Diabetes Complications in Dogs and Cats: Diabetes Ketoacidosis (DKA)


Unfortunately, we veterinarians are seeing an increased prevalence of diabetes mellitus in dogs and cats. This is likely due to the growing prevalence of obesity (secondary to inactive lifestyle, a high carbohydrate diet, lack of exercise, etc.). So, if you just had a dog or cat diagnosed with diabetes mellitus, what do you do? First, we encourage you to take a look at these articles for an explanation of the disease:

Diabetes Mellitus (Sugar Diabetes) in Dogs

Diabetes Mellitus (Sugar Diabetes) In Cats

Once you have a basic understanding of diabetes mellitus (or if you already had one), this article will teach you about life-threatening complications that can occur as a result of the disease; specifically, I discuss a life-threatening condition called diabetes ketoacidosis (DKA) so that you know how to help prevent it!

What is DKA?
When diabetes goes undiagnosed, or when it is difficult to control or regulate, the complication of DKA can occur. DKA develops because the body is so lacking in insulin that the sugar can’t get into the cells -- resulting in cell starvation. Cell starvation causes the body to start breaking down fat in an attempt to provide energy (or a fuel source) to the body. Unfortunately, these fat breakdown products, called “ketones,” are also poisonous to the body.

Symptoms of DKA
Clinical signs of DKA include the following:

  • Weakness
  • Not moving (in cats, hanging out by the water bowl)
  • Not eating to complete anorexia
  • Vomiting
  • Excessive thirst and urination (clear, dilute urine)
  • Large urinary clumps in the litter box (my guideline? If it’s bigger than a tennis ball, it’s abnormal)
  • Weight loss (most commonly over the back), despite an overweight body condition
  • Obesity
  • Flaky skin coat
  • Excessively dry or oily skin coat
  • Abnormal breath (typically a sweet “ketotic” odor)
  • Diarrhea

In severe cases DKA can also result in more significant signs:

  • Abnormal breathing pattern
  • Jaundice
  • Abdominal pain (sometimes due to the secondary problem of pancreatitis)
  • Tremors or seizures
  • Coma
  • Death

What can cause DKA?
When DKA occurs, it’s often triggered by an underlying medical problem such as an infection or metabolic (organ) problem. Some common problems that we see with DKA include the following:

  • Pancreatitis
  • Urinary tract infection
  • Chronic kidney failure
  • Endocrine diseases (e.g., hyperadrenocorticism [when the body makes too much steroid], or hyperthyroidism [an overactive thyroid gland])
  • Lung disease (such as pneumonia)
  • Heart disease (such as congestive heart failure)
  • Liver disease (such as fatty changes to the liver or “hepatic lipidosis”)
  • Cancer

Diagnosing DKA
While diagnosing DKA is simple, by looking at the blood sugar levels of dogs and cats and by measuring the presence of these fat breakdown products in the urine or blood, treatment can be costly (running between $3-5000). A battery of tests and diagnostics need to be performed, to look for underlying problems listed above, and treatment typically requires aggressive therapy and 24/7 hospitalization.

Treatment of DKA
Treatment, typically, is required for 3-7 days, and includes the following:

  • A special intravenous catheter called a “central line” (placed to aid in frequent blood draws)
  • Aggressive intravenous fluids
  • Electrolyte supplementation and monitoring
  • Blood sugar monitoring
  • A fast acting or ultra fast acting insulin, regular or Lispro, typically given intravenously or in the muscle
  • Blood pressure monitoring
  • Nutritional support (often in the form of a temporary feeding tube)
  • Anti-vomiting or anti-nausea medication
  • Antibiotics
  • Long-term blood sugar monitoring and a transition to a longer-acting insulin

Thankfully, with aggressive supportive care, many patients with DKA do well as long as pet parents are prepared for the long-term commitment (including twice-a-day insulin, frequent veterinary visits to monitor the blood sugar, and the ongoing costs of insulin, syringes, etc.).

