PowerPoint DiabetesMellitus

Sweet Success:
Managing the Diabetic

in Small Animal Practice
Wendy Blount, DVM

Glucose
Danger values - <40 g/dl; >1000 g/dl
• Hyperglycemia
– Brain dehydration due to hyperosmosis
– CNS signs (cerebral, brain stem) and seizures
DDx Hyperglycemia other than DM and
stress (especially in prediabetics):
• Beta adrenergics (terbutaline, albuterol, etc.)
• Corticosteroids
• Glaucoma treatments – acetazolamide, etc.
• Thiazide diuretics
• Levothyroxine, progestagens, estrogens
• (Diazoxide, glucagon)
The Endocrine Pancreas
• Islets of Langerhans dispersed in the

exocrine pancreas (acinar cells)
– Alpha cells – secrete glucagon
– Beta cells – secrete insulin
– Delta cells – secrete somatostatin
– Pancreatic Polypetide (PP) cells – secrete
pancreatic polypeptide
• Most common endocrinopathy of the
pancreas is diabetes mellitus
– Insulin deficiency
– Insulin resistance
Clinical Presentation
• High Risk Breeds
– Mixed Breed most common in dogs and cats
– Australian Terrier 32x risk
– Then Schnauzer, Samoyed, Fox Terrier
– Then Keeshond, Bichon, Spitz, Cairn Terrier.
Poodle, Husky, Border Terrier, English
Setter, Dachshund
– Burmese Cat
• Low Risk Breeds
– Boxer is the lowest risk
– Also GSP, Airedale, GSD, Pekingese, Collie,
Weimaraner, Staffordshire Bull Terrier,
Golden Retriever, Springer Spaniel
• Most dogs & cats >5 years
• History
– PU-PD – bigger clumps in the litter box
– weight loss, polyphagia
– Vomiting, illness of DKA
– Recent administration of corticosteroids
– History of triaditis, pancreatitis
– Recent heat
– Vision problems (cataracts)
• Exam
– Endocrine alopecia, pyoderma, poor
grooming in the cat
– Pot bellied – hepatomegaly
– Cranial abdominal mass – pancreatitis + pain
– 10% Diabetic neuropathy in the cat
– Pregnancy, pyometra, coming out of heat
– Cats are more likely to be overweight with
recent weight loss
– Dogs more likely to be underweight
Steps of Managing the Diabetic
As Simple as 1-2-3
1. Diagnosis & Stabilization

– Monitoring serology is key to success in
managing the DKA patient
2. Insulin Regulation & Treat

