Thanks, Bruce, and good good evening to everyone listening live. So I'm one of the vets here at MSD and technical lead for Keninsulin. And before we head into the main event tonight with Grant, I'm going to take you througheninsulin, the whole range, particularly the vet pen, and it shouldn't take us more than a few minutes.
So, I'm hoping you will all be familiar with the peninsulum range. It has been a trusted brand for cats and dogs for approximately 25 years. Peninsulin is a porcine-based insulin with a structure identical called canine insulin.
Which is of importance in dogs where anti-insulin antibodies have been documented to insulin recognised as non-self and could impact treatment efficacy. However, they do not seem to be a particular relevance in cats. The peninsulin range facilitates a cost-effective, flexible approach to diabetes.
With several different sized vials and the vet pen cartridge. Peninsulin is a lenta insulin with biphasic action. Now, what this means in practical terms is that there is an intermediate acting portion, and the crystalline fraction provides the long acting tail of the insulin, and that's what's shown in the graph here.
So for a closer look at the peninsulum vetam. This is it, in its entirety. The bet pen comes in two sizes, up to 8 international units with half unit increments, and then another pen that goes up to 16 international units with 1 unit increments.
The starter pack comes with everything you need to get going, except the insulin cartridges. And as seen here, the starter pack includes 28 single-use needles, a needle remover, and adapters for those with unsteady hands. Now, it's important when we discuss treatment options with our clients that we understand their needs as much as their pets.
And as vets and vet nurses, we not only handle a large amount of needles and syringes daily, making use of them really second nature to us, but we are also trained medical professionals. So however comfortable we may be with syringes and needles, this may not be the case for our clients. So discussing options for insulin administration, syringes and needles versus vetE should be part of every new diabetic consult.
Within the human diabetes market, over 90% of insulin is delivered via devices. So many of your clients will be familiar, maybe even comfortable with a pen-like device. Furthermore, the peninsulin vet Pen offers clients some additional benefits, such as accuracy.
For doses under 8 international units, it is up to 25% more accurate than drawing up with a syringe, and that is data taken from asking trained veterinary professionals to draw up. And therefore it limits the variability that can occur as a result of human error, which is especially handy if multiple people in a house are drawing up and injecting. Not to mention the single-use needles, which are silicon coated and triple sharpened for improved pet comfort.
And we expect that one vet pen should last the lifetime of the average diabetic pets. And when we asked pet owners what they thought of the vet pen. 97% of them had no difficulty learning it, how to use it.
And 94% of them were satisfied using the device, showing a high level of acceptance among pet owners. However, us vets didn't fare quite so well, with only 64% of vets finding it easy to teach owners how to use the vet pen, which makes sense, as using a device like this. Isn't generally something we do in our everyday lives.
So practise staff becoming familiar with the vet pen can be a real benefit to clients. And we can help with training, both face to face and over the internet via Skype like system. This can be requested through your local MSD account manager.
MSD is customer services, or Emailing the address on the slide here. We also have lots of resources to help you teach owners. Such as manuals about diabetes and a newly updated vet Pen video, which will be out very soon.
And what we've done is to simplify the process of using the VAT pen into 6 easy steps for each time a new cartridge is inserted, including removing the air from the cartridge, which we refer to as priming. Then for every subsequent use, it is as easy as attaching the needle, selecting the dose, injecting the dose, and removing the needle again with the specially designed needle remover. Now don't forget that not only do we offer vet pen training, but we also have a whole host of support materials to help you with the management of diabetes.
With materials to help you explain to your clients what diabetes is, to support it in setting up nurse clinics, and then also our diabetes app. The pet diabetes Tracker app is free to download from either Google Play on Android or the App Store on Apple devices. Just make sure that you download the UK specific version.
This app allows owners to monitor a whole host of measures related to their pet's diabetes at home. But most importantly, links them to your veterinary practise. It also offers reminders for things like injection times, and also when they need to come back to purchase their next lots of peninsulin.
When the app is first downloaded, aside from pet's name, sign, signalment, that sort of thing. The owner is asked to input their practises telephone number and email address. And this is really important.
They can monitor their pet's water and food intake, weight, or signs of illness. But also record measures such as urine glucose, if they're monitoring these at home. And then if the app detects anything abnormal as input, such as the pet is vomiting today.
It will immediately bring up a push notification to call the practise. And all they have to do is press the call button as they will have already input the number into the app. And then when it comes to check up time, the owner can send all the information they have and have collected at home.
Via email to you. And that goes straight from the app into your inbox as a PDF. Which should put an end to er mountains of scrappy coffee stained pieces of paper that turn up at the practise.
And just to show you here, this is an example of what the PDF looks like. So depending what they've sent, it will show you all the vital monitoring details you need to know, but obviously tell you how that pet's been doing at home. And quite often, PDFs can be attached to practise management systems, which really helps to streamline the clinical notes.
And that's everything from me this evening. If you would like to know more about the Peninsulum Vett PE or the support we can offer, please contact your local MSD accounts manager. Our customer services.
Or once again, the email address on the screen. So thanks once again for joining us tonight. And now I will hand over to Grant.
Blaze, thank you so much for that presentation and once again to MSD for their generous sponsorship tonight. Folks, if it wasn't for MSD we wouldn't be having this webinar tonight. So Blaze, thank you and MSD so much.
Grant, if you want to share your screen while I do a little bit of housekeeping, that would be great. Folks, bit of housekeeping, if you have a question for either Blaze or Grant, if you hover your cursor over the screen, you'll see there's a little Q&A box that pops up. Click on it, type it in there.
