“Fuzzy has what? I thought only people got diabetes.”
You have just gotten a patient history, performed a physical examination and started talking with your client about the diagnoses that concern you. The presentation of a polyuria, polydipsia, polyphagia and weight loss are pretty classic for a few conditions, but your knowledge and experience tell you that diabetes mellitus sits at the top of your list.
“I think Fuzzy may have diabetes,” you say. “We need to run some tests today to get a better understanding of what is going on and what we need to do.”
After that pronouncement, many pet owners will respond with, “I thought only people got diabetes.”
A Three-Part Equation
For the clinician, diabetes is easy to diagnose and challenging to attain full compliance. There are so many moving parts: pet, client, food, medication, veterinary practice, money.
For the pet owner, diabetes is a lifestyle disease — full of frustration, concern and costs — that affects the entire family and the four-legged family member.
For the pet — dog or cat — diabetes changes everything. Exercise, diet, treats, medications and veterinary visits are different now. The situation can’t be much fun for the pet.
As a clinician, diabetes taxes your ability to communicate and educate. It can put a significant burden on a client’s time and bank balance.
Bottom line: Diabetes is a common disease that can be managed or controlled, and rarely can be cured (cats!). It necessitates frequent monitoring at home by the client and at the clinic by the veterinarian and staff. The situation is neither easy nor cheap.
What can be done to ease the discomfort at all levels?
The Clinical Picture
Regarding diagnosis and treatment, a plethora of clinical resources is available that does a great job of summarizing basic case management. Check out these offerings from the American Association of Feline Practitioners and the American Animal Hospital Association:
- AAFP’s Diabetes Educational Toolkit: http://bit.ly/2kwUpW9
- AAHA’s 2018 Diabetes Management Guidelines for Dogs and Cats: http://bit.ly/2kuCG1y
In summary, polyuria, polydipsia, polyphagia and weight loss are the classic presenting signs. When a dog or cat presents with those signs, a laboratory evaluation is mandated in addition to a thorough history, risk factor analysis and physical exam. Full blood profile (chemistries and electrolytes), CBC, thyroid levels and urinalysis should be the minimum database. Urine-protein-creatinine and blood pressure also might be included.
The diagnosis will be based upon results showing hyperglycemia and glucosuria. Additional findings might include elevated cholesterol and triglycerides, stress leukogram and increased liver enzymes (dogs).
With a diagnosis in hand, the classic treatment involves insulin, dietary control, and blood and urine glucose monitoring.
But it’s not that simple, is it? Each case has its challenges.
This makes compliance with diabetes mellitus recommendations truly difficult.
Successfully regulating the diabetic patient is attainable only with a fully compliant client. Even the best clinicians and teams can’t stabilize a patient on their own. They are fully dependent upon the pet owner to feed the right foods, minimize between-meal snacks, ensure appropriate exercise and administer insulin. And then bring the pet back for routine evaluations and status checks.
From the beginning, explaining the short- and long-term treatment plans and the associated costs is of great importance. This means three stages of communication.
1. At the Time of Diagnosis
With a diagnosis in hand, the veterinarian must have a focused conversation with the client about the nature of diabetes mellitus. This is best done face to face because significant hands-on training is needed to explain how to handle and administer insulin. Additionally, when to feed the pet and provide insulin, and how to recognize signs of a good response or concern, must be discussed.
Transparency from the get-go is absolutely necessary. The condition requires ongoing monitoring at home, lifestyle changes, and ongoing monitoring and testing at the practice. All this comes at a cost that can vary from case to case, depending on the pet’s response to treatment and willingness to accept a new diet, and the client’s willingness and ability to follow the rules.
This is when you set a timeline for follow-up care, testing and monitoring. As we all know, clients hate surprises. If you want the pet back in 10 days for a re-evaluation that will include lab work or a glucose curve, now is the time to inform the client. The client might have to be told that a visit is needed every 10 days until the pet is regulated and that each visit comes with a cost.
Finally, don’t forget to discuss the risks if the condition is unregulated or poorly regulated: cataracts, increased likelihood of infections, diabetic ketoacidosis, for example. Once the client’s glazed look and tears are under control, it’s time to get real.
