{"id":1281,"date":"2013-07-01T18:08:59","date_gmt":"2013-07-01T18:08:59","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=1281"},"modified":"2022-02-17T19:00:42","modified_gmt":"2022-02-17T19:00:42","slug":"feline-diabetes-mellitus-updates-on-diagnosis-treatment","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/endocrinology\/feline-diabetes-mellitus-updates-on-diagnosis-treatment\/","title":{"rendered":"Feline Diabetes Mellitus Updates on Diagnosis &amp; Treatment"},"content":{"rendered":"<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2016\/09\/T1307F01.pdf\"><img decoding=\"async\" class=\"alignnone size-full wp-image-9886\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png\" alt=\"pdf_button\" width=\"110\" height=\"27\" \/><\/a><\/p>\n<hr \/>\n<p><i>David Bruyette, DVM, Diplomate ACVIM, and Karen Eiler, DVM, MS, Diplomate ACVIM<\/i><\/p>\n<p>Feline diabetes mellitus, one of the most commonly encountered feline endocrine diseases, is comprehensively reviewed, with an emphasis on providing up-to-date information on diagnosis and treatment based on current literature and research. The article outlines the insulins available for therapeutic use in cats and the nuances of each; a table provides insulin doses. Pathogenesis, diagnostics, other management modalities, and monitoring are also addressed.<\/p>\n<hr \/>\n<p>Diabetes mellitus (DM) is a commonly encountered feline endocrine disease.<sup>1<\/sup>\u00a0DM is defined as\u00a0<em>persistent hyperglycemia and glycosuria due to an absolute or relative insulin deficiency.<\/em>\u00a0The most common causes of feline DM are:<\/p>\n<ul>\n<li>Islet cell amyloidosis<\/li>\n<li>Obesity<\/li>\n<li>Chronic pancreatitis.<\/li>\n<\/ul>\n<h2><span class=\"bluboldheader\">CLASSIFICATION<\/span><\/h2>\n<p>Insulin is secreted exclusively from beta cells in the pancreas&#8217; Islets of Langerhans. Insulin deficiency occurs when beta cells are destroyed or their function impaired, and the pathogenesis of beta cell dysfunction is used to classify DM.<\/p>\n<p>In humans, DM is classified as:<\/p>\n<ul>\n<li><strong>Type I (insulin dependent):<\/strong>\u00a0Results from autoimmune damage to the Islets; associated with complete lack of insulin<\/li>\n<li><strong>Type II (noninsulin dependent):<\/strong>\u00a0Characterized by abnormal insulin secretion and peripheral insulin resistance<\/li>\n<li><strong>Gestational, congenital, neonatal, or monogenic.<\/strong><\/li>\n<\/ul>\n<p>Most feline diabetics have type II DM,<sup>2<\/sup>\u00a0and may have underlying susceptibilities to this type due to genetic predisposition and decreased insulin sensitivity (seen with obesity).<sup>3,4<\/sup><\/p>\n<p><strong>Type III DM<\/strong>\u00a0is similar to impaired glucose tolerance in humans. Medications or diabetogenic hormones (epinephrine, cortisol, glucagon, and growth hormone) interfere with the action of insulin, result in glucose intolerance, and ultimately lead to DM. This is in distinction to Type II DM in which the cause of insulin resistance is often unknown.<\/p>\n<h2><span class=\"bluboldheader\">PATHOGENESIS<\/span><\/h2>\n<p>Amylin, also known as\u00a0<em>islet amyloid polypeptide<\/em>\u00a0(IAPP), is synthesized in the Islets of Langerhans and co-secreted with insulin. In cats with insulin resistance, amylin and insulin secretion increase concurrently. Over time, amylin overproduction progresses to diabetes due to 2 phenomena:<\/p>\n<ol>\n<li>Amylin can be enzymatically converted to amyloid, which has a direct cytotoxic effect on islet cells.<sup>5<\/sup><\/li>\n<li>In addition, amylin itself inhibits further insulin secretion in a paracrine effect.<sup>5<\/sup><\/li>\n<\/ol>\n<p>Both contribute to initial glucose intolerance and, eventually, overt hyperglycemia and glucosuria.<\/p>\n<h2><strong><span class=\"bluboldheader\">DIAGNOSIS<\/span><\/strong><\/h2>\n<p>DM is diagnosed based on clinical signs and laboratory testing.<\/p>\n<h3><strong><span class=\"aquabold\">Clinical Signs<\/span><\/strong><\/h3>\n<p>DM is typically diagnosed once blood glucose (BG) exceeds renal threshold (mean threshold, 290 mg\/dL6), resulting in osmotic diuresis and compensatory polydipsia. Other classical clinical signs include polyphagia and weight loss.