It is not uncommon for a CKD cat to also have or develop diabetes.
The dietary needs of a diabetic cat may seem incompatible with the
needs of a CKD cat but the diabetes must take precedence.
What is Diabetes
Mellitus?
Insulin is a
hormone which enables the body to process food and to produce energy from
it. Diabetes mellitus is a disease in which:
not enough insulin is produced by the pancreas; or
the cat’s body cells do not properly process insulin which the pancreas
has produced.
As a result,
the cat develops high blood sugar levels (hyperglycaemia), which
eventually lead to high sugar levels in the urine (glucosuria).
Diabetes may present as:
uncomplicated; or
diabetes with ketoacidosis (DKA)
Cats with the former may only have mild symptoms, at
least in the early stages, but cats with
ketoacidosis are usually very
ill, and may die if not treated promptly.
There is
another, much rarer form of diabetes called diabetes insipidus which is
beyond the scope of this website.
Increasing age
is a factor (as it is for CKD cats).
Steroid-induced diabetes in cats
(2013) Peterson ME Veterinary Endocrinology says "The average age at
diagnosis for feline diabetes is 10
years, with a peak incidence between 9 and 13 years."
Obesity in cats, as in humans, is a strong
predisposing factor for diabetes.
For some
reason, male cats and neutered cats are more at risk of diabetes.
(2017) Öhlund M, Egenvall A, Fall T, Hansson-Hamlin H,
Röcklinsberg H, Holst BS Journal of Veterinary Internal Medicine
31(1) pp29-35 looked at cats insured by a Swedish insurance company
between 2009 and 2013. It found that cats who developed diabetes were more
likely to be indoor only, greedy, and overweight. In cats who were not
overweight, diabetes was more likely if they ate mainly dry food.
Burmese cats in
the UK and Australasia (but not the USA) appear to be more at risk. Norwegian Forest Cats
also seemed to be more at risk, but Persian and Birman
cats had a lower risk. In the USA, Maine Coone, Russian Blue, Siamese, DLH
and DSH cats have a higher incidence in the USA.
CKD, pancreatitis,
hyperthyroidism
and infections all cause insulin resistance in cats, making them more
susceptible to diabetes, according to
Feline diabetes mellitus (2012) Huang A
NAVC Clinician's BriefOct 2012 pp21-24.
Canyon Creek Animal Clinic
states "studies in humans have linked periodontal disease to a variety of health
problems including poor control of diabetes mellitus and increased
severity of diabetic complications. Additionally, it has been shown that
diabetes is a risk factor for periodontal disease."
The increase in sugar in the urine causes
polyuria
(increased urination) and
polydipsia (increased drinking).
Diabetic cats also tend to lose weight, so to some extent the
symptoms of diabetes may resemble those of CKD, although there is one
noticeable difference, namely that diabetic cats tend not to lose their
appetites – they lose weight despite continuing to eat, and may in fact
eat more (this
can also be a symptom of
hyperthyroidism).
However, more advanced diabetes may cause lack of appetite,
plus poor coat
quality, vomiting and dehydration and occasionally breathing problems.
Bladder infections are also relatively common because of the sugar in the
urine, and inappropriate elimination may occur.
You may
also see a plantigrade posture (as demonstrated by
Ollie to the left), where the cat walks on his/her hocks
instead of his/her feet. In diabetic cats this is usually
caused by diabetic neuropathy, where the nerves in the legs are damaged by
the disease; but
it may
sometimes be seen in cats with high phosphorus levels,
or with neurological problems from other causes.
Ollie was never diabetic, he did this because of
low
potassium levels.
Long Beach Animal Hospital has a photograph of a cat with
diabetic neuropathy doing this (click on Symptoms).
Newman Veterinary
has a good before and after photo of a diabetic cat with this
problem, scroll down a little to Other Common Consequences, then click on
Plantigrade Stance (in red font).
The Mayo Clinic
has some information about
peripheral neuropathy, including that caused by diabetes.
The symptoms of
diabetic ketoacidosis are discussed
here.
The symptoms of
hypoglycaemia (low blood sugar levels) are discussed
here.
