Hi everybody, welcome to tonight's webinar with me, Sophie McMurra. I'm a registered veterinary nurse and a veterinary technician specialist or VTS in small animal internal medicine. I work for North West Veterinary Specialists, where I'm the head nurse of the internal medicine department, which is part of the Linnaeus Group.
And I also have my own social media platform called Veterin Medicine Geek on Facebook and social media, which you can head over and follow if you do like internal medicine. And today I'm here to talk to you about diabetic nurse clinics and what we can do as nurses, what advice we need to give to the owner, and how far we can go with these clinics. So first of all, we need to think about how the owner will be feeling before we go and delve into a full diabetic nurse clinic.
So these owners have just had a lifelong diagnosis given to them for their beloved pet. They're likely to feel quite anxious, they will have a mixture of feelings prior to coming to this consult. Can I do it?
Am I capable of managing this diabetes? How will my pet be? Will it shorten their life?
And what happens if I'm not capable? So for us, we need to appreciate that this is all very overwhelming on a multitude of levels for them. It's very daunting having a disease, being, being told that your pet has a disease.
It's very emotional. They have emotions on different levels, whether that be the financial commitment that they've just had a massive bill after their pet has been hospitalised for a week, and now it's about to have a continual veterinary bill throughout the rest of its life. Maybe they're not insured and that's quite a big thing for them.
It's also a very big lifelong commitment that not everybody can commit to. But that burden can seem much smaller. After these consults and after the support and the reassurance that we can give to those owners that they are capable and that they can manage it, and although it seems quite overwhelming and daunting to begin with, we are there with them for this whole journey, and they can ask us any questions that they might, that might come up across the the course of the pet's life.
We're only at the other end of a phone call. If they're unsure at all about anything, we would much rather they called and we can give them a quick answer, and a lot of these calls can be directed towards us as nurses. We need to use our professional skills, and if you are capable of doing this diabetic nurse clinic or discharge, you are absolutely capable of answering the majority of the questions that these owners will have.
And if you're not, then it can be escalated to the vet, and that's no problem. But the vet doesn't have to be the first port of call for these diabetic owners. It's all about teamwork and that's where this whole team approach comes in.
The successful management of a diabetic pet involves the vet, the nurse, and the owner, and all three of those components are absolutely vital. But reassurance is really important to the owner to make sure that they know that we are here as a support network and we will teach them, and this is their opportunity to ask any questions regardless of how silly they may feel. So our job as a veterinary professional is to educate the owner, and we need to pitch this correctly.
So we need to speak their language. We don't want to be using a lot of funky terminology, which makes a lot of sense to us and makes us appear very clever. It's not going to.
It's not going to resonate with them. We need to make sure that we are pitching it to somebody who doesn't have that medical background and that education on the terminology and what that may mean. I would much rather speak in layman's terms for an hour and have that owner go out of that consult feeling completely well equipped, well informed.
And capable of taking on anything, even if they go out thinking of the words blood sugar rather than glucose. It doesn't matter, it means the same thing. We need to be on their level and make sure that we are educating them in a way that they will understand.
And also we need to be careful not to assume a certain knowledge level. If the patient was diagnosed with diabetes yesterday or a couple of days ago, the chances are that owner has gone home and has been on Doctor Google. They may come in with a certain knowledge base and some of the terminology, so you think great, they have a bit of an understanding, and that is wonderful.
They're doing what they can to try and educate themselves on their pet's new disease, but what we need to be careful of is assuming a certain level of knowledge. We don't know what they've read and where that information has come from, whether it's from a reliable source. And if we assume a certain knowledge level, we can end up missing quite vital pieces of information.
If they are an owner who says, yeah, I know all about that because I read about it last night, then we can just test that level of knowledge and ask them questions to see what. What they really did learn and we can, or you can even say what I say to a lot of people who I'm teaching. I don't know where your knowledge gaps sit and where you have that knowledge and what how much reading up you've done.
So I'm going to teach you as if you don't know what diabetes is. Please don't be offended. I know that you already have a really good knowledge of this, but to make sure that we're covering all bases, I'm starting from the, from the bottom, and we're gonna work on everything that I would usually feel that you need to take home from this consultation.
Just be transparent with them from the start, because a lot of people will come in with a decent level of knowledge, but that's where we need to make sure that we are filling in those gaps. OK, typically in my clinic I take an hour to go through a diabetic clinic and that includes teaching them what diabetes is. It's important that they have a good level of knowledge, although they don't need too much information in this one hour.
They need enough so that they know what the dangers are, what the symptoms are and what they're looking out for and how to act on those. And then there's a lot more to to cram in. They need to learn to inject and how to manage these patients long term.
So we need a certain level of knowledge, but we don't want to overwhelm them. They're not, this is not a veterinary degree, it's just a diabetic clinic for one hour. So we educate them to the appropriate level.
And then we can kind of trickle feed as the patient goes along this, this diabetic journey and we can educate as we go along. So they need to learn a basic about the basics about what diabetes mellitus is, what is insulin and why is it important to the patient? Why are they having to inject it every day?
What are the signs and symptoms of diabetes so that they can see if the patient becomes stable in the future. Look out for those signs and symptoms that may reoccur again, or also look at those signs and symptoms that may start to diminish as the patient becomes more stable because they are vital monitoring tools. Talk a little bit about the diagnosis of diabetes, which is not always the most straightforward thing, especially with cats.
We need to talk about the possible complications that can occur with diabetes such as hypoglycemia if the pet has been given too much insulin or if they've. Gone on on holiday and being on the beach for 4 hours in in one day, whereas usually they'll spend the day on the couch and they've burnt off more energy than what they normally would. We need to educate them about hypoglycemia and we'll talk about that in more depth in a moment.
Also diabetic ketoacidosis, there may be periods of their life where they become unstable for a multitude of reasons, so we need to be aware of that. Maybe they've already had it and that's why they present it to your clinic. They need to be aware of the treatment and what the treatment involves and how that looks long term.
We need to give dietary exercise and advice on access to water at all times. And the long term monitoring options, such as having a glucometer at home, or also the use of freestyle Libras where you, which you may need to use intimittently throughout the patient's life. And then if we have a a cat in our clinic, then we can briefly talk about remission, what that looks like, how we can gain, how we can put a diabetic pet into remission and what that means for them long term.
