The goal in long term management of diabetes mellitus is the alleviation of unpleasant clinical signs (constant thirst, weight loss etc.) and prevention of dangerous secondary conditions (infections,
ketoacidosis etc.). To accomplish this, blood sugar levels should be regulated between 250 mg/dl and 80 mg/dl. This is not as good as the body’s natural regulation but is a fair and achievable goal in
Some patients just seem completely unaffected by even high doses of insulin and it is important to have a step by step plan to rule out causes of insulin resistance so that regulation can be achieved.
Insulin resistance is defined as:
persistent high blood sugar levels throughout the day
when 3 units of insulin per 4 lbs of patient body weight are used
A unit or more of insulin per lb of patient body weight is needed to achieve regulation
Step One: Rule out Owner Related Factors
This may seem very basic but it is important not to skip the basics. Confirm that the amount of insulin being drawn into the insulin syringe is correct, that the injection
technique is correct and that the patient is actually receiving the injection. Rule out any snacking or changes in the patient’s feeding schedule. Be sure the bottle of insulin is
not expired and that it has been properly stored.
To review insulin storage and handling click here.
Step Two: Determine for sure that the Patient is Insulin Resistant
A glucose curve is needed to distinguish the following three phenomena:
- Somogyi Overswing
In this case, the insulin dose is too high and drives the blood sugar low for part
of the day. When the blood sugar is low, other hormones such as cortisone or adrenalin are released to raise blood sugar. These hormones can have a
prolonged effect (many hours) thus creating hyperglycemia (high blood sugar). If the patient’s high blood sugar has been caused by a Somogyi overswing, a
lower dose should be used and a new curve performed in a week or two.
- Rapid Insulin Metabolism
In this case, the insulin simply isn’t lasting long enough to create sustained
normal blood sugar levels. If the curve shows that the insulin effect is wearing off too soon, twice a day administration of the insulin may solve this problem or
a longer acting insulin may be needed. Longer acting insulins tend to have poorer absorption into the body from an injection site. This may also necessitate change to a different insulin type.
- True Insulin Resistance
Here no significant drop in blood sugar level (levels stay greater than 300 mg/dl)
is seen in response to the insulin dose used. Usually there is a history of prior increases in insulin dose all met with minimal response.
Step Three: Spay
If the patient is a dog, a female and un-spayed, hormone fluctuations will easily account for insulin resistance as progesterone is one of many hormones that raise blood sugar
levels (by stimulating growth hormone secretion). Canine unspayed female diabetics need to be spayed if regulation is to be achieved. Feline patients do not have a similar
relationship with naturally occurring progesterones and do not require spaying; however, progestone-type medications can produced diabetes in cats. Diabetic
patients of either species should not take progesterone-related medications.
Step Four: Rule out Infection
Diabetic animals are at special risk for developing bladder infections since they have so much sugar in their urine. Stress of any kind will contribute to high blood sugar and
infection would lead to stress. A urine culture should be done to rule out bladder infection plus the teeth and skin should be inspected for infection in these areas. If
infection per se is not found, the patient should be screened for other chronic illnesses that might constitute a stress. A basic blood panel would be a logical starting point.
If infection, or other stress is allowed to go unchecked, ketoacidosis, an especially life-threatening complication of diabetes mellitus can develop.
Step Five: Control Obesity
Insulin response is typically blunted in obese patients. If obesity is an issue, it should be addressed. A formal weight loss program using measured amounts of a prescription
diet and regular weigh-in’s is necessary for success. For general information about weight loss for pets visit: www.petfit.com
If these steps do not reveal a relatively simple explanation for the poor insulin response, then it is time to seek more complicated causes. This generally means an additional hormone imbalance.
HYPERADRENOCORTICISM (“CUSHING’S DISEASE”)
This condition is relatively common in the dog but less so in the cat. In short, this condition involves an excess in “cortisone”-type hormones either from over-production
within the body or over-treatment with medication. Cortisone (more accurately referred to as “cortisol”) is secreted naturally in response to a fight or flight situation and
prepares the body for exercise by mobilizing sugar stores. If sugar is mobilized into the blood stream in the absence of a fight or flight situation, diabetes mellitus can result. If
the excess cortisone situation is resolved, it is possible that the diabetes will also resolve.