<\/p>\n<h3><strong><span class=\"aquabold\">Basic Laboratory Evaluation<\/span><\/strong><\/h3>\n<p>Baseline laboratory evaluation should include a serum biochemistry profile, CBC, urinalysis, and urine culture. Diabetic patients frequently have urinary tract infections even in the absence of active urine sediment (<strong>Table 1<\/strong>).<sup>7<\/sup><\/p>\n<table border=\"1\" width=\"600\" cellspacing=\"0\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"GreenAqua\" colspan=\"3\" align=\"center\">Table 1. Feline Diabetes Mellitus: Common Biochemical Abnormalities &amp; Causes<\/td>\n<\/tr>\n<tr>\n<td class=\"GreenAqua\">Test<\/td>\n<td class=\"GreenAqua\">Abnormalities<\/td>\n<td class=\"GreenAqua\">Cause<\/td>\n<\/tr>\n<tr>\n<td class=\"bold\" valign=\"top\" bgcolor=\"#eff8fa\">Complete Blood Count<\/td>\n<td valign=\"top\" bgcolor=\"#eff8fa\">Often unremarkable<br \/>\nHemoconcentration<\/td>\n<td valign=\"top\" bgcolor=\"#eff8fa\">Dehydration<\/td>\n<\/tr>\n<tr>\n<td class=\"bold\" valign=\"top\" bgcolor=\"#eff8fa\">Serum Biochemical Profile<\/td>\n<td valign=\"top\" bgcolor=\"#eff8fa\">Elevated alanine transaminase<br \/>\nElevated alkaline phosphatase<br \/>\nElevated bilirubin<br \/>\nHyperglycemia<\/td>\n<td valign=\"top\" bgcolor=\"#eff8fa\">Biliary disease\/pancreatitis<br \/>\nHepatic lipidosis\/hepatitis<br \/>\nPancreatitis\/lipidosis<\/td>\n<\/tr>\n<tr>\n<td class=\"bold\" valign=\"top\" bgcolor=\"#eff8fa\">Urinalysis<\/td>\n<td valign=\"top\" bgcolor=\"#eff8fa\">Active sediment (indicating infection)<br \/>\nGlucosuria<br \/>\nKetonuria<\/td>\n<td valign=\"top\" bgcolor=\"#eff8fa\">Urinary tract infection<br \/>\nBlood glucose in excess of renal threshold<br \/>\nKetogenesis<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Transient hyperglycemia may be caused by stress, diabetogenic hormones, and post prandially in animals with glucose intolerance. Cats are particularly sensitive to stress hyperglycemia due to catecholamine release.<sup>8<\/sup><\/p>\n<h3><strong><span class=\"aquabold\">Fructosamine Evaluation<\/span><\/strong><\/h3>\n<p>Fructosamine is formed when glucose reacts with amino acids of serum proteins, such as albumin. In hyperglycemic states, levels of fructosamine increase. Fructosamine levels can be used for several purposes:<\/p>\n<ul>\n<li><strong>To help confirm a diagnosis of DM<\/strong><\/li>\n<li><strong>To monitor persistent hyperglycemia<\/strong>; levels above the reference range indicate persistent hyperglycemia and, therefore, help differentiate diabetes from other causes of transient hyperglycemia.<\/li>\n<li><strong>To evaluate response to treatment<\/strong>; in well-controlled diabetics, fructosamine is often in the low end of the reference range or normal.<\/li>\n<\/ul>\n<h3><strong><span class=\"aquabold\">Total Thyroxine Evaluation<\/span><\/strong><\/h3>\n<p>Total thyroxine levels should be evaluated to\u00a0<span class=\"timesroman\">rule<\/span>\u00a0out hyperthyroidism as a cause for insulin resistance.<\/p>\n<div class=\"orange-box\">\n<h2>Clinical Signs of Concurrent\/Secondary Disease<\/h2>\n<ul>\n<li>Cats may present with\u00a0<strong>icterus<\/strong>\u00a0due to concurrent\u00a0<em>hepatic lipidosis<\/em>\u00a0or\u00a0<em>pancreatitis<\/em>.<\/li>\n<li>A\u00a0<strong>plantigrade stance<\/strong>\u00a0may be noted secondary to prolonged or severe hyperglycemia, resulting in a\u00a0<em>peripheral neuropathy<\/em>.<\/li>\n<\/ul>\n<\/div>\n<h2><\/h2>\n<div class=\"orange-box\">\n<h2><span class=\"aquabold\">Goals of Treatment<\/span><\/h2>\n<ul>\n<li>Minimize clinical signs<\/li>\n<li>Avoid complications, such as diabetic ketoacidosis and peripheral neuropathy<\/li>\n<li>Avoid symptomatic hypoglycemia<\/li>\n<li>Maintain owner compliance with treatment regimen and follow-up<\/li>\n<li>Achieve patient quality of life<\/li>\n<li>If possible, achieve diabetic remission<\/li>\n<\/ul>\n<\/div>\n<h2><span class=\"bluboldheader\">INSULIN OVERVIEW<\/span><\/h2>\n<p>Several types of insulin are available for use in diabetic cats.