1. Diabetes Mellitus Feline by Gerard Derminasyan DVM
2. Definition Persistent Hyperglycemia due to absolute or
relative insulin deficiency
3. Common Causes Islet Cell Amyloidosis Obesity Chronic
Pancreatitis
4. Type II Diabetes Abnormal Insulin Secretion Peripheral
Insulin Resistance
5. Pathogenesis
6. Islet Amyloid Polypeptide
7. Amyloid
8. Amyloidosis
9. Islet Cell Amyloid
10. Amylin Overproduction leads to Diabetes 2 Amylin is
secreted with insulin Amylin is converted to Amyloid Amyloid is
toxic to B-Cells Amylin further inhibits insulin secretion
24. Fructosamine Sugar molecules circulating in blood stick to
proteins ( amines ) These proteins circulate in the blood stream
for 14-21 days Measuring them gives a picture of the amount of
sugar in the blood for that time period
25. Glucose Fructosamine
26. Stress Hyperglycemia
27. Subclinical Diabetes Cats in early stage of developing
diabetes Usually healthy cats , stable weight Identified when
routine laboratory tests performed for other reasons
28. Stress Hyperlycemia vs Subclinical Diabetes Remember cats
with subclinical diabetes do not show symptoms of diabetes
Fructosamine test will confirm the diagnosis
35. What other condition can mimic Diabetes ? Hyperthyroid
disease Causes similar signs to Diabetes Can occur
concurrently
36. Treatment Goals Minimize clinical signs Avoid complications
( e.g. Diabetic Ketoacidosis , peripheral neuropathy) Avoid
hypoglycemia Maintain owner compliance with treatment and follow up
Achieve quality of life Achieve Diabetic Remission ( if possible
)
37. AAHA Diabetes Management Guidelines
38. Subclinical Diabetes Treatment Goals Prevent onset of
Clinical Diabetes Manage obesity and optimize Body weight Goal : To
obtain normal Blood Glucose concentration without need for
insulin
39. Subclinical Diabetes Treatment Goals Weight Loss in Obese
cats Goal : 1 - 2 % loss per week ( maximum 4- 8% per month Weigh
monthly and adjust intake of food to reach optimal weight
40. Feed a High Protein Diet > 45 % Protein metabolizable
energy ( ME) to maximize metabolic rate , improve satiety and
prevent lean musle- mass loss Protein normalizes fat metabolism and
provides consistent energy source Arginine ( amino acid )
stimulates insulin release
41. Limit Carbohydrate Intake Dietary Carbohydrate may
contribute to hyperglycaemia and glucose toxicity Carbohydrate
levels classified as ultra low ( < 5 % ME ) , low ( 5 to 25 % ME
) , moderate ( 26 to 50 % ME ) and high ( > 50% ME )
42. Control Portion via Meal Feeding Allows for appetite and
intake monitoring Essential to achieve weight loss in obese
cats
43. Canned foods are preferred Lower Carbohydrate Levels Easier
to control portions Lower Caloric Density : cat can eat a higher
volume of canned food for the same caloric intake Additional Water
intake
44. Clinical Diabetes Management Minimal or no clinical signs
Owner perceives good quality of life and is satisfied with
treatment Avoid complications ( DKA , peripheral neuropathy Avoid
symptomatic hypoglycaemia
45. Feeding Management Feeding meals 4 times daily is ideal to
prevent clinical hypoglycaemia for cats on insulin Time feeders are
useful for cats that require multiple meals per day to manage
weight and control calories free choice is acceptable for
underweight cats on insulin therapy
46. ?
