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Adam Rudinsky, DVM, MS, DACVIM, works in the internal medicine service at The Ohio State University. He has performed research in gastroenterology, pancreatology, and hepatology. Adam earned his DVM from The Ohio State University, and completed a small animal rotating internship at Purdue University and a residency at The Ohio State University. He has received several teaching and hospital service awards.
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This quiz on feline diabetes mellitus reviews key principles in the diagnosis and management of the disease. Feeding recommendations, differential diagnoses, diagnostic testing, insulin therapy, diabetic neuropathy, and long-term monitoring are covered.
George, a 10-year-old castrated domestic short-haired cat (Figure 1), is presented for evaluation of previously diagnosed diabetes mellitus. He weighs 8.1 kg and has a BCS of 8/9, with a muscle condition score showing mild diffuse muscle wasting. A clinic associate had previously seen George for classic clinical signs of diabetes mellitus (ie, polyuria, polydipsia, polyphagia, weight loss, lethargy). According to the owners, their cat is tolerating insulin therapy well and the clinical signs of diabetes mellitus are improving. However, the owners have a few questions regarding the best dietary management strategy for their cat. He is currently fed ad libitum using a high-carbohydrate, moderate-protein diet, offered in both canned and dry formulations.
Which of the following factors is most important when designing a feeding plan for this cat?
Continue feeding the current diet ad libitum to encourage maintenance of the cat’s current body weight.
Switch the diet to one that minimizes carbohydrate macronutrient content.
Restrict the diet to once-daily feedings to provide regularity in the daily feeding pattern.
Feed a dry diet, which is the preferred formulation for diabetic cats.
Switch the diet to one that minimizes protein macronutrient content.
The most important factor in dietary management of feline diabetics is macronutrient concentration, specifically restricting carbohydrate content. Low-carbohydrate diets have been shown to possibly increase remission rates and improve glycemic control.1-4
A healthy body condition also is important, as excess body fat increases insulin resistance and complicates diabetic management.5,6 Therefore, maintaining a BCS of 8/9 would not be recommended. Caloric estimates, with restricted feedings when needed, should target the ideal body weight on an individual patient basis.7
Currently, no evidence has shown that frequency of feedings and timing of insulin administration are important considerations in managing feline diabetics. Consistency and a regular time schedule with feeding are the major key factors.8
Feeding dry and/or wet diets can help achieve diabetic control. Canned foods are typically (but not always) lower in both caloric and carbohydrate content, which may be beneficial in realizing successful diabetic management and a reason some practitioners recommend them.9-12
The most important factor in dietary management of feline diabetics is macronutrient concentration, specifically restricting carbohydrate content. Low-carbohydrate diets have been shown to possibly increase remission rates and improve glycemic control.1-4
A healthy body condition also is important, as excess body fat increases insulin resistance and complicates diabetic management.5,6 Therefore, maintaining a BCS of 8/9 would not be recommended. Caloric estimates, with restricted feedings when needed, should target the ideal body weight on an individual patient basis.7
Currently, no evidence has shown that frequency of feedings and timing of insulin administration are important considerations in managing feline diabetics. Consistency and a regular time schedule with feeding are the major key factors.8
Feeding dry and/or wet diets can help achieve diabetic control. Canned foods are typically (but not always) lower in both caloric and carbohydrate content, which may be beneficial in realizing successful diabetic management and a reason some practitioners recommend them.9-12
The most important factor in dietary management of feline diabetics is macronutrient concentration, specifically restricting carbohydrate content. Low-carbohydrate diets have been shown to possibly increase remission rates and improve glycemic control.1-4
A healthy body condition also is important, as excess body fat increases insulin resistance and complicates diabetic management.5,6 Therefore, maintaining a BCS of 8/9 would not be recommended. Caloric estimates, with restricted feedings when needed, should target the ideal body weight on an individual patient basis.7
Currently, no evidence has shown that frequency of feedings and timing of insulin administration are important considerations in managing feline diabetics. Consistency and a regular time schedule with feeding are the major key factors.8
Feeding dry and/or wet diets can help achieve diabetic control. Canned foods are typically (but not always) lower in both caloric and carbohydrate content, which may be beneficial in realizing successful diabetic management and a reason some practitioners recommend them.9-12
The most important factor in dietary management of feline diabetics is macronutrient concentration, specifically restricting carbohydrate content. Low-carbohydrate diets have been shown to possibly increase remission rates and improve glycemic control.1-4
A healthy body condition also is important, as excess body fat increases insulin resistance and complicates diabetic management.5,6 Therefore, maintaining a BCS of 8/9 would not be recommended. Caloric estimates, with restricted feedings when needed, should target the ideal body weight on an individual patient basis.7
Currently, no evidence has shown that frequency of feedings and timing of insulin administration are important considerations in managing feline diabetics. Consistency and a regular time schedule with feeding are the major key factors.8
Feeding dry and/or wet diets can help achieve diabetic control. Canned foods are typically (but not always) lower in both caloric and carbohydrate content, which may be beneficial in realizing successful diabetic management and a reason some practitioners recommend them.9-12
The most important factor in dietary management of feline diabetics is macronutrient concentration, specifically restricting carbohydrate content. Low-carbohydrate diets have been shown to possibly increase remission rates and improve glycemic control.1-4
A healthy body condition also is important, as excess body fat increases insulin resistance and complicates diabetic management.5,6 Therefore, maintaining a BCS of 8/9 would not be recommended. Caloric estimates, with restricted feedings when needed, should target the ideal body weight on an individual patient basis.7
Currently, no evidence has shown that frequency of feedings and timing of insulin administration are important considerations in managing feline diabetics. Consistency and a regular time schedule with feeding are the major key factors.8
Feeding dry and/or wet diets can help achieve diabetic control. Canned foods are typically (but not always) lower in both caloric and carbohydrate content, which may be beneficial in realizing successful diabetic management and a reason some practitioners recommend them.9-12
Pixie, a 6-year-old spayed domestic short-haired cat weighing 4.2 kg (Figure 2), is presented for polyphagia and weight loss. According to the owners, ≈2 months before the appointment, they noticed larger urine clumps in the cat’s litter box. Shortly thereafter, they also realized that Pixie appeared to be losing weight, even though they were filling her food bowl more often. Review of the cat’s dietary history confirmed that she is eating ≈300 kcal/day (resting energy requirement [RER] = 70 × [body weightkg]0.75 = 209 kcal/day). The physical examination was unremarkable, except for generalized decreased muscle wasting despite an ideal BCS of 4/9.
