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Diabetes in Pets

Hypoglycemia

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Hypoglycemia is what every diabetic fears -- very low blood glucose. Since the brain requires glucose for fuel at every second, it's possible to induce coma, seizures,brain damage[1][2][3] and death by letting blood glucose drop too low. Because the brain is almost totally dependent on glucose to make use of oxygen[4], it is somewhat like having severe breathing problems. Though the causes and mechanisms are different, in both cases the brain does not have enough oxygen, and similar symptoms and problems can occur. It is caused by giving too much insulin for the body's current needs.

The blood glucose level at which an animal (or person) is dangerously hypoglycemic is fuzzy, and depends on several factors.[5] The line is different for diabetics and non-diabetics, and differs between individuals and depending on exogenous insulin and what the individual is accustomed to.

The most likely time for an acute hypoglycemia episode is when the insulin is working hardest, or at its peak; mild lows may cause lethargy and sleepiness[6].

An acute hypoglycemic episode can happen even if you are careful, since pets' insulin requirements sometimes change without warning. Pets and people can have hypoglycemic episodes because of increases to physical activity. What makes those with diabetes prone to hypoglycemia is that muscles require glucose for proper function. The more active muscles become, the more their need for glucose increases[7]. Conversely, there can also be hyperglycemic reactions from this; it depends on the individual/caregiver knowing him/herself and the pet's reactions.

Vomiting and diarrhea episodes can bring on a hypoglycemia reaction, due to dehydration[8].

According to a 2000 JAVMA study, dogs receiving insulin injections only once daily at high doses[9] are more likely to have hypoglycemic episodes than those who receive insulin twice daily.

Symptoms and TreatmentEdit

The symptoms are:

  • depression/lethargy
  • confusion/dizziness
  • trembling[10],
  • ataxia (loss of coordination and/or balance)
  • loss of excretory/bladder control
  • vomiting, and then loss of consciousness and/or seizures.
  • sleepiness/unresponsiveness
    An important sign, easily missed, that blood glucose levels are becoming too low; calling you pet and he/she either fails to respond or is slow to respond[11].
  • Pets can also become more vocal as a hypoglycemia symptom[12]--some may possibly become aggressive[13].

As soon as possible, administer honey or corn syrup by rubbing it on the gums (even if unconscious, but not if in seizures), and rush it to the vet. Carry more honey or corn syrup with you on the way and keep rubbing it on the gums, where it can be absorbed -- it could save the pet's life. Every minute without blood sugar causes brain damage. Some recommend administering syrup anally, with a feeding syringe or dropper, if the animal is in seizures!

NEVER try to make an seizing or unconsicous animal swallow. The food or liquid could possibly choke him/her. There is also a chance that the materials could be aspirated (wind up in the lungs instead of being swallowed)[14].

Intervet suggests an especially good place to also rub sugar, syrup or honey is under the pet's tongue[15]. Reading the Wikipedia definition for the medical term of administering a drug or substance under the tongue, sublingual[16], makes it clear that the high concentration of blood vessels present means rapid absorption and passage to the carotid artery, which is directly connected to the brain. In hypoglycemia, this would provide the brain with the glucose fuel it needs to make proper use of oxygen.

A photo link below[17] of how to apply corn syrup to gums.

Symptoms of hypoglycemia should always be taken seriously and addressed promptly. Better to risk treating a "non-legal" hypo than to fail to respond quickly to the signs of actual hypoglycemia[18].

If the pet has hypoglycemia according to the blood glucose meter (<2.2mmol/L or 40mg/dL), but no symptoms, give treats or food if possible. If they won't eat, try putting food in their mouth.

If that doesn't work, administer some honey or syrup followed by food or cat treats, and continue to do so until the blood glucose is rising, and the latest insulin shot's peak action is past.

The honey, syrup or "fast-acting" sugar will make the blood glucose rise, but the rise will not last very long[19].

Feeding something with carbohydrates in it when the pet is able to take it will make sure hypoglycemia doesn't overtake the "quick" sugar fix[20][21][22].

According to BD Diabetes Diabetes in Pets website, the amount of syrup for dogs is: for small dogs-one teaspoon; for larger dogs- one tablespoon[23]. For cats, they opt for one tablespoon of syrup for every 10lb. in body weight[24].

