foreign Cassie from vetfolio and the host of vet to vet today we're discussing ways to help owners with the challenging task of taking care of a diabetic pet here to discuss some of the tips and tricks for creating a monitoring and treatment plan that works is Dr Catherine Scott Moncrief Dr Scott Moncrief is a professor of small animal internal medicine at Purdue University her clinical interests include internal medicine and Endocrinology Dr Scott Moncrief thank you so much for joining us today thank you it's wonderful to be here it's wonderful to have you today we're talking about managing diabetic patients and one of the primary tools that we use is a continuous glucose monitor I'm usually a freestyle Libre I understand there are multiple iterations of the freestyle Libre and when I call them in I'm always a little confused as to what the difference is between them can you review the types of freestyle Libre monitors and the indications for each one yes of course so the freestyle Libre glucose monitors all measure interstitial glucose in and they can be used to measure interstitial glucose in dogs and cats there are three versions of the freestyle Libre glucose monitors the original validated version for dogs and cats was the freestyle Libre 14 day and the newer versions are the Libra 2 and the Libra 3. as I said the freestyle Libre 14 day has been validated in both dogs and cats in in peer-reviewed Publications so that is the one that we usually recommend but in some areas of the country it's becoming hard to find the freestyle Libre 14-day reader and in other areas they're even having trouble finding the sensor and so people are having to move to using the Libra 2 which is very similar to the 14 day but it has some slight differences um differences in Bluetooth compatibility um it looks exactly the same um but it has some the sensory assault it's slightly different um and it hasn't been validated in the same way that the 14-day sensor has um the Libra 3 um is just has just come on the market I actually have one sitting in my office which I haven't had a chance to use yet it just became available in pharmacies um so we don't know much about its performance in dogs and cats um but the major advantage is that it's much smaller so the Libra um 14 day and the Libra 2 are about the size a little bit bigger than a quarter the Libra 3 is the size of a penny and so um that smaller size is going to be really great for our smaller dogs and cats if we can't get a hold of the 14-day monitor is it reasonable then to go ahead and sub in the freestyle Libre too I think at this point it's reasonable to sub in the um Libre too um but people need to realize that there are some subtle differences for example with the 14-day reader you can place it with you can place the sensor with the reader and then use a cell phone um for the owners at home and so because the readers has been on of it is but come on unavailable we have readers in our hospital we use them to place the freestyle Libre and then the owners use their cell phones at home that doesn't work with the Libra 2 because of the difference in the Bluetooth compatibility if you place it with the reader you'd have to use the reader continually if you price it with the with a cell phone you have to use the cell phone so there are some subtle differences between the two and it's a different sensor slightly different sensor and we haven't got many Publications on it but overall it seems that people are getting pretty good results with the Libra 2 although there aren't that aren't any Publications yet interesting thank you for clarifying that because I think that's the main question I get when I'm calling them in is which one do you want I'm like I don't know so that kind of gives everybody some good options as far as how to answer that question and in the future I think we'll um you know be looking at the freestyle Libre 3 and that may end up being all default reader I'm not planning I'm planning on evaluating the freestyle Libre 3 and and jumping to that if it works well um from the 14 day once we have some information on the on the on the Libra 3. very cool well I can't wait to hear more about it especially the smaller size seems very very good for our patients yeah yeah when we call these monitors in we're kind of asking the owner to jump through some hoops you know we call it in they have to go pick it up from the pharmacy um which means they they cost money and then bring it bring the sensor and bring the pet into the clinic to have this placed and so of course we want to make sure we're doing this right when we're asking an owner to do this especially you know they're going to take them home and monitor the pet this is going to be a be kind of a big thing so can you share with us your hospitals protocol for placing the Libra who places it how do you get the reader up and running how do you communicate with the owner can you kind of run us through all of that yeah so this to for the owners to get the um reader and the sensor there is actually there are actually two options they can you can write a prescription and send them to the pharmacy with their prescription and of course if you're being a reader you just need to buy one reader and then for the future that'll last every sensor you have to you know purchase another sensor because the sensor only lasts for