So just from this one slide, you can see how much there is to fit into a diabetic clinic. And I'm gonna talk through all of these steps one by one so that we can fulfil that clinic and all of the information that the owner will. So I mentioned about talking on the owners' level, we need to give them a brief bit of education on what diabetes is.
And we know that it's a common endocrine disorder. To them, we can call it a a hormonal disease. We know that the endocrine disease is the disease of our hormones.
So it's a hormonal disease that affects dogs and cats. And to break down easily what is happening and why, why the patient's blood sugar may be high with diabetes is when we eat, our food is broken down and this is our main source of energy, so that we can go about our daily life with a an adequate energy form. Once the energy, the food is broken down into energy, this is in the bloodstream and then we have an organ called the pancreas, which releases insulin.
Now, without insulin we have our, our blood sugar in our, our bloodstream and it can't be utilised. So the insulin is released so that we can use that blood sugar. So look at the insulin as the key to the cell, and without it, the sugar just sits in the bloodstream and can't be used.
So we need that key to open up the cell and send that blood sugar in. Without it, you will just have glucose sat in your bloodstream and it will continue to become elevated, so it will, you will have a really high level because you're just not able to utilise it. And when the pet is diabetic, they either can't produce insulin or they have something that's causing a resistance to the insulin that they are producing, meaning that it's not able to act as effectively as it should be able to.
So that key to the cell is just not there or not being used. And that's where we come in with the injections of insulin. And once we administer that insulin, it brings down that blood glucose because it's now gone into the cell, the body can then use it as energy.
Now the signs and symptoms that we look out for and that the owner may have seen at home already, is passing urine more frequently, so we call this polyurea. Drinking more, so Polydipsia. And then the patient may want to eat more than usual, so an increased appetite which we call polyphagia, and that's the three Ps that we need to look out for, for many endocrine diseases, and diabetes is one of them.
And the reason they want to eat more is because their blood glucose, so their blood sugar is sat in the bloodstream, but we can't use it. So. If we can't use it, the body can't survive without energy.
Every cell in your body needs energy in order to survive and to work effectively. So the body will then go to the fat and the protein stores in the body and will break these down as energy instead. But the body doesn't know that.
So it's, it's sending signals to say eat more, eat more because the glucose level is. Even though it's remaining high, we're not able to use it and the body's natural mechanism to increase your blood glucose is to eat. So that's why you may, despite the polyphasia, you may still see weight loss because the body is having to divert it's normal process and go to the fat and the the protein and break that down.
To use as energy. And the reason that we have polyurea is because we have a high glucose level, high sugar level in our blood, which then goes to the kidneys, it's excreted in the urine. That causes what we call er an osmotic diuresis.
So it just, the urine has a higher osmotic pool and it withdraws the water with it because it's just so sugary, it just withdraws that water as well. And if we don't have access to water. We can very quickly become dehydrated, so water is absolutely vital for our diabetic patients and in terms to compensate for that increased polyuria or urinary output, our body sends a signal to say drink more and then they become polydips polydipsic in response to the osmotic diuresis which is causing the polyuria.
So in order to diagnose diabetes, it's not always very straightforward, and particularly in cats. We know that cats can have a stress hyperglycemia. So if they are stressed coming into the clinic, we can see a stress hyperglycemia, which can also be high enough to send some glucose into the urine as well.
So they can be particularly tricky to diagnose. And we need to look at a multitude of things, so signs and symptoms of diabetes that we've just mentioned, a persistent hyperglycemia. So this needs to be across multiple readings and we need to see glucoseuria as well, persistently to make sure that we are correctly diagnosing the cat with diabetes.
That's why it's not just a simple. As doing one test, sometimes we may need to do multiple with cats because it can be a bit more tricky. We also need to screen for any concurrent diseases, so maybe the patient has kidney disease, cardiac disease, hepatic or pancreatic disease, and some of these other concurrent diseases could be the cause of the diabetes.
So we talked about cats in particular may still be producing insulin, but there's something causing a, an insulin resistance. And that could be one of these other diseases. And it's absolutely vital that if there is a concurrent disease going on, that we treat that concurrent disease because that may then stop the insulin resistance and may even send the cat into a diabetic remission, but we'll talk about that later on.
And If we don't treat the even if we don't gain remission, if we, if we don't have a successful treatment of the other concurrent disease, it will make the treatment and the management and the control of our diabetes very difficult. So we need to make sure that we're looking at both diseases here if there is one, and that we detect it early by test using other tests and looking at the patient from other angles, so whether that be, run more bloods or do some more diagnostics to make sure that we are ruling out any concurrent diseases before we start our treatment. We need to educate the owner on some of the complications which can occur with diabetes, because that may be one of the questions that they come with.
What if I don't treat the diabetes? Well, without treatment, diabetes can lead to some very serious issues such as your diabetic ketoacidosis. This is a serious complication and it can occur if it can occur at any point.
Maybe they've presented with diabetic ketoacidosis, or maybe they're stable and then they've got a source of insulin resistance like a. A concurrent disease that's occurred or the patients become unstable in some way, they can then go into a diabetic DKA, later on down the line. And when we talked about how the body goes to fat and protein stores with before the patient is managed for their diabetes, as that fat is broken down, it releases ketones into the bloodstream.
These ketones at high levels are dangerous and they cause changes to our acid base balance our pH in our blood, which we know needs to stay in a very fine tuned range. Anything outside of that range can have really dramatic effects on the patient. It also changes our electrolytes and can cause a severe dehydration, so the patient can become seriously unwell with this disease.
And it can quite quickly become a life threatening emergency if it's not dealt with effectively. And then another complication of diabetes is hypoglycemia or a low blood sugar level. So we need to tell the owner what a normal range is in order for them to know when the patient is going into a low blood sugar range or a hypoglycemic episode.
And every textbook that you read will say something different, but around 3.2 to 8.5 millimoles per litre is what we tend to go off in the veterinary field.
Textbooks will vary from this, but if we can use this as a rough guide for the owners, then we know that what we're aiming for. And quite often diabetics may still remain above this normal range, and we may never get them to within this, this range at all, but that's not what we're aiming for. We're aiming for the resolution of symptoms and improvement of the patient's quality of life and for.
To minimise complication risk, so even if they do sit slightly higher but all of those things are achieved, that's absolutely fine. We don't always get every patient into this normal range. They need to know that a low blood sugar level is much more dangerous than a high blood sugar level.