It'll come through to me and we will hold it over to the end of the presentation. And then, both Grant and Blaze will be around to answer those for us. We will be having some poll questions.
It's quite simple when the poll question pops up on your screen. Simply just click on the answer which most suits what you believe to be correct. Remember, it is completely anonymous, so there's no reason why you should sit on the fence and not answer.
Once we've given you some time, we will then reveal the answers and Grant will talk them, talk us through them. So tonight's presenter is Grant Petrie. He qualified from Cambridge University and then went to Bristol Vet School for an internship.
He subsequently undertook specialist training in small animal internal medicine at the Royal College in London. After a period in private referral practise, he returned to the RVC as a lecturer in small animal medicine. Grant now runs an internal medicine referral service in London at the London and Bayswater referral clinics.
He has a particular interest in endocrine diseases and particularly diabetes mellitus. So who better to talk to us? Grant, welcome to the webinar vet and it's over to you.
Thank you very much, Blaze and Bruce. Good evening, everyone, and welcome. So, I think before we start, why don't we just test out our polling system?
So I just really wanted to know why you're here tonight. Is it because it's free and you've got nothing better to do? Maybe you don't want to upset your MSD reps.
You thought you'd better sign in. Hopefully some of you have come along to find out more about diabetes, but maybe it's just a question of getting a few more CPD hours under your belt to satisfy the RCDS requirements. And in fact, I suspect some of you probably aren't even here at all.
Maybe you've logged on, but you're actually watching Blue Planet Live. So let's see what, let's see what people say. Well, Grant, I can tell you that there are people who have clicked on the last odds, I think just a little bit tongue in cheek there because they couldn't have clicked on it if they weren't live with us.
Folks, as I said to you, this is an anonymous voting system. So, don't sit, don't worry, don't stress about it. Just click on the answer and it will come through to us.
And it just helps give Grant some feedback so he knows who he's talking to and . As we go through the presentation, we have a few other polls as well, which will give Grant some answers for us. I think we've had enough time for this one, so let's end that poll and let's share those results.
Can you see those, Grant? Well, 84% are here to know more about diabetes. I guess that's an encouraging start.
So we'll move on. The aim of this presentation is to provide my thoughts on some of the guiding principles for managing diabetes in cats and dogs. We know diabetes is an immensely complex condition.
In fact, can be quite overwhelming for many of our pet owners. Our job. Is to try and provide a management plan that is both practical and achievable for every owner.
Of necessity, of course, that plan will not be the same for every diabetic cat or dog. So, of the principles that I want to cover tonight, the first one is teamwork. Clearly very important.
If we look at the situation in human medicine. It's quite common for standards of care to be derived and detailed for human patients with all sorts of diseases, and of course diabetes is no exception. This poster produced by Diabetes UK gives us a sense of the sorts of issues that face human diabetics and the support services that they can expect to receive.
Now as vets, we strive to provide similar standards for our patients, and indeed owners often expect gold standard care for their pets. However, such care is associated with cost. Now that's not only financial cost, but also emotional and physical.
Diabetic humans can, and indeed have to assume personal responsibility for the management and monitoring of their own diabetes. But if you are diabetic as a human, then you can count on a massive support team, a huge number of experts that are there to look after you with your diabetes. You have your general practitioner, your primary doctor, but it's likely you'll also have a specialist consultant with knowledge of diabetes and other endocrine disorders.
Diet we know is important in our patients likewise in humans, so you may well have a dietician. Typically there'll be a specialist nurse, practise nurse who will be taking care of you on a more frequent basis perhaps than your GP, but there are people to look after your feet, your eyes, your drugs, your mind, your teeth, even exercise trainers, this huge team of supporting experts to take care of your human diabetes. Now, approximately 10% of the UK NHS budget, now that equates to billions of pounds.
Is spent on managing diabetes and its complications. Here are some of the healthcare essentials that a human diabetic should receive at least once a year. You would expect your glycated blood proteins to be checked, your blood pressure, your lipid profiles.
You'd get your eyes checked out, you'd have your feet and legs looked at, you'd have your kidneys checked. There'd be emotional support. There'd be education, jabs for flu, and help with any, .
Sexual problems, you may be experiencing. Help to give up smoking and, help if you're deciding to, to start a family. And if we were to equate this to our cats and dogs, an annual health check with your doctor as a human would probably equate to 3 to 4 monthly diabetic assessments for cats or dogs.
And that's probably fairly typical for us when we recall our patients for review is that we see them every 3 to 4 months. What about the veterinary diabetic team? Obviously, contrary to humans, cats and dogs can't manage their own diabetes.
So therefore owners of diabetic pets have these responsibilities essentially thrust upon them. Some owners are prepared to make managing their pets their absolute priority, but we have to understand and recognise that other owners are unable or indeed unwilling to do so. It's essential that we adopt a flexible approach and recognise that one size does not fit all.
The veterinary diabetic team, of course, is much smaller than its human equivalent, and owners are clearly essential to implement the management recommendations. As vets and nurses, we don't live with our diabetic patients. Our role is to provide the education and support to owners to allow them to best manage their diabetic pets.
Now, if we're going to achieve this and discharge that responsibility, it's absolutely imperative that the diabetic team members fully understand what diabetes is all about. What is and what causes diabetes? What does insulin do?
The good things and of course, the negative things. What are the signs of diabetes? What complications might we anticipate to arise?
What are we trying to achieve with our treatment? How are we actually going to manage the disease? What routines are we going to set up for, nutrition, exercise, and so on.
