Nurse Clinics. for diabetic pets.

Transcription

1 Nurse Clinics for diabetic pets A practical guide to running successful nurse clinics for diabetic cats & dogs Rewriting pet diabetes management What you should know What resources you need What owners should know Resources for vets and nurses Information for diabetic-pet owners

2 Introduction to nurse clinics for diabetic pets Diabetes mellitus is a complex disease which requires significant involvement from the pet owner in order to achieve a successful outcome. With so much new to learn, the diabetic pet owner requires high quality ongoing support and reassurance from the practice team and the veterinary nurse is ideally placed to provide much of what is needed. For the trained veterinary nurse, better utilisation of knowledge and skills provides greater job satisfaction. The efficient use of veterinary nurses in diabetic management releases the veterinary surgeon to do other clinical duties and can, therefore improve practice efficiency. For the owner of a diabetic pet, managing their pet s condition can be very daunting at first. Taking the time to discuss the condition and its management will provide vital reassurance and the essential information needed for owners to perservere. The net result of effectively implementing diabetes nurse clinics will be better care with a consistent practice-wide approach, greater satisfaction for both the practice team and the diabetic pet owner and of course improved clinical outcomes for the patient. Implementing and running diabetes nurse clinics To successfully implement and run diabetes nurse clinics, a practice needs to have at least one veterinary nurse trained to Diabetes Adviser standard. The nurse will need to be familiar with and comfortable discussing the causes, diagnosis, stabilisation and management of diabetes in cats and dogs. This can be achieved by successfully completing the MSD Animal Health Diabetes Adviser Course and by being aware and confident in the use of all the support tools and literature available for Caninsulin users. Diabetic nurse clinics have a different focus depending on the management phase of the pet s diabetes. These types of clinic can be summarised as: Initial post-diagnosis clinic Stabilisation clinic Maintenance clinic Following initial diagnosis Diabetes Stabilisation Diabetes Maintenance 1-3 weeks every 3 months Key stages in diabetes management and approximate time taken to achieve Initial post-diagnosis clinic Having a pet diagnosed as a diabetic can be initially daunting for owners. It is imperative that clients are given sufficient time to consider this news and have the disease and its treatment explained to them in an easily digestible form. Supplying owners with reference material support items before attending an initial post-diagnosis nurse clinic is ideal for this purpose. This initial post-diagnosis clinic is likely to take an hour to complete. During this clinic, it is vital to take this time to cover the most important aspects of diabetes treatment and to ensure owners feel confident regarding their pet s diabetic management. As there is so much informatioin to impart to the client, there will undoubtedly be a need to reiterate key points at further clinics or via telephone or . Utilising the full range of diabetic pet support items available from MSD Animal Health can go a long way to help this process. Available tools for owners include the Caring for your Diabetic Pet DVD, Diabetes Owner Manuals, Diabetes Owner Website as well as the Diabetes Training Owner Presenter. Key information to impart to owners: An explanation of what diabetes is including potential causes and the common clinical signs of diabetes Diabetes Mellitus is a life-long condition, however with appropriate treatment, affected pets can live a healthy normal life Successful management depends on regular and consistent quantities of exercise, diet and insulin Several different strengths/formulations of insulin are available. When using Caninsulin, the appropriate syringes/cartridges must be used Insulin must be handled, mixed and stored appropriately How to draw up and administer insulin properly using Caninsulin syringes or VetPen What a hypo (hypoglycaemic episode) is, the clinical signs that are commonly seen and what to do if it occurs Broached shelf life (28 days) must be respected. Unfinished insulin vials/cartridges as well as Caninsulin syringes/vetpen needles must be disposed of properly When to contact the practice for advice Cats can go into diabetic remission and the signs of this to watch out for Diabetes stabilisation can take up to three months and all family members needs to take ownership of their pet s diabetes Most of all, owners need to be aware that the practice team is there to help and to answer questions as and when required Stabilisation clinic Diabetes stabilisation commences with a conservative dose of insulin (often administered twice daily) and the pet being sent home on a consistent and regular management regime of exercise, insulin and diet. The aim of the stabilisation phase of diabetic control revolves around titrating the insulin dose to the pet s needs. This stabilisation phase may take up to several months depending on the individual diabetic.