<\/p>\n<ul>\n<li><strong>Ultra long acting:<\/strong>\u00a0Glargine (Lantus, sanofi.us) and\u00a0detemir (Levemir, novonordisk-us.com)<\/li>\n<li><strong>Long acting:<\/strong>\u00a0Human recombinant protamine zinc (PZI) (ProZinc, boehringer-ingelheim.com)<\/li>\n<li><strong>Intermediate acting:<\/strong>\u00a0Lente (Vetsulin, merck.com), which was recently reintroduced to the veterinary market, and neutral protamine Hagedorn (NPH) (Humulin N, lilly.com, or Novolin N, novonordisk-us.com).<\/li>\n<\/ul>\n<p>For dosing recommendations, see\u00a0<strong>Table 2<\/strong>.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/07\/Screen-Shot-2015-06-23-at-2.19.29-PM.png\"><img fetchpriority=\"high\" decoding=\"async\" class=\"alignnone size-full wp-image-5130\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/07\/Screen-Shot-2015-06-23-at-2.19.29-PM.png\" alt=\"Screen Shot 2015-06-23 at 2.19.29 PM\" width=\"588\" height=\"432\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/07\/Screen-Shot-2015-06-23-at-2.19.29-PM.png 588w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/07\/Screen-Shot-2015-06-23-at-2.19.29-PM-300x220.png 300w\" sizes=\"(max-width: 588px) 100vw, 588px\" \/><\/a><\/p>\n<h2>ULTRA LONG-ACTING INSULINS<\/h2>\n<h3><strong>Glargine<\/strong><\/h3>\n<p>Glargine is a long-acting insulin analogue that is designed to provide basal insulin concentrations in humans. It remains soluble in acidic solutions but forms precipitates in the neutral environment of subcutaneous tissue. The change in pH associated with precipitation contraindicates diluting or mixing glargine for administration.<\/p>\n<p><strong>Efficacy.<\/strong>\u00a0Glargine has been shown to be effective in felines with DM. A recent study compared the glycemic control and remission probabilities in 24 newly diagnosed diabetic cats treated twice daily with either glargine, PZI, or lente insulin and fed a low-carbohydrate diet.<sup>9<\/sup><\/p>\n<ul>\n<li>Probability of remission was substantially higher for cats with lower mean 12 H BG concentrations on day 17, irrespective of insulin type.<sup>9<\/sup><\/li>\n<li>In this small study, cats treated with glargine had better glycemic control and higher probability of remission than those treated with PZI or lente insulin.<sup>9<\/sup>\u00a0However, further studies with larger numbers of cats are needed before it can be concluded that glargine is more effective at achieving remission than other insulins.<\/li>\n<li>In a different study of owner responses on an online forum, a remission rate of 84% was noted in patients treated with glargine within 6 months of diagnosis; cats treated with glargine 6 months after diagnosis achieved a 35% remission rate. Caution should be exercised not to overinterpret owner reports that were not confirmed by a veterinarian.<sup>10<\/sup><\/li>\n<\/ul>\n<div class=\"orange-box\">\n<p><strong><span class=\"aquabold\">Diabetic remission<\/span><\/strong>\u00a0is defined as\u00a0<em>the ability to maintain euglycemia without insulin for 2 to 4 weeks after insulin therapy has been discontinued, without the reappearance of clinical signs of diabetes<\/em>. Remission appears more likely to occur if:<\/p>\n<ul>\n<li>Blood glucose levels are strictly controlled using insulin<\/li>\n<li>Cats are fed a low-carbohydrate diet.<\/li>\n<\/ul>\n<p>At least 25% to 30% of cats that have achieved remission subsequently relapse into overt diabetes and need reinstitution of insulin treatment. In these cats, a second remission is unlikely to be achieved and permanent insulin therapy is usually needed.<\/p>\n<p>Good glycemic control soon after diagnosis is associated with increased probability of remission and should be the goal of insulin therapy.<sup>10,11<\/sup><\/p>\n<\/div>\n<p><strong>Monitoring.<\/strong>\u00a0Because glargine is a basal insulin, 4-hour post injection BG monitoring can be performed. If performing a 12-hour BG curve (BGC), samples can be drawn every 4 hours. This type of monitoring is inappropriate for nonbasal insulins, such as NPH or recombinant PZI.<\/p>\n<ul>\n<li><strong>Increase<\/strong>\u00a0insulin dose by 1 unit Q 12 H if:\n<ul>\n<li>Pre-insulin BG concentration is\u00a0<strong>&gt; 216 mg\/dL<\/strong>\u00a0<em>and\/or<\/em><\/li>\n<li>Nadir BG concentration is\u00a0<strong>&gt;= 180 mg\/dL<\/strong>\u00a0(often at 4-hour post insulin injection).