Diagnosis
The vet will base the diagnosis on
clinical signs and blood and urine tests, particularly high levels of sugar (glucose) in the blood and urine on an ongoing
basis.
Glucose
(Glu) in the Blood
Glucose
is also known as blood sugar, and it will be elevated in diabetic cats.
Elevated blood sugar levels outside the normal range are known as
hyperglycaemia.
This value may increase suddenly because of
stress – it is not uncommon for this value to be high in cats who get
stressed or frightened at the vet’s. Therefore a high level on one
occasion should not be taken to indicate diabetes, urine
testing is also required.
Overview of feline bloodwork (2008) Jensen A 2008 Zimmer
Feline Foundation states "Glucose also has a tendency to show dramatic
increases in a healthy cat under acute stress. Normal blood glucose
should be well below 150 mg/dl. In most species, a glucose
measurement of over 200 would strongly suggest diabetes. In the
feline, however, stress alone can cause glucose to spike as high as 250
mg/dl. A value over 300 is unlikely to be due to stress alone."
Hyperglycemia
(2020) Schermerhorn T Clinician's BriefSept 2020
pp16-22 is a detailed paper about hyperglycaemia.
Glucosuria (Glucose in
Urine)
If your cat has
high blood glucose levels, your
vet may wish to test for glucose in the urine. Normally cats
do not have glucose in their urine, so increased levels may indicate
diabetes.
Overview of feline bloodwork (2008) Jensen A 2008 Zimmer
Feline Foundation states "One way to differentiate between a
glucose spike due to acute stress and high blood glucose due to diabetes
is through urinalysis. If there is no glucose in the urine in the face of
high blood glucose, it may be due to the fact that the blood glucose has
not been high long enough to overflow into the urine, suggesting an acute
spike. This is not definitive, however. Presence of glucose in the urine
is, however, highly suggestive of diabetes."
2018 AAHA diabetes management guidelines for dogs
and cats (2018) Behrend E, Holford
A, Lathan P, Rucinsky R & Schulman R Journal of the American Animal
Hospital54(1) pp1-21 say "Glucosuria
will typically develop when the BG concentration exceeds
approximately...250–300 mg/dL in cats."
Cats with renal
tubular disease may have glucosuria, but in this case glucose levels are high because the kidneys
are not able to filter the
glucose out of the blood properly; however, this is extremely rare.
Renal tubular defects in small animals
(2016) Brown SA Merck Veterinary Manual explains more about this.
Since high blood
glucose levels may be caused by the stress of a vet visit, it is a good
idea to check fructosamine.
It
is the ongoing nature of the increased
glucose level
that is important, and the fructosamine test
measures
concentrations of glucose molecules historically over a period of
approximately 2-3 weeks.
Glycosylated
haemoglobin is a similar test to fructosamine, but it measures
concentrations of glucose molecules historically over a longer period of
approximately 2-4 months.
Kidney Values
Cats with
ketoacidosis may have elevated BUN and creatinine levels, which in this
situation may not necessarily be a sign of CKD, particularly if phosphorus
and potassium levels are normal.
Once the diabetes is under control, the BUN and creatinine levels may
improve.
Diabetic cats
also often have dilute urine, and the resulting
dehydration may also cause increased kidney values.
Initially t
he
bloodwork may also indicate liver damage, which should improve as the
diabetes is brought under control.
Treatments
Cats with ketoacidotic diabetes normally require
hospitalisation including IV fluids and insulin therapy, until they are
stabilised; thereafter they will be treated as cats with uncomplicated
diabetes.
Uncomplicated diabetes is usually managed by means of insulin injections
given at home, though initially these may be given in hospital.
Controlling any infection
that is present, such as a urinary
tract infection, may make the diabetes easier to manage.
Sometimes
diabetic cats can be treated with an oral medication called glipizide
instead of injectable insulin. However, only about 30% of diabetic cats
respond to glipizide, and cats taking it must be carefully monitored
because the drug can damage the liver.