Complications
3. Maintenance & Insulin Adjustment

Diagnosis
1. Confirm Hyperglycemia
• Stressed cats can have transient
hyperglycemia (200-400)
• Critically ill non-diabetic pets can also
have marked hyperglycemia (>400)
• Stress hyperglycemia due to glucocorticoids,
epinephrine and insulin resistance
• Acute hyperglycemia has adverse effects on
the immune system, coagulation, heart and
brain
• Chronic hyperglycemia is toxic to beta cells
• Treat with judicious insulin PRN
• Hyperglycemia due to DM can be
intermittent at first
Diagnosis
2. Stress Hyperglycemia or DM?
• “No glycosuria” makes DM unlikely
• Stressed cats can have glycosuria
• Renal threshold 180-220 mg/dl in the dog
• 200-300 mg/dl in the cat
• Ketones in the urine indicate catabolism –
investigate DKA
• DKA = Diabetic ketoacidosis
• Any sick cat who has not eaten for days can
have ketonuria
• If all else fails, run a fructosamine
• Fructosamine elevated with DM
• Decreased with hyperthyroidism
• Normal with stress hyperglycemia
Diagnosis
3. Confirm PU-PD
• Can’t always rely on the history
• Urine specific gravity higher than usual
for PU-PD dog (1.020’s-1.030’s)
• Glucose increases USG
• water intake > 100 ml/kg/day
• 11 lb. cat > 16 ounces per day
• 25 lb. dog > 1 quart per day
• 45 lb. dog > 1 half a gallon per day
• 85 lb. dog > 1 gallon per day
Diagnosis
4. Initial Work-up
• Prior to regulation – Why?
• Assess for DKA, pancreatitis which
usually require hospitalization &
correction of other problems prior to
insulin therapy
• Assess for pancreatitis, fatty liver which
might require feeding tube placement
• Assess for concurrent problems which
might change long term prognosis
• Identify urinary tract infection or other
problems that will complicate regulation
Diagnosis
4. Initial Work-up
• CBC – evidence of infection or pancreatitis
• General health profile
• Hyperglycemia – of course
• include phosphorus
• Almost all unregulated diabetics have
high liver enzymes
– Many have hepatomegaly, even if no fatty
liver
• Cholesterol and triglycerides high in dogs
with unregulated diabetes
• Look for CRF if glucose >800
Diagnosis
4. Initial Work-up
• Electrolytes and venous blood gases
• blood pH important if sick
• If hypokalemic and sick, put on IV fluids
with potassium phosphates prior to first
dose of insulin
• ESPECIALLY IF ACIDOTIC
• If hypokalemic and well, this will often
correct with insulin therapy, if the cat is
eating
Diagnosis
4. Initial Work-Up
• Urinalysis + urine culture
• Check for ketones (look for DKA, feed)
• Glucosuria, dilute urine and
immunosuppression predispose to UTI
• 25% of new diabetics have a UTI, often without
clinical signs (>50% if Cushingoid)
• Immunosuppression prevents active sediment
and symptoms
• Dilute urine prevents detection of bacteriuria
• Blood pressure
• FeLV/FIV for cats, HWAg for dogs
• For A+ Clients
• Imaging “looking for trouble”
• Chest x-rays, Abdominal US
• Or GlobalFAST® US
Diagnosis
5. If panel or exam indicates pancreatitis
• Can follow cPLI and fPLI??? long term to
monitor resolution of pancreatitis
• Abdominal US to help Dx
cPLI is the best test for pancreatitis in

the dog
Ultrasound is the best test for

pancreatitis in the cat
Stephanie Adian
Jacksonville TX
Diagnosis
6. Middle aged to older cats
• TT4, fT4 if >5 years old
7. Dogs with endocrine alopecia

• After stabilization, during regulation
• TSH, TT4, fT4
• If symptoms of hyperadrenocorticism
• Urine C:C, ACTH Stim, Low Dose Dex
Test, Abdominal US
• If all else fails, don’t forget about
Alopecia X
Pattern Recognition - Diabetes
Mellitus
1. Indications of DKA
– Low HCO3, low TCO2, low pH, high anion gap,
ketonuria, vomiting, lethargy
– Indicates: ICU care, higher level of IV potassium
supplementation, more phosphates
– Insulin carries K+ & Phos into the cell
– Correcting acidosis worsens K+ & phos
– Phos <1.5 can cause severe hemolysis
– Low K+ can cause weakness and paralysis
Mellitus
2. Pancreatitis pattern – need fluid support

• CBC – thrombocytopenia, neutrophilia + left shift,
anemia
• Panel – lipemia after prolonged fast (esp. the cat),
hypocalcemia, hypoalbuminemia, + elevated liver
enzymes, inc bilirubin, whacked out glucose,
hypophosphatemia, hypochloridemia, hypokalemia
• Amylase is seldom helpful, and a weak indicator
• Lipase has very low sensitivity, but specific
Mellitus
2. Pancreatitis pattern – need fluid support

• cPLI, (fPLI) elevated
• pancreatitis is the most common cause of
hyperlipidemia in the cat
• Pancreatitis is on the short list of things that
will cause icterus without anemia elevated liver
enzymes
Mellitus
3. Fatty liver pattern – feed cats

• Hx – heavy cat has not eaten in several days
• Exam - liver enlarged, + icterus, sick
– HE indicates poor prognosis
• Panel - ALKP significantly exceeds GGT only in feline hepatic lipidosis
– + elevated bili
– Elevated ALT is common
– Changes associated with co-morbidities that may be initial cause
• Abd US
– diffusely hyperechoic liver
– Co-morbidities that may be initial cause
– Often diagnosed on cytology
Mellitus
4. Fatty liver pattern – feed cats