<\/li>\n<\/ul>\n<\/li>\n<li><strong>Maintain<\/strong>\u00a0insulin dose if:\n<ul>\n<li>Pre-insulin BG concentration is\u00a0<strong>180 to 216 mg\/dL<\/strong>\u00a0<em>and\/or<\/em><\/li>\n<li>Nadir BG concentration is\u00a0<strong>90 to 160 mg\/dL<\/strong>\u00a0(4-hour post insulin injection).<\/li>\n<\/ul>\n<\/li>\n<li><strong>Decrease<\/strong>\u00a0insulin dose by 1 unit Q 12 H if:\n<ul>\n<li>Pre-insulin BG concentration is\u00a0<strong>&lt;= 180 mg\/dL<\/strong>\u00a0<em>and\/or<\/em><\/li>\n<li>Nadir BG concentration is\u00a0<strong>54 to 90 mg\/dL<\/strong>\u00a0(4-hour post insulin injection).<\/li>\n<li><em>If the nadir BG concentration is &lt; 54 mg\/dL, the next dose of insulin can be skipped rather than taking the chance of an overdose. If the total insulin dose is already 1 unit Q 12 H, stop the insulin (or administer 1 unit Q 24 H) and evaluate for diabetic remission<\/em>.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong>Additional Notes.<\/strong>\u00a0The manufacturer recommends discarding opened vials after 4 weeks of use; however, if refrigerated, opened vials can be used for 6 months (unless discoloration is noted).<\/p>\n<h2><span class=\"bluboldheader\">DETEMIR<\/span><\/h2>\n<p>Detemir, like glargine, is a basal human insulin analogue and binds reversibly to albumin, resulting in a long duration of action. It has been demonstrated to be effective in the treatment of feline DM and is also associated with remission in cats that receive at-home, intensive BG monitoring.<\/p>\n<p><strong>Efficacy.<\/strong>\u00a0Another recent study of owner results collected through an online forum evaluated detemir and a protocol of intensive BG control with home monitoring in diabetic cats, and compared the results with a previous study that used the same protocol with glargine.<sup>12<\/sup><\/p>\n<ul>\n<li>The study included 18 cats diagnosed with diabetes and previously treated with other insulins.<\/li>\n<li>No significant differences were identified between the glargine and detemir studies, with the exception of 3 possibly interrelated factors:\n<ol>\n<li>Slightly older median age of the detemir cohort at diabetes diagnosis<\/li>\n<li>Higher rate of chronic renal disease in the detemir cohort<\/li>\n<li>Lower maximal dose for detemir.<\/li>\n<\/ol>\n<\/li>\n<li>Overall remission rate was 67%; cats that began the protocol before or after 6 months of diagnosis had remission rates of 81% and 42%, respectively.<\/li>\n<li>However, once again, caution should be exercised not to overinterpret owner reports that were not confirmed by a veterinarian.<br \/>\nAdministration. In contrast to dogs, detemir does not appear to be more potent than glargine; therefore, the starting dose is the same for both insulins in cats.<sup>12<\/sup><\/li>\n<\/ul>\n<p><strong>Monitoring.<\/strong>\u00a0Although detemir is a basal insulin, studies have not been performed to evaluate spot BG monitoring. Therefore, BGCs should be performed and BG monitored every 2 hours when using this type of insulin.<\/p>\n<h2><span class=\"bluboldheader\">LONG-ACTING INSULINS<\/span><\/h2>\n<h3><strong><span class=\"aquabold\">Protamine Zinc Insulin<\/span><\/strong><\/h3>\n<p>Human recombinant PZI has been demonstrated to be effective and is approved for use in cats (ProZinc, boehringer-ingelheim.com).<sup>13,14<\/sup>\u00a0Zinc is added to the protamine to prolong duration of action.<\/p>\n<p><strong>Efficacy.<\/strong>\u00a0In a large clinical trial, 133 cats were treated with PZI twice daily for 45 days.<sup>13<\/sup><\/p>\n<ul>\n<li>Glycemic control was assessed by evaluating change in water consumption, frequency of urination, appetite, body weight, and serum fructosamine concentration.<\/li>\n<li>BG concentrations were determined 1, 3, 5, 7, and 9 hours after administration of PZI. Adjustments in PZI dosage were made as needed to control glycemia.<\/li>\n<li>PZI administration resulted in a significant decrease in 9-hour mean BG and serum fructosamine concentrations and a significant increase in mean body weight (day 45 compared with day 0).