3 Owners should be asked at each stabilisation clinic whether there have been any changes in the animal s water intake, food consumption, urination, general demeanour as well as if they have seen any vomiting, diarrhoea or neurological signs. In depth questioning regarding diabetes management e.g. diet, exercise, insulin storage, injection of insulin etc. is also important. The pet should be examined and weighed at each visit and the owner encouraged to discuss any concerns they might have. The pet may require hospitalisation for a blood glucose curve and/or blood samples taken for fructosamine assessment. Based on clinical signs, history, examination and further diagnostic tests, the dose of insulin may be adjusted in consultation with the veterinary surgeon. The pet is then discharged and a revisit booked for the next stabilisation clinic. Maintenance clinics The main aim of the maintenance phase of diabetes management is to achieve a good quality of life for the pet though continued effective diabetic managment. Of course the client should seek advice if something of concern arises in the intervening period. During this period, changes in water intake, appetite, urination, or the pet s weight or demeanour can all indicate that control may be compromised. During the nurse clinic thorough questioning is vital to ensure that such clues are not missed. The importance of diet, exercise consistency and routine should always be reiterated since over time lapses in compliance can readily occur. As well as accurate history taking and a physical examination, the collection of diagnostic samples such as blood for a fructosamine level may be appropriate. In addition, serial blood glucose measurements can help to establish the timing and peak effect of administered insulin where appropriate. Screening for diabetes As well as the above structured nurse clinics there is an opportunity to actively screen for diabetics in the practice. This screening is aimed at increasing owner awareness of diabetes as well as improving rates of diagnosis. Screening for diabetic patients can be easily achieved by asking appropriate questions to clients during other relevant nurse clinics (weight-loss, geriatric etc). Alternatively, this screening could be conducted by a targeted search of the practice management system and follow-up mailing to clients that own animals that may be at greater risk, for example middle-aged dogs of predisposed breeds or perhaps pets that have an underlying disease that predisposes them to diabetes (e.g. hyperthyroidism in cats, hyperadrenocorticism or hypothyroidism in dogs). Initial post-diagnosis clinic 1 hour approximately Single clinic in first week of diagnosis Diabetes Owner Manual Diabetes Owner Website - Diabetes Owner Presenter - download from Caring for your Diabetic Pet DVD Injection training device VetPen Instructional DVD Client information to impart: Insulin: Revisit for Stabilisation Nurse Clinic: What is diabetes and how it occurs Common clinical signs of diabetes (PU, PD, PP, weight loss) Diabetes is treatable but lifelong Diabetic management requires routine & consistency (diet, insulin, exercise) Stabilisation may take several months Difference between insulins and importance of appropriate syringes /cartridges Insulin handling, storage and shelf life Insulin administration using syringes or VetPen Signs of hypoglycaemia Appropriate disposal of syringes or VetPen needles Record keeping Diabetic remission in cats Ensure new Caninsulin vials/cartridges and appropriate Caninsulin syringes/vetpen dispensed 1-3 weeks time

4 Stabilisation Clinic 20 minutes (+/- time for blood samples/curves etc. if required) Clinics every 1-3 weeks Diabetes Owner Manual Diabetes Owner Website - Diabetes Owner Presenter - download from Caring for your Diabetic Pet DVD VetPen Instructional DVD Areas on which to question the owner: Management related questions Possible clinical tasks Revisit for next Stabilisation Clinic PU, PD, PP, weight loss General demeanour and activity Pet s vision Neurological signs (ataxia, disorientation, plantigrade stance in cats) Hypoglycaemia signs Gastrointestinal signs (vomiting, diarrhoea) Remission in cats Record taking Any concerns regarding insulin injection, storage, disposal of syringes/needles Is diet, exercise and insulin provision routine and consistent Blood collection for Fructosamine Full/partial blood glucose curve Insulin dose adjustment (in consultation with the vet) Urinanalysis 1-3 weeks Maintenance Clinic 15 minutes Clinics every 3 months Diabetes Diary Clinical questions to ask owner: Management related questions: Clinical Tasks: Revisit for next Maintenance Clinic: PU, PD, PP, weight loss General demeanour and activity Pet s vision Neurological signs (ataxia, disorientation, plantigrade stance in cats) Hypoglycaemia signs Gastrointestinal signs (vomiting, diarrhoea) Remission in cats Record taking Any concerns regarding insulin injection, storage, disposal of syringes/needles Is diet, exercise and insulin provision routine and consistent Blood collection for Fructosamine or HbA1c (dogs) Full/partial blood glucose curve Urinanalysis 3 months