Intervet suggests 1 gram of glucose for every kilogram (2.2 lb) of the animal's body weight and extra food every 1-2 hours to counter the insulin's effects[25].

Suggested for dogs when the important sign of sleepiness and/or lethargy are seen is to give 1 tablespoon of corn syrup by mouth. If the symptoms do not abate within 15 minutes, follow up with another tablespoon of corn syrup. If there's still lethargy and/or sleepiness after a total of 2 tablespoons of corn syrup are given, contact your vet right away for more information[26].

An interesting quick treatment tip is to keep frozen ice cubes of syrup for emergencies and simply slipping it into the pet's mouth[27].

AftermathEdit

Its also important to remember that it takes a little time to fully come back from a hypo incident. In people, cognitive function is impaired at levels below 54mg/dL. Full recovery from the hypo can take 40-90 minutes after blood glucose levels have returned to normal[28]. Like insulin, the sugar given doesn't have a total effect instantaneously.

Swift intervention after a hypo incident with doses of Pyruvate may reduce brain damage.

Sometimes a mild hypoglycemic episode will go unnoticed, or leave evidence such as an "accident" where kitty fails to make it to the litterbox[29]. In these cases the blood sugar will often be paradoxically high upon the next test hours later, since the pet's body will react to the low blood sugar by stimulating the liver to release stored glycogen. This condition is known as Somogyi rebound, and requires a lowered insulin dosage for the next few days. The Somogyi rebound may also occur when the pet's blood glucose drops too rapidly, even if it never actually reaches a low reading.

A single hypoglycemia or near hypoglycemia episode[30] can result in hyperglycemia for up to 3 days following it. In response to the threat of low blood sugar, the body releases counter-regulatory hormones intended to raise bg's; the body's way of trying to save itself.

Reduced Insulin NeedsEdit

It is also possible to have a hypoglycemic event from improved blood glucose levels. Improving control reduces glucose toxicity and therefore brings increased insulin sensitivity. An increase in sensitivity can mean a decreased need for insulin, (or possibly even a remission in cats). Continuing to dose as usual can lead to more hypoglycemia. See Abstract #68[31] from American College of Veterinary Internal Medicine, 2004, for its implications in canine diabetes.

Fast Drops in Blood GlucoseEdit

People and pets can also exhibit signs of hypoglycemia if their glucose levels drop rapidly[32]. This is true with the use of all insulins, even though glucose values are not in hypoglycemic range[33].

For example, let's say someone's bg is at 400. He/she uses fast or rapid-acting insulin for corrective purposes which lowers the blood glucose values to 200 within an hour. The meter says 200, but there are signs of hypo. The body responds to the rapid drop as it automatically is meant to, sending out hypoglycemic warning signs, even though the 200 reading is far from hypo levels.

The system can only determine that blood glucose levels are falling at a rapid rate, not whether they are "supposed to" in this hypothetical case, and sends out "hypo" warning signals to protect itself. This may include gluconeogenesis, leading to a Somogyi rebound, or it may not.

Warning signals in dogsEdit

Inflamation of the eye blood vessels in dogs is an indication of hypoglycemia. In both hypoglycemia and hyperglycemia, the whites of the eye become reddened and appear quite irritated. The difference is best likened to the difference in the color of venous blood and arterial blood. Venous blood is of a darker red than is arterial blood. In hypoglycemia, the inflamation is of a "venous blood" color.

In both hypoglycemia and hyperglycemia, the inflamation lessens as the proper bg corrections are made, reverting to no visible irritation when euglycemia is achieved. The symptoms were first discovered with an individual dog, and extended to all diabetic dogs in the veterinary practice. All presented with the same degree of eye inflamation for hypoglycemia, hyperglycemia or lack of it for euglycemia. The eyes were examined prior to blood testing, which confirmed the eye results each time.

Tight control and hypoglycemia unawarenessEdit

The question of why some diabetics exhibit more overt signs of low blood glucose than others came up in a talk with a Certified Diabetes Educator who is also a registered nurse. Her response was that the better one's control is, the lower someone's blood glucose can go without them feeling or showing signs of illness. It has to do with the blood glucose levels not dropping as far and thus the body doesn't feel the need to send out as many "warning" signals.