<\/li>\n<\/ul>\n<p>By day 45:<\/p>\n<ul>\n<li>Polyuria and polydipsia had improved in 79% of cats and 89% had good body condition.<\/li>\n<li>Nine-hour mean BG concentration, serum fructosamine concentration, or both had improved in 84%.<\/li>\n<li>Hypoglycemia (&lt; 80 mg\/dL) was identified in 151 of 678, 9-hour serial BG determinations and in 85 of 133 diabetic cats. Hypoglycemia resulting in clinical signs was confirmed in 2 diabetic cats.<\/li>\n<\/ul>\n<p><strong>Administration.<\/strong>\u00a0PZI is effective for controlling glycemia in diabetic cats and can be used as an initial or alternative treatment in diabetic cats that do not respond to treatment with other insulin preparations. Starting dose is 1 to 2 IU\/cat Q 12 H.<sup>14<\/sup><\/p>\n<h2><span class=\"bluboldheader\">INTERMEDIATE-ACTING INSULINS<\/span><\/h2>\n<h3><strong><span class=\"aquabold\">Lente<\/span><\/strong><\/h3>\n<p>Lente, which is of porcine origin and contains zinc, is approved for dogs and cats, and has recently been reintroduced to the market (Vetsulin, Merck.com).<\/p>\n<p>Efficacy. A prospective, multicenter, nonblinded study evaluated 46 diabetic cats during treatment with porcine lente insulin (also known as porcine insulin zinc suspension) for 16 \u00b1 1 weeks (stabilization phase), with additional monitoring of some cats (<em>n<\/em>\u00a0= 23) for a variable period.<sup>15<\/sup><\/p>\n<ul>\n<li>At least 3 of the following were present at initial presentation:\n<ul>\n<li>Appropriate history of clinical signs consistent with DM<\/li>\n<li>Glucosuria<\/li>\n<li>BG &gt; 15 mmol\/L<\/li>\n<li>Fructosamine &gt; 380 micromol\/L<\/li>\n<\/ul>\n<\/li>\n<li>Insulin treatment was started at a dose rate of 0.25 to 0.5 IU\/kg Q 12 H, with a maximum starting dose of 2 IU\/injection.<\/li>\n<li>Results of the study included:\n<ul>\n<li>28 cats reached clinical stability during the study; 23 during the stabilization phase<\/li>\n<li>7 cats went into remission during the stabilization phase and one during week 56<\/li>\n<li>In 9 of 46 cats, signs of hypoglycemia, which were significantly associated with a dose of 3 IU or 0.5 IU\/kg (or more) twice daily, were observed; concomitant biochemical hypoglycemia was recorded in most cases.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong>Administration.<\/strong>\u00a0The protocol used in this study is suitable for and easy to use in practice.<\/p>\n<p><strong>Additional Notes.<\/strong>\u00a0An important change that occurred with the relaunch of Vetsulin is the manufacturer recommends that Vetsulin be shaken thoroughly until a homogeneous, uniformly milky suspension is obtained. Foam formed during shaking should be allowed to disperse before use and, if required, the product should be gently mixed to maintain a homogeneous, uniformly milky suspension before use. Clumps or white particles can form in insulin suspensions: do not use the product if these persist after thorough shaking. Other types of insulins should be mixed gently, not shaken.<\/p>\n<p>The product has a shelf life of 12 months and is usable for 42 days once the vial has been opened.<\/p>\n<p>Note that Vetsulin has amorphous insulin in it, which brings on an earlier peak action time. Therefore, glucose curves should be carefully monitored, especially in the first 2 to 6 hours after administration.<\/p>\n<h3><strong><span class=\"aquabold\">Neutral Protamine Hagedorn<\/span><\/strong><\/h3>\n<p>NPH is an intermediate-acting human insulin that contains zinc and has been used more frequently in dogs than cats. There is little data to support its use in cats, and it is not approved for use in cats.<\/p>\n<div class=\"orange-box\">\n<h2><strong><span class=\"aquabold\">Insulin Resistance<\/span><\/strong><\/h2>\n<p><strong>Insulin resistance in cats<\/strong>\u00a0is typically defined as an insulin dose &gt; 1.5 IU\/kg or 6 IU per dose. The most common causes of insulin resistance are:<sup><span style=\"font-size: small\">21-24<\/span><\/sup><\/p>\n<ul>\n<li>Bacterial infections<\/li>\n<li>Heart failure<\/li>\n<li>Hyperthyroidism<\/li>\n<li>Obesity<\/li>\n<li>Pancreatitis<\/li>\n<li>Renal failure.