• Hx – heavy cat has not eaten in several days
• Exam - liver enlarged, + icterus, sick
– HE indicates poor prognosis
• Panel - ALKP significantly exceeds GGT only in feline hepatic lipidosis
– + elevated bili, often without severe anemia
– Elevated ALT is common
– Changes associated with co-morbidities that may be initial cause
• Abd US
– diffusely hyperechoic liver
– Co-morbidities that may be initial cause
– Often diagnosed on cytology
Insulin Regulation
Don’t be in a hurry
• It can take a few months (2-3 months ave.)
• Prepare the owner
• Insulin needs often change over the first
weeks of insulin therapy
– Control symptoms of hyperglycemia,
while avoiding hypoglycemia
– Severe hypoglycemia is immediately life
threatening
– Severe hyperglycemia a problem only
when prolonged
– Not quite enough insulin is better than a
little too much
Insulin Regulation
Start insulin at 1-2 units per 10 pounds
• Dogs:
• 1 unit per 10 lbs if glucose <350
• 2 units per 10 lbs if glucose >350
• AAHA Guidelines – 0.25U/kg BID
• Cats (Feldman & Nelson)
• 0.5 U BID for very small cats (<2 kg)
• 1 U BID for small cats < 4kg
• 1.5 U BID for average cats >4 kg
• 2 U BID for large cats (>8 kg)
Insulin Regulation
0.5 mg/kg is too high to start
Catherine Scott-Moncrief, CVMA 2013
Insulin Starting Dose Median Dose Dose Range
NPH 0.25-0.5 U/kg 0.5 U/kg 0.2-1 U/kg
Lente 0.25-0.5 U/kg 0.7 U/kg 0.3-1.4 U/kg
PZI 0.5 U/kg 1 U/kg 0.4-1.5 U/kg
Glargine 0.25-0.5 U/kg 0.6 U/kg 0.1-1.1 U/kg
Detemir 0.1-0.2 U/kg ?? 0.07-0.23 U/kg
• For every insulin, the starting dose of 0.5 U/kg is

more than the lower end of the dose range
– Some pets will be overdosed
• For NPH, half of the patients will be overdosed
Insulin Regulation
First insulin dose for well new diabetics:
• Glucose checks to rule out hypoglycemia
• 3, 6 and 9 hours post insulin
• If well, send home that evening if curve
shows no hypoglycemia
• Even if glucose values are high
• Reduce dose if any value <80 and repeat
the next day
• Keep no more than one night, if you can
help it
• If sick, keep in hospital until stable
Insulin Regulation
Recheck one week for glucose curve
• sooner if problems
Owner instructions
• Talk owner through the first injection
– Draw up insulin without bubbles
• Give owner handouts
– diabetes in dogs , diabetes in cats
– Insulin and Feeding Instructions
– Insulin Handout
• Save home glucose testing for later,
when they are ready
Insulin Regulation
Weekly to bi-weekly rechecks until stable
• Then every 3-4 weeks until regulated
• Indicators longer recheck intervals are OK
• PU-PD is relatively well controlled
• No significant weight loss since last visit
• Feeling well, no vomiting, eating well
• Owner is coping well
Once you get a good curve – recheck in
6-8 weeks or so
If all is well, go to maintenance for
regulated diabetics
Which Insulin for Dogs?
Regular Insulin (Humulin R®, Novolin R®, Lispro®) –

*U100* - short acting
• Used only in the hospital, for critical care IV/IM q 1-6 hrs
• Shortest acting
NPH – neutral protamine hagedorn (Humulin N®, Novolin
N®) - *U100* - medium acting - BID
• Often used because affordable, but too short acting for
some dogs
Lente (Vetsulin®, Caninsulin®) – 30% semilente + 70%
ultralente – *U40* - medium to long acting - BID
• An excellent first choice – actual canine insulin
Protamine zinc (ProZinc®) - *U40* - long acting - BID
• Now approved for dogs – longer than ideal for most dogs
• Labeled for SID, but often does not work well
Which Insulin for Dogs?
Glargine – insulin analog (Lantus®, Basaglar®, Toujeo®,