They can live for a while with a high blood sugar level, but a low blood sugar can quickly become very serious, and they can also die from this if we don't act quickly. So they need to know about the signs of hypoglycemia. So if the patient becomes lethargic or weak, if they become very hungry or ravenous for food, more than what they usually do.
So we mentioned earlier that if you are, if your blood glucose is low, we use that glucose as energy so the body will tell you to eat, so they may want to eat more. And you know yourself, if you've had a period where you haven't been able to eat and you think, God, I'm starving now, you might even become weak and shaky. They are signs of a low glucose level, so we may see that in our veterinary patients too.
It could even go on to twitching and seizures. The patients could collapse and become unresponsive and they can even go into a diabetic coma. And if the owner suspects a hypoglycemic episode, it's very important that we act on that.
If we act on it and we were wrong, fine, it's not gonna do much harm. We might see a a spike in our blood glucose on that one day, but we could have saved the patient's life. If we don't act on it because we think, oh, but what if I'm not right, then the patient could become seriously ill or even die.
So it's it's very, very important that we act in doubt. Now we need to give the owner an action plan so that when they're outside of the veterinary clinic without any veterinary advice, they know what to do. So they've gone walking in the hills somewhere or on a park, they need to know what to do without us being there.
So first things first, go with the most natural method. If the patient is conscious, give it some food. It doesn't need to be, it's normal diet, just give it any food to prevent a hypoglycemic episode.
If they're unconscious or they won't eat, we need something sugary to go on their gums. So I would recommend a glucose gel or honey or syrup or anything you can get hold of, mix some sugar in water, just make sure it's not too thin a consistency. We don't want the patient to aspirate, make it really thick, like a gel.
Once they've done this, phone the vet straight away so that we can give them some advice, and we may recommend altering the next insulin dose or time depending on when this has happened. Ideally, you want to keep a glucose monitor and a glucose gel at home in case this does happen. I would also recommend having one in the handbag or in their car if they take a lot of car journeys with their pet.
The glucose gel that I would recommend is glucogel or Glucoboost, they have many different names, you can usually get them from us at the vets, but you can also buy them at the pharmacy. And the glucose monitor is an alpha track blood glucose monitoring system which is calibrated for veterinary use. There's absolutely hundreds of these out there.
Not all of them are calibrated for veterinary use, and if they are, some of them are not great quality. This is the one that we would recommend. I think they're about 90 pounds on Amazon, so they can order one and get it by tomorrow.
If they don't want to go for this, there are other ones available on the market. But having this safety net that will allow them to just quickly take the patient's blood glucose and then act on it. If they don't have one, if in doubt, act on it anyway and just put some glucose on the gel on the.
OK, so we need to talk about the treatment of diabetes and as we mentioned earlier, the treatment of diabetes in a cat or a dog is different to that of a human. So we don't need to get these patients within that normal blood glucose range. We don't need to get them fully back to normal.
What we need to do is resolve the signs and the symptoms of diabetes. Which will reduce the risk of diabetic complications if we get them under control and to a stable level, and it will also improve the quality of life for both the pet and the owner. We need to remember that the pet, Excuse me, the pet is not the only one going through this journey.
The owner is as well, and it's a very big life change for both of them. So we need to do what we can to improve the quality of life for both the pet and the owner. So the insulin, insulin is the main treatment source of diabetes mellitus.
There are other things available now on the market, but I, up to this date, they're still very new and I don't have any experience using them. So my focus today is going to be on what I know about and that is insulin. Now there are different types of insulin.
They do all vary, and they don't all suit every single patient. So they vary in strength and their half life also varies the duration of action. All patients respond differently, we're all unique and so are the cats and dogs.
And sometimes it can take months to fine tune and perfect the the type of insulin that the patient needs and also the dose as well. So we don't start off thinking this dose and this insulin that we've given now will be the same insulin and the same dose for the rest of this patient's life. We hope that that insulin will suit this patient so that we can keep it on it.
The dose, we will have to titrate to effect, so. We usually start off at the lower doses because it's so much safer to start off at the lower dose and build it up gradually with gaps of, say, 14 days in between each alteration of the dose. Much safer to do it that way than to jump at the higher level and cause a hypoglycemia.
So this may take a course, a series of months, especially if we have patients who have other concurrent diseases alongside that can be much more tricky to try and stabilise, so. Be aware and make sure the owner aware that this is a long lengthy process, but together we will hopefully achieve the correct dose and the dose that is adequate for their pet. We need to make the owners aware that insulin for animals is different to that of humans and the same for the syringes as well.
The syringes for veterinary use are different to the human syringes, so they should only use what has been prescribed by their vet in order to prevent any dangerous things occurring to their pet. You hear it all the time. Oh, my husband is diabetic, so I can use his syringes or my such a person is on antibiotics, so we just use some of those.
Absolutely cannot happen in this case, must be a veterinary. Prescribed product with the the matching syringes because even some of our veterinary syringes are not appropriate for the different types of insulin. So we need to make sure that they are the correct type prescribed by the vet.
Now, typically insulin we give 2 injections at the same time every day, roughly as well as close as we can to being 12 hours apart. We need to give this at the same time as food, we said that our food elevates our blood glucose level, so we give the insulin at the same time to prevent any. Big peaks and troughs, and so that we can act on that inch on that glucose and bring it down to a more adequate level.
We give it at the same time as food, however, I do like to recommend to check that the patient has eaten around half of the meal first to prevent hypoglycemia. If the patient's having an off day and thinks, oh, actually, I don't want to eat right now, but we've already given the insulin, we're likely to see a hypoglycemic episodes, so I think it's much safer to just wait until they've eaten half of their meal first. Cats can have food left out for them through the day and when we give the insulin, we give this through the tinted skin between the shoulder blades.
But we'll go into that in more depth when we teach the owner how to inject. Now storage of insulin is very important because it can affect the effectiveness of that insulin. I would recommend putting it in its own little tub, maybe a Tupperware in the fridge on the shelf, not in the door, because the door is opened multiple times and it will fluctuate the temperature of that insulin and it needs to be on a nice steady.
Kept at a steady temperature. Don't put it too far to the back where it may be near the, the frozen panel at the back. Have it just in the middle of the fridge in its own little tub where it can stay and stay at the correct temperature for storage.
Now the different insulin types do differ slightly, some of them say to shake. Others say not to shake, but just to gently rotate. So always as the veterinary professionals, we should read the data sheet or have a be familiar with the different insulin types before we go into that consult so that we can tell the owner which one, this particular insulin, what we should do with that particular insulin.