Which of the following conditions is the most likely diagnosis?
Hyperthyroidism
Inflammatory bowel disease
Chronic kidney disease
Diabetes mellitus
Exocrine pancreatic insufficiency
Diabetes mellitus is the most likely diagnosis in this cat, as it explains all abnormalities as presented.13-14
Hyperthyroidism is an unlikely diagnosis given the cat’s age, as it is more commonly expected in cats older than 6 years of age.15-16 Inflammatory bowel disease and exocrine pancreatic insufficiency should not cause polyuria or polydipsia.17-18 If the clinical signs were attributed to chronic kidney disease, it would be unusual for the cat to have an increased appetite.19 Therefore, the most likely diagnosis in this cat remains diabetes mellitus, as it supports all of the present abnormalities.13-14
Diabetes mellitus is the most likely diagnosis in this cat, as it explains all abnormalities as presented.13-14
Hyperthyroidism is an unlikely diagnosis given the cat’s age, as it is more commonly expected in cats older than 6 years of age.15-16 Inflammatory bowel disease and exocrine pancreatic insufficiency should not cause polyuria or polydipsia.17-18 If the clinical signs were attributed to chronic kidney disease, it would be unusual for the cat to have an increased appetite.19 Therefore, the most likely diagnosis in this cat remains diabetes mellitus, as it supports all of the present abnormalities.13-14
Diabetes mellitus is the most likely diagnosis in this cat, as it explains all abnormalities as presented.13-14
Hyperthyroidism is an unlikely diagnosis given the cat’s age, as it is more commonly expected in cats older than 6 years of age.15-16 Inflammatory bowel disease and exocrine pancreatic insufficiency should not cause polyuria or polydipsia.17-18 If the clinical signs were attributed to chronic kidney disease, it would be unusual for the cat to have an increased appetite.19 Therefore, the most likely diagnosis in this cat remains diabetes mellitus, as it supports all of the present abnormalities.13-14
Diabetes mellitus is the most likely diagnosis in this cat, as it explains all abnormalities as presented.13-14
Hyperthyroidism is an unlikely diagnosis given the cat’s age, as it is more commonly expected in cats older than 6 years of age.15-16 Inflammatory bowel disease and exocrine pancreatic insufficiency should not cause polyuria or polydipsia.17-18 If the clinical signs were attributed to chronic kidney disease, it would be unusual for the cat to have an increased appetite.19 Therefore, the most likely diagnosis in this cat remains diabetes mellitus, as it supports all of the present abnormalities.13-14
Diabetes mellitus is the most likely diagnosis in this cat, as it explains all abnormalities as presented.13-14
Hyperthyroidism is an unlikely diagnosis given the cat’s age, as it is more commonly expected in cats older than 6 years of age.15-16 Inflammatory bowel disease and exocrine pancreatic insufficiency should not cause polyuria or polydipsia.17-18 If the clinical signs were attributed to chronic kidney disease, it would be unusual for the cat to have an increased appetite.19 Therefore, the most likely diagnosis in this cat remains diabetes mellitus, as it supports all of the present abnormalities.13-14
Oscar, an 11-year-old castrated domestic short-haired cat (Figure 3), is presented for polyuria, polydipsia, and weight loss. Based on clinical signs at presentation and diagnostic findings (Table) of hyperglycemia, glucosuria, and elevated serum fructosamine concentration, diabetes mellitus is diagnosed.
Table
| Test | Result | Reference Interval |
| Blood glucose | 389 mg/dL (21.6 mmol/L) | 74-120 mg/dL(4.1-6.7 mmol/L) |
| Glucose (urine dipstick) | 3+ | Negative |
| Serum fructosamine level | 576 µmol/L | >550 µmol/L (poor control) |
Which of the following is not an appropriate primary or adjunctive treatment option for this cat?
Glucagon-like peptide-1 analogs (eg, exenatide)
Dietary management
Long-acting insulin analogs
Intermediate-acting insulins
Immunomodulatory drugs
Despite proposed mechanisms of immune-mediated destruction of the endocrine pancreas as a cause of diabetes in some species, immunomodulatory drug therapy (eg, cyclosporine) is not recommended in diabetic cats.20,21 Rather, the important concept to remember is that management of diabetes mellitus requires a truly multifaceted approach.
Insulin therapy is the gold standard for therapy. Multiple insulin choices are available in most markets, with insulin glargine, insulin detemir, and porcine insulin used most often. Thus, practitioners should be familiar with multiple insulin formulations, as there is no single best fit for each animal.20 Diabetic control can be achieved with both long-acting (eg. protamine zinc insulin, glargine, detemir) or intermediate acting (eg, Vetsulin) insulins.20 Currently there are no comparative studies looking at the relative effectiveness of intermediate versus long-acting insuins in cats.