Preventing DKA
By following your veterinarian’s guidelines and recommendations you can help regulate and control your pet’s diabetic state better; also, monitor your pet carefully for clinical signs. For example, if your pet is still excessively thirsty or urinating frequently despite insulin therapy he is likely poorly controlled and needs an adjustment of his insulin dose. (Of course, never adjust your pet’s insulin or medications without consulting your veterinarian!)

When in doubt remember that the sooner you detect a problem in your dog or cat, the less expensive that problem is to treat. If you notice any clinical signs of diabetes mellitus or DKA, seek immediate veterinary attention. Most importantly, blood glucose curves (when a veterinarian measures your pet’s response to their insulin level) often need to be done multiple times per year (especially in the beginning stages of diabetes mellitus).

Help keep your diabetic pet healthy – after all, it’s treatable!

If you have any questions or concerns, you should always visit or call your veterinarian -- they are your best resource to ensure the health and well-being of your pets.


What is DKA?

Diabetic ketoacidosis is a serious metabolic condition that occurs in diabetic dogs and cats. The body normally converts sugars and starches from food into glucose, which circulates in the blood. Insulin, produced by the pancreas, acts as a gatekeeper that allows circulating blood glucose to enter cells, to be used for energy. In diabetes, the body does not produce insulin or may be resistant to insulin. Because insulin is not acting to allow glucose into the cells of the diabetic patient, circulating blood glucose levels become high and eventually spill into the urine. Elevated blood glucose and glucosuria (glucose in the urine) are seen in the diabetic patient. When the body does not receive adequate energy from glucose, it must instead break down fats stored in the body for energy this process creates ketones, which build up in the blood. Ketones in DKA are comprised of several types of ketoacids, which cause metabolic acidosis to occur. The detection of these ketones in the blood and possibly in the urine, elevated blood glucose, glucosuria, and a state of metabolic acidosis are signs of diabetic ketoacidosis.

What are the symptoms of DKA in dogs?

Pets with DKA may look vastly different depending on the severity and longevity of the disease. Common signs of diabetes include excessive drinking and urination this is often accompanied by weight loss. A certain type of cataract may develop with diabetes which can cause vision loss. Because DKA is a sequela to diabetes, these signs may be present. Common signs that a pet is in DKA include lethargy, vomiting, and decreased appetite. Eventually, pets with diabetic ketoacidosis may become weak, dehydrated, or unable to stand. Sometimes the pet will have a sudden onset of cardiovascular collapse. The symptoms of DKA are variable and mimic numerous other diseases. DKA is only diagnosed by testing, which includes blood and urine tests. Common symptoms of DKA include:

  • Vomiting
  • Diarrhea
  • Weight loss
  • Decreased appetite
  • Weakness or inability to stand
  • Dehydration
  • Increased drinking and urination
  • Lethargy or depression
  • Collapse
  • Loss of vision
  • Panting

What can cause DKA in dogs?

Diabetic ketoacidosis develops in cases of diabetes that are not well controlled. This may happen if diabetes has not yet been diagnosed. It may occur in a pet who is known to be diabetic, but the insulin dose is not high enough. Insulin requirements may change over time. A regulated pet may require a change in insulin dose, as the body’s insulin production changes. This may occur if the body is producing less insulin, and the dose is not increased accordingly. DKA may also occur in cases of insulin resistance this often occurs with other medical conditions that increase hormones that are counter-regulatory to diabetes. Some conditions that may contribute to diabetes and DKA are growth hormone tumors, pregnancy, and excess cortisol. The cells that produce insulin are in the pancreas. A pet who has recurrent or severe pancreatitis may have damage to these cells this may cause an inability to produce insulin, which can lead to diabetes and subsequent DKA.

How do you diagnose DKA in dogs?

Diabetic ketoacidosis cannot be diagnosed by history or exam. Blood and urine samples must be analyzed. Common findings with DKA include metabolic acidosis (low blood level of HCO 3 and a more negative base deficit), high blood glucose levels, glucose in the urine, ketones in the blood and possibly in the urine. Electrolyte imbalances are also commonly seen with DKA.

What is the treatment for DKA in dogs?