2018 AAHA diabetes management guidelines for dogs
and cats (2018) Behrend E, Holford
A, Lathan P, Rucinsky R & Schulman R Journal of the American Animal
Hospital54(1) pp1-21 state "There is concern that
glipizide may contribute to progression of DM [diabetes mellitus] and
pancreatic amyloidosis. The Task Force only recommends glipizide for use
in cats with owners who refuse insulin therapy, and only with concurrent
dietary therapy."
In any event,
most cats are far easier to inject than to pill.
Diet
2018 AAHA diabetes management guidelines for dogs
and cats (2018) Behrend E, Holford
A, Lathan P, Rucinsky R & Schulman R Journal of the American Animal
Hospital54(1) pp1-21 state "The
goals of dietary therapy are to optimize body weight with appropriate
protein and carbohydrate levels, fat restriction, and calorie and portion
control."
if your cat is
overweight (highly unlikely if your cat also has CKD), your vet will
usually recommend a weight loss plan, which will aim to help your cat
gradually lose the excess weight.
Managing the obese diabetic cat
(2007) Greco DS The 2007 Nestlé Purina Veterinary Symposium on
Companion Animal Medicine discusses how to handle obesity in a diabetic
cat.
Diabetic diets for dogs and cats: assessing the
evidence (2017) Linder DE Today's Veterinary Practice
7(6) pp24-27 says "Any dietary change, especially one incorporating
weight loss, should be introduced only after the cat has been stabilized
on an insulin regimen."
If your cat is
not overweight, your vet can advise you on diet. Dr Linder goes on to say
"Regardless of overweight status, adequate protein should remain a
priority throughout diabetic management. Protein needs may change during
weight loss (because of caloric restriction and relative nutrient density)
or as a result of the catabolism that can accompany uncontrolled diabetes.
The exact needs of each cat will differ and should be monitored by
assessing muscle condition and altering protein content of the diet as
needed."
Free feeding is not normally appropriate for diabetic cats. Cats
receiving insulin twice a day are usually fed half their daily food ration
each time. Cats receiving glipizide
are normally fed several small meals a day.
Cats have a low natural requirement for carbohydrates, and recent
research indicates that higher protein, higher fat and lower carbohydrate
diets may be most suitable for diabetic cats.
Keys to management of diabetes in cats
Little S (2011) Presentation to the 36th World Small
Animal Veterinary Association World Congress states "Current
recommendations support the use of a high protein (> 30% DM), low
carbohydrate (< 40% DM) diet for management of feline diabetes. Several
studies have demonstrated an improvement in blood glucose (BG) levels and
a decreased need for insulin therapy on this type of diet. Canned food is
preferred in diabetic cats to maintain hydration, lower carbohydrate
content, and improve satiety."
Diet changes should be made
gradually if a cat is already taking insulin, and blood glucose levels should
be carefully monitored, because sometimes there is a dramatic drop in blood glucose in
response to reduced carbohydrate intake, with a possible risk of an overdose of
insulin (see
hypoglycaemia).
Diabetic cats have decreased gut microbial diversity
and a lack of butyrate producing bacteria
(2019) Kieler IN, Osto M, Hugentobler L, Puetz L, Gilbert MTP, Hansen T,
Pedersen O, Reusch CE, Zini E, Lutz TA & Bjørnvad CR
Scientific Reports9(1) found that diabetic cats have reduced microbiome diversity
(fewer types of gut bacteria), and particularly those that produce
butyrate. Butyrate is a short chain fatty acid that helps to regulate
glucose metabolism. You therefore might wish to discuss the use of
probiotics with your vet.
Carbohydrates
Feeding a low carbohydrate diet combined with insulin treatment often
leads to remission
in cats.
Foods for diabetic cats are often considered in terms of what percentage
of total daily calorie intake comes from carbohydrates (metabolisable
energy or ME) rather than in terms of
dry matter analysis.