Therefore, if one is always primarily high, he/she would show more physical responses to low blood sugar levels than someone whose control is tight. (Going down 25 floors rapidly in an elevator may not make your ears "pop"--going down 50 rapidly likely will.) Personal experience says this also holds true for canines with diabetes; those in tight control can show few, if any, hypo symptoms even though the meter says otherwise.

Dr. Orzick, a professor at Baylor College of Medicine in Houston, also says that the rate at which blood glucose levels fall is the primary reason for lack of body warning responses[34]. He also offers an opinion regarding longer-duration insulins: that for some using them, blood glucose levels fall at rates too slow for the body to recognize and thus set the hypoglycemic warning responses into action.

Many humans with diabetes suffer from what's known as hypoglycemia unawareness. This means they often have no physical warning signs they are low and approaching hypo status. There's been much research regarding the unawareness factor in the human diabetes community but for the most part, there have been few real solutions. Those with this condition must test many, many times a day, as they have no other way of telling whether they are too low or not.

Some people using insulin have had their physical hypoglycemia symptoms return after switching to either bovine or porcine insulins from either r-DNA/GE/GM or analog ones.

What has definitely been learned from all the human research into the problem is that having serious hypoglycemia episodes puts one at risk for becoming hypoglycemia unaware. A person who is a "long time" diabetic can also become unaware, due to the subtle changes the disease makes in the body over time.

Those who have suffered bouts of serious hypoglycemia are also more at risk, unfortunately, to have more of them, as opposed to persons with diabetes who have never experienced any serious hypoglycemia incidents.

MedicationsEdit

Medication warnings mentions medications that can cause problems with hypoglycemia.

Further readingEdit

Wikicat3


Wikidog3



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ReferencesEdit

  1. Determination of Insulin Sensitivity in the Dog: An Assessment of Three Methods-American Society for Nutritional Sciences-2002
  2. Southpaws.com-Fall, 2000-Glucagon Infusions
  3. Hypoglycemic Brain Damage-Metabolic Brain Disease, 2004
  4. Hypoglycemic Effects
  5. Jess, a vet tech with diabetes experience, describes different levels of "hypo"
  6. Diabetes Mellitus-Hypoglycemia
  7. Gulf Coast Veterinary Specialists-Diabetes Mellitus
  8. DiabetesNow-UK-Page 4
  9. Effect of Insulin Dosage on Glycemic Response in Dogs With Diabetes Mellitus
  10. Fleeman & Rand: Long-Term Management of the Diabetic Dog
  11. Diabetes Mellitus-Hypoglycemia
  12. Gulf Coast Veterinary Specialists-Diabetes Mellitus
  13. Diabetes in Pets-Diabetes Voice 2003-Monitoring-Page 2-Dr. Hoenig
  14. Hypoglycemia-WB Thomas D.V.M Dipl.ACVIM(Neurology)
  15. Intervet-Caninsulin Guide-Page 9
  16. Wikipedia-Sublingual
  17. Photo-Applying Corn Syrup to Gums for Hypoglycemia
  18. Diabetes Mellitus-Hypoglycemia
  19. BD Diabetes-Hypoglycemia-Cats
  20. BD Diabetes-Hypoglycemia-Dogs
  21. Childrenwithdiabetes.com-Ask the D Team-2005
  22. Caninsulin-Hypoglycemia-Page 4
  23. BD Diabetes-Hypoglycemia-Dogs
  24. BD Diabetes-Hypoglycemia-Cats
  25. Caninsulin-Hypoglycemia-Page 4
  26. Diabetes Mellitus-Hypoglycemia
  27. Veterinarypartner.com Insulin Administration Guide-Insulin Shock/Hypoglycemia
  28. Closeconcerns-Hypoglycemia-EASD 9/12/2005
  29. BD Diabetes-FAQ's About Diabetic cats-Dr. Greco
  30. Treatment of Diabetes Mellitus in Dogs-Page 21
  31. ACVIM 2004 Abstract #68 Improved Glucose Control and Increased Insulin Sensitivity in Dogs
  32. FDA-Novolog-Precautions-General-Page 7
  33. FDA-Humalog-Prercautions-General-Page 6
  34. Diabetes Self-Management: Hypoglycemia Unawareness
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