And then we need to teach them how to draw up. And this is the part that I think we take for granted and we think, oh, it's super easy drawing up. It's not if you've never touched a needle or syringe before, and actually I think this is the part that I go over probably the most when it comes to injecting.
We teaching the owners to inject the drawing up process, they seem to get a little bit confused with, so I always make sure that they've repeated this back to me a multitude of of times because they do seem to get a little bit overwhelmed sometimes with the the drawing up process. I would practise with water for injection and practise on a teddy first, just to demonstrate everything to them. And when we tell them how to draw up, it's very important that we don't just do it because it's second nature to us, and we just say, oh, this is what you do, you just draw it up and you give it.
We need to demonstrate everything so that it's a visual reminder for them and they can take that home and they can understand every part of that process. So whether we mix or we rotate the insulin, we then need to hold it in an inverted position. The needles and syringe are always attached so we don't need to go put the needle onto the syringe.
Sometimes they come with a protective hub over the plunger, just remove that first. So invert the insulin. You want to insert the needle into the centre of the hub and make sure that it's going in straight rather than on an angle, because you could just be going straight into the rubber if you're going on an angle, and you won't get the appropriate level, if any, insulin in your, your knee, your syringe.
So it's going in straight, you should see, depending on the colour of the bottle, you might see the needle sat in the insulin once it's inserted correctly. You then need to turn the needle and syringe to make sure that you can read the measurements. I've had owners put the needle and syringe in.
And then just start drawing up to where they think that you drew up to and then they'll say, oh, is that OK? When the actual measurements are facing the wrong way and they're not looking at them, because this is very overwhelming. They've taken in so much information.
This is probably the part that they're most nervous about. So just break the steps down and show them and then get them to repeat it back. So turn that needle and syringe so that you can read the measurements, point out where they're going to draw it up to.
And do it nice and slowly so that you can prevent air bubbles. Sometimes people are shaking or they'll just draw back really quickly. If we do it nice and slowly, you will get the the appropriate amount of insulin without the air bubbles.
If you do get an air bubble, we need to teach them how to get rid of that. Don't worry, you can just flick the syringe to make the air bubble go to the top and then put it back into the bottle and then redraw up again. If you've got loads of little air bubbles, just put it all back in and start again, nice and slowly.
Remove the needle from the bottle and you're ready to go. Now before we go on to the next step, hand that needle and syringe to the owner with the bottle, ask them to demonstrate it back. Do this as many times as you need to until you're confident that they can action all of those things at home when you're not stood there.
You can also ask questions to test their knowledge. So what if I've drawn up and I have an air bubble? What do I do then?
What are the ways of getting rid of that air bubble? What can we do? And just test that they've been listening to those the parts of the information that you've given them, because it is a very daunting task, but we need to be confident and make sure that we know they can draw up the correct volume and they know how to use that needle and syringe.
Once they're confident, we can use that needle and syringe and we can inject into a teddy, which I like to use. I know some people like to use like oranges because the consistency of skin, but I personally just prefer to have a teddy there where they can picture their animal and go into the back of the the teddy in the same way that they would for their pet. You can ask owners to repeat this back to you as many times as you need to.
Tell them this consult is for them, not for us. Utilise it, become confident with it, and ask any questions that they may have. Nothing is silly because they've never done this before and they need to use and abuse as much as they can in that consult so that they get every bit of information and they leave with a lot of their questions answered.
You can also use vet pens as well, which are useful for some owners and not so useful for others. The vet pen, you would use the insulin, you kind of, it's, I don't actually have a picture of the vet pen, that would have been useful, but I'm sure you've all seen them before. The insulin is in the pen, you then just turn the the dial to the appropriate level that you need, you use a new needle on the end and then you would inject the pet by just popping the needle into the skin, clicking the button and it does it for you at the appropriate dosage.
You would then have to hold it in place, depending on what vet pen you're using, you have to hold it in place for a minute or two. Sometimes that's the part that the owners don't like and keeping the pet still after the injection is the tricky part. So they either love or hate the the vet pens.
I personally think they're great and they're really useful, especially if you have some older clients who, Find it difficult to utilise the needle and syringe, which can be a little bit fiddly, then these vet pens are absolutely brilliant for those owners. And then once we've taught them how to inject and what the insulin is used for and it's important, we need to talk about the diet that we can then go on to. Diet is very important for our diabetic patients.
We know that carbohydrates are converted into sugars, so ideally we want a lower carbohydrate diet with a higher protein level. And this will just prevent any fluctuations in our blood glucose levels. We mentioned about polyure and polydipsia and dehydration being at a greater risk for these patients.
So wet food is very good because it has the higher moisture content. However, if the patient does have a dry diet, that's absolutely fine as long as they have full access to water at all times. And one thing that I think is quite often overlooked is that we need to measure the food.
We can't do a guesstimate, we can't just guess how much food we're given and think, oh that looks about the same. If we're trying to achieve a patient who is . Achieving a normal glycaemic range throughout the day, how can we expect that range to not have fluctuations if we're given different amounts of food.
That food is where we get our glucose from and it will be higher, even if our diet, we've guessed and we think it's the same amount, but it's higher by 10%. That will elevate our glucose by 10% more. So we need to be measuring our meals, give exactly the same amount in each meal and at the same time each day.
And then if we do give treats throughout the day, that's gonna spike our glucose, so we have to expect spikes in that glucose and. For the patient to become stable over a much longer period of time because they're not going to achieve that normal glycaemic range, and especially during those early stages, if the owner's given treats through the day, we may see that patient as unstable, but it's actually because they're just giving treats instead of listening to our advice, and if they give no treats at all, then that patient will achieve a more . A quicker eugglycaemic range and will become stable much quicker.
So although, yes, a treat is a lovely thing. Ideally, especially during this, the early diagnostic proc period and during that early treatment, we need to make sure that we are staying away from treats. Cats are slightly different and they can graze on dry food throughout the day.
That's absolutely fine for cats, but not so much for dogs. And we talked about insulin resistance, especially with cats. This can happen with both species, but cats seem to be affected with, by obesity causing an insulin resistance more.
