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See These Cats “Meow!” Early Detection of Feline Diabetes

Natalie L. Marks, DVM, CVJ, CCFP, Elite FFCP-V

While our profession originated in preventive medicine, many veterinarians today spend most of their time on chronic disease detection and management. Some of this shift is due to cats living inside the home with longer lifespans. However, other significant factors include pet parents waiting longer to seek veterinary care due to myths about cat health and the rising costs of veterinary medicine.

As Fear Free Certified Professionals, we don’t just consider physical health but also the emotional health of the feline patient, pet parent, and our teams. When specifically thinking about how this applies to the diagnosis and management of our feline diabetic patients, there are two fundamental tenets for success: educating cat caregivers on signs of diabetes for earlier detection and offering alternative treatment options for qualifying patients to ensure complete health.

With a diagnosis of diabetes, some colleagues may question why we need another treatment besides insulin. For one, owner compliance with needles, insulin administration, and insulin overdosing are of concern. Also, we know that there is an increasing number of cats being diagnosed with diabetes. An estimated 600,000 cats in the U.S. are diagnosed with diabetes during their lifetime, with the prevalence of this devastating disease increasing over the past decade. However, the most crucial statistic from research shows that 125,000 cats go untreated1.

Early Detection

We must continue to educate pet parents about the more common signs of diabetes. Urban myths circulate with inaccurate information, such as the idea that indoor cats don’t need routine veterinary care and that these cats vocalize when they don’t feel well.

Instead of acquiescing, let’s provide simple early-detection guidelines. Here are the four most common signs of feline diabetics displayed through the mnemonic “MEOW:”

More eating and drinking
Excessive appetite
Overweight
Weight loss that occurs suddenly

This can be used in several social media posts—be sure to communicate this to pet parents where they can best receive information!

In addition to the most common signs, it’s also helpful to give pet parents an idea of other risks. Some of the increased risk factors for dogs hold for cats, like chronic pancreatitis, being middle age, and use of steroids, but there are definite differences

that your cat’s parents want to know! This is especially true with how much of a role obesity plays – cats with an obese body condition score are four times more likely to develop diabetes! Besides the other complications of obesity, this is a big reason to ALWAYS give our patients a body condition score and discuss appropriate weight management guidelines. Indoor cats, neutered males, chronic kidney cats, and hyperthyroid kitties are also at risk.

When pet parents call for an appointment based on the clinical signs observed at home, continuing the education process during the physical exam is essential. Cats are very similar in pathophysiology to overweight adults; 80% (or more)2 have Type 2 diabetes. This is due to either an insensitivity or resistance to insulin in tissues. Pancreatic beta cells don’t like a high glucose environment or being overtaxed. When that happens, we see the progressive loss of beta-cell insulin production and burnout.

Diagnosis of diabetes also requires diagnostics. Let’s recommend a foundational diagnostic workup instead of just a blood glucose spot check. This includes a full CBC (complete blood count), a chemistry panel with electrolytes, a concurrent urinalysis with culture (preferably low colony count), a UPC (urine protein: creatinine ratio), blood pressure, and a thyroid panel. While many of our patients develop their diabetic state secondary to adipocyte inflammation, we can see other associated disease states like chronic kidney disease, hypertension, hyperthyroidism, and acromegaly.

Fear Free Treatment Options

Insulin is a successful treatment option for many diabetic cats. However, a large population remains completely untreated, and for those yet to be diagnosed, insulin may not be a good fit for the family’s lifestyle. Veterinary teams must provide safe and effective treatment alternatives.

Bexacat™ (bexagliflozin tablets) is the first sodium-glucose cotransporter 2 (SGLT2) inhibitor approved by the FDA in any animal species. Bexacat™ introduces a mechanism of action for veterinarians and pet owners that offers a non-insulin, needle-free, once-daily oral medication specifically designed for cats with diabetes mellitus. This first-in-class therapeutic is indicated to improve glycemic control in otherwise healthy cats with diabetes mellitus NOT previously treated with insulin.

Let’s consider what’s different about the mechanism of Bexacat™ vs. traditional insulin. Insulin drives glucose into the cells, whereas Bexacat™ drops blood glucose levels by promoting urinary excretion or preventing renal glucose reabsorption.