Soliqua®) - *U100* - very long acting – SID-BID
• Absorption can be erratic in some dogs
• Used SID for “background insulin” in large dogs
Detemir – insulin analog (Levemir®) - *U100* - very
longest acting – SID-BID (usually BID)
• Seems to be more reliable than Lantus if a long acting
insulin is needed
• But still not a first choice
• Starting dose much lower – 0.1 U/kg SID
• Can be an affordable option for the occasional dog that
may need a longer acting insulin
Pens available - NPH, Lente (VetPen®), glargine & detemir
Which Insulin for Cats?
NPH – neutral protamine hagedorn (Humulin N®, Novolin

N®) - *U100* - very short acting
• Usually too short acting for cats – not recommended
Lente (Vetsulin®, Caninsulin®) – 30% semilente + 70%
ultralente – *U40* - short acting
• Works for many cats, but may be too short acting for some
• Feline differs from canine insulin by 3 AA
• $40 per bottle (400 units - $0.10/U)
• “Buy In” is the cheapest - $18 a month for a cat that takes 3U BID
Protamine zinc (ProZinc®) - *U40* - medium acting
• A good first choice for cats
• Cats burn through insulin faster than dogs
• Costly - $100 per bottle (400 units - $0.25/U)
• $45 a month for a cat that takes 3U BID
Glargine – insulin analog (Lantus®, Basaglar®,

Toujeo®, Soliqua®) - *U100* - long acting
• Probably the best first choice for cats
• Most likely to result in remission, with low carb diet
• Curves are smoother
• Costs >$300 for 10ml (1000 units - $0.30/U)
• For a cat taking 3U BID, it is $54 a month
• 3 ml pen is $80 (300 units - $0.27/U) – 3U BID - $50/month
• It pays for itself in saved vet bills
Detemir – insulin analog (Levemir®) - *U100* - long
acting
• Starting dose much lower – 0.1 U/kg
• Many cats would take less than a unit BID
• Cost for 5 3-ml pens $420, one pen $84 ($0.28/U)
• For a cat taking 1.5 U BID, cost is $25 a month
Original PZI and ProZinc are not the same insulin

– Original PZI (Idexx) was beef and pork – most likely
to produce insulin antibodies
– ProZinc (BI) is recombinant human – unlikely to
produce insulin antibodies.
AAHA Guidelines recommend Lantus® and
ProZinc® as best insulins for cat
– Lantus® preferred by most endocrinologists
– Some cats have a flat curve with Lantus® and
others a significant peak
Once a Day Insulin?
• Virtually all dogs and cats do better on BID insulin

• Very few dogs or cats will have acceptable quality of life
on SID insulin
– detemir may be the exception, if a dog happens to do well
on it
• Cats on Lantus have the best chance for SID
– Studies show glycemic control is better when given BID
• Better to give BID on every day possible, and SID when
that’s the best that can happen, than to resign to SID
every day
• PZI is labeled for SID in dogs, but in my experience it
seldom works well
Oral Hypoglycemics?
Type I Diabetes – IDDM – Insulin

Dependent Diabetes Mellitus
• Minimal spontaneous secretion of insulin
• Almost all dogs have this type
– Most often caused by immune mediated destruction
of the beta cells
• Insulin injections required for survival
• Oral hypoglycemics do not work on this
type
– thus have no effect on most dogs with DM
Oral Hypoglycemics?
Type II Diabetes – NIDDM – Non-Insulin

• Abnormal insulin secretion, Peripheral insulin
resistance
• Controlled with diet, weight control and oral
hypoglycemics
• Many cats have this type, rare in the dog
– Exceptions for the dog are intact females that go into
remission after OHE
– Consider ovarian remnant syndrome in the spayed
female, if there are signs of estrus
– Another exception for the dog is pancreatitis
Oral Hypoglycemics?
Type II Diabetes – NIDDM – Non-Insulin