ISFM consensus guidelines on the practical
management of diabetes mellitus in cats
(2015) Sparkes AH, Cannon M, Church D, Fleeman L, Harvey A, Hoenig
M, Peterson ME, Reusch CE, Taylor S, Rosenberg D Journal of Feline
Medicine and Surgery17 pp235-250 states "Although
the optimal dietary CHo content has not been determined, diets with
restricted CHo content (≤12% metabolisable energy [ME] or 3 g/100 kcal)
was suggested by the majority of the Panel) are appropriate pending
further studies."
Many people I hear from with diabetic cats seem to aim for tighter
carbohydrate control, aiming for less than 10%
of calorie intake from carbohydrate. Feeding the diabetic cat
(2014) Spector D Vetstreet explains more about this.
Many kitten foods, which are usually high in protein and fat, are suitable
for this approach. Fancy Feast Classic and Friskies pate varieties may be
suitable, but are too high in phosphorus for cats who also have CKD.
Some diabetic cats are so sensitive to carbohydrate that
they need less insulin, or in a few cases stop needing it altogether, if switched to a low carbohydrate diet
(this is known as going into remission).
Comparison of a low carbohydrate-low fiber diet and
a moderate carbohydrate-high fiber diet in the management of feline
diabetes mellitus (2005) Bennett N, Greco DS, Peterson ME, Kirk
C, Mathes M, Fettman MJ. Journal of Feline Medicine and Surgery
Nov 3 found that the diabetic cats in this study who were fed the low
carbohydrate-low fibre diet were significantly more likely to stop
needing insulin than the cats fed the moderate carbohydrate-high fibre diet. Canned foods
are usually much lower in carbohydrate than dry foods, so canned foods low in cereals and added
sugars may be helpful in such cases, whereas dry foods, which tend to have
a high carbohydrate content, are usually avoided.
Diet for Cats with
Diabetes and CKD
If you are
dealing with both diabetes and CKD, it is more important that the diabetes
should be regulated, and in fact once this is achieved, you may find the
CKD improves too.
With diabetes,
the focus is on carbohydrate control (see
above). This is not a problem
for CKD cats but people dealing
with both diabetes and CKD are sometimes anxious because it appears that
the protein requirements of the two conditions are incompatible. In
fact reduced protein is not necessarily essential in the treatment of CKD
in the early stages, see
Nutritional Requirements for more information.
Even if your cat's CKD
is more advanced,
Keys to management of diabetes in cats
(2011) Little S Presentation to the 36th World Small
Animal Veterinary Association World Congress states "Current
recommendations support the use of a high protein (> 30% DM), low
carbohydrate (< 40% DM) diet for management of feline diabetes." A
protein level of 28-35% DMA is often recommended for CKD cats so I would
aim for a protein level of around 35% DMA for a cat with both conditions
if your vet agrees.
2018 AAHA diabetes management guidelines for dogs
and cats (2018) Behrend E, Holford
A, Lathan P, Rucinsky R & Schulman R Journal of the American Animal
Hospital54(1) pp1-21 recommend a higher protein intake of over
40% on an
ME
basis. If your cat's CKD is early stage, this might be appropriate. The
guidelines do state that they should be adjusted for cats who also have
CKD, so for cats in IRIS stages 3 and 4, a protein intake of 35% might be
more appropriate,
so discuss with your vet.
The need to moderate
phosphorus intake for
CKD cats still applies to cats with both CKD and diabetes.
Phosphorus levels are usually given in % DMA values for CKD cats
(e.g. 0.5% phosphorus on a DMA basis), whereas phosphorus levels are
sometimes given in mg per 100 calories for diabetic cats (e.g. 250mg/100
cals). Understandably, many people find it confusing trying to decide if a
food is suitable for a cat with both CKD and diabetes. The simplest thing
is to aim to feed a food with less than 10% carbs (ME) and as low a
protein and phosphorus level (DMA) as your cat will eat.
If necessary, add phosphorus binders.
One of Tanya's CKD Support Group members, April, has kindly created a
short list of US cat food with less than 10% carbs (ME) and below 1%
phosphorus (DMA). You can find the document
here. I have not checked this in any way,
and the data date from 2018 so some may have changed.
Methylcobalamin
Vitamin B12 in the form of methylcobalamin may be helpful for diabetic
cats, particularly those with diabetic neuropathy. See
Vitamin B
for more information.