<\/li>\n<\/ul>\n<p>Severe insulin resistance and marked hyperglycemia, despite high dose insulin, can be caused by:<\/p>\n<ul>\n<li>Excess glucocorticoids<\/li>\n<li>Acromegaly or excess growth hormone<\/li>\n<li>Progestagens.<\/li>\n<\/ul>\n<\/div>\n<h2><span class=\"bluboldheader\">NONINSULIN TREATMENTS<\/span><\/h2>\n<h3><strong><span class=\"aquabold\">Glipizide<\/span><\/strong><\/h3>\n<p>Glipizide is a second-generation sulfonylurea derivative administered orally. Sulfonylurea drugs bind the beta cell ATPase, which stimulates insulin release.<\/p>\n<p>Effectiveness of treatment with this class of drugs depends on functional beta cells. Therefore, in cats\u00a0suffering from beta cell exhaustion or glucose toxicity, response can be variable.<\/p>\n<p>Side effects can include vomiting, hepatotoxicity, and hypoglycemia. In addition, insulin secretion stimulated by sulfonylurea drugs has been accompanied by concurrent amylin secretion,<sup>16<\/sup>\u00a0which may result in further damage to beta cells.<\/p>\n<p>Due to variable response rates and side effects its use is not typically recommended.<\/p>\n<h3><strong><span class=\"aquabold\">Glyburide<\/span><\/strong><\/h3>\n<p>Glyburide is a second-generation sulfonylurea drug with a longer duration of action than glipizide. It has been evaluated in normal cats and resulted in the release of insulin. Both sulfonylureas may result in progression of diabetes due to increased production of IAPP and its subsequent conversion to amyloid in the pancreatic islets.<sup>16<\/sup><\/p>\n<h3><strong><span class=\"aquabold\">Chromium Picolinate &amp; Vanadium<\/span><\/strong><\/h3>\n<p>Chromium picolinate is a trace element and cofactor for the function of insulin. It increases both insulin binding and number of insulin receptors. Chromium deficiency can lead to insulin resistance; in humans, supplementation has been shown to improve glycemic control.<sup>18<\/sup><\/p>\n<p>Vanadium is another trace element that has glucose-lowering effects and may improve insulin secretion and glucose metabolism.<\/p>\n<p>Studies in cats have shown little efficacy of chromium or vanadium in controlling clinical signs of DM.<sup>17<\/sup><\/p>\n<h3><strong><span class=\"aquabold\">Exenatide<\/span><\/strong><\/h3>\n<p>Exenatide (Byetta, amylin.com), a glucagon-like peptide-1 mimetic, is an injectable medication that plays a role in treatment of DM by stimulating insulin release. Other potential benefits include:<\/p>\n<ul>\n<li>Delayed gastric emptying, which blunts post prandial hyperglycemia<\/li>\n<li>Appetite curbing<\/li>\n<li>Promotion of beta-cell regeneration by inhibition of beta cell apoptosis.<\/li>\n<\/ul>\n<p>Exenatide was studied in healthy cats and shown to affect insulin secretion in a glucose dependent manner.<sup>18<\/sup><\/p>\n<h2><span class=\"bluboldheader\">DIET<\/span><\/h2>\n<p>Low-carbohydrate\/high-protein diets are recommended for diabetic cats.<\/p>\n<ul>\n<li>Canned wet foods are preferable to kibble because they contain lower carbohydrate concentrations.<\/li>\n<li>Ideally, cats should be fed twice daily at the time of insulin injection. However, the timing of meals is not as critical in cats as it is in dogs due to lack of prolonged post-prandial hyperglycemia.<sup>19<\/sup><\/li>\n<li>Insulin resistance is affected by obesity; therefore, in order to achieve and maintain remission, an ideal body weight is recommended.<\/li>\n<\/ul>\n<h2><span class=\"bluboldheader\">AT-HOME MONITORING<\/span><\/h2>\n<p>In-clinic BGCs are more likely to be affected by stress hyperglycemia than BGCs generated at home. Veterinarians should be cautious of responding to high glucose results by overzealously increasing insulin doses. Monitoring strategies may be influenced by persistence or resolution of clinical signs.<\/p>\n<p>A pressing concern for the newly diagnosed and treated cat is the possibility of development of hypoglycemia in individuals that may quickly go into remission. This can be addressed by using an at-home glucometer that is accurately calibrated for cats at the low end of the reference range.