So obesity is A very important thing to diagnose and also to manage, and it can also help cats go into remission if we can resolve the obesity or the weight issues. So weight loss is really important part of this journey, especially if that's what's causing the resistance. And to show some statistics in the UK, around 75% of dogs are overweight or obese, and around nearly 40% of those are juveniles.
And about just under 40% of cats in the UK are overweight or obese. Those numbers are different slightly in the USA, so around 60% of cats and 56% of dogs are overweight or obese. So a large chunk of those may be the patients who are becoming diabetic because of the resistance that obesity causes.
So we can help get that obesity down, get that weight management managed well, and then the patient will have a much healthier life. However, we need to make sure that anything that we do is done gradually over a long period of time. This is a lifelong condition, we don't need any dramatic changes.
And actually, if we change the diet and the patient is not keen on that diet, we need to make sure that we are just switching back. We cannot have a diabetic patient turning its nose up of food because we've changed it. Because we, we are more likely to then have a hypoglycemia.
Just give it its normal food back and we will tackle it again once we're back to normal. So if we are changing the diet, gradually mix the new diet over 7 to 10 days. So just take out a little bit of the food and mix in the new diet so that they don't notice quite so much.
And if the patient has a concurrent disease. Choose the diet for the other condition over a diabetic diet. Some other conditions are really reliant upon er a change of diet like your kidney disease or any gastrointestinal diseases.
So go with that diet first and then we can just titrate our diabetic management to suit the needs of the other diet. Equally, when we look at exercise. If we are trying to introduce things like these, the toy feeders to dogs or cats, so they have to work for their food, we need to make sure that they are able to use these things before we just give it to them.
So let them test it out first. If we try to introduce a puzzle feeder to our dog or cat and they actually can't figure it out. You're running the risk of them not having the same level with the same amount of food in that meal, and then we go and give them their insulin.
So we talked before about how important it is that they, they receive the same amount of food in each meal. And that's something that we need to be aware of when we're giving them these different puzzle feeders and things. Absolutely great, but just do everything gradually so that they have time to adjust and they have time to figure out what they what they need to do to get that food.
But it is a great source of exercise. And our exercise needs to be consistent. We need to figure out if this is an owner who works long shifts, doesn't walk their dog for 5 days a week, and then they go on mammoth journeys up mountains over a weekend, that's not going to work for a diabetic pet.
Those mammoth journeys of a weekend will require a much greater energy source and will burn off a lot more of that blood glucose and will risk a hypoglycemic episode. Consistency is key, smaller, shorter walks, as long as it's consistent every single day will be much better than those long journeys of a weekend. It also helps to maintain that norglycemia, so the body gets into this normal rhythm and normal routine.
We eat, we exercise X amount every day, and it helps achieve normal glycemia. If we have a high glucose level in our bloodstream, exercise will help to bring that down because we need to use it as energy. So it just plays an important role in a healthy lifestyle.
And it also helps us manage our weight loss. Now we need to pay extra caution to pets who go on holiday and exercise more. The amount of times you hear owners say, oh, we went on holiday and Fluffy was on the beach for 6 hours running around and then had a hypoglycemic episode.
We need to make sure that this is not happening. If the owner goes on holiday, they need to make sure that they are reducing that pet exercise and staying consistent to what their normal routine is. Because they will just burn off more energy and that's quite dangerous for a diabetic.
So consistency is the take home message when it comes to exercise. Water excess, so we said about the increase in our glucose level then goes to our kidneys, which is then excreted through our through our urine. That causes an osmotic diuresis which pulls the water with it.
They're at much greater risk of severe dehydration, and this can become severe enough to cause a coma or even death. So if the owner, especially if they work long shifts, they'll inject the pet in the morning and feed them and then they go out for 8 hours. They need to make sure that that water bowl is big enough that it won't run dry and fountains are ideal as well.
Have a multitude of bowls or fountains available so that the pets, if they, you know, if they do run one of them dry, there is multiple sources of water available. Absolutely vital for us. And infections, so a diabetic is somewhat immunocompromised, so they are more likely to develop infections.
Excuse me, one of the most common things that we see is a urinary tract infection. So that bladder is just a perfect reservoir for an infection because they have a large amount of sugar in the bladder, it's just sat there and the bacteria can thrive on that. Urinary tract infections are common and if we do .
If we do think that one is a caring, it's absolutely vital that we take a urine sample and test it and then we treat it as well. But infections can occur anywhere in the body. They can have skin infections, especially if you are, if the pet is a breed that has skin issues, ear issues, any infection can, is a cause.
Of or can be a cause of insulin resistance. So if we have a really stable pet who's had diabetes for 2 years, really stable, and then they suddenly become unstable, we need to look for infections as a source of instability because it can even be enough to cause the onset of an unstable diabetic and even cause the onset of DKA. If gone untreated, so we do really need to look at infections if the patient becomes unstable, and we certainly need to treat.
And then long term management, so what does the long term monitoring look like for this person's. Diabetic pet. They don't know what this looks like.
Is it going to be this overwhelming and this time consuming throughout the whole of their life? Absolutely not. They will get used to this.
It will become second nature to them. They will know their pet, they will know the routine, and they will then easily, quickly pick up on any issues if they do occur throughout their life. And what we, what we deem as a stable diabetic is a pet who has a good appetite.
They drink a normal amount. They urinate normally, so no PUPD or polyphagia, so those three Ps that we like to talk about. They're maintaining a stable body weight and bodily condition.
No signs of any hypoglycemia. And be aware that it may take months to get hold of this stable diabetic state. So be patient and it doesn't mean that either of us are doing anything wrong if we don't achieve it quickly.
Concurrent diseases like renal disease or heart disease or anything that the patient may have alongside this can make it really tricky to gain a stable diabetic management and it may even make it impossible sometimes, depending on what the, the disease is. So we need to make sure that we're looking at both of those conditions, looking at the treatment of the other condition. And seeing how we can kind of fine tune to make those both work well, if at all possible.
It does require teamwork. This is a long standing condition. It's something that the pet is likely to have for the rest of its life, and we need to work together.
We are always there at the end of the phone for the owner, so at any point, if they're unsure, they can give us a call, but. Just reassure them that they are capable of this. They're able to do this and this, these are the signs that they are looking out for.
. And then monitoring our glucose, there's a few different ways that we can do this. So we've always done blood glucose curves, which are useful, but we've also moved on from those as well. They can do glucose curves at home or they can have a a stick glucose monitor at home so that they can do it if they're ever uncertain.