Insulin is a hormone which can be given via injection when the body is not
producing enough insulin itself.
Most cats with diabetes need to be given insulin to manage their diabetes
properly, though many cats do enter a remission phase, during which
insulin is not necessary.
Cornell University College of Veterinary Medicine
has a series of videos covering all aspects of diabetic cat care,
including how to give insulin, monitoring your cat, and recognising and
treating hypoglycaemia.
The Winn Feline Foundation
has funded research into obtaining insulin-producing cells from
stem cells removed during spaying or neutering. They hope this will
improve a cat's response to standard insulin therapy and lead to fewer
changes in treatment and the potential side effects of other types of
insulin.
This is not
commercially available at present. In the meantime, there are a
number of different insulins available. Available insulins for feline use
include:
glargine
(Lanctus)
protamine zinc insulin or PZI
(ProZinc): FDA-approved for cats
determir
(Levemir)
lente (Vetsulin
or Caninsulin): FDA- approved for cats; approved in the UK for cats
2018 AAHA diabetes management guidelines for dogs
and cats (2018) Behrend E, Holford
A, Lathan P, Rucinsky R & Schulman R Journal of the American Animal
Hospital54(1) pp1-21 discuss the pros and cons of the various
insulins available and recommend starting with glargine because it appears
to achieve high remission rates.
ISFM consensus guidelines on the practical
management of diabetes mellitus in cats
(2015) Sparkes AH, Cannon M, Church D, Fleeman L, Harvey A, Hoenig
M, Peterson ME, Reusch CE, Taylor S, Rosenberg D Journal of Feline
Medicine and Surgery17 pp235-250 has an overview of the various
types of insulin available and states "the Panel recommends, whenever
possible, the use of longer acting insulin preparations (eg, glargine,
detemir or PZi), injected twice daily, for optimal diabetic control."
Caninsulin
is not very long lasting but it is the only insulin approved
for use in cats in the UK, so it must be used first. This is because UK
regulations require that a
medication approved for a species in the UK be used as the first
choice, and alternatives can only be considered if the first choice
medication does not work or causes too many side effects. This policy is
known as the cascade and
The British Small Animal Veterinary Association
explains more about how it works.
Bovine insulin
is most similar genetically to feline insulin, but is only available from
compounding pharmacies in the USA. However,
2018 AAHA diabetes management guidelines for dogs
and cats (2018) Behrend E, Holford
A, Lathan P, Rucinsky R & Schulman R Journal of the American Animal
Hospital54(1) pp1-21 state "A study comparing commercially
available insulin with its compounded counterparts showed that the
manufactured insulin met all US Pharmacopeia requirements and only 1 of 12
compounders met US Pharmacopeia specifications at all time points. The
variability between compounded insulins was also significant enough to
have clinical consequences."
Glargine
(Lantus) is very expensive. One member of Tanya's CKD Support Group was paying US$265 for a vial, which would last 1-6 months. Some
people source their insulin from
Marks Marine Pharmacy in Canada, which in 2018 apparently charged
US$170 including shipping for about a year's supply (five pens).
Keys to management of diabetes in cats (2011)Little S Presentation to the 36th World Small
Animal Veterinary Association World Congress compares the
various brands of insulin available and advises on how to adjust insulin
dosage.
A couple of American vet schools are running trials into the use of a type
of insulin which only has to be given once a week. See
below for more information.
Insulin: How to Give
There are a
number of different protocols for managing diabetes, and your vet will use the
protocol s/he feels most comfortable with.
The Roomp and Rand protocol
(2008) favours tight regulation and seems to work well for many
cats, but according to
Management of diabetic cats in primary care
practices: ABVP roundtable discussion (2015) Norsworthy DG &
Wexler-Mitchell E Journal of Feline Medicine and Surgery17(11)
pp967-974, this approach requires very close monitoring or it may lead to
a higher incidence of hypoglycaemia.
Many vets
choose to
start with one unit of insulin, which is usually administered every twelve
hours but occasionally
once daily.