Diet has also been shown to be a major factor in improving glycemic control and lowering remission rates in cats with diabetes mellitus. A thorough dietary history should be obtained for each patient and used as a basis to formulate the ideal dietary management plan.2-4,8,20,22-23
Newer (novel) drug treatments (eg, extended-release glucagon-like peptide-1 [GLP-1] analogs such as exenatide) may revolutionize the way feline diabetics are managed and are already showing success.23 GLP-1 is an incretin hormone secreted from the GI tract into circulation in response to ingestion of nutrients in normal cats, thereby enhancing glucose-stimulated insulin secretion.23 In cats with type 2 diabetes, GLP-1 secretion is decreased; however, insulinotropic effects are retained. Furthermore, the effects of incretin hormones are more diversified than potentiation of insulin alone, including decreased glucagon secretion, induced satiation, and slowed gastric emptying.23
Despite proposed mechanisms of immune-mediated destruction of the endocrine pancreas as a cause of diabetes in some species, immunomodulatory drug therapy (eg, cyclosporine) is not recommended in diabetic cats.20,21 Rather, the important concept to remember is that management of diabetes mellitus requires a truly multifaceted approach.
Insulin therapy is the gold standard for therapy. Multiple insulin choices are available in most markets, with insulin glargine, insulin detemir, and porcine insulin used most often. Thus, practitioners should be familiar with multiple insulin formulations, as there is no single best fit for each animal.20 Diabetic control can be achieved with both long-acting (eg. protamine zinc insulin, glargine, detemir) or intermediate acting (eg, Vetsulin) insulins.20 Currently there are no comparative studies looking at the relative effectiveness of intermediate versus long-acting insuins in cats.
Diet has also been shown to be a major factor in improving glycemic control and lowering remission rates in cats with diabetes mellitus. A thorough dietary history should be obtained for each patient and used as a basis to formulate the ideal dietary management plan.2-4,8,20,22-23
Newer (novel) drug treatments (eg, extended-release glucagon-like peptide-1 [GLP-1] analogs such as exenatide) may revolutionize the way feline diabetics are managed and are already showing success.23 GLP-1 is an incretin hormone secreted from the GI tract into circulation in response to ingestion of nutrients in normal cats, thereby enhancing glucose-stimulated insulin secretion.23 In cats with type 2 diabetes, GLP-1 secretion is decreased; however, insulinotropic effects are retained. Furthermore, the effects of incretin hormones are more diversified than potentiation of insulin alone, including decreased glucagon secretion, induced satiation, and slowed gastric emptying.23
Despite proposed mechanisms of immune-mediated destruction of the endocrine pancreas as a cause of diabetes in some species, immunomodulatory drug therapy (eg, cyclosporine) is not recommended in diabetic cats.20,21 Rather, the important concept to remember is that management of diabetes mellitus requires a truly multifaceted approach.
Insulin therapy is the gold standard for therapy. Multiple insulin choices are available in most markets, with insulin glargine, insulin detemir, and porcine insulin used most often. Thus, practitioners should be familiar with multiple insulin formulations, as there is no single best fit for each animal.20 Diabetic control can be achieved with both long-acting (eg. protamine zinc insulin, glargine, detemir) or intermediate acting (eg, Vetsulin) insulins.20 Currently there are no comparative studies looking at the relative effectiveness of intermediate versus long-acting insuins in cats.
Diet has also been shown to be a major factor in improving glycemic control and lowering remission rates in cats with diabetes mellitus. A thorough dietary history should be obtained for each patient and used as a basis to formulate the ideal dietary management plan.2-4,8,20,22-23
Newer (novel) drug treatments (eg, extended-release glucagon-like peptide-1 [GLP-1] analogs such as exenatide) may revolutionize the way feline diabetics are managed and are already showing success.23 GLP-1 is an incretin hormone secreted from the GI tract into circulation in response to ingestion of nutrients in normal cats, thereby enhancing glucose-stimulated insulin secretion.23 In cats with type 2 diabetes, GLP-1 secretion is decreased; however, insulinotropic effects are retained. Furthermore, the effects of incretin hormones are more diversified than potentiation of insulin alone, including decreased glucagon secretion, induced satiation, and slowed gastric emptying.23
Despite proposed mechanisms of immune-mediated destruction of the endocrine pancreas as a cause of diabetes in some species, immunomodulatory drug therapy (eg, cyclosporine) is not recommended in diabetic cats.20,21 Rather, the important concept to remember is that management of diabetes mellitus requires a truly multifaceted approach.
Insulin therapy is the gold standard for therapy. Multiple insulin choices are available in most markets, with insulin glargine, insulin detemir, and porcine insulin used most often. Thus, practitioners should be familiar with multiple insulin formulations, as there is no single best fit for each animal.20 Diabetic control can be achieved with both long-acting (eg. protamine zinc insulin, glargine, detemir) or intermediate acting (eg, Vetsulin) insulins.20 Currently there are no comparative studies looking at the relative effectiveness of intermediate versus long-acting insuins in cats.
Diet has also been shown to be a major factor in improving glycemic control and lowering remission rates in cats with diabetes mellitus. A thorough dietary history should be obtained for each patient and used as a basis to formulate the ideal dietary management plan.2-4,8,20,22-23
Newer (novel) drug treatments (eg, extended-release glucagon-like peptide-1 [GLP-1] analogs such as exenatide) may revolutionize the way feline diabetics are managed and are already showing success.23 GLP-1 is an incretin hormone secreted from the GI tract into circulation in response to ingestion of nutrients in normal cats, thereby enhancing glucose-stimulated insulin secretion.23 In cats with type 2 diabetes, GLP-1 secretion is decreased; however, insulinotropic effects are retained. Furthermore, the effects of incretin hormones are more diversified than potentiation of insulin alone, including decreased glucagon secretion, induced satiation, and slowed gastric emptying.23
Despite proposed mechanisms of immune-mediated destruction of the endocrine pancreas as a cause of diabetes in some species, immunomodulatory drug therapy (eg, cyclosporine) is not recommended in diabetic cats.20,21 Rather, the important concept to remember is that management of diabetes mellitus requires a truly multifaceted approach.