47. Insulin Therapy Approved for Cats
48. AAHA Recommends U-100 U-40
49. Initial Insulin Therapy Initial Dosage = 0,25 U /kg q12 hrs
based on an estimate of the cats lean body weight ( AAHA panel )
This equals to 1 U q12hrs in an average cat Even in very large cat
, starting dose should not exceed 2 U per cat q 12 hrs
50. First Week of Treatment Insulin Start at 1 U per cat q 12
hrs At this stage the goal of monitoring is to only identify
hypoglycaemia The insulin dose should not be increased based on 1
st day BG evaluation If monitoring is elected , measure BG every
2-3 hrs for cats on PZI , and every 4 hrs for cats on Glargine for
12 hrs following insulin administration
51. First Week Insulin Treatment Ctd Decrease insulin dose by
0,5 U if BG < 8,3 mmol/L , at any time during the day Treat as
outpatient and plan to reevaluate in 7 days Immediately reevaluate
if clinical signs worsen : if clinical signs suggest hypoglycaemia:
or if lethargy , anorexia or vomiting is noted
52. Signs of Mild Hypoglycemia Cats do not show overt signs
until the BG is dangerously low ( < 4,4mmol/L) Weakness ,
Lethargy Sleepy Reluctance to move Slow to respond to owner
53. Hypoglycemia link video
54. Glucose Curve
55. Ongoing Monitoring of the Cat The primary concern for the
newly diagnosed and treated cat is the development of hypoglycaemia
in individuals that may quickly go into remission Home blood
glucose monitoring offers the most efficient and accurate diabetes
monitoring If BG monitoring is not available , monitor and document
changes in clinical signs Urine glucose testing using glucose
detecting crystals in the litter can be used to detect diabetic
remission
56. Diary At Home
57. Ongoing Home monitoring Log food , water , and appetite
daily Log insulin dose daily Note any signs suggestive of
hypoglycaemia : contact veterinarian if persistent Periodically
test urine , looking for negative glycosuria ( suggestive of
hypoglycaemia or diabetic remission ) or positive ketonuria (
suggestive of substantial hyperglycaemia)
58. Urine Glucose Detection
59. Ketonuria
60. At 1 week after Insulin Treatment If Clinical signs
Improved Continue Present Dose of Insulin Introduce Home Monitoring
if not done already If a Spot Check on the BG is possible , assess
for hypoglycaemia at 6-8 hours following insulin injection If BG is
< 8,3 mmol/L , decrease insulin dose to 0,5 Units q 12 hrs
61. If Clinical Signs Have Persisted or Worsened Evaluate
Client compliance and Dosing Technique If Compliance good ,
increase dose to 2 Units q 12hrs If the cat is Ketonuric , has
developed peripheral neuropathy , or does not have good appetite ,
Evaluate for DKA and Rule Out Complicating Disease ( e.g.
Pancreatitis)
62. During the First Month Weekly : Spot Checks of BG at 6-8
hrs following insulin injection ( more often if Hypoglycemia is
suspected ) Every 2 weeks : Perform Blood Glucose Curve Utilize
Urine dipstick or urine glucose detecting crystals Consider insulin
overdose or possible diabetic remission if 3 consecutive negative
urine glucose results are obtained
63. At 1 Month after Insulin Treatment In Clinic Examination
recommended for all cats Thourough History , Physical Exam , Weight
and Urinalysis Measure Fructosamine unless detailed home monitoring
records are available Additional lab tests may be needed Adjust
insulin dose , insulin dose should not be increased more than 1
Unit at a time The majority of cats on Glargine or PZI do not need
> 3 Units of Insulin q 12 hrs
64. Long Term Monitoring of Insulin Treatment at Home Daily :
Clinical signs , Food/Water intake , Insulin Dose Weekly : Body
Weight Monthly : BG spot checks ( twice monthly better ); if on
Glargine , evaluate BG prior to insulin and 8 hrs post insulin ; if
on PZI evaluate BG prior to insulin and 3, 6, 9 hrs later Twice
Monthly: Urine Glucose and Ketones : If urine is consistently
negative DIABETIC REMISSION
65. Long Term Monitoring in Clinic If the cat is doing well ,
dont make changes based on increased BG measurements alone ,
especially if measured in the clinic (?) Every 3 months :
Examination and Weight Every 3-6 months : Serum Fructosamine : If
at the lower end of the reference range or below the reference
range Consider Chronic Hypoglycemia and Diabetic Remission :
Decrease insulin dose and recheck in 4 weeks
66. If BG consistently < 8,3 mmol/L or urine persistently
Negative for Glucose Decrease Insulin Dose Switch treatment to q 24
hrs Stop Insulin and monitor response
67. Clinical Remission Clinical Remission Up to 60% of cats
enter diabetic remission with insulin and dietary therapy.
Remission may not be permanent . Approximately 30% of cats in
remission will revert to diabetic state and require reinstitution
of insulin therapy Remission rates increase in cases with good
glycemic control within 6 months of diagnosis
68. Causes of Insulin Resistance G Obesity G Chronic
pancreatitis G Bacterial infection G Kidney disease G
Hyperthyroidism G Heart disease G Neoplasia G Hyperadrenocorticism
G Acromegaly G Glucocorticoid or progestogen administration
69. Home Blood Glucose monitoring
70. Somoygi effect Nadir
71. To Give or not To Give Insulin : That is The Question
NO