And then, of course, how are we going to monitor our diabetic patients? Fortunately, there are fantastic support materials available to vets and nurses. The International Society of Feline Medicine Open Access guidelines.
That the practical management of diabetes in cats were published in 2015. And we have a second open access resource, which is the American Animal Hospital Association guidelines for diabetic cats and dogs, written by a panel of experts initially in 2010 and then updated last year in 2018. Both documents serve to remind us that the management of diabetes mellitus is a combination of art and science.
Namely that we need to tailor the management to the requirements of each diabetic pet and its owners. Yeah. So now it's time for a more serious poll question.
And here I want to ask you to think about the last straightforward non-ketotic diabetic patient that you saw. And I'd like you to answer, and there is no correct answer with any of these questions, it's just getting a sense of what people are thinking. But what was your first treatment the last time you made a diagnosis of non-ketotic diabetes?
Did you reach for the insulin? Did you perhaps make a change of diet? Did you give oral hypoglycemic drugs?
Did you go for neutri? Did you actually put the pet to sleep, or was it actually none of the above? So start voting now.
Alright folks, you know how it works. Most of you are already voting like crazy. Just click on the answer that best suits what you feel and what you did in that last case that was non-ketotic.
We'll give you just another couple of seconds to answer that. We've still got a couple of votes coming in. Right, let's end that poll and share those results.
There you go, Grant. So as I guess it's no surprise to attendees, insulin was the treatment of choice, the first treatment that was given. Change of diet, certainly there are circumstances, particularly with our feline diabetics, where we know that a change of diet can have a profound benefit on glycemic control.
Fairly low number of, oral hypoglycemic, selectors. These are drugs that are very occasionally used in cats, have no value in dogs. Neutering, of course, the entire female dogs.
If they are neutered, we may turn diabetes around. And 1% of euthanasia, I'd be curious what the none of the above were. Anyway, we'll move on.
So that's curious that only 1% were put to sleep, and I'm very, very encouraged by that. Thinking back over the last 5 years though, I'd like to get a sense of, what the participants, have done in relation to, to euthanasia. So the question that I pose is, how many diabetics have you put to sleep within 12 months of diagnosis?
Was it just 1 perhaps? 2345 or more, or perhaps you haven't put any to sleep within the 1st 12 months. Let's, see what you think about that.
Interesting results coming through. Grant, we've got a two horse race running at this stage. And come on folks keep those votes coming in.
I see they're coming in quite nicely. They are slowing down a bit, . It is anonymous, so don't feel embarrassed to.
To give us your correct answer. Right, 3 more seconds and then we're gonna stop that poll. There we go and there are your close answers.
Great. Well, there's a good spread there, and there are obviously many reasons why diabetics end up being euthanized, . Particularly those patients that perhaps are in diabetic ketoacidosis with severe concurrent diseases, perhaps a far from certain outcome may end up being euthanized.
The, the reason for asking this question comes from, a study that was, designed to explore why it was that, diabetics are put to sleep. Rather than treated, this was the so-called big pet diabetes survey. Now, this was a worldwide questionnaire, which documented the perceptions.
This was the perceptions of vets around 1200 on how often and why diabetics are euthanized at the time of diagnosis and, or within the first year of treatment. And the findings of this study were quite interesting. Perhaps not reflected by our audience tonight.
Perhaps, well, we'll explore the reasons for that. But the finding was that 10%, 1 in 10 cats or dogs were euthanized at the time of diagnosis across this worldwide study, which included countries obviously outside the United Kingdom. And that a further 10% were then euthanized within a year of diagnosis because of lack of success or, or compliance.
The authors tried to determine what were the reasons for this pretty high rate of euthanasia and the presence of Current disease was deemed to be the top reason. Cost was also a major factor. Animal age, difficulties getting adequate glycemic control.
Pet welfare Quite important, the impact on the owner's lifestyle. And what was quite curious from this study was that actually, what we might think would be a big problem for owners was actually perceived to be least important, and that was difficulty with injections. Part of the motivation for bringing this meeting to the, this evening was to see if reviewing our thinking about diabetes might enable us to manage more patients and put fewer to sleep.
Now, maybe we're putting fewer to sleep in the UK. Maybe it's just our selected audience. But anyway, we'll, we'll press on.
The second guiding principle is education. Most people have heard of diabetes, and many will know about diabetes through family or friends. However, when you actually ask people what does diabetes mean, then we find that the majority pretty much have a poor understanding about the disease.
Except perhaps for some of the disastrous complications that might occur with diabetics. So for owners and indeed ourselves, vets and nurses, to be effective team members, we really need to know what is diabetes mellitus. And of course we know it's a syndrome characterised by hyperglycemia.
And it results from two major processes either a defect in insulin secretion, and that can be a relative or absolute lack of insulin, coupled with or Due to peripheral cell insensitivity to insulin, otherwise known as insulin resistance. What causes diabetes? Well, the truth is, in the majority of our patients we don't actually identify the specific cause or causes of diabetes.
However, that shouldn't stop us from looking. There's a greater acceptance now that diabetes, not diabetes, is not a single disease but rather the end stage consequence of many different processes. Increasingly we recognise risk factors.
And more importantly, we understand that identifying and resolving underlying causes may reverse diabetes in some of our patients. In dogs, diabetes is often associated with an absolute lack of insulin. These dogs have a requirement for exogenous insulin for their very survival.