Insulin therapy is the gold standard for therapy. Multiple insulin choices are available in most markets, with insulin glargine, insulin detemir, and porcine insulin used most often. Thus, practitioners should be familiar with multiple insulin formulations, as there is no single best fit for each animal.20 Diabetic control can be achieved with both long-acting (eg. protamine zinc insulin, glargine, detemir) or intermediate acting (eg, Vetsulin) insulins.20 Currently there are no comparative studies looking at the relative effectiveness of intermediate versus long-acting insuins in cats.
Diet has also been shown to be a major factor in improving glycemic control and lowering remission rates in cats with diabetes mellitus. A thorough dietary history should be obtained for each patient and used as a basis to formulate the ideal dietary management plan.2-4,8,20,22-23
Newer (novel) drug treatments (eg, extended-release glucagon-like peptide-1 [GLP-1] analogs such as exenatide) may revolutionize the way feline diabetics are managed and are already showing success.23 GLP-1 is an incretin hormone secreted from the GI tract into circulation in response to ingestion of nutrients in normal cats, thereby enhancing glucose-stimulated insulin secretion.23 In cats with type 2 diabetes, GLP-1 secretion is decreased; however, insulinotropic effects are retained. Furthermore, the effects of incretin hormones are more diversified than potentiation of insulin alone, including decreased glucagon secretion, induced satiation, and slowed gastric emptying.23
Sandy, an 11-year-old spayed domestic short-haired cat (Figure 4), had been diagnosed with diabetes mellitus 3 weeks earlier. During the initial appointment, the owner reported polyuria, polydipsia, polyphagia, and weight loss. Physical examination revealed mild diffuse muscle wasting, BCS of 6/9, and body weight of 5.3 kg. Diagnostic testing revealed an elevated serum fructosamine concentration of 651 µmol/L (reference interval, >550 µmol/L), an indicator of poor control and thus consistent with a diagnosis of uncomplicated diabetes mellitus. Therapy consisting of insulin glargine was initiated at a dose of 1 unit/cat SC q12h.
At the recheck appointment, the cat now weighs 4.9 kg for an additional loss of 0.4 kg. According to the owner, mild improvement of polyphagia has occurred, but polydipsia and polyuria persist. The cat was fed its normal meal and received its normal dose of insulin as prescribed at 7:00 am prior to the recheck appointment. The change in serum fructosamine concentration (ie, 643 µmol/L) is insignificant (Table), and blood glucose findings reveal levels higher than the typical ideal goal of 100 to 300 mg/dL (5.6-16.7 mmol/L) for diabetic cats (Table).24
Table
| Test | Result | Reference Interval |
| Serum fructosamine | 643 µmol/L | >550 µmol/L (poor control) |
Blood glucose curve 1. 8:00 AM 2. 10:00 AM 3. 12:00 PM 4. 2:00 PM 5. 4:00 PM 6. 6:00 PM |
1. 443 mg/dL (24.6 mmol/L) 2. 422 mg/dL (23.4 mmol/L) 3. 408 mg/dL (22.6 mmol/L) 4. 343 mg/dL (19.0 mmol/L) 5. 409 mg/dL (22.7 mmol/L) 6. 481 mg/dL (26.7 mmol/L) |
1. Ideal goal, 100-300 mg/dL (5.6-16.7 mmol/L) in diabetic cats |
Based on updated findings, which of the following options represents the best clinical decision?
It is too early to adjust the insulin dose and treatment course.
Persistently high serum fructosamine concentrations are indicative of the Somogyi effect; the insulin dose should be decreased.
Although mild improvement had occurred, there was overall lack of control; the insulin dose should be increased.
Therapy consisting of insulin glargine is apparently ineffective; a new insulin choice (eg, insulin detemir) should be prescribed.
Serum fructosamine testing and blood glucose curves should not be performed at the same time.
Insulin at 1 unit/cat (0.2 units/kg) is an appropriate starting dose; however, the expected response in glycemic control is typically minimal.20 Thus, the dose of insulin should be adjusted in an incremental manner,20,24 with repeat diagnostic testing based on clinical response.
Three weeks following initiation of therapy is a reasonable time to recheck a newly diagnosed diabetic. In general, protocols vary from weekly diabetic rechecks and insulin adjustments to less frequent rechecks occurring every couple of weeks.20,24 To date, there is no consensus on the best interval for diabetic rechecks in the immediate postdiagnosis period. Rather, this is better determined by individual patient status.
Fructosamine, a glycosylated protein in the bloodstream, gives an average of the glycemic control over the previous 1 to 3 weeks.20,24 Various patient-dependent factors are responsible for the window in which fructosamine is representative. Therefore, in a relatively stable patient such as this cat, the 3-week recheck would be appropriate and a reasonable time to make treatment adjustments. Serum fructosamine concentrations and blood glucose curves provide complementary information and can be used jointly to monitor diabetics if needed. Fructosamine findings alone, however, cannot be used to determine whether a Somogyi effect (rebound hyperglycemic response) is occurring.24 Further blood glucose monitoring would be needed.