up to 14 days um you can also stop these in your hospital um we get you can get them from Cardinal help and stock them in your hospital it tends to for us it tends to add little costs but sometimes owners prefer convenience over cost um so those are two options and so if we have an owner who we decide what needs of freestyle Libre maybe for the first time the first thing we're going to talk about with them is what the advantages of the technology um are on what the costs are and then um if the owners are willing to go ahead with that then we will um ask them to either go up and go and pick out the sensor pick up the sensor from a pharmacy or to we'll provide it from our hospital and then we'll ask them to download the libreview app and then we can send them an invitation from the libreview software that invites them to share that data um with us in our hospital and so we have a professional account and if they give us permission to share that data then we can go on to any of the computers in our hospital and look at the data as it's as it's accumulated as far as how it's the logistics of placing it so most of the time it's our Veterinary nurses replacing um these sensors you know I do one once in a while just to keep my hand in um they place it and basically we'll talk a little bit about the logistics of of placing these sensors but once you place them um the first thing to do after you've placed the sensor is to activate it and you do that by running swiping or passing the the reader or a cell phone across the place sensor and that starts the sensor working but it takes 60 minutes for the sensor to actually start giving glucose data and so because of that what we usually do is we'll have the animal in the hospital we'll often place it with one of our readers and then um we'll wait that 60 Minutes make sure everything's working correctly before we send the owner home with the sensor and their cell phone or the reader um because every now and again we'll have a placements fail and we don't want to send them home until we know the the sensor is working after placement can be complicated for the owners when you send them that invitation they have to know what link to pick and there's quite a few variable you know there's quite a few iterations some own some owners really get it pretty fast others struggle with that so actually in our hospital right now we're working on a handout that kind of walks them through with screenshots exactly what they're going to see when they get that invitation which links to pick and and how to move it forward so that they've got the technology working once the technology is working they seem to have no problems with it it's that first initiation that can be a little tricky sure I love that you're making a client hand out sheet so that they can understand it because that would be me not not knowing where to click or what I was looking at uh and it sounds like like so many things that once you get everything up and running it's smooth it's smooth sailing but that initial build out and getting everything working can be really challenging so I think the take-home Point here is a good emphasis on client communication and making sure they understand how this is going to go and how it's going to work to help avoid some of the frustration that can inevitably come with technology when you don't know how to use it which is the story of my life so and exactly so I bet me knows is actually you know who said we need to put together a handout for this because I spend an hour after hours last night explaining things to these owners and I don't want to have to do that every single time well good for them yeah yeah so I understand you have some video on how to place this monitor can we take a look at that yes of course so the first step is to prepare an area of skin to place the sensor and we do that by clipping the area and wiping it with alcohol and allowing the alcohol to dry you can also use a skin tack wipe that adds um some protection to the skin and has also adds a little bit of stickiness once the skin has been prepared for placement of the sensor the next step is to load the sensor into the applicator and there's very good instructions that come with the um with the sensor and applicator but there are lines that you can see on the applicator pack and on the sensor that you line up and then you push the um applicator down on top of the sensor and that loads the sensor into the applicator once the sensors is loaded into the applicator you can turn it upside down you can see the sticky disk that is going to be in contact with the skin and in the video you'll see that they put a circle of skin glue around that sticky part we've actually tried to decrease the amount of glue so that we actually now do more of like a clock face of glue rather than a whole circle of glue you want to minimize the amount of glue that you use without having it fall off so that that's that's the balance you're then going to deploy the sensor and the important things when you deploy the sensor is that you deployed at 90 degrees to the skin surface and you avoid any kind of bony prominences if you hit a bony prominence um it will bend the needle and that can cause failure of the applicator to release the sensor um once you've deployed the sensor then you need to separate the applicator from the sensor and