2. Once the Diagnosis Sinks In
Panic frequently sets in when clients are told they will have to inject the pet at home, on their own and with nobody from the practice present. Clients are terrified that they might hurt the pets. Using empathy and compassion, a practice member’s role is to calm and teach clients and validate their ability to administer insulin and possibly take blood and urine samples. Team-based health care will have a skilled and trained person (a diabetes mellitus advocate) to act as a liaison between the practice and client and serve as the client’s cheerleader during the scary process.
After the diet, insulin and home-care discussion, a fully transparent explanation of long-term and follow-up care is next. Using a spreadsheet, email or some other reporting mechanism, the client should regularly update the advocate. The client should report the pet’s clinical signs and appetite, the insulin dosage (when administered and how much), and a “How’s it going?” subjective measure using a scale running from 1 (not so good) to 5 (wonderful). All this information can be submitted online or emailed daily to the advocate.
By keeping the client involved, you will enhance compliance. Get the pet’s entire family involved with the reporting as well. Doing so will engage everybody in the patient’s care, promoting long-term compliance and success.
3. An Ongoing Basis
Follow-up care will vary depending on the response to treatment, but follow-up care is a given. This is where forward-booking is important and where your advocate can support client compliance by staying in touch using whatever technologies work best for all parties.
A chronic condition like diabetes mellitus fits beautifully into current discussions on telemedicine. You have a veterinarian-client-patient relationship, a diagnosis and ongoing treatment. You can offer the convenience of telemedicine to evaluate the patient’s status and observe the pet. The service can be included in the cost-of-care estimates and promoted as a cost-, time- and stress-saving option.
Except in cases of remission (mostly in cats), diabetes mellitus is a lifetime disease. It is a roller coaster because things like dental disease and skin or urinary infections can knock a pet out of regulation. If clients aren’t staying in touch with you, you need to contact them. If 12 months have passed and you haven’t heard from the client, you dropped the ball and might have put the pet at risk.
Final Thoughts
Diagnosing a diabetic patient was easy for me as a clinician because the clinical signs and laboratory test results were clear. Then came the hardest part: communicating to the client the diagnosis, treatment plan, and long-term care and monitoring needs.
The ultimate goal, as AAHA puts it, is “a well-defined, case-
specific treatment plan [that] can be developed with a reasonable expectation for control, and in the case of cats, a chance for remission.”
Clinical success can be defined as the absence of the classic signs of polyuria, polydipsia, polyphagia and weight loss. From the practice and pet owner standpoint, success is defined as a client who is compliant in a pet’s care and follow-up appointments and who has accepted needed lifestyle changes. From the pet standpoint, success is receiving the necessary diet and a pinprick.
Add it all up and that’s a win for everybody.
Dr. Peter Weinstein owns PAW Consulting and is executive director of the Southern California Veterinary Medical Association.
AN OFF-THE-WALL THOUGHT
Think about creating a program for the average diabetic dog or cat that includes the initial workup, follow-up visit, maintenance and ongoing care during the first year. What would you charge the client? Would it be pre-paid? Would it include insulin and syringes?
Another program, one for after the initial workup, could cover follow-up exams, lab work, glucose curves and other tests — whatever your routine dictates.
If your wellness plans work because the pet owner knows what to expect cost-wise, wouldn’t a diabetes mellitus regulation system with a known cost help with compliance?
YOUR DIABETES MELLITUS ADVOCATE
A selected team member can talk with clients about the technical aspects of diabetes mellitus, such as at-home insulin administration and monitoring. Consider providing the client with a checklist of important topics. These include:
- Insulin and syringe handling
- Disposing of sharps
- Drawing up insulin
- Administering insulin: when, where and how?
- Changing dosages
- Feeding: what, when and how much?
- At-home urine and blood testing
- Status reports
- Recognizing and responding to low blood glucose and high blood glucose readings
- Frequently asked questions such as “What happens if I’m not sure the insulin went in?,” “Will it hurt?,” “What if my pets isn’t eating or vomits after eating?” and “What if the clinical signs get worse?”