At the initial recheck, there is insufficient information to determine whether the insulin used is ineffective. This cat was placed on an appropriately low starting dose. However, in many cats, this starting dose is too low to achieve adequate control. A majority of cats are controlled with doses of 0.5 to 6 units/cat.20 A low starting dose is used as it provides a lower risk for hypoglycemic events, which may be common and potentially life-threatening.24-25 Then the dose can be incrementally increased in a slow, methodical manner until control is achieved or the dose reaches a point where insulin resistance is a concern based on the insulin dose and concurrent lack of response. As the insulin dose approaches the higher end of the range most cat’s are controlled within, the clinicians suspicion of insulin resistance should increase. In conclusion, higher doses of insulin should be attempted in this scenario before deeming the insulin ineffective. Regardless, if any concern about insulin effectiveness arises, it is important to review the basics of diabetic management with the owners, including insulin storage, administration, and general management before proceeding with changing insulins and recommending further diagnostic testing.
Insulin at 1 unit/cat (0.2 units/kg) is an appropriate starting dose; however, the expected response in glycemic control is typically minimal.20 Thus, the dose of insulin should be adjusted in an incremental manner,20,24 with repeat diagnostic testing based on clinical response.
Three weeks following initiation of therapy is a reasonable time to recheck a newly diagnosed diabetic. In general, protocols vary from weekly diabetic rechecks and insulin adjustments to less frequent rechecks occurring every couple of weeks.20,24 To date, there is no consensus on the best interval for diabetic rechecks in the immediate postdiagnosis period. Rather, this is better determined by individual patient status.
Fructosamine, a glycosylated protein in the bloodstream, gives an average of the glycemic control over the previous 1 to 3 weeks.20,24 Various patient-dependent factors are responsible for the window in which fructosamine is representative. Therefore, in a relatively stable patient such as this cat, the 3-week recheck would be appropriate and a reasonable time to make treatment adjustments. Serum fructosamine concentrations and blood glucose curves provide complementary information and can be used jointly to monitor diabetics if needed. Fructosamine findings alone, however, cannot be used to determine whether a Somogyi effect (rebound hyperglycemic response) is occurring.24 Further blood glucose monitoring would be needed.
At the initial recheck, there is insufficient information to determine whether the insulin used is ineffective. This cat was placed on an appropriately low starting dose. However, in many cats, this starting dose is too low to achieve adequate control. A majority of cats are controlled with doses of 0.5 to 6 units/cat.20 A low starting dose is used as it provides a lower risk for hypoglycemic events, which may be common and potentially life-threatening.24-25 Then the dose can be incrementally increased in a slow, methodical manner until control is achieved or the dose reaches a point where insulin resistance is a concern based on the insulin dose and concurrent lack of response. As the insulin dose approaches the higher end of the range most cat’s are controlled within, the clinicians suspicion of insulin resistance should increase. In conclusion, higher doses of insulin should be attempted in this scenario before deeming the insulin ineffective. Regardless, if any concern about insulin effectiveness arises, it is important to review the basics of diabetic management with the owners, including insulin storage, administration, and general management before proceeding with changing insulins and recommending further diagnostic testing.
Insulin at 1 unit/cat (0.2 units/kg) is an appropriate starting dose; however, the expected response in glycemic control is typically minimal.20 Thus, the dose of insulin should be adjusted in an incremental manner,20,24 with repeat diagnostic testing based on clinical response.
Three weeks following initiation of therapy is a reasonable time to recheck a newly diagnosed diabetic. In general, protocols vary from weekly diabetic rechecks and insulin adjustments to less frequent rechecks occurring every couple of weeks.20,24 To date, there is no consensus on the best interval for diabetic rechecks in the immediate postdiagnosis period. Rather, this is better determined by individual patient status.
Fructosamine, a glycosylated protein in the bloodstream, gives an average of the glycemic control over the previous 1 to 3 weeks.20,24 Various patient-dependent factors are responsible for the window in which fructosamine is representative. Therefore, in a relatively stable patient such as this cat, the 3-week recheck would be appropriate and a reasonable time to make treatment adjustments. Serum fructosamine concentrations and blood glucose curves provide complementary information and can be used jointly to monitor diabetics if needed. Fructosamine findings alone, however, cannot be used to determine whether a Somogyi effect (rebound hyperglycemic response) is occurring.24 Further blood glucose monitoring would be needed.
At the initial recheck, there is insufficient information to determine whether the insulin used is ineffective. This cat was placed on an appropriately low starting dose. However, in many cats, this starting dose is too low to achieve adequate control. A majority of cats are controlled with doses of 0.5 to 6 units/cat.20 A low starting dose is used as it provides a lower risk for hypoglycemic events, which may be common and potentially life-threatening.24-25 Then the dose can be incrementally increased in a slow, methodical manner until control is achieved or the dose reaches a point where insulin resistance is a concern based on the insulin dose and concurrent lack of response. As the insulin dose approaches the higher end of the range most cat’s are controlled within, the clinicians suspicion of insulin resistance should increase. In conclusion, higher doses of insulin should be attempted in this scenario before deeming the insulin ineffective. Regardless, if any concern about insulin effectiveness arises, it is important to review the basics of diabetic management with the owners, including insulin storage, administration, and general management before proceeding with changing insulins and recommending further diagnostic testing.
Insulin at 1 unit/cat (0.2 units/kg) is an appropriate starting dose; however, the expected response in glycemic control is typically minimal.20 Thus, the dose of insulin should be adjusted in an incremental manner,20,24 with repeat diagnostic testing based on clinical response.
Three weeks following initiation of therapy is a reasonable time to recheck a newly diagnosed diabetic. In general, protocols vary from weekly diabetic rechecks and insulin adjustments to less frequent rechecks occurring every couple of weeks.20,24 To date, there is no consensus on the best interval for diabetic rechecks in the immediate postdiagnosis period. Rather, this is better determined by individual patient status.