Cats, on the other hand, typically have insulin resistant diabetes, coupled with an inadequate compensatory response due to beta cell dysfunction. So let's look at some of the risk factors. We know that there are certain breeds of cats and dogs that are more predisposed to diabetes, so Burmese cats, Samoyed dogs, terriers.
Particularly prone to diabetes. Obesity, particularly in cats, is a known risk factor. Glucocorticoid therapy.
Pancreatitis, and of course dioreus in entire female dogs. Reduced insulin secretion can be absolute. Due to extensive pancreatic beta cell injury, or it may be relative due to beta cell dysfunction.
Correction of factors such as glucose toxicity, obesity, and pancreatic inflammation, which can impair beta cell function. And result in improved insulin secretion and possibly reverse diabetes. Causes of insulin resistance include hypercortisolism, for example, Cushing's syndrome in dogs, as seen here in the picture on the left.
Hypersomattotropism in cats. Progesterone excess and obesity. In the right-hand image, we have a pituitary tumour in a diabetic acromegalic cat, and hypophyectomy in this particular cat resulted in diabetic remission.
The diagnosis of diabetes is relatively straightforward. But carefully explaining to owners why their pet is showing clinical signs and what should happen with successful management is really helpful when it comes to monitoring diabetics. The sorts of dogs and cats that get diabetes, well, any breed, any age, any sex, but typically middle to old age and as we've discussed, certain at-risk breeds.
The cardinal signs of diabetes are polyuria, polydipsia, polyphagia, and weight loss. But what we need to remember is that these are the signs that we see in so-called happy diabetics, well diabetics. Sick diabetics may look completely different.
They may be anorexic, dehydrated, vomiting, or collapsed. Perhaps only on closer questioning might it become clear that prior to the onset of this marked deterioration, the classic clinical signs, signs of diabetes were present. Physical examination of diabetic cats and dogs is generally non-specific.
Although the presence of cataracts in dogs or a peripheral neuropathy in cats might be clues to the presence of the disease. The definitive diagnosis of clinical diabetes in the face of the above clinical signs. I persistent fasting hyperglycemia, glucosuria, and elevated glycated blood proteins.
Other findings that you might see on a blood panel, and urine analysis would be increased liver enzyme activity, hyperlipidemia, ketonuria, ketonemia, urinary tract infections, and so on. Clinical signs of course may be less obvious in some diabetic cats due to their secretive lifestyle. So frequent weighing assumes greater importance in this case and something that we obviously recommend each time a cat is presented to us.
Our next guiding principle is communication. If our diabetic team is to succeed with management, we need excellent communication. And certainly a clear idea of what we are trying to achieve with each of our diabetic patients.
Most diabetics present to us due to the development of clinical signs. Sometimes these are rather unwanted pets that are urinating in the home, dogs perhaps drinking from the toilet bowl, stealing food, and so on. And resolution of these clinical signs is usually our first and primary goal.
However, importantly, diabetic complications can be significant and extremely concerning for owners. Complications can occur as a consequence of the disease, for example, excessive urination. Cataract formation, peripheral neuropathies, or diabetic ketoacidosis.
The complications can also arise from our chosen management. Hypoglycemia due to a relative insulin overdose can cause signs that are more worrying to owners perhaps than those that are seen with untreated diabetes. Therefore, prevention of complications is of course a very important treatment aim.
In common with most medical complaints, we hope that our management improves or restores quality of life rather than impairs it. Hypoglycemia, of course, would be a case in point. But perhaps more with diabetes than many other conditions.
This disease can have an enormous impact on the owner's quality of life as well as that of the patient. Quality of life studies and diabetic dogs and cats were published in 2010 and 2012 respectively. By the team at the Royal Veterinary College.
These studies sought to identify factors that affected the quality of life of both patients and their owners. And when this data was distilled and a top 10 list of concerns for dogs and cats was produced, Strikingly, it became apparent that 19 out of the top 20 concerns were in fact owner related. And only one of the top 20 concerns, number 9 on the catalyst, pet moods, actually involve the patient.
So these studies served as an important reminder of the potential impact that the patient's illnesses can have on our owners. And furthermore, for success, we really need to address owner worries. There are many studies looking at diabetic remission.
It is certainly the case that a significant proportion of feline diabetics may achieve remission with appropriate management. However, Not all cats that go into remission remain in remission. While achieving remission may be an admirable goal, it may not necessarily be what every owner wants.
Of necessity, cats will develop hypoglycemia as a signal that they are producing their own insulin and that that insulin is effective. Thus they have a reducing requirement for exogenous insulin. This may bring unwanted clinical signs plus a level of re-examination, testing, and cost that may not be agreeable to every owner.
And then maybe one final end that doesn't usually find its way onto the sort of goals of therapy list, and that would be preventing euthanasia. And it was speculated in the study that There may be a number of factors that need to be considered. We think about 1 in 2015 diabetics around the world being put to sleep within their first year of diagnosis, perhaps we need to consider why that might be.
And it was speculated by the authors that there would be a benefit through improved diabetic education. An emphasis perhaps on offering a range of treatment styles from the very intense, potentially expensive. To the hands off approach which might be less expensive.
We could look at ways of devising new and more successful treatment protocols. And that perhaps the ideal treatment characteristics would indeed be lower cost, nevertheless effective, with a low risk of hypoglycemia and very importantly, a reduced impact on the lifestyle of the owner. Now, of course, diabetic pets cannot be managed without an owner, and that owner needs to be willing to participate in the management of their pet.
Hence my fourth guiding principle. The cornerstones of diabetic management are of course insulin. We need to consider any underlying diseases or drug therapies.