<sup>20<\/sup><\/p>\n<p>AlphaTRAK (abbottanimalhealth.com) is a species-specific glucometer calibrated for feline and canine patients. Use of human glucometers can lead to inaccurate readings and falsely low blood glucose values when used in dogs and cats.<\/p>\n<p class=\"references\">BG = blood glucose; BGC = blood glucose curve; DM = diabetes mellitus; IAPP = islet amyloid polypeptide; NPH = neutral protamine Hagedorn; PZI = protamine zinc insulin<\/p>\n<h3><span class=\"references\"><strong>References<\/strong><\/span><\/h3>\n<ol>\n<li><span class=\"references\">Panciera DL, Thomas CB, Eicker SW, Atkins CE. Epizootiologic patterns of diabetes mellitus in cats: 333 cases (1980-1986). <em>JAVMA<\/em> 1990; 197(11):1504-1508.<\/span><\/li>\n<li><span class=\"references\">Rand JS, Fleeman LM, Farrow HA, et al. Canine and feline diabetes mellitus: Nature or nurture?<em> J Nutr<\/em> 2004; 134(8):S2072-S2080.<\/span><\/li>\n<li><span class=\"references\">Goossens MM, Nelson RW, Feldman EC, Griffey SM. Response to insulin treatment and survival in 104 cats with diabetes mellitus (1985-1995).<em> J Vet Intern Med<\/em> 1998; 12(1):1-6.<\/span><\/li>\n<li><span class=\"references\">Appleton DJ, Rand JS, Sunvold GD. Insulin sensitivity decreases with obesity, and lean cats with low insulin sensitivity are at greatest risk of glucose intolerance with weight gain. <em>J Feline Med Surg<\/em> 2001; 3(4):211-228.<\/span><\/li>\n<li><span class=\"references\">O&#8217;Brian TD, Butler PC, Westermark P, Johnson KH. Islet amyloid polypeptide: A review of its biology and potential roles in the pathogenesis of diabetes mellitus. <em>Vet Pathol<\/em> 1993; 30:317-332.<\/span><\/li>\n<li><span class=\"references\">Feldman EC, Nelson RW. Feline diabetes mellitus. <em>Canine and Feline Endocrinology and Reproduction<\/em>, 3rd ed. St Louis: Saunders, 2004, p 547.<\/span><\/li>\n<li><span class=\"references\">Hess RS, Saunders HM, Van Winkle TJ, Ward CR. Concurrent disorders in dogs with diabetes mellitus: 221 cases (1993-1998). <em>JAVMA<\/em> 2000; 217(8):1166-1173.<\/span><\/li>\n<li><span class=\"references\">Rand JS, Kinnaird E, Baglioni A, et al. Acute stress hyperglycemia in cats is associated with struggling and increased concentrations of lactate and norepinephrine. <em>J Vet Intern Med<\/em> 2002; 16(2):123-132.<\/span><\/li>\n<li><span class=\"references\">Marshall RD, Rand JS, Morton JM. Treatment of newly diagnosed diabetic cats with glargine insulin improves glycaemic control and results in higher probability of remission than protamine zinc and lente insulins.<em> J Feline Med Surg<\/em> 2009; 11(8):683-691.<\/span><\/li>\n<li><span class=\"references\">Roomp K, Rand J. Intensive blood glucose control is safe and effective in diabetic cats using home monitoring and treatment with glargine. <em>J Feline Med Surg<\/em> 2009; 11(8):668-682.<\/span><\/li>\n<li><span class=\"references\">Gottlieb S, Rand JS. Remission in cats. <em>Vet Clin N Am Small Anim Pract<\/em> 2013; 43:245-249.<\/span><\/li>\n<li><span class=\"references\">Roomp K, Rand J. Evaluation of detemir in diabetic cats managed with a protocol for intensive blood glucose control. <em>J Feline Med Surg<\/em> 2012; 14(8):566-572.<\/span><\/li>\n<li><span class=\"references\">Norsworthy G, Lynn R, Cole C. Preliminary study of protamine zinc recombinant insulin for the treatment of diabetes mellitus in cats. <em>Vet Ther<\/em> 2009; 10(1-2):24-28.<\/span><\/li>\n<li><span class=\"references\">Nelson RW, Henley K, Cole C; PZIR Clinical Study Group. Field safety and efficacy of protamine zinc recombinant human insulin for treatment of diabetes mellitus in cats. <em>J Vet Intern Med<\/em> 2009; 23(4):787-793.<\/span><\/li>\n<li><span class=\"references\">Michiels L, Reusch CE, Boari A. Treatment of 46 cats with porcine lente insulin\u2014a prospective, multicentre study. <em>J Feline Med Surg<\/em> 2008; 10(5):439-451.<\/span><\/li>\n<li><span class=\"references\">Palm CA, Feldman EC. Oral hypoglycemic in cats with diabetes mellitus. <em>Vet Clin N Am Small Anim Pract<\/em> 2013; 43:408-415.<\/span><\/li>\n<li><span class=\"references\">Appleton DJ, Rand JS, Sunvold GD, Priest J. Dietary chromium tripicolinate supplementation reduces glucose concentrations and improves glucose tolerance in normal-weight cats. <em>J Feline Med Surg<\/em> 2002; 4(1):13-25.