Fructosamine, a glycosylated protein in the bloodstream, gives an average of the glycemic control over the previous 1 to 3 weeks.20,24 Various patient-dependent factors are responsible for the window in which fructosamine is representative. Therefore, in a relatively stable patient such as this cat, the 3-week recheck would be appropriate and a reasonable time to make treatment adjustments. Serum fructosamine concentrations and blood glucose curves provide complementary information and can be used jointly to monitor diabetics if needed. Fructosamine findings alone, however, cannot be used to determine whether a Somogyi effect (rebound hyperglycemic response) is occurring.24 Further blood glucose monitoring would be needed.
At the initial recheck, there is insufficient information to determine whether the insulin used is ineffective. This cat was placed on an appropriately low starting dose. However, in many cats, this starting dose is too low to achieve adequate control. A majority of cats are controlled with doses of 0.5 to 6 units/cat.20 A low starting dose is used as it provides a lower risk for hypoglycemic events, which may be common and potentially life-threatening.24-25 Then the dose can be incrementally increased in a slow, methodical manner until control is achieved or the dose reaches a point where insulin resistance is a concern based on the insulin dose and concurrent lack of response. As the insulin dose approaches the higher end of the range most cat’s are controlled within, the clinicians suspicion of insulin resistance should increase. In conclusion, higher doses of insulin should be attempted in this scenario before deeming the insulin ineffective. Regardless, if any concern about insulin effectiveness arises, it is important to review the basics of diabetic management with the owners, including insulin storage, administration, and general management before proceeding with changing insulins and recommending further diagnostic testing.
Insulin at 1 unit/cat (0.2 units/kg) is an appropriate starting dose; however, the expected response in glycemic control is typically minimal.20 Thus, the dose of insulin should be adjusted in an incremental manner,20,24 with repeat diagnostic testing based on clinical response.
Three weeks following initiation of therapy is a reasonable time to recheck a newly diagnosed diabetic. In general, protocols vary from weekly diabetic rechecks and insulin adjustments to less frequent rechecks occurring every couple of weeks.20,24 To date, there is no consensus on the best interval for diabetic rechecks in the immediate postdiagnosis period. Rather, this is better determined by individual patient status.
Fructosamine, a glycosylated protein in the bloodstream, gives an average of the glycemic control over the previous 1 to 3 weeks.20,24 Various patient-dependent factors are responsible for the window in which fructosamine is representative. Therefore, in a relatively stable patient such as this cat, the 3-week recheck would be appropriate and a reasonable time to make treatment adjustments. Serum fructosamine concentrations and blood glucose curves provide complementary information and can be used jointly to monitor diabetics if needed. Fructosamine findings alone, however, cannot be used to determine whether a Somogyi effect (rebound hyperglycemic response) is occurring.24 Further blood glucose monitoring would be needed.
At the initial recheck, there is insufficient information to determine whether the insulin used is ineffective. This cat was placed on an appropriately low starting dose. However, in many cats, this starting dose is too low to achieve adequate control. A majority of cats are controlled with doses of 0.5 to 6 units/cat.20 A low starting dose is used as it provides a lower risk for hypoglycemic events, which may be common and potentially life-threatening.24-25 Then the dose can be incrementally increased in a slow, methodical manner until control is achieved or the dose reaches a point where insulin resistance is a concern based on the insulin dose and concurrent lack of response. As the insulin dose approaches the higher end of the range most cat’s are controlled within, the clinicians suspicion of insulin resistance should increase. In conclusion, higher doses of insulin should be attempted in this scenario before deeming the insulin ineffective. Regardless, if any concern about insulin effectiveness arises, it is important to review the basics of diabetic management with the owners, including insulin storage, administration, and general management before proceeding with changing insulins and recommending further diagnostic testing.
Wesley, a 13-year-old castrated domestic short-haired cat (Figure 5), is presented for recheck examination of diabetes mellitus. Physical examination reveals a stable body weight, and the owner reports minimal clinical signs directly related to diabetes. However, the cat seems to have difficulty jumping onto furniture.
Which of the following statements is most accurate?
Orthopedic disease is the most likely explanation for the new owner complaint.
If appropriate orthopedic therapy is initiated, complete recovery would be expected.
Diabetic neuropathy is the most likely cause of the newly reported clinical sign.
Diabetic neuropathy is more common in dogs than cats.
Neuropathic medical therapy (eg, lipoic acid) would be an appropriate treatment option.