Several differentiating features of Bexacat™ help promote physical and emotional health. First, unlike traditional insulin, Bexacat™ does not require dosing calculations or titration, measuring in syringes, or potential dosing errors. It’s one flavored tablet per cat daily and can be given in food. Not only does this streamline the process for clients, but it also helps them efficiently manage their schedules or travel demands by

having other caregivers participate. The tablet has been shown to have 96-97% palatability in studies3, which also encourages easing client compliance!

Another unique characteristic of Bexacat™ is that dosing is independent of our patient’s blood sugar or if the cat gains or loses weight. This is incredibly helpful in easing the minds of cat parents, especially as we start to talk about the possibility of remission monitoring. We need a minimum weight of 3kg for cats taking Bexacat™.

The essential piece of success is case selection. At this point, Type 1 Diabetics and feline patients who have been on traditional insulin are not candidates for Bexacat™ use. This is because when cats have been diabetics for a long time or are Type 1 (insulin-dependent), they don’t have enough healthy B-cells in their pancreas to produce insulin – an essential qualification to use Bexacat™. The longer a cat has diabetes mellitus, the higher the risk of amyloidosis and beta cell depletion. A newly diagnosed cat will likely have a larger beta cell mass and be more likely to be able to produce at least some insulin. Cats also need to be able to secrete endogenous insulin. However, no accurate test exists to determine this. Glucose toxicity from hyperglycemia is toxic to beta cells.

Finally, patients also need qualifying lab work. Any significant renal (Stage III IRIS or higher) or significant hepatic disease disqualifies the patient. We also need to rule out DKA (diabetic ketoacidosis). But, the final piece, and what may be very new to many of us, is a beta-hydroxbutyrate (BHBA) level of <37 mg/dL or 3.6 mmol/L and precaution of <25 mg.dl or 2.4 mmol/L if history of renal disease or metabolic acidosis. We can use a BHBA level of 2.4 mmol/L if using a handheld monitor. If ketones are in the urine, exclude the cat from being a good candidate.

References:

https://www.businesswire.com/news/home/20221209005431/en/Elanco-Announces-FDA-Approval-of-Bexacat%E2%84%A2-bexagliflozin-tablets-%E2%80%93-the-First-of-its-Kind-Oral-Feline-Diabetes-Treatment-Option
Chandler M, Cunningham S, Lund EM, Khanna C, Naramore R, Patel A, Day MJ. Obesity and Associated Comorbidities in People and Companion Animals: A One Health Perspective. J Comp Pathol. 2017 May;156(4):296-309.
Elanco Animal Health. Data on File.

Important Safety Information:

Before using Bexacat, you must read the entire package insert, including the boxed warning. Cats treated with Bexacat may be at an increased risk for conditions called diabetic ketoacidosis or euglycemic diabetic ketoacidosis, both of which may result in death. It is critical that cats taking Bexacat be examined by a veterinarian promptly if sudden decreases in appetite or water consumption occur, or if weight loss, tiredness, vomiting, diarrhea, or weakness are seen. Discontinue Bexacat and call your veterinarian immediately if any of these occur as they could be signs of diabetic ketoacidosis or

euglycemic diabetic ketoacidosis. Before giving Bexacat, be sure to talk with your veterinarian about any past illnesses your cat has had including if your cat has ever been on insulin, as cats that have been treated with insulin should not receive Bexacat. Do not use Bexacat if your cat has experienced pancreatitis, liver disease or reduced kidney function as serious side effects may occur. Bexacat is available by veterinary prescription only. Not for human use. Keep out of reach of children. Contact a physician immediately if swallowed accidentally.

Bexacat, Elanco and the diagonal bar logo are trademarks of Elanco or its affiliates.

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.

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Crisis Communication: Tips for Calming Pet Owners

Maggie MartonA 2018 article published in Veterinary Sciences synopsized a dissertation examining the connection between owner loyalty to their pets’ veterinarians and their perception of the communication from the veterinarian and staff. The study found that good communication delivered all kinds of benefits, from customer loyalty to trust in the veterinarian to likelihood of following treatment instructions to perception of a greater value for services rendered.

But good communication can be difficult, and it can feel nearly impossible in times of crisis–when a pet is ill or injured, when an animal is dying, or when a client doesn’t understand or can’t afford care options, for instance. While many communication tools are available, one promising model for veterinarians to help calm pet owners is Nonviolent Communication (NVC).

What is NVC?

The goal of NVC is to communicate and express yourself clearly, then receive what you hear back without judgment. The communication model avoids language that promotes disconnection, such as blaming, comparing, judging, or doling out advice.