sometimes you need a pair of hemostats just to grab the edge of the sticky disk and hold it down and make sure it doesn't pull away um with the applicator um and then you're going to tap down the edges of the sensor patch maybe add a little bit more glue if necessary um and then at that point you're ready to scan the sensor with the reader or the cell phone and once you scan it um sometimes you'll um it'll say you know do you want to scan and do you want to add a new sensor and you say yes and then you pass the the reader over the sensor and then it'll say ready to read in 60 minutes and then at that point we're going to put the animal in a cage we're going to wait and double check that it's still working after 60 minutes and then the owner can take the animal home um and you know we have to decide whether or not you're going to protect that sensor with a jacket or with um a skin grip patch or a Thundershirt or whatever and that's really patient dependent sure I was gonna say when he said then you know we put him in a kennel and we wait for 60 minutes and I was going and ideally they don't chew the sensor out in the meantime yes exactly exactly and some older dogs really leave these alone you know some older dogs that you know have coffee table backs they don't even notice and and it's sometimes fine to leave them unprotected but in a younger dog or a wiggly dog or in households where there are other dogs they the other dogs will kind of grab onto them and remove them so um every animal is going to be a little bit different the skin grip patches really what they're made specifically for the freestyle Libre and they fit really nicely over it and they work really well in dogs and cats I find it kind of annoy the cats and they start looking at them so I don't tend to use the skin grip patches as much in cats and cats will typically use a protective t-shirt um or Thundershirt something like that absolutely that's interesting I've done the t-shirts but I've never done the skin patch so um I'll have to give that a try the skin grip pads they come in in rainbow colors so you can even color coordinate with your uh with the harness or you know whatever the pet whatever color the pet likes all the owners like I love that that's so you make it a little more fun to monitor diabetes here yeah coordinate with it with the ribbons in their hair you know perfect perfect well you know talking about doing this monitoring now we've got our sensor placed it's working the pet is not trying to chew it out and the owner is able to keep an eye on these numbers what are you looking for when we start to get these data points back what types of parameters either numerical or otherwise do you feel indicate that our diabetic patients are controlled yeah so the most important parameter of course in any diabetic is to evaluate whether the clinical signs are controlled so we're going to look at the clinical signs um together with the blood glucose numbers um and when you look at the reports that you get with the freestyle Libre monitor um you get a lot of data and you have to figure out what's the most important data and so it's still really like looking at a blood glucose curve except you have 14 days of blood glucose curves if you if if these sensors stay on for that long length of time so we're going to be looking at the Nadia how low does the blood glucose go and we're going to be looking at the duration how long is the insulin lasting and we'd like to have the blood glucose NADA in the 80 to 150 range but that is a little bit patient dependent it depends on you know if you have a cat that you think might go into diabetic remission you maybe want to have slightly lower numbers than a canine diabetic that you know is permanently diabetic um so 80 to 150 is you know is the range but every every patient's going to be a little bit different and then we're going to look at the duration of the effect and ideally of course you'd like to have the blood glucose um below 300 milligram per deciliter for the duration between insulin doses which is you know typically 12 hours um but if you can keep the blood sugar below 300 for the majority of that time period that will typically equate to good control of clinical science and if the control if you have that and the clinical science don't look well controlled there's something there's you know something not not right um so um so we're going to look at um the incident insulin I'm sorry blood glucose Nadia insulin duration and then we can use the reports from the freeze Libre Center to also look at other things like day-to-day variability and that's one of the powerful things about this this technology is you can look at multiple days and you'll realize how much day-to-day variability there is normally in any diabetic patient and you can get some statistics on you know how many times do you see a evidence of hypoglycemia how many times is the blood glucose way above the target range and then you can use that that data to decide whether or not you need to adjust the insulin dose up and down or whether or not you maybe need to change insulins okay and um when you say if you have all of these things exactly where you want them the numbers are working out and you don't have good control of clinical signs then something is wrong um so potentially looking into like a comorbidity or something along