About 10% of dogs with Cushing’s disease are also diabetic. About 80% of cats with Cushing’s disease are also diabetic. Testing for Cushing’s disease cannot proceed until
some degree of diabetic control has been achieved and the patient is not ketoacidotic.
For more information on Cushing’s disease and it’s treatment please visit our Cushing’s Disease Information Center.
HYPERTHYROIDISM (CATS ONLY)
Thyroid hormone is another hormone that alters glucose metabolism. While hyperthyroidism is a common condition of older cats, less than 1% of hyperthyroid cats
are also diabetic. Still, when a diabetic cat becomes hyperthyroid, control of the thyroid disease generally leads to better regulation of the diabetes.
For more information on Feline Hyperthyroidism please visit our Feline Hyperthyroidism Information Center.
EXCESS CIRCULATING LIPIDS
High levels of circulating triglycerides (fats) interferes with the binding of insulin to the cells it needs to act upon. While most dogs with excess circulating lipids are not
diabetic, when a diabetic patient is insulin resistant it may be helpful to attempt to reduce the circulating fats. Excess lipids in the blood usually occurs because of some
other hormone imbalance (Cushing’s disease, hypothyroidism in dogs etc.) but can simply happen spontaneously in the miniature schnauzer. Circulating fats are reduced
by treating the hormone imbalance that caused them if there is one. If there is no underlying disease, circulating lipids can be reduced with diet and omega 3 fatty acid supplementation.
Acromegaly results from an over-secretion of the pituitary hormone known as “growth hormone.” This hormone normally is responsible for one’s growth from infancy to
adulthood. When adulthood is achieved, its secretion dramatically slows, bone growth plates close, and growth essentially stops. If for some reason, this hormone begins
secreting again, growth resumes but not generally in normal proportions as the limb bones have closed their growth areas.
One of the effects of growth hormone is causing the body tissues to become resistant to insulin by interfering with tissue insulin receptors. Animals with acromegaly are frequently diabetic.
The prognosis and treatment for acromegaly is very different between dogs and cats. Dogs generally develop acromegaly due to excess progesterone secretion (as would
occur from an ovarian cyst). Canine patients are thus usually older unspayed females and spaying may be curative depending on the remaining ability of the pancreas to secrete insulin.
The feline situation more closely approximates the human situation. Cats (and people) develop acromegaly when they develop a growth hormone secreting pituitary tumor.
Over 90% of acromegalic cats are male (though there is no sex predisposition in humans.)
The diagnosis of acromegaly can be very difficult. Growth hormone can make soft tissue organs enlarge and cause characteristic proliferation of gum tissue in the mouth
but pituitary tumors require some kind of brain imaging (CT scan or MRI) for detection. Often this diagnosis is reached tentatively based on the clinical picture: intact female
dog with insulin resistant diabetes or male cat with heart disease (from the enlargement) and extremely insulin resistant diabetes. There is currently no blood test available to
test growth hormone levels but it is possible to measure something called “somatomedin C” which a regulator of growth hormone and patterns of this biochemical
may be helpful in diagnosis. Currently the best treatment for a cat with a pituitary tumor is radiation therapy.
ANTIBODIES AGAINST INSULIN
When a patient is treated with insulin from another species, the immune system recognizes the introduction of the foreign protein and generates antibodies. It was
because of this phenomenon that most commercial insulin available is genetically engineered human insulin so that the world’s human diabetics no longer need to worry about making insulin antibodies.
But where does this leave dogs and cats? It leaves them making antibodies against human insulin, that’s where.
One would think this would pose a big problem but in fact insulin antibodies are not always bad. Most of the time the antibodies simply interfere with removal of the insulin
leading to a longer acting insulin than would be achieved with the same type of insulin made from the native species. For example, Humulin L (human insulin) will last longer in
the dog than Canine Insulin L. This may be desirable depending on the patient; changing the species of origin of the insulin is one way to get the insulin to last a bit longer.
To become insulin resistant from antibodies, one must lose 70% or more of the insulin injection to antibody binding. This is very unusual but possible and should not be
forgotten as a possible cause of insulin resistance. Blood tests to measure insulin antibodies are available in some areas. Insulin can be switched to a species of origin more closely related to the species desired.
IF A CAUSE CANNOT BE FOUND:
If a cause cannot be found or if treatment for that cause is not practical or possible, the good news is that multiple high doses of insulin can generally overcome the resistance.
Sometimes combinations of short and long-acting insulins are used together to achieve reasonable regulation.