diabetes Archives - Fear Free

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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Fear Free Management of Feline Diabetes

Julie Liu, DVM
Before learning about Fear Free handling techniques, one of my biggest fears about my cat, Puff, was that he would someday become diabetic and require insulin injections. While he is a friendly cat, he is so resistant to restraint that even applying topical parasite preventive on him monthly could be a struggle, not to mention the nightmare of bringing him to the clinic and handling him for labwork (picture a 12-pound white and orange bucking bronco).

I have encountered a similar level of panic in a number of my clients faced with the diagnosis of diabetes in their cat. Beyond the stress associated with costs of initial diagnosis and treatment, many clients have a high level of anxiety at the thought of giving their cat injections and may even consider euthanasia for a disease that is often ultimately manageable. We can provide a huge service to our patients by educating both clients and our fellow veterinary professionals on Fear Free methods of handling diabetic cats.

Insulin Administration

Fear of needles is nothing new in the veterinary clinic. We see it develop all the time in pets when they jump with the poke of a vaccination. Over time, they begin to anticipate that when their skin is touched, pinched, or lifted, a needle will follow. You may even observe this occurring within the course of the same appointment when you have to give several vaccines. While we set a goal for diabetic remission in our feline patients, unfortunately this won’t be possible or permanent for all cats, so getting clients comfortable with handling their cat for injections is vital.

Prepping Pet Owners

The good news about managing diabetic cats is twofold: insulin needles are tiny and most diabetic cats love food. I normally ask owners to administer insulin while their cat is obliviously munching away on breakfast or dinner. For those with a cat like Puff, taking time to desensitize and countercondition the baby steps leading up to the injection is recommended since these types of cats always seem to know when their owners are up to something.

Start with having the owner find a comfortable location in the house for feeding and insulin administration and practice remaining next to their cat while the cat is eating. Next, have the owner desensitize the cat to being petted between the dorsal shoulders while eating, followed by desensitization and counterconditioning to the owner gently lifting and releasing the skin. For needle-reactive cats, practicing fake injections with the tip of a pen. Using the Fear Free vaccination technique of applying numbing cream a few minutes before injection will help ensure that the process remains more positive and less like a horror movie where the owner is chasing the cat around the house with an uncapped needle.

Blood Glucose Monitoring

Have you ever taken a blood glucose reading from a cat in the clinic while he’s growling and hissing and wondered how accurate your 391 value was? Similar to Doppler blood pressure, if your feline patient has an FAS level of 4 or 5, you may not be able to trust those blood glucose numbers.

To minimize stress hyperglycemia, all of the normal Fear Free recommendations you would make for reducing FAS associated with vet visits apply to in-clinic blood glucose curves: desensitization and counterconditioning to the carrier, low-stress handling at the clinic, and most of all, pre-visit pharmaceuticals. Unfortunately, even with taking all of these precautions, your feline patients will likely experience some stress. If you rely on serum fructosamine you’ll get a general idea of their level of blood glucose control over the preceding week but miss the nadir and other parameters. As a result, home blood glucose monitoring has become a much more common and Fear Free method of assessing diabetic control.

Historically, I’ve asked owners to purchase their own AlphaTRAK™ glucometer kit online and scheduled a technician appointment for a demo with their cat on how to obtain the needed microdrop of blood from the marginal vein along the haired portion of the ear pinna. Similar to desensitization and counterconditioning to handling the cat for insulin injections, the same approach can be used for blood glucose sampling. Using a cotton ball to stabilize the non-haired portion of the pinna and a 27-gauge needle will improve patient comfort.

Clinics can create a standardized home blood glucose curve form containing patient information, current diet, current insulin type/dose, blood glucose level prior to the start of feeding/insulin, and readings every 2 to 4 hours over a 12-hour period. Once this is completed and emailed back to the clinic, a blood glucose curve consult fee can be charged to the owner prior to having the doctor contact the client. While you may get some pushback from clients regarding this fee, keep in mind that the fee is typically a fraction of the cost charged for an in-clinic curve, and client education on home blood glucose sampling will empower owners to verify hypoglycemia if symptoms are seen and seek veterinary care if indicated.

Recently, continuous glucose monitors (CGM) such as the Abbott Freestyle Libre™ glucose monitor have provided another option for Fear Free management of diabetes. While these products are used off label in pets and require an in-clinic visit to apply the device, they can provide continuous interstitial (subcutaneous) glucose sampling for 10 to 14 days on feline patients where an at-home curve is not possible.

Once the small sensor is applied to the skin, the owner simply scans the device with their phone periodically to transmit the data, which can also be shared with the clinic. A glucose curve consult fee can be charged to the owner at the time of application of the CGM that will cover the consult with the veterinarian at the end of the two-week period. CGM can also be used to reduce FAS at the clinic for hospitalized diabetic cats such as those receiving treatment for diabetic ketoacidosis or pancreatitis.

Caution must be used to avoid overinterpretation of glucose readings by the owner, and even when placed correctly the sensors may fail to obtain data. However, the ability to avoid multiple needle pokes at home or in the clinic makes these devices an appealing Fear Free alternative to how we traditionally monitor diabetic patients.

Telemedicine

In the age of Covid and curbside veterinary care, many clinics have ventured into teleconsults, which are a great addition to the Fear Free toolkit. What could be more Fear Free than helping your patient from the comfort of their own home?

Once a veterinarian-client-patient relationship is established based on the rules of your state, clinics can offer paid video teleconsults with an experienced technician or a veterinarian to guide a client through low-stress handling for insulin injections and blood glucose sampling while they are working with their own cat. Teleconsults also allow for education on signs of FAS that the owner may not pick up on such as a flicking tail tip or flattening ears that necessitate a change in handling.

Feline diabetes can be a challenging disease for owners as well as veterinary staff, and as always, we need to consider the client’s lifestyle and the patient’s symptoms in our recommendations. Whether your patient is at home or at the clinic, tailoring your treatment plan to include Fear Free techniques will help build confidence and increase success with disease management.

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

Julie Liu, DVM, CVA (Certified Veterinary Acupuncturist) is a small-animal veterinarian who practices in Austin, Texas. In addition to advocating for Fear Free handling of pets, she is passionate about feline medicine and senior pet care.