The dose is rounded down to the nearest unit, and is generally ≤ 2
U/cat q12h
The higher dose of 0.5 U/kg may be appropriate if BG is >20 mmol/l
(360 mg/dl).
Obese and underweight cats should be dosed according to their
estimated ideal weight, and not their current weight."
Cats
vary in their response, so the amount and the frequency are determined by
checking blood glucose levels. This may need to be done every few hours at
first, but gradually the frequency
of checks
can be reduced to once or twice a day (see
monitoring).
If the diabetes is properly controlled, the earlier symptoms should
disappear.
Keys to management of diabetes in cats
(2011)Little S Presentation to the 36th World Small
Animal Veterinary Association World Congress which compares the
various brands of insulin available and advises on how to adjust insulin
dosage.
Insulin: Goals
Generally speaking, a cat is considered regulated if his/her blood glucose
consistently remains in the 5-14 mmol/l (US: 100-250 mg/dl) range.
"To control BG
to <14 mmol/l (252 mg/dl) for as much of a 24 h period as possible; and
To avoid
clinically significant hypoglycaemia at all times."
They do also
state that if closer monitoring is possible so that blood glucose can be
maintained ≤11 mmol/l or 198 mg/dl, this reduces risks associated with
diabetes and increases the chances of remission.
Monitoring: Blood
Glucose Testing
It is important to monitor your cat's blood sugar levels each day, so the
insulin dose can be adjusted as needed.
2018 AAHA diabetes management guidelines for dogs
and cats (2018) Behrend E, Holford
A, Lathan P, Rucinsky R & Schulman R Journal of the American Animal
Hospital54(1) pp1-21 have a helpful flow chart.
These days many people monitor their cat's glucose levels at home using a glucometer (available
from pharmacies for use by human diabetics) because home monitoring is much cheaper and less stressful for
the cat.
Many
UK vets are unfamiliar with this approach, but it is recommended in
ISFM consensus guidelines on the practical
management of diabetes mellitus in cats
(2015) Sparkes AH, Cannon M, Church D, Fleeman L, Harvey A, Hoenig
M, Peterson ME, Reusch CE, Taylor S, Rosenberg D Journal of Feline
Medicine and Surgery17 pp235-250 (many of the authors are UK
specialists)..
Home testing appears to be both safe and effective.
Intensive blood glucose control is safe and
effective in diabetic cats using home monitoring and treatment with
glargine
(2009) Roomp K & Rand J Journal of Feline Medicine & Surgery
11(8) pp668-82 states "Only one mild clinical
hypoglycaemic episode occurred observed despite tight blood glucose
control. In conclusion, intensive blood glucose control is safe and
effective in diabetic cats using home monitoring and treatment with
glargine."
The blood can normally be taken from the ear (make sure it is warm) using
a sterile lancet, and only a tiny amount is required. Some people take the
blood from a paw pad instead.
You normally test before you give any insulin so you can adjust the dose
accordingly. If you don't do this and your cat's blood sugar level is
already quite low
before giving the insulin, your cat is at risk of it falling too far
following the insulin injection (hypoglycaemia).
Veterinary Partner
has step by step
instructions for home blood glucose testing with
a slide show guide.
Flash gluclose monitoring with FreeStyle Libre in
dogs and cats (2019) Hammond-Lenzer M, Wilson S, Wasik B
Veterinary Partner reports on the use of the FreeStyle Libre continous
glucose monitoring (CGM) system. This system monitors glucose levels
without the need to take blood. It requires a small catheter and sensor to
be implanted into your cat, which will be done by your vet. You should
scan it regularly, usually every eight hours, using a supplied reader or
an iPhone (7 upwards) with an app. The reader costs around US$60-90 and
the sensor costs around US$40-80, though you may be able to get them
cheaper with a
discount card. The sensor only lasts for fourteen days, so this can
get quite expensive. Qute a few cats also dislodge their sensor.
Results of using Libre on my Badger
(2019) is a thread on the Feline Diabetes Message Board which discusses
one member's experience with the product.
Remission
Remission means that the cat no longer requires insulin injections. This
is usually because the pancreas begins producing insulin on its own again.