We also look at fructosamine, which is, our glucose is protein bound and it tends to, bind to some of the proteins which last around 2 to 3 weeks in the body. So if we look at fructosamine level, it will tell us what that blood glucose has done over the course of the 2 to 3 week period rather than individual spikes on a daily basis. So that is particularly useful.
And now we tend to use a continuous glucose monitoring device. Intermittently we may use these throughout the diabetic pet's life. And the one that I would recommend is the freestyle Libra.
They are human sensors. They're designed for humans, not for pets, but they do work very well. They're small discs with a small subcutaneous needle that just sits in the skin, and you can see one on this picture here, which is a cat called Kitty, and she has a freestyle Libra placed just on her lateral thorax.
Now this device measures your interstitial glucose, not your blood glucose, and we'll talk about that in the next slide. They link to a mobile phone app, so the owner can scan it once it's been placed and they will be able to look at the patient's glucose on their phone without having to do a a stick, a blood stick on their pet. The the phone then acts as a sensor, so they literally just scan it.
We can also use a reader that we have in practise or our practise has a a practise mobile phone which we use for freestyle Libras, so we will scan it on ours as well if we're using these in the hospital environment. We can also link it to our Freestyle Libra account which we can look at on our computers and we can pull up loads and loads of data while the pets at home. Every time the owner scans it, we can look at all of that continual information we can look at.
Averages over the day, the week, the month, owners can use them as a diary so they can log what food they've fed, what time, the amount, what exercise they've done so that we can look at trends if anything occurs or if there's any peaks and troughs that we have questions about. Each time the owner scans the device, it gives you a current glucose and also the glucose trend from the last 8 hours, and it will look at the trends whether it's going up or down. You can also set an alarm for hypoglycemia, so you can say to the owner or you can help them set it up on their phone through the app in the consult, which I tend to do.
Set the alarm to go off anything below, say 5 millimoles per litre. That will give you that small window so that if anything, if the glucose is starting to approach 5 or go lower than 5, even if that's within a normal range, we don't often see diabetics going down to that low unless it's about to have a hypoglycemic episode. If we set it at 5, it gives us a little bit of wiggle room to play with, and it will allow the owner to then go and get their glucometer, go and get their glucose gel, and to know that they need to monitor their pet for the next, say, half an hour or so until we start to see that glucose going back up if if necessary.
So I mentioned that these glucose devices measure interstitial glucose rather than blood glucose, but what does that mean we're not used to measuring that in the veterinary field. So interstitial glucose and blood glucose do equilibrate. So they are, they will.
Show the same number, however, there is a slight time lag between them. So the blood glucose, the way I like to describe it is like a series of train carriages. So the first train carriage will be your blood glucose, the most up to date, and that will give you the most, it responds to the most rapid changes that will be relevant to your patient at that moment in time.
Whereas the interstitial glucose represent the carriages lagging behind. So they will follow the same trend. There's just a slight time lag.
And where that comes in as being important is during those times of rapid change. So if your pet or something has happened, you've just given insulin or they've just been on a long walk and their glucose is suddenly dropping rapidly, that time lag may may be of greater concern. So we need to, if we're concerned, maybe our readers just beeped, it's gone, it's hit 5.
OK, 5 is OK, but we need to be aware that if it's dropping rapidly and the, the sensor will tell you that so it gives you an arrow, either a gradual arrow or a a straight arrow up or down for the rapid change. If it's 5, but it's got a rapid change going downwards trend, then we need to have a look with our blood glucose if possible. Because the patient may be about to enter a hypoglycemic episode.
These, these readers will give you a reading every minute. So, so much more information can be taken from these rather than a blood glucose every hour or every 2 hours. The glucose curve every 1 or 2 can miss peak so the nadir.
So this gives you a much more detailed picture of what's going on. And it will also give you a much, your vet a much easier . A much more detailed picture to allow for easier treatment decisions.
So if you think, oh, I don't know if that's a smoji over overswing. You could be acting in the wrong way and have these questions in your head. Oh, but what if and what if?
Because you've got huge gaps of hours in between these readings. This gives you a reading every minute, so you won't miss any of those things, and you can have more confidence with your treatment decisions. There's no calibration needed, unlike some of the older veterinary, the, the veterinary devices that have been available on the market like the Dexcom, which was actually quite tricky to to work and to calibrate.
All you need is to fit the sensor, scan it on the owner's phone, and it will take one hour until it will start reading. So scan it during, download the app on the owner's phone, during the consult, scan it with them, and then you've set the timer off then. So within an hour they should start to get readings.
And it also allows you to test if that sensor is working in the the consult room. Now it says up to a 14 day duration. If you achieve 14 day duration, then well done you.
Because I think on average, you get, I tend to see anything between 8 and 12 days, but some of them do get less than that. Even if you do get less than that, those, say, 5 days that you've achieved is still giving you a much more detailed picture. We don't do blood glucose curves over the course of a week or 2 weeks, so 5 days of that sensor before it's dropped off is still giving you so much more information, so they are still worth it.
And there are several advantages of using these, so one, they prevent you or the owner having to do a blood glucose stick on the owner, on the pet every hour or two. That equals less stress for the patient, less interference and less pain. Cats get stress hyperglycemia, so you're in the home environment, it's just on the pets.
They don't interfere with it usually. It doesn't hurt them. They're barely even aware of it, so you're going to get a much more accurate reading of what's going on with that pet glucose without the interference.
Now there are some downsides. This is a human device, so it reads high, anything above 27.8, it won't give you any reason above that, it will just say hi, and anything below 2.2, it will read as low.
Which we know that our pet glucose sits a bit higher than that, usually around 3.2 to 8.8.
However, you can set an alarm to whatever you would like this to. It just doesn't give you that detailed information outside of that range because it's a human device. Feline patients approaching remission, these are really useful because it tells you that the owner, that the pet's glucose is sitting at that lower level, so they're really useful for patients who you think are approaching remission.
They're useful for early diagnosis, so. I wouldn't use these if you have a pet that comes in and it's glucose is sitting in the 30s or even 40s range. Maybe they've had a week in hospital at the time of discharge, these are really useful then because they're now on the insulin, the glucose is starting to come down and it allows you to monitor that trend.
It also gives the reassurance to the owner as well, so that they have a device there which they can see and they can look at and know that their pet is safe. And it just gives that extra reassurance, so it's good during the early phase of diagnosis. Dose changes really useful or any periods of instability, pop one of these on, see what's going on.