Leslie Ritter-Jenkins, a certified trainer with the Center for Nonviolent Communication, says NVC is being practiced in the human medical field and fits veterinary medicine well. “Because veterinarians, like many people in the medical world, are people of authority, we tend to give them a lot of power,” she says.

Being mindful of language used matters because people tend to either rebel or submit to perceived authority. This is critical in times of crisis because when a client is triggered–by fear, anger, grief, and so on–that lack of control makes communication more difficult. As the “authority” in the room, using NVC tools can establish trust and confidence between the veterinarian and client while avoiding or mitigating conflict.

It’s just one framework for clear communication, but its principles fit veterinary medicine because the foundation is built on one thing: compassion. In times of crisis, especially when life and death decisions must be made, a compassionate response can shift the tone of the conversation.

The NVC Process

According to the Center for Nonviolent Communication, the model consists of two sides: empathetically listening and honestly expressing. You can’t control what your client says–or hears–especially while facing stress or fear, but you can control your listening skills and your response. Here are the four steps to the NVC process to employ:

Observations: without judgment
Feelings: underlying emotions
Needs: universal and what makes us human (e.g. mutuality, respect, freedom, choice, partnership)
Requests: a clear, doable ask

Ritter-Jenkins points out that what a client poses as a feeling is more often a need, so the NVC skill involves drilling down to identify what’s really going on. She says, “If someone says, ‘I feel disrespected,’ their feeling isn’t disrespect. The feeling is probably hurt or scared. Their need is respect.”

Listen closely to the data your client provides either overtly or through your observations and consider whether there’s an emotion or need masked by the language. It’s a skill that takes time to hone. Practice sessions during staff meetings may be helpful.

How Can NVC Help in the Exam Room?

“All humans share the same feelings and needs. When we get out of right and wrong thinking, better or worse, appropriate or inappropriate, and we speak this language of feelings and needs, we have a language that connects us universally. When a vet can hear behind what the customer, the human customer, is saying and then use a sentence or two of empathy, it’s very efficient connecting with feelings and needs. You can get to the heart of things, what’s really happening with the customer, fast,” Ritter-Jenkins says.

She shares an example from her own life when she faced an end-of-life decision with one of her cats. Her cat suffered from an undiagnosed GI disorder. They tried various approaches, and she ultimately went to the vet for help because her cat wasn’t eating, he was losing weight, yet he was acting completely normal.

“She could hear in that data and say, ‘It sounds like you’re feeling torn because you know that there’s something physiologically wrong and the cat is likely in pain and suffering, and you’re torn because you’re seeing some normal behavior and you’re needing clarity about what’s going on.’ That would’ve been exactly right–an empathic guess,” she says. “Or she could have said, ‘It sounds like you’re feeling exasperated and want some clarity or want some support in this decision.’”

When faced with a potentially costly procedure, a devastating diagnosis, or an end-of-life decision, client reactions run the gamut, but people often shift swiftly into panic or crisis mode. Listen, then present the data, the science, while being clear that you’re not telling the client what to do. Jumping in with unsolicited advice, especially when a client is in crisis, creates a barrier to empathy, as does judging, storytelling, one-upping, and philosophizing.

One of the easiest ways to achieve this? A quick question.

Take some time during or toward the end of an appointment to ask, “Have your questions been answered? Do you have anything else that you’re concerned about that we haven’t covered?”

Practice NVC

The science supports this model of communication. “What happens is the vagus nerve that goes from our brain and feeds our heart, our lungs, and our digestive system, empathy calms that. When someone empathizes with us, our whole body relaxes. We have the beauty of this connection, and it’s not just emotional. It’s physiological,” Ritter-Jenkins says.

Earlier this year, VIN offered a course on empathy and reflective listening, which included the Nonviolent Communication text as recommended reading. The concept is gaining traction in veterinary medicine. On its website, the Center for Nonviolent Communication posts practice group meetups open to anyone wanting to learn and practice the skills. Or pick up a copy of the book, Nonviolent Communication, and practice with your staff.

Bottom line: It’s a worthwhile endeavor to communicate well with your clients, especially during times of crisis, and it might even help build your business by increasing customer loyalty. The NVC model provides a framework to achieve those goals.

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.

Maggie Marton is an award-winning pet writer based in the Indianapolis area. She covers dogs, cats, kids, and often the intersection of all three for print and online publications. Maggie is the author of Clicker Dog Training: The Better Path to a Well-Behaved Pup and the blogger behind OhMyDogBlog.com and TheZeroWastePet.com.