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Persistent fasting hyperglycemia and glucosuria should be verified with _________.
fructosamine
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What will you see on UA of a diabetic patient?
glycosuria, proteinuria, ketonuria, bacteruria
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What will you see on CBC of a diabetic patient?
increased hematocrit if dehydrated, increased WBC with infection
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What will you see on the blood chem of a diabetic patient?
liver enzyme abnormalities due to hepatic lipidosis and pancreatitis, increased cholesterol, pre-rena azotemia, electrolyte abnormalities
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What might you feel when palpating the abdomen of a diabetic patient?
hepatomegaly due to fatty liver
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Diabetic dogs should be put on a ____________ diet.
high fiber, complex carb
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Diet for diabetic dogs should avoid excess __(2)__.
fat and protein
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The most important aspect of dietary management of diabetes is ___________.
consistency
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Diabetic cats should be put on a ___________ diet.
high protein, low carb, low fiber
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In cats, _________ are strong stimulators of insulin release.
amino acids
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__________ diets are better for diabetic cats because they have lower carbs.
Canned food
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The goal of insulin therapy is the minimize ____________, which is critical for minimizing the risk of ___________.
day-to-day variability; hypoglycemia
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In order to extend the duration of action of regular insulin, it is formulated with... (3)
zinc (lente), protamine (NPH), or both (protamine-zinc formulation).
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Protamine and zinc increase the tendency of insulin to _________ to slow its absorption.
crystallize
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Lente, NPH, and PZI are injected as _________; the cons to this are... (2)
suspensions; decreased accuracy of dosing ad variability of time-action of de-precipitation.
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What is the major advantage to recombinant insulin?
MUCH less variability throughout the day
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Insulin glargine (Lantus) is ____________; there is an altered _______, making it stable in ________ but crystallized in __________, slowing its absorption.
recombinant human insulin analog; AA; pH4; physiologic pH
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Which insulin is long-acting and peakless?
insulin glargine
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Lente, NPH, and PZI formulations are ________ insulin.
intermediate-acting
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Insulin detemir (Levemir) is ____________; there is an altered _________, which facilitates self-association and association with ________ to slow absorption.
recombinant human insulin analog; AA to FA; albumin
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What insulin formulation has the lowest within-patient pharmacokinetic and pharmcodynamic variability?
insulin detemir
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A duration of action increases, _________ decreases.
potency
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Canine and _______ insulin have 100% homology.
porcine
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What insulin is the best for dogs?
BID vetsulin
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The most common type of insulin used for dogs is ___________; it is given in a(n) ______ syringe; its dose interval is _________.
porcine lente; U-40; 12-24h
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The 3 most common types of insulin used in cats.
human PZI, glargine, detemir
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Detemir is given to cats in a(n) _______ syringe; its dosing interval is ________.
U-100; 12-24hr
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Glargine is given to cat in a(n) ________ syringe; its dosing interval is _________.
U-100; 12h
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Human PZI is given to cats in a(n) _______ syringe; its dosing interval is _________.
U-40; 12-24hr
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___________ is formed as a result of non-enzymatic glycation of blood proteins; it is not affected by ___(2)___; it is affected by __________.
Fructosamine; stress and food intake; half-life of proteins
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Fructosamine reflects __________, which is proportional to ___________.
glycemic control over the past 2-3 weeks; average BG
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When analyzing fructosamine levels, use _______ more than ________.
trends; reported guidelines
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Normal fructosamine might be indicative of...
excellent control, prolonged periods of hypoglycemia due to insulin overdose (usually), diabetic remission (in cats)
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A glucose curve is a plot of ______ vs. ______; samples taken every ________.
BG; time; 2 hrs (at least 4 samples)
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Using a glucose curve, you can estimate... (2)
duration of insulin effect, efficacy of dose.
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How can you use a glucose curve to determine the efficacy of the dose?
based on degree of decline from pre-injection to nadir (never change dose based on one curve)
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If the duration of insulin is too short,...
switch to longer-acting insulin
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If the blood glucose curve shows hypoglycemia,...
decrease the insulin dose (hypoglycemia is bad in all contexts)
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What are possible causes of excessively high glucose on a glucose curve? (5)
incidental, technical problems with insulin handling/administration, stress hyperglycemia, inadequate dosage, insulin resistance
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Insulin-induced hyperglycemia occurs when there is an ___________, causing _________ followed by ______________; ___________ is necessary.
excessively high insulin dosage; hypoglycemia; excessive counter-regulatory hormone release; insulin dose reduction
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Always correlate blood glucose curves with... (2)
clinical signs and fructosamine.