And also if the owner goes on holiday, we talked about quality of life being very important to the owner and the pet. If the owners go on holiday, they're going to have to find somebody to inject. If they can just pop one of these on, it allows the owners to have that bit of reassurance to know what's going on with their pet, and whoever's looking after them can just scan it with their phone.
So it's one less thing for them to look, to look out for. Ouch. Now as nurses, this is absolutely a nursing skill.
If your vet is doing these, I'm going to teach you how to do it so that they can step aside and go and write their notes or do whatever else they need to do while you place these freestyle Libra devices. You can place them, you can manage them, you can communicate. With the owner and check the data and just liaise with the vet.
I talked about teamwork in my first slide. Diabetes is something that we can completely take the reins on with the input of the vet and the owner, and we can lead the way with this condition. So let's start that by placing the freestyle Libra, and I will teach you how to do that and what the complications are likely to that may occur.
A lot of people may have already done this in practise and been using them already, but those of you who aren't, hopefully you will learn and be confident to place in these because they are super, super easy, after this step by step guide. Now I've always placed them conscious. If you do have a patient who is getting a sedation, you can do it while they're under, but they don't usually require sedation unless they are particularly anxious.
Then you can use there's plenty of anxiolytics out there on the market now and if that doesn't work, then we may sedate the patient, especially if they are undergoing other procedures. But usually, it's a pain free. Procedure and you can just do it in the consult with the owner.
I've even taught owners how to do this as well and they can do them at home, and they get really confident and they're great at doing this. Now with regards to location, the lateral thorax I've highlighted in red because it seems to have the lowest complication risk, possibly because pets are so agile, if it's one of the areas which doesn't move quite as much as the the rest. Having said that, you can put it wherever seems suitable for that pet.
So whether that be on the dorsal thorax rather than lateral, it can go on the the neck, it can go on the flank, on the abdomen, wherever you think the patient is less likely to interfere. And have a feel of the patient. If they are a little bit underweight, you don't want to go over any bony areas and place it where you seem fit.
And you will see a number of different pictures throughout this talk of them placed in different areas. You should have an assistant just holding the patient to keep them still. You need to clip the area because these sensors are made for humans, not for fairy pets, and clean it with an alcohol wipe.
You don't need a surgical scrub for this, just alcohol because if there's any grease on the skin or excess dirt, it won't stick properly. So just use an alcohol wipe or two just to get rid of any of that grease. And then allow the skin to fully dry before you go placing it on.
I like to use the adhesive sprays as well, the same as what you would use if you're placing a primer pore, and the dressing that kind of sits around the centre is just like a primer pore. So I think they're not overly sticky, and again they're made for humans who aren't overly hairy. So, by the end of that 2 week mark, that fare will have started to grow back, and the detachment rate just increases as the fare grows back.
So, if you can use some of the adhesive spray, that will give you a little bit of extra hold. And I tend to place some small dots of tissue glue around the adhesive layer and I'll show you that in a moment. But we need to avoid any excess amount of glue because.
We do sometimes see skin complications and that's highly likely to be from the glue. I think without the glue it just won't stick and you're not gonna get a very long period out of this. But with too much you can cause some skin irritation.
So we need to cause we need to just apply the correct amount in order to the complications. Now before we go placing it, we need to prepare. In the box, you will have a sensor pack and an application.
What we need additional to that is the alcohol wipes, some clippers, tissue glue, tissue forceps, and I personally like to just leave these. I don't cover them up. Some owners like a Buster collar on their pet, some owners like a t-shirt, a Sergi fix, or a primapo.
This odour in particular of this husky that I had, they loved a prima pore over them. I think it just made them feel a little bit more secure, even though the pet couldn't reach this device, which was just placed on on the door some. I would just leave them, but it depends what you prefer, what you get used to, and what your practise likes as well.
So take both parts out of the box, open the sensor pack and remove that lid fully. So that's the image you can see here to the left with the foil lid over the top. Some people think they'll just peel it back.
It needs to be completely removed so that we get a proper application. Unscrew the applicator and set the cap aside and then as you can see in this second image, line up the two marks so that it's in. Delicate application.
So the applicator is in line with the, the sensor pack. And then once it's in line, just press down straight down until it stops, you'll hear a loud click. That means that the applicator is now connected to the sensor and.
Now I mentioned about the small dots of blue, so you can see on this image here, I would say put about 8 to 10 small dots of glue around the outside of the sensor. And that just allows small amounts but not too much. You may still get a little bit of skin dryness, or complications with this small amount of glue, but hopefully it won't be too much that it will just disappear on its own.
You want to place the application and you can just see the small needle in the in the centre of the the sensor there as well, just like the thickness of a a thick hair. You want to place the applicator over the prepared skin and then once you're ready, hold it firmly and just press down until you hear a loud click. Keep that in place for about 30 seconds, you want that glue to dry and you want the the adhesive dressing to also stick to the skin before you just quickly pull it off.
Now the reason I say use forceps is because sometimes some of this glue comes out and decides to stick to some of the sensor. Now that's fine, it does just easily peel off, but I often go around with my forceps and just pat down and make sure you've got good contact with that dressing onto the skin and then just hold it before gradually peeling off that applicator. So you want to just take it off gradually so that you don't risk pulling the sensor back off the skin.
And then once it's on, check it's all secure, pat any dressing down if it's not if it's sticking up, scan it with the owner's phone, and then the clock has started within one hour. By the time they get home, it will hopefully be starting to work. Now the owners need to transfer the data off this sensor every 8 hours, so they need to scan the sensor with their phone, a minimum of every 8 hours.
But the more they do it, the more information we will get. But as an absolute minimum, we need every 8 hours, so before they go to bed, they need to scan that sensor, go to bed and then it will continue to read for 8 hours while they sleep. If it goes over that 8 hours, you will just start to see gaps in the information because the sensor can only hold 8 hours' worth of data.
Now, as with everything, it comes with some limitations and some complications. One study found that around 61% remain detached and functional for 14 days. This seems quite high.
I personally think you get around 12, between 8 and 12 days out of the sensor, but that probably depends on. Excuse me, that probably depends on the individual patient, how agile they are, the application, the confidence of the person using the, the applicator as well and applying the device. Early sensor detachment is common and the median sensor activity time is around 5 to 7 days.