Perhaps we can, correct those. We need to think about nutrition and physical inactivity. And of course, it's very pertinent, with the epidemic of diabetes in humans, to not forget that diabetes is a prevent is potentially a preventable disease.
Maybe this is something we should be thinking about earlier in the pet's life. These were the two resources that I showed earlier, and I particularly like the title of the ISFM guidelines, which make a point of describing practical management of diabetes. And from these guidelines is this table.
The main goals of management should be to limit or eliminate, in this case, the cat, but equally relevant to the dog. The cat's clinical signs using a treatment regime that fits into the owner's daily routines. While avoiding insulin-induced hypoglycemia and preventing other complications.
So now we move on to our next poll question, please. You've made a diagnosis of simple non-ketotic diabetes. The question is, what is the first thing you should do?
Should you be starting insulin? Should you change to a prescription diet? Forget the injections.
Tablets are clearly better for diabetics. No, neuter immediately. That will fix things.
No, maybe you've decided you shouldn't do anything, just go straight for euthanasia. Or would it be none of the above? Grant, I think our audience is wide awake on this one.
We've got some very fast rapid responses and we have got these votes pouring in very, very quickly. So another 15 seconds, folks, and then we are going to close that poll so that Grant can carry on in this fascinating presentation. 5 more seconds.
Right, here we go. And so yeah, the main question of course was what is the first thing you should do. And of course the majority of our audis said yes, let's just jump in with the insulin and then a variety of other options.
Nobody going for tablets. Nobody going for neutering. Nobody going for euthanasia, actually just one person, but a 0%.
But in actual fact, What I would contend is that you shouldn't be doing any of these things first. The first thing you should be doing is actually speaking to your owners. Before we embark upon delivering management, it's really important to find out from the owner's perspective where are they going with this.
You need plenty of time. This is not something you can shoehorn into even in consultations. You need to set aside a period of time, half an hour, 45 minutes where you can discuss matters in detail.
And of course if at the end of that discussion the owners are up for management, then of course we're going to start with our treatment. It's really important that we establish whether these owners have the emotional energy to treat. This is something that they can physically achieve.
Do they have the time? I would contend that the time required to feed a cat or a dog is the time that you can be you can be giving injections, so time perhaps would not necessarily be a reason, but can they actually afford the cost of treatment? It's really important that we manage expectations.
We need to address how long it might take to stabilise the patient. We need to advise that the dose of insulin is likely to change over time. It may go up.
Indeed, it may come down, for example, in cats that are going into remission. It may be necessary to change the type of insulin. These are all factors that need to be explained.
We need to discuss complications. Dog owners, for example, need to be warned that there's a high probability that their dog will develop cataracts and go blind. Having covered these, we then need to advise how owners can be supported and reassure owners that good diabetic control is certainly possible and their pets can lead full and enjoyable lives.
I think it's valuable if we can identify members of the practise team, preferably nurses, that can be the single point of contact at the practise for owners with their diabetic pets, earning a rapport between the nurses and the owners results in a more fulfilling role for nurses, and invariably owners seem to contact us at the time of day when there's maybe a consultation, a waiting room full of consultations, and so on. We need to provide information and support. There's plenty of literature, websites.
Pharmaceutical companies support and so on. But I think one undervalued resource is other owners who have diabetic pets, who have been through the process of starting treatment of diabetes, have seen the pitfalls, and hopefully have come out the other side to see the joy and happiness that their diabetic pets bring once their treatment comes under control. Getting to grips with looking after a diabetic pet can seem suffocating for owners.
Hopefully, you've reassured them that between the team, we have a great chance of helping their pets. However, I believe flexibility is absolutely essential if we're going to keep owners on board and achieve success. So this is what I do.
When I've made my diagnosis, I'll sit down and I'll lay out a strict routine. Many owners really prefer to be told this is what you have to do. But having said to them, this is the plan that I would propose, my next question immediately is, does that work for you?
Because once you find out people's work patterns, social patterns, and so on, we can start to mould and bend our routine to accommodate our owners. Of course, you then need to pick your insulin, select a starting dose, decide on your frequency of injections. You need to think about food, exercise.
Which parameters you're going to monitor water consumption. Wait We're going to think about exercise and then record our information in some form of diary. Many of our owners still like the traditional approach of writing things down, and of course, others prefer modern technology like smartphone houses.
Insulin, of course, is our initial therapeutic intervention in our diabetic patients. My starting dose for insulin for cats and dogs is 0.25 of a unit per kilo based on lean body weight every 12 hours.
Our owners will need tuition to appropriately deliver the insulin to their pets. Certainly consider using a vet pen. For more accurate dosing, especially with smaller doses of insulin.
Or if owners physically struggle with using traditional syringes and needles. Now here's a diary from one of my patients showing twice daily injections, almost bang onto our vowels apart. We look at the 19th of October, we can see that the insulin was given at 7:15 in the morning, 7:30 in the evening.
And on the 24th of October 8 a.m. And 7:50 p.m.
What about here? Let's look at the 3rd and 4th of October. Injections were 7:50 a.m., 8:45 p.m., 1:05 p.m.
The following day, and then 10:45 p.m. So what?
It may not be ideal, but this is a stable diabetic with a good quality of life. Is it acceptable to skip injections? You don't want to do that, do you?
Well, it's certainly not a good habit, and we try to discourage skipping injections. We're taught missing injections might push a diabetic towards ketosis. Let's look at the diary from this same diabetic pet.