those lines right for example what if you have a diabetic dog that's also cushioned and and the pupd is coming from the Cushings um yes I feel like I've had that conversation talking to internists where they've said well what if he's also cushioned and I said but I don't want him to be cushioned away that will make it more complicated exactly exactly absolutely well in thinking about the diabetic patients that I've treated it would be so nice if we could say your your pet is diabetic we could start insulin and then boom we get nice diabetic control maybe with a little bit of adjustment here and there but personally I've found that that's not always the case and we have to make some lifestyle changes as well so can you talk about some of the ancillary things that we can do in addition to insulin therapy to help our diabetic patients regulate as quickly as possible yeah so there are lots of other aspects of diabetic regulation you know insulin's not the only thing right so um dietary modification um is really important that depends on whether it's a dog or a cat so a local carbohydrate diets in cats um higher fiber diets usually in dogs um controlling obesity um increasing exercise routine exercise um and then as far as dieting diabetic dogs and cats you know cutting out high high calorie treats you know making sure they follow recommendations about the number of meals um so they're consistent in the meals from day to day is really important and then ruling out other illnesses as we talked about the complicated diabetic control so um and cats you know recurrent pancreatitis is a huge issue in dogs looking for underlying Cushings in poorly controlled diabetic dogs is going to be a really important in both species bacterial infections and of course particularly the urinary tract um are going to be something we're going to look for the type of insulin and dose can also make a difference if the insulin does not last long enough due to Rapid metabolism or if insulin dose is too low or too high this can cause problems of diabetic regulation for example insulin used hypoglycemia can actually worsen diabetic control lastly it is really important to make sure that owners are well informed on how to store and administer insulin and how to recognize clinical signs of hypo and hypoglycemia well talking about this technology and like you said a very powerful technology that can give us a lot of really necessary really useful data it seems like there's a lot of Pros to using a freestyle Libre can you compare it to the traditional glucose curve I know you brought that up earlier so I was just kind of interested in the differences and pros and cons between the two yeah so um you know a couple and we've really talked about the pros it's a very powerful technology and we get lots of data um and so um it really is important that the veterinarian and the owner understand that data and so um it's easy for the owner for the owner to overreact to every little change in the blood glucose um so that's one thing to to be concerned about um the blood glucose does fluctuate and that can sometimes the amount of fluctuation can Panic owners um and the other thing that you need to be aware of is that there's a difference between interstitial glucose and the blood glucose they're not identical and one the interstitial glucose typically lags behind the blood glucose so if the blood glucose is changing very fast the interstitial glucose will have a will not be quite as close to the blood glucose as it would be at the steady state and so that can lead to some inconsistency so no um you if your if owners are checking with an alpha track for example the number may not may not be identical um and then we do have our um senses that fail we have sensor errors um so if the circumstances where the data you're getting doesn't make sense you kind of have to know when to think about that we can see that in dehydrated patients um we can see that when the sensor is starting to fail you'll start seeing um weird numbers you'll maybe see the blood glucose fluctuating up and down um when you haven't done anything to change the blood glucose so you know so there are things that can trigger um someone who's familiar with the technology say that looks like the sense is failing the other thing we'll see is gaps in the data so that you know it's not you don't see a nice steady line you see you know times when the when the sensor is not recording like you said familiar with the technology I'm glad that you bring that up so we know what to look for it makes me think of like monitoring anesthesia or monitoring blood pressure while a pet is under anesthesia when you just you know sometimes you just get some weird numbers where like that's not consistent with what I'm seeing here and you know maybe you need a different cuff a different machine and so it sounds like a similar looking at the whole patient type of concept exactly I think you put it absolutely um hit the nail on the head Cassie and I think that one of the things you have to realize is that um the more data you have the more room there is for um you know things to not be correct and so you have to have an index of Suspicion yes this doesn't really quite fit um you know an example of that is that one of the great advantages of technology is it's much more sensitive for detecting hypoglycemia because