If you achieve the 14 days, it won't work after that, we'll just stop reading and then we can take it off. But the sensor can often fall off before that point. But as I mentioned earlier, even getting 5 to 7 days is so much more information than what you would get with a blood glucose curve.
So it's still worth it. The owners can also buy these from human pharmacies because they are a human device, so they may be able to source it a little bit cheaper if they're using them frequently. And sometimes we can see some redness of the skin or some crusts, which we believe is possibly from the tissue glue.
Very, very unlikely but can potentially occur skin erosion and abscess formation. I have luckily never seen this happen, but it is noted in some of the studies. Some of our patients can have a slow hair regrowth anyway, so then if we're clipping it, the owners need to be aware that it may take a while to grow back.
Some of them don't grow back at all depending on the patient. And if you do have any pointed cats, you can see this lovely image here, which was kindly given to me by Sam Taylor. This is the, the hair, the regrowth of hair on a pointed cat.
So we need to inform the owners of these cats that it may grow back a different colour. So that we have informed consent and they are fully aware and they still want to go ahead even though it may regrow something similar to this. And then another limitation which we mentioned earlier, it only reads up to 27.8.
So during that initial stability period, it may not be that useful because it will just say hi, especially some of our cats can sit a lot higher than that. So maybe once the patient is discharged from the hospital and it's starting to become a bit lower, this is where the the freestyle labours have their place. And then finally we'll talk about diabetic remission, which is possible in some of our feline pets.
Now this is a possibility in some of the cats who have insulin resistance. So maybe if the cat has obesity, and that's what's causing the resistance, because obesity causes insulin resistance, we know that. If we can tackle that obesity, we have a greater chance of achieving remission.
Or maybe it's a concurrent disease that can make some of the . The chance of. Achieving remission a little bit more difficult because we, some of the diseases are not curable, they're just things that they have to manage long term, like kidney disease.
We can't get rid of that kidney disease and therefore it may make remission that bit harder or impossible to achieve. Now, typically, if we're going to achieve remission, they have the best remission rate within the 1st 6 months of treatment. And the remission rate for cats with insulin resistance is around 30 to 50% of cats.
Some cats may also be unable to produce insulin for themselves, and they are certainly the ones that you will not achieve remission in those pets. Now usually you will just start to titrate the you'll see that the patient is less dependent on the insulin and you'll start to titrate the insulin dosage down until eventually it may be discontinued without the reoccurrence of hyperglycemia, and that classes the patient as in remission. But once it's achieved, you're not completely out of the woods.
We need to maintain and control that body weight, especially if it, if obesity or a weight issue has been an issue with the cause of the diabetes. But even if it isn't, the management of that weight control will lead to a healthier life and will prevent the reoccurrence of it later on. We need to maintain that low carbohydrate diet, we said that carbs are converted into sugars.
If we have a low carb diet, we will naturally have a lower sugar level in our bloodstream. We need to encourage exercise and make the owners aware that diabetes can return at any point. So educate them on the signs to look out for, monitor for those three Ps, increase urination, increase drinking, increased appetite of polyuria, polydipsia, and polyphasia.
If they see any of those signs, they can get in touch with us and we can start to look at whether the diabetes could be. And then this one hour is a crash course on diabetes and what they need to do for the rest of this cats or dog's life. So it's a lot to take in.
They need continuous support, tell them they can phone us at any time. They don't need to always phone the vet, they can phone us and we can, the chances are we can answer the majority of their questions. If we can't, then that's where the vet comes in and we can then escalate it to the vet.
But we can have that real bond with the owner and they may also feel a little bit more comfortable asking us a question rather than the vet, but it absolutely needs to be a team effort with all of us involved. Diabetic handouts, there will be a handout that comes along with this webinar which I've written. It's written in nice, easy terms so that the owners can understand it.
And the, the thing we need to look at is we've given them a lot of information, they will not remember all of it. What are they gonna do? Excuse me, they're going to go home.
They're going to try and absorb it all in and they're going to go on Doctor Google. We all do it, we're all guilty, but if we give them some diabetic handouts, they're much more likely to go home and read it from the handouts, which is a reliable source of information. We know that we are tailoring where they're getting their information from, whereas Doctor Google can bring up all weird and wonderfuls.
So it it it allows us to, it complements our service, it reassures the owner, it educates the owner, but it allows us to control where they're getting that information from. And it also is a useful go to guide for if they come up with questions later on down the line. Oh, I think my pet is having a hypoglycemic episode.
I'm suddenly panicking and I don't know what to do. They've got that hand out there that they can keep in their handbag with the glucose and the glucose monitor if they're going on a walk with their dog. They have it as a go to bit of advice that is from a reliable source.
We can monitor their continuous glucose device remotely from our computer while the patient is ticking away nice and happily at home. We can look at those at any time when we have the time to look at it in our clinic. I would advise calling them weekly to begin with and especially during any dosage changes, we change the dose, we call them again within a week to just check in and make sure that's OK.
You can also check all of the data from your freestyle Libra before you call them so that you know what's going on with that patient and if there's any questions like, oh, what happened there? There was a bit of a drop there. Did you exercise or have a look at the notes that they may have put on.
You can get an idea as to how they're doing before you call them. And once the patient's more stable, obviously you can reduce and back off with those check-ins. The owner's confidence will be growing and the stability of the patient will be increasing.
So you can just back off and go to every 3 months, every 6 months until the patient is more stable. And then again just reiterate those dangerous symptoms of hypoglycemia and I always give them one of the gluco boost or gluco gels in the consult so that they've got one instantly. It just makes them feel that bit more safe.
It's like a comfort blanket for them, they're not going out and having to source all of these things like a a glucose monitor. They've got freestyle Libra on, they've got to inject tonight and they've never done it before, and now they've got to go and get a glucose boost from a pharmacy. If you can give them as many of those things, if they would like to purchase a glucose monitor from you, that'd be great.
But the more you can give, the more reassurance you can provide to that owner, the better success you are likely to have for that pet, for their life, and the quality of life for the owner as well. OK, that's all from me, slightly over time, my apologies, but it is a very interesting topic and one that I'm quite passionate about. If you do like internal medicine, please follow my page, veterinary nurse Medicine Geek, and there is also a website coming soon, which will be filled with useful information and webinars for veterinary professionals, but also some downloadable content for owners as well, particularly for diabetes, so.
Follow my page and keep an eye out for the website coming soon. That's all from me, thank you very much.