1. 1. Diabetes Mellitus Feline by Gerard Derminasyan DVM
2. 2. Definition Persistent Hyperglycemia due to absolute or relative insulin deficiency
3. 3. Common Causes Islet Cell Amyloidosis Obesity Chronic Pancreatitis
4. 4. Type II Diabetes Abnormal Insulin Secretion Peripheral Insulin Resistance
5. 5. Pathogenesis
6. 6. Islet Amyloid Polypeptide
7. 7. Amyloid
8. 8. Amyloidosis
9. 9. Islet Cell Amyloid
10. 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
11. 11. OBESITY leads to Insulin Resistance
12. 12. How Insulin Works
13. 13. Key and Lock Mechanism
14. 14. Insulin Resistance
15. 15. Pancreatitis and Diabetes
16. 16. SYMPTOMS Polyuria / Polydypsia Weight Loss Increased Appetite Plantigrade Stance/Weakness/Difficulty jumping
17. 17. Polyuria /Polydypsia
18. 18. Ravenous Appetite
19. 19. Plantigrade Stance
20. 20. Diabetic Neuropathy
21. 21. Plantigrade Posture
22. 22. Cataracts
23. 23. Biochemistry
24. 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. 25. Glucose Fructosamine
26. 26. Stress Hyperglycemia
27. 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. 28. Stress Hyperlycemia vs Subclinical Diabetes Remember cats with subclinical diabetes do not show symptoms of diabetes Fructosamine test will confirm the diagnosis
29. 29. Diabetic ? Subclinical Diabetic ? Stress Hyperglycemia ?
30. 30. Concurrent Diseases Pancreatitis : Acute vs Chronic Urinary Tract Infection Renal disease Hyperthyroidism Oral disease
31. 31. Corticosteroids : Risk factor for Diabetes
32. 32. Urinalysis and Urine culture
33. 33. Urinalysis
34. 34. Culture & Sensitivity
35. 35. What other condition can mimic Diabetes ? Hyperthyroid disease Causes similar signs to Diabetes Can occur concurrently
36. 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. 37. AAHA Diabetes Management Guidelines
38. 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. 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. 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. 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. 42. Control Portion via Meal Feeding Allows for appetite and intake monitoring Essential to achieve weight loss in obese cats
43. 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. 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. 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. 46. ?
47. 47. Insulin Therapy Approved for Cats
48. 48. AAHA Recommends U-100 U-40
49. 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. 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. 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. 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. 53. Hypoglycemia link video
54. 54. Glucose Curve
55. 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. 56. Diary At Home
57. 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. 58. Urine Glucose Detection
59. 59. Ketonuria
60. 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. 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. 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. 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. 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. 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. 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. 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. 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. 69. Home Blood Glucose monitoring
70. 70. Somoygi effect Nadir
71. 71. To Give or not To Give Insulin : That is The Question NO
72. 72. M E R C I Gerard Derminasyan DVM