Dogs and cats in DKA will require emergency veterinary care for several days. Prognosis is guarded, although many pets survive and return to normal lives, although diabetes must be continually managed. The treatment goals of DKA are to restore hydration, and to correct electrolyte and acid-base imbalances. DKA patients are often given a slow continuous administration of insulin, but periodic insulin injections may be given instead. Insulin may be started immediately, or delayed until after several hours of fluid support. Glucose levels will be frequently monitored during treatment. The goal of treatment is to use insulin to stop ketone production and to stabilize the patient, not to regulate diabetes. When the pet becomes stabilized and ketone production has stopped, treatment becomes aimed at regulation of diabetes, often with insulin. Treatment includes identifying and correcting other disease processes that may be contributing to DKA. Recheck examinations for testing will be necessary. Pets can return home on insulin when the pet is hydrated, eating, and no trace ketones are detected.

How can you prevent DKA in dogs?

Diabetic ketoacidosis is a complication of diabetes. If your pet is not diabetic, the best way to prevent diabetes is to avoid obesity, which can lead to insulin resistance. Diabetes is often not preventable. Diabetes is thought to have a genetic component some breeds of dogs are more prone to becoming diabetic than others. Other causes may be immune-mediated or hormone-induced. Diabetes may be caused by other diseases. Pancreatitis may cause diabetes by the destruction of the cells in the pancreas that produce insulin. Regular screening blood and urine tests are recommended in a healthy pet, to help detect diabetes.

If a dog or cat is known to be diabetic, glucose monitoring helps to ensure that diabetes will not develop into diabetic ketoacidosis. Many people with diabetic pets monitor glucose at home. Monitoring blood glucose on a glucometer is important, but keep mind that it only provides a picture in time. Your veterinarian will likely also recommend periodic glucose curves or fructosamine levels. Glucose curves are serial glucose levels charted to demonstrate glucose trends. Fructosamine levels are measured in the blood to demonstrate glucose regulation over a period-of-time.

Summary

DKA is a serious disease that requires emergency veterinary care. Regular examinations and routine diagnostic screenings help to diagnose diabetes so that your pet can be treated before she develops this life-threatening complication. If you know that your pet is diabetic, it is important to follow up regularly with your veterinarian to keep her diabetes regulated to help prevent DKA.

I’m a Licensed Vet Tech with a passion to spread awareness for animal welfare and knowledge as far and often as I can!


Treatment of Diabetes in Dogs and Cats

Diets that have a low glycemic index (meaning they don’t cause spikes in blood sugar) are ideal for diabetics. Treats that aren’t sweet are allowed, but it is important to be as consistent as possible in both the food given and the time your pet is fed. We will discuss diet options readily available as well as restrictions you should plan to follow.

  • Insulin

Most diabetic pets are dependent on insulin shots to control their blood sugar. There are many types of insulin on the market including some produced specifically for pets. Finding the right type of insulin and the proper dose requires time and some trial and error. For many owners, giving insulin injections is the most intimidating part of caring for a diabetic pet. While it is normal to have difficulty giving shots the first week or so, once you have been shown how to give the insulin and get used to the process, you will be surprised at how easy it is and how little most pets mind getting their shot.


Diabetes In Dogs: Complications And Emergencies

It is most often caused by a lack of insulin – a hormone produced by the pancreas that is essential for the normal function of glucose metabolism.

When it comes to diabetes induced complications and emergency situations, there are two main conditions:

  • Hypoglycaemia
  • Diabetic ketoacidosis


Diabetic ketoacidosis (DKA) is one of the most extreme complications of diabetes mellitus that can occur. Unfortunately, most cases of ketoacidosis are in patients that were not previously known to be diabetic so both pet and owner face two serious diagnoses seemingly out of the blue: one life-threatening and expensive and the other requiring on-going commitment and daily treatment.

Dog with DKA displaying lethargy

The diabetic patient cannot produce enough insulin (type I) or its cells are resistant to the effects of insulin (type 2) Insulin is the substance that enables the cells to take in and utilize blood glucose/sugar. Insulin production and utilization are also affected by concurrent illnesses such as pancreatitis and even urinary tract infections.