The owners went on holiday and the cat went walkabout. So if we look at the 17th to the 19th of July. No insulin at all on the 17th, missed dose on the 18th and the 19th.
Again, not ideal, but no harm arose. So if we refer back to the ISFM guidelines, We need to remember that twice daily insulin injections only approximate to what a healthy pancreas can achieve. We will not achieve perfect glycemic control with intermittent insulin administration.
And so in the grand scheme of things, varying the time of injection by a couple of hours here or there or skipping the odd injection will not cause irreparable harm. But allowing owners the flexibility to vary the times of injection and not stress overly if they can't get back one evening to give an injection, but actually their diabetic pet will be fine. We need to remember to look for and manage associated illnesses and stop medications that may cause insulin resistance.
Neutering entire female dogs as soon as it's safe to do so is prudent. Diet we know can have a profound impact on diabetic management. Maintaining a lean body condition may prevent the development of diabetes.
So why don't we take a look at some of the dietary considerations? It's clearly important to achieve and maintain optimal body condition. We need to feed a food that is palatable, nutritionally balanced and complete.
It should be a consistent formulation. We need portion control, not ad lib feeding. We need to think about the most appropriate timing to achieve the best glycaemic control.
Does the cat or the dog actually like the food? And indeed does the owner like the food, or is there something about the smell, the consistency, or the cost that means that owners don't want to give it. Think again about tailoring the plan to fit the owner's requirements.
Without the compliance of our owners, our diabetic pets don't stand a chance. Treats are OK, it's absolutely fine to give cats and dogs some treats and build it into the diabetic programme, to create as close to a normal existence for the diabetic family as possible. It can be useful to create opportunities for activity, for example, feeding balls that cats have to bat around rather than lie around sleeping all day and just wandering over to eat once or twice during the day.
And of course our dietary considerations need to think about any possible concurrent illnesses for which the, the dietary imperative may be greater than for the diabetes. A classic example of that would be renal disease in cats, where a restricted protein restricted phosphorous diet might be our choice over a high protein, low carbohydrate diet for the diabetes. My final guide guiding principle is empowerment.
Owners ultimately have to take responsibility for their pet's diabetes, albeit under the guidance of the veterinary team. And this empowerment relates not just to the management but also the monitoring of the pet's diabetes. So we just move on to our final poll question then.
Amongst the audience, what do you consider to be the best way to monitor diabetic stability in cats and dogs? Would it be urine glucose testing? Looking at fructosamine, can we just get away with doing spot blood glucose tests?
Or we better do serial blood glucose measurements, what we'd call the glucose curve. Or perhaps you think it's none of these. Let us know what you think.
Right, those votes are coming in thick and fast, Grant. You have everybody riveted and hanging on every word of your fascinating presentation. So folks, keep those votes coming in.
We're gonna give you another 10 seconds or so to to answer. Oh, we're slowing down a bit now. Come on guys, get off the fence.
Give us an answer. It is anonymous. 5 more seconds.
Let's get some answers. And there's an interesting spread. So urine glucose is fairly low, fructosamine coming in at nearly 50%.
Glucose curves are only at 30%, and then about 1/5 of our audience is suggesting that none of these would be their test of choice. Well, for me, all those tests have value. But the best way to monitor diabetes is actually the presence or absence of clinical signs.
If we achieve good glycemic control, that should result in the diminution or indeed the resolution of clinical signs. That's not to say that there isn't a place for these other, monitoring tools. Most diabetics have glucose in the urine at some point each day.
Therefore, the absence of glucoseura usually indicates good glycemic control, and certainly in cats, the absence of glucose would prompt me to consider the possibility of remission. Fructosamine could certainly be a useful trend monitor. But remember, it's a measure of average blood glucose concentration.
And no single value of fructosamine informs about glycemic control. Spot blood glucose concentrations certainly can be helpful. For example, if a patient is showing clinical signs suggestive of hypoglycemia, and a spot blood glucose can rapidly corroborate or rule out.
But again, spot blood glucoses are of relatively limited value. Serial blood glucose curves, taking blood glucose every 1 to 23 hours and plotting a curve, the glucose curve, is extremely important when we're trying to establish the action of insulin in a new diabetic patient or where we've had a patient who was stable and we've lost glycaemic control. But it's my contention.
That blood glucose curse should never be undertaken in stable diabetics as a monitoring tool. Studies have been shown, studies have shown, I'm sorry, that blood glucose curves can change from day to day. And we can be confused by the results of glucose curves in stable diabetics.
Flash or interstitial glucose monitors are becoming more popular, and these allow a remote hands-off glucose monitoring, and perhaps they're ideally suited to the performance of blood glucose curves away from the practise. So that pretty much brings me to the end of the presentation. In summary, we've taken a journey through diabetes looking at some of the guiding principles for management.
Vets, nurses, and owners need to work as a team. We need a clear understanding of the disease, and we require good communication to to achieve success. Diabetic pets cannot be managed effectively without participation from owners.
As stated earlier, it's vital to manage expectations from the outset. Treatment needs to be practical and achievable, and your plan should be flexible to meet the needs of each diabetic and of course its own. Finally, we need to empower owners to implement our plans and monitor their pet's progress.
And with that, I thank you very much for your attention and, we'll be happy to receive any questions. Thank you very much. Well, that was absolutely fascinating.
And I think we could see by the speed at which people were answering those poll questions that everybody was absolutely riveted and paying attention. We do have a lot of questions that have come through. There's a lot of overlap in, in a lot of the questions.