you can imagine you're you're monitoring the blood glucose for 24 7 for up to 14 days and so it's much more sensitive for detecting episodes of hypoglycemia um but there is a little bit less accuracy at the lower end of the range and so you have to know how when to worry about you know if you just see one small episode of hypoglycemia that's probably not something to worry about if the blood sugar if the interstitial glucosaurus is running in the um 40s then that's really an indication you need to decrease the dose um so kind of interpreting through that not panicking when you see one small episode of hypoglycemia but realizing if you have profound hypoglycemia that can really cause poor diabetic control and obviously increase the likelihood of the animal is going to end up in the emergency room see I love these talks because I've used freestyle Libre monitors I feel like a fair bit where I have some familiarity with them and I still learn so much when I sit down and have these talks as far as what to look for and what might be a false reading and when to worry so I appreciate you going through all of this with us a couple of key points I mean the technology is always evolving the reports are changing the the company changes how the reports look all the time you know the sensor technology is evolving um and so yes it's something you really have to kind of stay on stay on top of as far as what's what's what's happening in this space um absolutely so it sounds like you do have to be aware of potential issues and look at your whole patient but there's a lot of Pros to reaching for a freestyle Libre are there cases where you should definitely use a Libre and avoid a glucose curve or or the opposite cases where you absolutely should not reach for a Libre and you should do a glucose curve instead well I have to say that I think there are very few circumstances when a bug a traditional blood glucose curve is going to be the the the treat you know the monitoring tool of choice um we can use this technology in newly diagnosed diabetic patients um it's very helpful so you can adjust carefully adjust the insulin in those first few days you don't want to adjust the insulin um too rapidly so you want to wait you know five to six days and then you might want to adjust up just up of course if you document hypoglycemia you can adjust down um in any unstable diabetic patient these are just critical so the patients that have you know pancreatitis and you're trying to get them through that pancreatitis and you may be needing to adjust insulin on a you know a daily basis under the under the care of veterinarian um very important not to let the owners just go off and make decisions on their own and we can use this in diabetic ketoacidotic patients with the caveat that be a little careful when the patients are dehydrated because dehydration can make it make this technology less accurate and then we can use it like a traditional blood glucose curve where one might recommend a blood glucose curve every three months or three to six months instead of doing that you place a freestyle Libre um the main times that we don't do that are when owners say well we did this and it didn't work um and I think people get you know if it doesn't work the first time the you know the sensor fell off they get you know put off by the technology and I think that you can sometimes say okay well we could do a blood glucose curve um but you know the other thing you can do is just try this technology again we're kind of moving forward in in keeping the sensor on and the technology is evolving like you said it's evolving I feel like when it first became available wasn't it a 10-day Monitor and there was like a 12-hour waiting period that's right yes that's correct yes and so some of the old videos that are out there um on the internet are regarding that technology so it really is changing changing all the time and there are some vet re monitors on the horizon too so you know we may be moving on from the freestyle Libre to some Veterinary specific um interstitial glucose monitors in the future that would be so cool very much well can we talk about some case examples as far as using continuous glucose monitoring um can you talk about some success stories you've had or you know maybe even some cautionary tales yeah just a couple of cautionary tales I think from the point of view of General use it's important that the owners understand that the freestyle Libre is recording the glucose all the time not and they're not just not just recording when they swipe so this is recording all the time um but um they do need to swipe the the reader or cell phone over the center every eight hours all the data will get overwritten so that's the minimum they have to they have to do this every eight hours if they want to do it more multiple times that's fine um but sometimes owners get kind of obsessive with it and they just swiping and looking at the glucose concentrations all the time and they're staying up all night worrying about it and they have to realize it's being recorded whether or not they they swipe or not um so that's an important thing and sometimes you just have to tell the owners you know you really need to give the owner the animal a break let's take this meter you know we've got the information we need let's take the the monitor off for a few days so