AAHA Releases Updated Diabetes Guidelines

Much has changed in the management of canine and feline diabetes mellitus (DM) since the American Animal Hospital Association (AAHA) Diabetes Management Guidelines Task Force released its first guidelines in 2010. The 2018 guidelines,¹ released last month, include the latest expert recommendations on the diagnosis and management of diabetes and feature several important updates, such as:

• Algorithms to help clinicians interpret and monitor blood glucose readings, manage hypoglycemia, and troubleshoot patients near the upper limit of insulin dosing
• An updated overview of insulin types, with suggestions for initiating therapy and optimizing therapeutic response
• Recommendations on the appropriate implementation of non-insulin therapies (eg, oral hypoglycemic agents) and dietary modification
• Tips for identifying, managing, and monitoring at-risk patients
• An online resource center for veterinary teams and pet owners that features customizable patient discharge instructions, tips for anesthetizing diabetic pets, client information handouts, instructional videos on at-home glucose testing, urine glucose monitoring, insulin administration, and more

A Changing Conversation

The new guidelines arrive at an important time, because the conversation about diabetes is changing. For starters, the disease affects more of our patients now than in the past. If it seems like you’re seeing more diabetic pets in your practice than you were 10 years ago, your suspicions are probably correct. According to a 2016 study released by Banfield Pet Hospital, the incidence of diabetes is on the rise in dogs and cats throughout the country. Between 2006 and 2015, researchers identified a startling 80% increase in diabetes in dogs and an 18% increase in cats.² With this disease affecting more pets than ever, it’s critical that veterinary professionals have updated, easy-to-use resources on hand when deciding how to approach these patients and advise pet owners.

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But the increasing number of diabetic patients isn’t the only challenge. Today’s veterinarians must decipher shifting dietary recommendations, stay informed about new insulin options (and contend with the disappearance of some we relied on in the past), and compete with untrustworthy online information sources when clients need answers about their diabetic pets. Diabetes always has been a complex disease, but these additional challenges can make it more difficult for veterinary staff to continue offering pet owners the best and most current advice.

The updated guidelines address many of these issues and suggest resources for both veterinary staff and pet owners. The online resource center even includes mobile apps to help clients track their pets’ progress throughout therapy.

The guidelines also offer detailed advice for clinicians regarding diagnosis and short- and long-term diabetes management, including differentiating stress-induced or transient hyperglycemia from true diabetes, selecting insulin and initiating therapy, determining when and how to adjust insulin dosing, and helping pet owners develop at-home monitoring skills.

Although the guidelines are detailed and extensive, the Task Force stresses that the recommendations are not intended to rep-resent a standard of care. Instead, they encourage clinicians to individualize treatment based on patient needs. “Management of diabetes is often complicated,” the Task Force noted. “Success requires understanding of current scientific evidence and sound clinical judgment. Each patient requires an individualized treat-ment plan, frequent reassessment, and modification of that plan based on the patient’s response.”

Redefining Therepeutic Goals

One important recommendation in the new guidelines concerns rethinking the goals of therapy and the definition of “successful” diabetes management. Although performing blood glucose curves and monitoring fructosamine levels are important, achieving specific numbers should not be the goal. Blood glucose levels can vary significantly based on the pet’s stress level and other factors, and fructosamine levels may be elevated in well-controlled diabetic patients, as well as in cats that are not diabetic at all. For these and other reasons, the guidelines encourage clinicians to focus more on the pet’s general condition and activities at home (eg, appetite, fluid intake, urination, and weight changes) than on measurable blood glucose parameters.

“Where DM monitoring is concerned, clinical signs supersede all else. When the patient has no clinical signs and the body weight is steady or increasing, DM is likely well controlled,” the Task Force noted. “The overarching goal of monitoring diabetic cats and dogs is to control clinical signs of DM while avoiding hypoglycemia… the definition of a controlled diabetic is absence of clinical signs and hypoglycemia.” Using this holistic approach brings adequate control within the reach of the pet owner, particularly when ongoing support from the veterinary staff is readily available.

The Role of Technicians

The Task Force also acknowledged the pivotal role of veterinary technicians in client education and communication, as well as in patient care. According to Renee Rucinsky, DVM, DABVP (Feline Practice), owner of Mid Atlantic Cat Hospital in Queenstown, Maryland, and co-chair of the Diabetes Management Guidelines Task Force, “Veterinary nurses are an integral part of diabetes management and are often the most frequent communicators with the owners of diabetic pets. The guidelines are a fantastic resource for them to help patients, owners, and doctors with all aspects of diabetic treatment.”

Dr. Todd-Jenkins received her VMD degree from the University of Pennsylvania School of Veterinary Medicine. She is a medical writer and has remained in clinical practice for over 20 years. She is a member of the American Medical Writers Association and One Health Initiative.

References:

• Behrend E, Holford A, Lathan P, Rucinsky R, Schulman R. 2018 AAHA diabetes man-agement guidelines for dogs and cats. AAHA website. aaha.org/public_documents/ guidelines/diabetes%20guidelines_final.pdf. Published January 4, 2018. Accessed January 30, 2018.
• Kay N. Pets, obesity and diabetes: An epidemic in 2016. Pet Health Network website. pethealthnetwork.com/news-blogs/a-vets-life/pets-obesity-and-diabetes-epidemic-2016. Published July 8, 2016. Accessed January 30, 2018.