So I'm not going to read specific questions necessarily. I'm just going to ask broad questions of, of covering a couple of them. One of the, common themes of the questions that are coming through is about changing doses and waiting for lengths of time before you, you know, reassess, has it worked?
Is it good or isn't it. Could you give us a discussion around that point? Of course.
So when we are stabilising our diabetics and we do our glucose curves to get a sense of how well our patient is responding. Then typically, we're going to look at the Nardier blood glucose, the blood glucose at its lowest point. And we'll assess how far away we are from ideal.
For me, I'm looking for a blood glucose Nadia of somewhere between 5 and 8 millimoles per litre. I'm happy to see the Nadia just down at the top end of the reference range. We're obviously trying to avoid going too far down and below the reference range.
If our Nadia is at 15 millimoles per litre, we clearly have a long way to go to getting our Nadia down to 6 or 7. Usually it's recommended that we increase the dose of insulin dogs by 10%. But if we have a Naria of 15, it may be that you would increase your dose by 20, 25% in that particular case.
10% probably would bring your blood glucose down a minimal amount. In cats, we tend to increase by increments of half a unit, per injection, at a time. In terms of reassessment, I personally wouldn't recommend reassessing more frequently than once a week.
We'll read in the literature, intensive stabilisation protocols, particularly in cats chasing diabetic remission, where with very close and intensive monitoring, it's recommended that those changes may be made. On a daily basis. But, for the majority of diabetic cats and dogs that we're seeing in primary practise being managed at home.
The secret to success is to start with low doses and build up slowly. More owners are put off by crises with hypoglycemia than a slow improvement in the clinical signs of diabetes. So for me, the rule of thumb would be increased by 10% in dogs and half a unit in cats per injection.
But looking at that Nadia, if it is relatively high, then you can be bolder. Of course, owners should be warned about hypoglycemia, and if they are able to test at home, then they can look at blood glucose at the anticipated Nadia and see where we've dropped. So I hope that addresses the question that's been asked.
Absolutely. We've got a whole lot of other questions coming through. Grant as well pertaining to the timing of injections.
So, to the point of, you know, a couple of hours either side. But how far over do you go before you skip an injection and say, you know, it's been 6 hours that you're late now, don't give it or give a half a dose, that kind of idea. Yeah, that's a good question.
As I say, I'm very relaxed about the 2 hours, so as little as 10 or as much as 14 hours between injections. Clearly if we're getting to 18 to 20 hours from the previous injection at that point it would probably be better to skip the dose and restart at the at the next dosing point. In terms of a reduced dose, I do sometimes do this.
Perhaps we've got to 1415, 16 hours since the last injection. At that, at that point, if I wanted to give a dose, I might give a lower dose in anticipation of the fact that I'm going to give the next dose only 67 hours later. What, what would be your advice then, on the other side of it, if the owners are being, very diligent in giving it, but the animal doesn't eat.
There's a lot of questions about no eating, no insulin, or what do you recommend? So in that situation, yes, owners can get quite worried that if they've injected their animal and their animal hasn't eaten, the blood glucose is going to fall through the floor and we're going to end up with hypoglycemia. Now on the assumption that our diabetic pet is happy and healthy and well.
If the animal chooses not to eat at the time of the injection as the blood glucose falls in response to the insulin, It is likely that that pet will feel hungry and will eat. So if owners are going to be at home, I tell them not to worry, and that it is likely that the pet will eat at some point in the coming hours. If the owners are going to be going to work and the pet's going to be left unattended, then we should always give the owners the option of bringing their pets into the clinic to, to be observed by us in the practise.
If the pet has impending illness, then of course loss of appetite may be a sign that the pet is going into ketosis or about the pancreatitis. And in that situation, failing to eat would be a concern, and, that the owners should obviously be seeking attention from us. That's fabulous, Grant.
A lot of questions coming through about diet. The first part is, what diet do you normally recommend? The second one is, you know, cats that are used to ad-lib feeding.
How do you convince them to change to set meals? And then the third one was, your comment you made about it's OK to give treats. How many, how often?
OK, let's talk about cats. I am a great believer in high protein, low carbohydrate diets. And there is compelling evidence that these diets can produce profound benefits in terms of glycaemic control.
In fact, I would go as far to say that if, you are facing a cat that is on insulin. And you choose to switch from the cat's regular diet to a high protein low carbohydrate diet, I would halve the dose of insulin at the point that you make that dietary change because I would anticipate glycaemic control is going to be very much improved as a consequence of changing that diet. I'm more relaxed about dietting dogs.
There's plenty of literature about the use of fiber-rich diets, and they're absolutely fine. But my practical experience is that most dogs seem to stabilise pretty well if they remain on the food that they've always eaten. So that was in terms of the diet.
Now there were just a couple of other aspects to the question, Bruce, just remind me. Yeah, the other one was about treats and the frequency and volumes of treats. And ad lib feeding versus, sorry, grazing behaviour as opposed to set meals, I think you said.
So in terms of, cats that like to graze, absolutely fine. I'm perfectly happy that cats continue to adopt their preferred eating styles. You can't force a cat to eat two meals a day, one at the time of each injection if it's never, if it's no, never done that.
The important thing with diabetics is that you determine the portion that that animal requires to maintain a lean, optimal body condition and that that portion is then split. Into 2, half the portion is given in the 1st 12 hours, the second portion in the 2nd 12 hours, and then the cat can then choose to eat it when it chooses. Cats exhibit minimal postcranial hyperglycemia.