those are some generals that precautionary Tales one example I can show you here is a cat that came in for suspected insulin resistance and the cat was doing very well at home clinically but the Anna was concerned about these really high numbers glucose numbers they were getting when they checked it using an alpha track in the morning so all we really did was do some basic blood work and place a freestyle Libre and what we found is that although the cat had high blood glucoses in the morning it was actually having pretty significant hypoglycemic episodes during the night time and that was actually what was causing the high morning glucoses and of course nobody does the blood glucose curve in the middle of the night so it's one example is it's a great technology to evaluate animals that maybe have something different going on in the day than is going on at night so interesting yeah so that's one example another example is it's a really good way of picking up rapid metabolism where the insulin just isn't lasting long enough and on this particular um freestyle Libre report you can see that the insulin is only lasting about two to three hours of the day and so that means that the animal is still having pretty marked clinical signs of of um diabetes this freestyle Libre daily log shows a cat who has excellent control of their diabetes this should be a cat that you monitor for the possibility of diabetic remission this daily log shows a dog on once daily prozinc insulin and you can see that although the blood glucose is a little above the reference range during the day in the evening late afternoon evening and overnight the blood glucose concentrations are very well controlled very cool I mean it a lot of things caught on these monitors that you know maybe we wouldn't have been able to catch in the past just on our traditional glucose curves right exactly and the other really powerful um place for this in cats that you're monitoring for possible diabetic remission um so you know this can really help you figure out um when you do a blood glucose curve you know is the other high numbers you're seeing in the hospital just a result of stress and maybe the blood glucose is a much lower at home and so in cats that you think are going to the diabetic remissioning having one of these freestyle libraries in place can help you detect those blood sugars going down as and and the need for decreasing the insulin dose or even stopping insulin therapy absolutely I'm thinking back to before we had this technology and trying to do glucose curves on the cat that didn't want you to touch him and going how is this even close to Accurate so a much better clinical picture yeah one of the things we should say is that you know it the freestyle Libre 14 day implies that the senses are always staying in place for 14 days and that's not the case on average they stay in place in dogs for about 12 days and in cats it's a little bit shorter um on on average eight days of of of recordings is the most you're going to get in cats but there's some evidence that cats get used to wearing these or owners get used to keeping them on because some cats when they've had multiple sensors seem to keep them in place longer which I think is kind of interesting learning curve that is interesting and that's what I was going to ask you is it that the sensor is falling off after that period of time or is it just that the animal will no longer tolerate it or a combination of the two yeah I mean sometimes it's that the sensor just fails but more commonly in cats is they just start nibbling at it trying to get it off on and um and it's that they remove it so that's the most common in cats they start being cats they stop being cats yet well Dr Scott Moncrief this has been a great discussion I've learned so much thank you so much for joining me it was a pleasure it was lovely to talk with you Cassie and thank you to Beringer ingelheim animal health for sponsoring this edition of vet to vet check out thatfolio.com for more of our V2 discussions on various topics in veterinary medicine and remember if one animal is better off because of you today it's a great day important safety information prozing protamine zinc recombinant human insulin is for use in dogs and cats only keep Out Of Reach of children animals presenting with severe ketoacidosis anorexia lethargy and or vomiting should be stabilized with short-acting insulin and appropriate supportive therapy until their condition is stabilized as with all insulin products careful patient monitoring for hypoglycemia and hyperglycemia is essential to attain and maintain adequate glycemic control and to prevent Associated complications overdose can result in profound hypoglycemia and death the most common adverse reactions were lethargy anorexia hypoglycemia vomiting seizures shaking dogs only diarrhea and ataxia many of the adverse reactions such as lethargy seizures shaking and Ataxia are associated with hypoglycemia glucocorticoid and progestin use should be avoided the safety and effectiveness of protein in puppies kittens or breeding pregnant and lactating animals has not been evaluated prozinc is contraindicated during episodes of hypoglycemia and an animal sensitive to protamine zinc recombinant human insulin or any other ingredients in prozinc for full product information please refer to the package insert