5 Caninsulin & VetPen Rewriting pet diabetes management for pets, clients, and veterinary staff Caninsulin trusted used for almost 20 years in millions of diabetic pets 40 i.u./ml formulation allows accurate dosing small cartridge and vial sizes to help eliminate wastage proven capable of achieving remission in cats 1,2,3,4 no significant increase in anti-insulin antibodies in dogs 5 and cats 6 VetPen simplifies insulin administration and improves dosing accuracy sleek pen design is user-friendly and less intimidating improves initial acceptance and ongoing compliance helps to make pet owner instruction easier ideal for administration on-the-go Resources for vets and nurses Information for diabetic-pet owners References 1. Horspool L.J., Martin G.J. & Rand J.S. 9th Annual Congress of the European Society of Veterinary Internal Medicine October 1999, Perugia, Italy: Martin G. J. and Rand J.S., (2000) J Vet Int Med 14(2): Michiels L. Preliminary results: Proceedings of the European Society of Veterinary Internal Medicine 10th Congress September 2000, Neuchatal, Switzerland: Michiels L. Preliminary results: Journal of Small Animal Practice Davison, L. J., Ristic J. M. E, Herrtage M. E., Ramsey I. K and Catchpole B. (2002). J Vet Int Med 16(5): J. P. Adams, B. Catchpole, Prevalence of anti-insulin antibodies in insulin-treated diabetic cats, Proceedings BSAVA Congress, 3-6 April 2008, Caninsulin is indicated for the treatment of diabetes mellitus in cats and dogs. Caninsulin is an intermediate acting insulin product containing porcine insulin, which is structurally identical to canine insulin. Legal category POM-V Contra indications, warnings, etc: The product must not be administered by the intravenous route. The product is a medium duration insulin and is not intended for the treatment of animals with severe acute diabetes presenting in a ketoacidotic state. Local injection site reactions have been reported rarely in dogs and very rarely in cats. These reactions are usually mild and reversible. In very rare cases, allergic reactions to porcine insulin have been reported. In the cat diabetic remission is possible. Before the product is administered owners should be instructed to have a box of powdered glucose at home. Signs of hunger, increasing anxiety, unstable locomotion, muscle twitching, stumbling or sinking in the rear legs and disorientation indicate progression of hypoglycaemia and requires immediate administration of glucose solution and food to restore blood glucose levels. Polyuria, polydipsia and polyphagia in combination in chronic cases with weight loss, general bad condition, loss of hair or abnormal furry coat and lethargy are the most common clinical symptoms of hyperglycaemia and require administration of insulin to restore blood glucose levels to the normal range. The use of progestagens (oestrus inhibitors) in patients suffering from diabetes mellitus should be avoided. Stress and irregular extra exercise must be avoided. Care must be taken with the use of corticosteroids. Ovariohysterectomy may have to be considered. It is important to establish a strict feeding schedule in consultation with the owner which will include a minimum of fluctuations and changes. Administration of the product must be carried out by an adult responsible for the welfare of the animal. The use of the product is not contra-indicated during pregnancy or lactation but requires close veterinary supervision to account for changes in metabolic requirements during this period. Changes in insulin requirements may result from administration of substances which alter glucose tolerance, such as corticosteroids, thiazide diuretics, progestogens, amitraz and alpha-2 agonists, such as medetomidine, dexmedetomidine, xylazine. Monitoring of glucose concentrations should be used to adjust the dose accordingly. Similarly, changes in diet or exercise may alter insulin requirements. User warnings: Accidental self-injection can provoke clinical signs of hypoglycaemia and there is a low possibility of an allergic reaction. In case of accidental self-injection seek medical advice immediately and show the package leaflet to the doctor. Withdrawal period: Not applicable. For animal treatment only. Keep out of reach and sight of children. Further information is available from: MSD Animal Helath, Walton Manor, Walton, Milton Keynes MK7 7AJ Tel: vet-support.uk@merck.com