Treats, treats. I think they are great. The love, the bond between a pet and its owner centres on a whole bunch of factors, but to deprive a diabetic of treats, I think is depriving owners and pets of the joy and love and the bond.
Clearly we don't want it to be the dominant part of the ration, 5, 10%. The idea is to try and keep treats to, the same quantity each day. I think what it's important to remind owners is.
That treating animals is not necessarily about what is given, but rather how it's given. The perception that the owner is making time away from regular meals to engage with their pets. Is more important than it being, a sugary treat or whatever.
So I try and encourage owners to give the pets regular food as a treat, but to give it in a way and in an environment that is different from, from regular feeding. But if they want to give a dog chew, you know, a dental chew or whatever, I don't have a problem with that. It should obviously be a small part of the daily ration and make it consistent.
Excellent. We have a specific question from, one of the nurses on and, they've asked, is it possible to control an acromegalic cat's diabetes or is it best to recommend euthanasia? Well, it's a very specific question.
So acromegaly, as the audience will be aware, is, a clinical syndrome caused by hypersomattotrophies, and that's typically a growth hormone producing tumour in the pituitary gland. And it certainly is the case that in the face of elevated levels of growth hormone, Insulin works less effectively. The degree of insulin resistance is actually very variable.
I've had acromegalic cats that have stabilised reasonably well without specific treatment of their acromegaly on as little as 4 or 5 units twice a day. But the contrary, I've had some diabetic cats on 30 to 50, 30 to 50 units per kilogramme. Per injection To overcome the resistance that is is is engendered by the acromegalic state.
So you can treat diabetics with acromegaly without having to put them to sleep. Some will respond to relatively low doses of insulin. The definitive treatment, as the audience are aware, is to remove the pituitary gland and take away the cause of the disease.
There are some medical treatments that have been, described in, in the literature, but most of that work has been done in referral institutions and is not yet mainstream therapy. But don't give up on these cats. They can be managed with insulin.
You will need higher doses than cats without acromegaly, but some of them can stay stabilise pretty well. Obviously, if you're not treating the underlying disease, the acromegaly, the growth hormone tumour continues to secrete growth hormone, then that will result in significant disease in, in the various body organs and ultimately will lead to organ failure. So that patient may die prematurely compared to a diabetic that doesn't have.
OK, Blaze, if you can unmute yourself, I have a specific question for you. I'm going to ask Grant another one while you're unmuting yourself. Grant, there's a lot of questions about, would you try and, and control diabetes in cats by changing their diet, first, or would you go straight to insulin?
There is certainly evidence that in some cats with normalisation of weights, this is obese cats where we can return them back to a normal body condition, that that might be sufficient to reverse their diabetes. For me, it's important that we do start insulin straight away because the glucose toxicity that's associated with persistent hyperglycemia. Can result in in insulin resistance and beta cell dysfunction and left unchecked while we wait to see whether the diet works, can in some cats lead to a state where the diabetes is no longer reversible.
So I would prefer that we start diet alongside insulin rather than trying the diet first and seeing what happens. Yes, of course, we have to be aware that some of those cats may go into remission. Now, as I alluded in my talk, The only way we can tell that a cat is going into remission is actually to push them to the brink of hypoglycemia because at that point we know that the cat is starting to produce insulin for itself and that the insulin we're injecting is surplus to requirement.
So we do need to monitor for signs of hypoglycemia. But for me, yeah, I would use diet and insulin together. If we're fortunate enough to get, a cat into remission and come off insulin and maintain, good glycemic control with diet alone, that's great.
Thank you. Blaze, welcome back. Interesting question.
I, I personally have never had this from a client, but Bethany says she's been asked by several owners, does the dosing of the vet pen account for the droplet left after withdrawal from the skin? So that really does depend on whether it is truly the dead weight droplet or whether it's actually another issue. So we would expect that, a very small amount of insulin is obviously left in the needle post dosing, and as you take it out the skin, the pressure will cause release.
And that doesn't affect dose accuracy. And that's a small dead weight droplet. However, if the pen hasn't been correctly primed, so when we talk about removing air, the first time we put a cartridge in, or the owner hasn't, held the pen in the skin for long, under the skin for long enough, we advise a minimum of 5 seconds after depressing.
Then actually that could be some of the dose. So I would always double check with these clients, maybe get them to administer a dose in front of you to check that it, it is only that small dead weight droplet rather than a larger volume of insulin. Thank you for that.
Folks, we have got loads and loads more questions coming through. Unfortunately, we are out of time. Grant, we do have lots and lots of comments coming through about how fascinating it was and how insightful and how people have enjoyed it.
So, as Anthony always likes to say, if we were in an auditorium, you would be receiving thunderous applause. Well, that's very kind. Thank you very much.
I, I hope it has been helpful for, for many of you guys that have attended. I was incredibly encouraged that the euthanasia rate was so low, because in, in contrast to what is seen in other parts of the world, where rates are much higher, I hope that's because the training at college and the education that, is available through, through multiple sources. Is improving our knowledge of this fascinating disease, but we will always strive to do better.
So thank you, everybody, and good evening. And I think, just to follow on what you're saying there, Grant, it also comes from a great education and support by companies like MSD like they have done for tonight. So once again, to Blaze and MSD thank you so much for your support, and your sponsorship for tonight's webinar.
Thanks, Bruce. Grant, thank you for your time. Folks, thank you for attending.
I hope you've enjoyed this as much as I have and look forward to seeing you again on the next webinar. To my controllers in the background, Lewis and Phil, thanks for making everything work seamlessly and good night to everybody.