If glucose is not getting taken up into the cells, body tissues, including the brain, become especially desperate and the body begins to break down fat to liberate the small amount of carbohydrate (which can be converted to glucose) contained in the fat.

Fat is converted to a biochemical substance called a ketone body. Ketone bodies can be used as an alternative fuel source by tissues that require glucose (brain, red blood cells etc.). This will save the day in the short term but ketones have serious side effects including being very acidic. When ketone bodies are burned, the blood becomes acidic and electrolyte imbalances ensue. These imbalances coupled with the loss of glucose in the urine create dehydration, which in turn creates more acidic and electrolyte imbalances. In short, a disaster results if this continues to cycle.

Most patients in diabetic ketoacidosis are lethargic, depressed, and will not eat. They are dehydrated and frequently nauseated. Blood glucose is extremely high and ketones can be found in the urine. The goal is to gradually correct all the imbalances, get the patient out of the extreme fat-burning state, and establish some sort of initial regulation of the diabetes.

Prognosis is generally fair as long as the complicating disease (the disease that is happening on top of the diabetes mellitus such as pancreatitis) can be resolved. That said, round-the-clock monitoring of electrolytes and blood sugar is needed to safely get the patient through the crisis, and this care is expensive. Ketoacidosis involves potential disasters in potassium, phosphorus, pH, blood sugar, and sodium. All of these parameters must be controlled. The goal is to convert the complicated diabetic patient into an uncomplicated diabetic patient, and then the patient can be managed as a “normal’ diabetic.

What to Expect in the Hospital

The sooner the crisis is recognized, the faster treatment can be started. Because crucial blood substances can shift rapidly during treatment, blood testing is necessary throughout the day to keep track and stay up to date with correcting the imbalances. A facility that offers 24-hour care is ideal.

In dogs, the most common inciting/concurrent conditions are: pancreatitis, urinary tract infection, and Cushing’s disease. In cats, precipitating/concurrent conditions include: hepatic lipidosis, kidney infection, pancreatitis, and cholangiohepatitis.

Patient receiving IV Fluids

Intravenous Fluids

Intravenous fluid therapy is an essential part of treatment. The patient is very dehydrated from the illness, which causes excess urination as well as from vomiting and/or diarrhea. Aside from simply providing fluids, the IV fluids can have other things added to it such as potassium and insulin to help correct other metabolic derangements.

Blood sugar must be controlled if treatment is to be successful but to prevent brain damage, blood sugar levels must be dropped slowly. To achieve this, “regular insulin” (typically Humulin R®) is used, given either as multiple intramuscular injections or as a continuous drip. This type of insulin is short acting and wears off quickly, which allows it to provide small adjustments. It is not until the patient is eating and nausea has been controlled that a maintenance long-acting insulin can be started.

Patients in ketoacidosis are greatly depleted in potassium. While insulin is needed to control blood sugar, insulin makes the problem worse by driving potassium into the body’s cells and out of the bloodstream. Typically, high amounts of potassium must be supplemented in the intravenous fluid solution.

Low levels of phosphorus also accompany diabetic ketoacidosis and if levels drop too low, the patient’s red blood cells will begin to burst and be unable to maintain integrity. Phosphorus is also supplemented through the intravenous fluid solution.

The term ketoacidosis implies that the blood pH is overly acidic. If the situation is severe enough, sodium bicarbonate (a basic substance) must be added to the intravenous therapy.

All these aspects require regular monitoring, which means lab work perhaps four times daily or more. Patients in diabetic ketoacidosis require close monitoring and intensive care.

Monitoring blood glucose with a veterinary glucometer

When ketones are no longer in the urine and the patient is eating well and in good spirits, he or she is able to go home and be managed as a regular diabetic. Diet, blood sugar monitoring, and insulin adjustments will be on-going things for you and your veterinarian to do to get your diabetic patient’s disease under control.


Watch the video: TOP 10 Foods that do NOT affect the blood sugar


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