2018 AAHA diabetes management guidelines for dogs
and cats (2018) Behrend E, Holford
A, Lathan P, Rucinsky R & Schulman R Journal of the American Animal
Hospital54(1) pp1-21 state "In cats, diabetic remission is a
reasonable goal."
Cats who develop diabetes because of
corticosteroid use may go into remission once the steroids are stopped
(which should always be done gradually).
Going
into remission is relatively common in cats with well controlled diabetes,
even if they are not on steroids.
Predictors of clinical remission in cats with
diabetes mellitus (2010) Zini E, Hafner M, Franchini M,
Ackermann M, Lutz TA & Reusch CE Journal of Veterinary Internal
Medicine24(6) pp 1313-21 found that 50% of cats in the study
went into remission and that this was more common in older cats.
Tight control of blood sugar levels increases the chances of remission.
Intensive blood glucose control is safe and
effective in diabetic cats using home monitoring and treatment with
glargine
(2009) Roomp K & Rand J Journal of Feline Medicine & Surgery
11(8) pp668-82 states "An overall
remission rate of 64% was achieved in the cohort. Significantly higher
remission rates were observed if good glycaemic control was achieved soon
after diagnosis: 84% for cats started on the protocol within 6 months of
diagnosis went into remission, and only 35% for cats that began more than
6 months after diagnosis."
However, around 25-30% of cats in remission may relapse, meaning they need
to go back on insulin.
Glycemic status and predictors of relapse for
diabetic cats in remission (2015) Gottlieb S, Rand JS, Marshall
R & Morton J Journal of Veterinary Internal Medicine
29(1) pp184-92 found that relapsing was more likely in cats with poor
blood glucose control, in cats who had been given corticosteroids, or cats
who had pancreatitis, hyperthyroidism or CKD. The study recommends low
carbohydrate diets and the avoidance of corticosteroid use in diabetic
cats.
The University of California at Davis is looking into the use of
exanatide-ER (Bydureon) to help diabetic cats in remission stay that way.
The Royal Veterinary College in the UK is also running a trial, though I
don't know which medication they are using. See
below for details.
Possible Problems
Although diabetes is a scary diagnosis, most people seem to get into a
routine that enables them to manage it very well. Occasionally problems
may arise, so it is worth being aware of them, just in case:
Diabetic ketoacidosis is a very serious condition that usually occurs in
poorly regulated diabetic cats. If the cells in the cat's body cannot use
the glucose produced by the body, they break down fat and protein in the
body instead in an attempt to obtain energy. If body fat and proteins are
broken down too much, ketones are released and can cause potentially
life-threatening imbalances to electrolytes.
Symptoms of ketoacidosis include:
a distinctive sweet smell to the breath
vomiting
fast or laboured breathing
dehydration
low blood pressure
(Other possible
causes for some of these symptoms in CKD cats can be found
here).
Ketoacidosis is a medical emergency and you must seek veterinary help as
soon as possible.
Urine glucose is only really useful for initial
diagnosis – healthy cats do not have glucose in their urine – because it
is too imprecise a measure to make proper decisions about insulin dosage.
However, urine testing for ketone levels can help avoid ketoacidosis, and
is easy to do at home using dipsticks such as Ketostix, available from pharmacies.
Even if you are testing blood glucose at home, it is worth checking for
ketones if your cat doesn't seem quite right. Even a trace of
ketones is a cause for concern and warrants an immediate vet visit.
Sometimes cats
are started on too high a dose of insulin, which leads to a sudden drop in
blood sugar levels, and the body reacts to this by releasing glucagons
which raise blood sugar levels again. It thus appears, based on spot
checks at the vet's, that the cat requires even more insulin, when in fact
the opposite is the case. This is known as rebound hyperglycaemia or the Somogyi
effect and
Feline Diabetes has information
about it.
Home blood glucose monitoring gives more accurate results and can help you
to avoid such problems.