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Insulin therapeutic range overlaps with ___________; therefore, start with _________.
hypoglycemia; low dose and increase as necessary
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What do you usually start the insulin dose at for dogs and cats?
- cats: 1U/inj
- dogs: 0.25U/kg/inj (determir 0.1 U/kg)
- BID!!!
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What should you expect following the onset of insulin therapy? (5)
decrease urine volume and water intake, decreased appetite, weight gain, overall improvement in health and attitude
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What are the goals on insulin therapy? (3)
resolve clinical signs, prevent consequences, avoid hypoglycemia
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Hypoglycemia causes...(5)
weakness, ataxia, disorientation, seizures, death
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Insulin resistance is suspected when there is ...
a perceived inappropriate response to insulin therapy.
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If compliance issue have been ruled out, insulin resistance may be caused by... (6)
bacterial infections, organ failure, pancreatitis, concurrent endocrinopathies, drugs, heat cycles, insulin induced hyperlgycemia
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Insulin-induced hyperglycemia can result in... (5)
increased BG, massive fluctuations in BG, worsening signs of uncontrolled DM, worse PU/PD, increased fructosamine
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________ is a good screening test for pancreatitis in non-diabetic patients, but it is unreliable in diabetic patients because...
PLI; it is frequently elevated in diabetics that are not symptomatic for pancreatitis.
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Obesity can cause _________, but is not usually ________ in diabetic patients in vetmed.
insulin resistance; significant
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Hypothyroidism occurs mainly in _______; it causes weight ______ in the face of _______ appetite; it can be masked by DM, which causes...
dogs; weight gain; decreased appetite; weight loss in the face of polyphagia.
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What are the overlapping parameters b/w hypothyroidism and DM? (2)
increased liver enzymes, high cholesterol
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Why is fructosamine unreliable in hypothyroid dogs?
it can increase as a result of decreased protein catabolism
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Hyperthyroid occurs mainly in _______; the overlapping parameters with DM include... (5)
cats; PU/PD, polyphagia, increased liver enzymes, hyperglycemia, glucosuria
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Why is there often hyperglycemia and glucosuria in hypothyroid cats?
stress
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Why is fructosamine unreliable in hyperthyroid cats?
it can decrease as a result on increased protein catabolism
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Hypercortisolism (Cushing's) causes the following overlapping parameters with DM... (6)
PU/PD, polyphagia, increased liver enzymes, increased cholesterol, dilute urine, UTIs
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When is it difficult to discern Cushing's and DM?
in a cushings animal, concurrent DM is easy to confirm by hyperglycemia, fructosamine, glucouria; in a diabetic, it is difficult to confirm cushings because DM causes chronic stress and will result in false positive ACTH stim tests
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Hypersomatotropism occurs in cats with __________ and in dogs with __(2)__.
acidophil adenoma; mammary gland tumors or increased progesterone (diestrus)
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What are the effects of excessive GH? (5)
decreased insulin sensitivity, increased protein synthesis, increased bone growth, increased lipolysis, increased IGF-1 production
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GH _________ IGF-1 production; insulin has __________ effects on IGF-1 production.
stimulates; permissive (ie. without insulin, IGF-1 will not be produced)
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What 2 syndromes are associated with hypersomatotropism?
insulin resistance (and DM), acromegaly
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How do hypersomatotropic cats usually present?
PU?PD, polyphagia (acromegaly often not present, or develops in late stages)
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What is an important clue that a diabetic cat may also have hypersomatotropism?
lack of weight loss in a diabetic cat that is otherwise uncontrolled
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What are common clinical signs of hypersomatotropism? (7)
PU/PD, polyphagia, weight gain, renomegaly, hepatomegaly, systolic murmur, plantigrade stance
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What are clinical signs in late stages of hypersomatotropism? (4)
proganthia inferior, broad face, stridor/stertor (enlarged soft palate), enlarged organs
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__________ is a good screening test in a cat that is difficult to regulate when other differentials have been ruled out.
IGF-1 measurment
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When do you screen cats for hypersomatotropism?
treat diabetes first and consider IGF-1 measurment after diagnosis of insulin resistance; confirm hypersomtatropism with brain imaging
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Why is measurement of GH not used to diagnose hypersomatotropism?
because of its pulsatile secretion
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Left untreated, hypersomatotropism will lead to...
death from heart failure, laryngeal obstruction, brain compression
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How can you treat hypersomatotropism?
radiation therapy, hypophysectomy (best chance for DM remission- not in USA), Pasireotide (somatostatin analog- EXPENSIVE)
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