Clinical presentation of this cat is consistent with diabetic neuropathy. However, the range of clinical signs can be quite diverse and include weakness, trouble jumping, muscle atrophy, neurologic deficits, and plantigrade stance.24 A complete understanding of why diabetic neuropathy develops remains elusive, although multifaceted metabolic derangements likely play a role in nerve dysfunction and probably are related to poor glycemic control.24
Neuropathy is one of the most common complications of feline diabetes mellitus, reportedly occurring to some degree in nearly 90% of feline diabetics.24,26-27 However, it is seen less frequently in canine diabetics.24,27
Medical therapy options are often promoted online and in medical literature, but to date there are no proven methods of medical management for diabetic neuropathy in cats. Although some drugs have been evaluated in clinical trials, little benefit has been seen and the potential for side effects associated with some drugs (eg, lipoic acid) is high.24 The best way to minimize and avoid neuropathy in diabetic patients is through attentive monitoring designed to achieve good diabetic control as early as possible in the course of the disease. Once clinical signs of neuropathy and neurologic deficits are noted, reversal is uncommon.20,24,27
Clinical presentation of this cat is consistent with diabetic neuropathy. However, the range of clinical signs can be quite diverse and include weakness, trouble jumping, muscle atrophy, neurologic deficits, and plantigrade stance.24 A complete understanding of why diabetic neuropathy develops remains elusive, although multifaceted metabolic derangements likely play a role in nerve dysfunction and probably are related to poor glycemic control.24
Neuropathy is one of the most common complications of feline diabetes mellitus, reportedly occurring to some degree in nearly 90% of feline diabetics.24,26-27 However, it is seen less frequently in canine diabetics.24,27
Medical therapy options are often promoted online and in medical literature, but to date there are no proven methods of medical management for diabetic neuropathy in cats. Although some drugs have been evaluated in clinical trials, little benefit has been seen and the potential for side effects associated with some drugs (eg, lipoic acid) is high.24 The best way to minimize and avoid neuropathy in diabetic patients is through attentive monitoring designed to achieve good diabetic control as early as possible in the course of the disease. Once clinical signs of neuropathy and neurologic deficits are noted, reversal is uncommon.20,24,27
Clinical presentation of this cat is consistent with diabetic neuropathy. However, the range of clinical signs can be quite diverse and include weakness, trouble jumping, muscle atrophy, neurologic deficits, and plantigrade stance.24 A complete understanding of why diabetic neuropathy develops remains elusive, although multifaceted metabolic derangements likely play a role in nerve dysfunction and probably are related to poor glycemic control.24
Neuropathy is one of the most common complications of feline diabetes mellitus, reportedly occurring to some degree in nearly 90% of feline diabetics.24,26-27 However, it is seen less frequently in canine diabetics.24,27
Medical therapy options are often promoted online and in medical literature, but to date there are no proven methods of medical management for diabetic neuropathy in cats. Although some drugs have been evaluated in clinical trials, little benefit has been seen and the potential for side effects associated with some drugs (eg, lipoic acid) is high.24 The best way to minimize and avoid neuropathy in diabetic patients is through attentive monitoring designed to achieve good diabetic control as early as possible in the course of the disease. Once clinical signs of neuropathy and neurologic deficits are noted, reversal is uncommon.20,24,27
Clinical presentation of this cat is consistent with diabetic neuropathy. However, the range of clinical signs can be quite diverse and include weakness, trouble jumping, muscle atrophy, neurologic deficits, and plantigrade stance.24 A complete understanding of why diabetic neuropathy develops remains elusive, although multifaceted metabolic derangements likely play a role in nerve dysfunction and probably are related to poor glycemic control.24
Neuropathy is one of the most common complications of feline diabetes mellitus, reportedly occurring to some degree in nearly 90% of feline diabetics.24,26-27 However, it is seen less frequently in canine diabetics.24,27
Medical therapy options are often promoted online and in medical literature, but to date there are no proven methods of medical management for diabetic neuropathy in cats. Although some drugs have been evaluated in clinical trials, little benefit has been seen and the potential for side effects associated with some drugs (eg, lipoic acid) is high.24 The best way to minimize and avoid neuropathy in diabetic patients is through attentive monitoring designed to achieve good diabetic control as early as possible in the course of the disease. Once clinical signs of neuropathy and neurologic deficits are noted, reversal is uncommon.20,24,27
Clinical presentation of this cat is consistent with diabetic neuropathy. However, the range of clinical signs can be quite diverse and include weakness, trouble jumping, muscle atrophy, neurologic deficits, and plantigrade stance.24 A complete understanding of why diabetic neuropathy develops remains elusive, although multifaceted metabolic derangements likely play a role in nerve dysfunction and probably are related to poor glycemic control.24
Neuropathy is one of the most common complications of feline diabetes mellitus, reportedly occurring to some degree in nearly 90% of feline diabetics.24,26-27 However, it is seen less frequently in canine diabetics.24,27
Medical therapy options are often promoted online and in medical literature, but to date there are no proven methods of medical management for diabetic neuropathy in cats. Although some drugs have been evaluated in clinical trials, little benefit has been seen and the potential for side effects associated with some drugs (eg, lipoic acid) is high.24 The best way to minimize and avoid neuropathy in diabetic patients is through attentive monitoring designed to achieve good diabetic control as early as possible in the course of the disease. Once clinical signs of neuropathy and neurologic deficits are noted, reversal is uncommon.20,24,27
Test results confirm diagnosis of diabetes mellitus in Gerald, a 10-year-old castrated domestic short-haired cat (Figure 6). The family is waiting to learn more about the diagnosis.
Which of the following take-home points conveyed to family members during the initial diabetic discussion is most accurate?
Exercise is contraindicated because the catabolic state and muscle loss associated with feline diabetes can promote exercise intolerance.
The owner should monitor urine glucose via dipstick testing because it is the most important diabetic monitoring tool.
Diabetic cats are at increased risk for secondary infections (eg, urinary tract infection), as compared with healthy cats.
Insulin dose adjustments should always be based on the results of a spot blood glucose check at each follow-up evaluation.
Acromegaly testing is contraindicated in feline diabetic patients and is not worth the expense because of the disease prevalence.
Because diabetic patients are predisposed to secondary infections, routine follow-up examinations should focus on continuous evaluation and monitoring for this complication. In 2 studies, 10% to 15% of newly diagnosed diabetic cats had urinary tract infections.24,28-29
Exercise, an important component of a healthy diabetic lifestyle, potentially can improve glycemic control, reduce insulin resistance, and maintain a healthy weight.24 In cats, however, exercise can be a difficult challenge, although environmental enrichment can greatly increase a cat’s indoor activity.