<\/span><\/li>\n<li><span class=\"references\">Gilor C, Graves TK, Gilor S, et al. The GLP-1 mimetic exenatide potentiates insulin secretion in healthy cats. <em>Domest Anim Endocrinol<\/em> 2011; 41(1):42-49.<\/span><\/li>\n<li><span class=\"references\">Martin GW, Rand JS. Food intake and blood glucose in normal and diabetic cats fed ad libitum. <em>J Fel Med Surg<\/em> 1999; 1:241-251.<\/span><\/li>\n<li><span class=\"references\">Zini E, Moretti S, Tschuor F, Reusch CE. Evaluation of a new portable glucose meter designed for use in cats. <em>Originalarbeiten<\/em> 2009; 151(9):448-451.<\/span><\/li>\n<li><span class=\"references\">Bruskiewicz KA, Nelson RW, Feldman EC, Griffey SM. Diabetic ketosis and ketoacidosis in cats: 42 cases (1980-1995). <em>JAVMA<\/em> 1997; 211(2):188-192.<br \/>\n<\/span><\/li>\n<li><span class=\"references\">Little CJ, Gettinby G. Heart failure is common in diabetic cats: Findings from a retrospective case-controlled study in first-opinion practice. <em>J Small Anim Pract<\/em> 2008; 49(1):17-25.<\/span><\/li>\n<li><span class=\"references\">Goossens MM, Nelson RW, Feldman EC, Griffey SM. Response to insulin treatment and survival in 104 cats with diabetes mellitus (1985-1995). <em>J Vet Intern Med<\/em> 1998; 12(1):1-6.<\/span><\/li>\n<li><span class=\"references\">Bailiff NL, Nelson RW, Feldman EC, et al. Frequency and risk factors for urinary tract infection in cats with diabetes mellitus.<em> J Vet Intern Med<\/em> 2006; 20(4):850-855.<\/span><\/li>\n<\/ol>\n<p><span class=\"author-bio\"><strong><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/07\/f01_Bruyette.png\"><img decoding=\"async\" class=\"alignleft size-full wp-image-7136\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/07\/f01_Bruyette.png\" alt=\"f01_Bruyette\" width=\"100\" height=\"124\" \/><\/a>David Bruyette<\/strong>, DVM, Diplomate ACVIM, is the medical director at West Los Angeles Animal Hospital and a clinical professor in the Department of Radiation Oncology at University of California\u2014Los Angeles. Prior to his current positions, he was an assistant professor and head of internal medicine at Kansas State University and director of its Analytical Chemistry Laboratory. Dr. Bruyette received his DVM from University of Missouri and completed an internship at Purdue University and residency in internal medicine at University of California\u2014Davis. He then became a staff internist at West Los Angeles Veterinary Medical Group and member of the Department of Comparative Medicine at Stanford University.<\/span><\/p>\n<p><span class=\"author-bio\"><strong><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/07\/f01_Eiler.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-full wp-image-7137\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/07\/f01_Eiler.png\" alt=\"f01_Eiler\" width=\"100\" height=\"124\" \/><\/a>Karen Eiler<\/strong>, DVM, MS, Diplomate ACVIM, is a staff internist at VCA West Los Angeles Animal Hospital. Dr. Eiler received her DVM from Western University of Health Sciences College of Veterinary Medicine followed by a rotating internship and internal medicine residency at VCA West Los Angeles Animal Hospital.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>David Bruyette, DVM, Diplomate ACVIM, and Karen Eiler, DVM, MS, Diplomate ACVIM Feline diabetes mellitus, one of the most commonly encountered feline endocrine diseases, is comprehensively reviewed, with an emphasis on providing up-to-date information on diagnosis and treatment based on current literature and research.<\/p>\n","protected":false},"author":1,"featured_media":2764,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":3008,"footnotes":""},"categories":[373],"tags":[13],"class_list":["post-1281","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-july-august-2013","tag-peer-reviewed","column-features","clinical_topics-endocrinology"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Feline Diabetes Mellitus Updates on Diagnosis &amp; 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