Rebound hyperglycemia in diabetic cats
(2016) Room K & Rand J Journal of Feline Medicine & Surgery
18(8) pp587-596 found that the Somogyi effect is rare in cats and concludes "despite
the frequent occurrence of biochemical hypoglycaemia, rebound
hyperglycaemia is rare in cats treated with glargine on a protocol aimed
at tight glycaemic control. For glargine-treated cats, insulin dose should
not be reduced when there is hyperglycaemia in the absence of biochemical
or clinical evidence of hypoglycaemia."
Hypoglycaemia
As a general rule,
too much insulin is far more dangerous for a diabetic cat than too little,
and may cause low blood sugar (hypoglycaemia). Symptoms include:
weakness
lack of
co-ordination
seizures
coma
(Other possible
causes for these symptoms in CKD cats can be found
here).
The cat should be offered food immediately if still able to eat, or you
may need to rub corn syrup
or
powdered glucose
on the gums (in the UK you can also buy a human OTC diabetic product called
Hypo-Stop); otherwise you should contact your vet urgently.
You will need to discuss your treatment programme with your vet following
an incident of hypoglycaemia.
Looking at the use of exanatide-ER (Bydureon) to help diabetic cats in
remission stay that way. Enrollment until 20 May 2020, but this may be
extended because of Covid-19.
Glycemic variability in newly diagnosed diabetic
cats treated with the glocagon-like peptide-1 analogue exenatide
extended release (2020) Krämer
AL, Riederer A, Fracassi F, Boretti FS, Sieber-Ruckstuhl NS, Lutz TA,
Contiero B, Zini E & Reusch CE Journal of Veterinary Internal
Medicineepub looked at the effects of exenatide extended
release on glycaemic variability, a measure of blood sugar control, in
cats receiving insulin. It was found to have a positive effect compared
to placebo, and cats receiving exenatide and insulin had lower glycaemic
variability than cats receiving insulin alone..
Burmese cats in the UK and some other countries are at increased risk of
diabetes. The study aims to help identify the genetic mutations and also
possible environmental factors responsible.
Will give diabetic cats in remission a new treatment aimed at helping
the cats remain in remission.
Diabetes and CKD
The main cause of CKD in humans is diabetes. It was not
known if there is a similar link in cats, but
Assessment of the association between diabetes mellitus and chronic kidney
disease in adult cats (2019)
Pérez-López L, Boronat M, Melián C, Saavedra P, Brito-Casillas Y & Wägner AM
Journal of Veterinary Internal Medicine33(5) pp1921-1925 showed
that even after adjusting for age, an assocation exists between CKD and
diabetes in cats.
See
above for information on
diet for cats with both diabetes and CKD.
A dehydrated
cat may respond less well to insulin, and many people have found that once
sub-Qs are begun, the insulin seems to work more effectively, sometimes
with longer duration than was previously the case.
Anecdotal
evidence suggests that diabetic cats with CKD may do less well on
benazepril (Fortekor) than cats with CKD only.
TREATING YOUR CAT WITHOUT VETERINARY ADVICE CAN BE
EXTREMELY DANGEROUS.
I have
tried very hard to ensure that the information provided in this website is
accurate, but I am NOT a vet, just an ordinary person who has lived
through CKD with three cats. This website is for educational purposes
only, and is not intended to be used to diagnose or treat any cat. Before
trying any of the treatments described herein, you MUST consult a
qualified veterinarian and obtain professional advice on the correct
regimen for your cat and his or her particular requirements; and you
should only use any treatments described here with the full knowledge and
approval of your vet. No responsibility can be accepted.
If your cat
appears to be in pain or distress, do not waste time on the internet,
contact your vet immediately.
This site was
created using Microsoft software, and therefore it is best viewed in
Internet Explorer. I know it doesn't always display too well in other
browsers, but I'm not an IT expert so I'm afraid I don't know how to
change that. I would love it to display perfectly everywhere, but my focus
is on making the information available. When I get time, I'll try to
improve how it displays in other browsers.
This site is a labour of love, from which I do not make
a penny. Please do not steal from me by taking credit for my work.
If you wish to
link to this site, please feel free to do so. Please make it clear that
this is a link and not your own work. I would appreciate being informed of
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