At-home or in-hospital monitoring of urine glucose by dipstick can be effective but is most useful when evaluating animals at-risk for hypoglycemia; thus, it is not routinely used as the primary means of monitoring diabetes.20,24 Similarly, spot blood glucose monitoring is most effective in diagnosing hypoglycemia, but routine spot blood glucose testing is not considered an appropriate monitoring strategy and should not be used to adjust a cat’s insulin dose.20,24
Concurrent disease (ie, pancreatitis, acromegaly) can occur in patients with diabetes mellitus. Acromegaly is becoming increasingly identified in felines as a cause for insulin resistance and thus, poor diabetic control. Testing (high insulin-like growth factor [IGF-1] concentration) for acromegaly should be performed in a diabetic cat that has been diagnosed with insulin resistance.30
Because diabetic patients are predisposed to secondary infections, routine follow-up examinations should focus on continuous evaluation and monitoring for this complication. In 2 studies, 10% to 15% of newly diagnosed diabetic cats had urinary tract infections.24,28-29
Exercise, an important component of a healthy diabetic lifestyle, potentially can improve glycemic control, reduce insulin resistance, and maintain a healthy weight.24 In cats, however, exercise can be a difficult challenge, although environmental enrichment can greatly increase a cat’s indoor activity.
At-home or in-hospital monitoring of urine glucose by dipstick can be effective but is most useful when evaluating animals at-risk for hypoglycemia; thus, it is not routinely used as the primary means of monitoring diabetes.20,24 Similarly, spot blood glucose monitoring is most effective in diagnosing hypoglycemia, but routine spot blood glucose testing is not considered an appropriate monitoring strategy and should not be used to adjust a cat’s insulin dose.20,24
Concurrent disease (ie, pancreatitis, acromegaly) can occur in patients with diabetes mellitus. Acromegaly is becoming increasingly identified in felines as a cause for insulin resistance and thus, poor diabetic control. Testing (high insulin-like growth factor [IGF-1] concentration) for acromegaly should be performed in a diabetic cat that has been diagnosed with insulin resistance.30
Because diabetic patients are predisposed to secondary infections, routine follow-up examinations should focus on continuous evaluation and monitoring for this complication. In 2 studies, 10% to 15% of newly diagnosed diabetic cats had urinary tract infections.24,28-29
Exercise, an important component of a healthy diabetic lifestyle, potentially can improve glycemic control, reduce insulin resistance, and maintain a healthy weight.24 In cats, however, exercise can be a difficult challenge, although environmental enrichment can greatly increase a cat’s indoor activity.
At-home or in-hospital monitoring of urine glucose by dipstick can be effective but is most useful when evaluating animals at-risk for hypoglycemia; thus, it is not routinely used as the primary means of monitoring diabetes.20,24 Similarly, spot blood glucose monitoring is most effective in diagnosing hypoglycemia, but routine spot blood glucose testing is not considered an appropriate monitoring strategy and should not be used to adjust a cat’s insulin dose.20,24
Concurrent disease (ie, pancreatitis, acromegaly) can occur in patients with diabetes mellitus. Acromegaly is becoming increasingly identified in felines as a cause for insulin resistance and thus, poor diabetic control. Testing (high insulin-like growth factor [IGF-1] concentration) for acromegaly should be performed in a diabetic cat that has been diagnosed with insulin resistance.30
Because diabetic patients are predisposed to secondary infections, routine follow-up examinations should focus on continuous evaluation and monitoring for this complication. In 2 studies, 10% to 15% of newly diagnosed diabetic cats had urinary tract infections.24,28-29
Exercise, an important component of a healthy diabetic lifestyle, potentially can improve glycemic control, reduce insulin resistance, and maintain a healthy weight.24 In cats, however, exercise can be a difficult challenge, although environmental enrichment can greatly increase a cat’s indoor activity.
At-home or in-hospital monitoring of urine glucose by dipstick can be effective but is most useful when evaluating animals at-risk for hypoglycemia; thus, it is not routinely used as the primary means of monitoring diabetes.20,24 Similarly, spot blood glucose monitoring is most effective in diagnosing hypoglycemia, but routine spot blood glucose testing is not considered an appropriate monitoring strategy and should not be used to adjust a cat’s insulin dose.20,24
Concurrent disease (ie, pancreatitis, acromegaly) can occur in patients with diabetes mellitus. Acromegaly is becoming increasingly identified in felines as a cause for insulin resistance and thus, poor diabetic control. Testing (high insulin-like growth factor [IGF-1] concentration) for acromegaly should be performed in a diabetic cat that has been diagnosed with insulin resistance.30
Because diabetic patients are predisposed to secondary infections, routine follow-up examinations should focus on continuous evaluation and monitoring for this complication. In 2 studies, 10% to 15% of newly diagnosed diabetic cats had urinary tract infections.24,28-29
Exercise, an important component of a healthy diabetic lifestyle, potentially can improve glycemic control, reduce insulin resistance, and maintain a healthy weight.24 In cats, however, exercise can be a difficult challenge, although environmental enrichment can greatly increase a cat’s indoor activity.
At-home or in-hospital monitoring of urine glucose by dipstick can be effective but is most useful when evaluating animals at-risk for hypoglycemia; thus, it is not routinely used as the primary means of monitoring diabetes.20,24 Similarly, spot blood glucose monitoring is most effective in diagnosing hypoglycemia, but routine spot blood glucose testing is not considered an appropriate monitoring strategy and should not be used to adjust a cat’s insulin dose.20,24
Concurrent disease (ie, pancreatitis, acromegaly) can occur in patients with diabetes mellitus. Acromegaly is becoming increasingly identified in felines as a cause for insulin resistance and thus, poor diabetic control. Testing (high insulin-like growth factor [IGF-1] concentration) for acromegaly should be performed in a diabetic cat that has been diagnosed with insulin resistance.30
Quiz: Feline Diabetes
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