have quite a lot of errors. So it's very important that we are doing this.
And around 76% found that the owners went to websites and forums and found them the most useful when learning about their pet's diabetes. 45% confidence identified in hypoglycemia. And again, the average vet consult in the UK is 10 to 15 minutes.
So it's no wonder that you cannot fill all of this information in diagnosis. How nobody could do that, but that's where your nurse comes in and that's where the drip feeding comes in, because this is a long journey. We don't need to teach them everything in day one.
But we do need to try and drip feed and have that team approach to these patients. When the owners were asked if anything could improve the quality of life for both them and their pet, there were a few things that they mentioned. They wished that the veterinary team were more knowledgeable on the role of diet when it comes to treating diabetes.
I think as a veterinary team, we often focus on the drugs quite a lot and see the diet as a as less important. Actually for diabetes, if we're given insulin, but then it's on an inappropriate diet, that's massively spike in the glucose. It's just not appropriate.
So I think they've probably got a point there. We could, we could do better on that front. And the most significant factors for the owner was being taught about insulin, switching to a low carb diet, and home glucose monitoring.
I think the home glucose monitoring allows them to feel more involved and feel like they have some control over the pets, diabetes and management. And also it reassures them, especially during those early days when they don't really know what to expect yet. They've got a glucose monitor on.
They know the numbers are OK, and they know that if they fall asleep and they've given the insulin wrong or they've walked them for too long, they can see the response instantly on that glucose monitoring device. So by calming their anxiety improves the quality of life and then gives us a more long stay, owner and pet. There are a couple of different tools available.
The ones that I like when assessing quality of life are the Quality of life tool on the RVC, the Royal Veterinary College Pet Diabetes app. Now this isn't available on all phones for some reason it doesn't work on certain Androids. I have a Samsung and it won't work on mine, but it will work on my husband's Samsung.
It seems to work on Apple. I think it was originally created on an Apple phone, so if the owner can download it, it's a really, really useful tool. It gives them a diary so they can log what time and what dose they've given insulin, what food they've given, what symptoms they may see.
All of those things, it, it's, it has those resources on there. And also there's the Quality of life feedback tool which has a series of about 15 different questions all about the different aspects of diabetes and their pet and them. And little things like going on holiday, do you worry about going on holiday?
They can fill that in and then email it to you. You can then or the nurse can then tailor the next couple of phone calls around the outcome of those of that of that quality of life assessment. Because if we reassure them.
Then it becomes second nature to them as well as us, and it really, it really does help with the management. So the RBC pet diabetes app, really, really useful. And then again, we have a hell of a lot of information to give to an owner in a, in a small consultation.
So, teamwork, absolutely vital. Don't do this by yourself, rope in your nurses, get them involved, they will love you for it. And educate the owner as well.
Get your nurses to do regular check-ins, whether that be in person, over the phone. They can give support in many, many different ways. Diabetic handouts, useful for when they go home, they sit down and they think, oh, I need something to read now because I really want to get my head around this.
It stops them going on Dr. Google. It will allow them to have a tailored piece of information that is approved by yourself if you've given them that handout.
Monitor the continual glucose monitoring devices regularly so they can do that and we can do it as well. We can check in, log on at any point online. We can call them weekly to begin with, just to check in how are things there anything we can help with, again, this can be the nurse.
And then once the pet is stable, they those check-ins can be reduced. And each phone call during in the early days reiterate those dangerous symptoms, so the lethargy, shivering. Some people say that the pores go really cold during the hypo or the onset of a hypoglycemic episodes, that's something else to look out for.
Just reiterating those symptoms and what to do. And remember to give them the tip of having some kibble or some gluco gel or honey in their handbag at all times if they have a diabetic pet. And the prognosis totally depends on the client's commitment really, and the teamwork that we give and the individual pet.
So the ease of the diabetic control and the presence of concurrent diseases has a big part to play in the prognosis. I mean survival times around 3 years, although it can be up to 5. And data has shown that the 1st 6 months is the most critical period in determining whether this owner is going to continue and succeed in this journey and whether the pet is as well if they do have a concurrent disease in the 1st 6 months, we should get a lot of information about whether this patient is likely to be successful on their journey or sadly not.
That's all from me. If you do like internal medicine, especially anything endocrine, please follow my page, veterinary nurse medicine geek. That's on Facebook and Instagram.
I do have a QR code, but I'm aware that the micro. Camera is right in front of it, so you can't use it. But I hope you've enjoyed my talk on diabetes, or canines and enjoy the rest of your evening.