• Cats are more likely to go into remission than
dogs, due to correction of glucose toxicity
– Glucose toxicity – glucose is toxic to beta cells
– Type II can progress to Type I if untreated
• Some type II cats can achieve remission with
weight loss and diet alone, using interim insulin
• Oral hypoglycemics can work temporarily in
some cats
Oral Hypoglycemics?
Sulfonylureas – stimulate beta cells to secrete

more insulin
• They work only if sufficient beta cells remain
• Will become ineffective with time
• The oldest oral hypoglycemics – “first generation”
– Tolbutamide, Carbutamide, Acetohexamide
– Tolazemide, Chlorpropamide
• Have largely been replaced by “second
generation” sulfonylurea
– Glipizide, Glyburide (glibenclamide)
– Gliclazide, glimepiride
• Often result in weight gain
• Glipizide has been studied most in cats
Oral Hypoglycemics?
Criteria for Glipizide

• Good physical condition - Non-ketotic
• ONLY *with* high protein, low carb diet
• Mild to moderate symptoms of diabetes
• Can be monitored closely
Starting Dose 2.5 mg/cat PO BID, with food
Increased to 5 mg PO BID in 2 weeks if:
• Hyperglycemia still present
• No unacceptable side effects
Continue as long as symptoms controlled
• Stable weight, Glucose curve 80-300
• Liver toxicity can occur (icterus)
Oral Hypoglycemics?
Typical response to Glipizide

• Effective 30% of the time, when criteria are met
• Often stops working in weeks to months
• May accelerate beta cell loss
Transdermal delivery is not effective
Little experience with other sulfonylureas on
cats
• Glyburide 0.625 mg PO BID
• Increase to 1.25 mg PO BID if needed
May keep the cat alive while owners adjust to
the idea of insulin injections
If not effective in 4-6 weeks insulin is necessary
Oral Hypoglycemics?
Glinides also increase insulin secretion

• natglinide
Some inhibit glucagon secretion (gliptins)
Some enhance tissue sensitivity to insulin
• Biguanides - Metformin
• Thiazolidinediones (TZDs), aka glitazones
• Chromium, vanadium
Some slow post-prandial intestinal glucose
absorption
• Alpha-glucosidase inhibitors (acarbose)
Oral Hypoglycemics?
DPP-4 (dipeptidyl peptidase) inhibitors

• DPP-4 breaks down GLP-1
• Oral
• No data in diabetic cats
• Sitagliptin - $$$$$
Oral Hypoglycemics?
Metformin
• Does not cause weight gain as glipizide
• Contraindicated if impaired renal function,
cardiopulmonary disease, liver disease
• Most serious adverse effect is lactic acidosis (rare)
• Dose varies from 10-50 mg per cat PO BID
• Very little data on its use in cats
Oral Hypoglycemics?
Acarbose
• 12.5 mg PO BID with each meal
• GI side effects can be reduced by lowering the dose
• Contraindicated in people with renal disease
• Has been used with insulin in dogs or cats to improve
regulation
Oral Hypoglycemics?
Incretins (GLP-1 – glucagon-like peptide 1)

• gastrointestinal hormones used in dogs & cats along
with glargine insulin therapy
• Also used with diet alone in cats to help achieve
remission
• Increases insulin secretion and protects beta cells from
oxidative and toxic injury, and promotes expansion of
the b-cell population
• helps delay gastric emptying and increase satiety
• improved diabetic control is presumed to be via
glucagon suppression
• Although more research is needed, the most
promising results have been reported in cats
treated with exenatide ER (Bydureon®) and in dogs
with liraglutide (Victoza®)
Oral Hypoglycemics?
Chromium – enhances tissue insulin sensitivity

• chromium deficiency can cause insulin resistance
• One study showed it did not improve glycemic
control in diabetic dogs
• Few side effects
• Chromium chloride, nicotinate or picolinate
– Picolinate absorbed most consistently
• No data in diabetic cats
Oral Hypoglycemics?
Vanadium –insulinomimetic properties

• All vanadium salts seem to be similar
• Improved glycemic control in people, but GI side
effects
• One study shows slightly improved glycemic
control in diabetic cats treated with PZI
– 45 mg PO SID vanadium dipicolinate
– Can cause anorexia and vomiting
Nutrition for Diabetic Dogs
• High complex carbs (>50% dry matter)

– Low glycemic index
• High fiber (>10% dry matter)
– Increased soluble fiber slows GI transit and
potentiates insulin in tissues
• Fruits, legumes, oats
– Increased insoluble fiber slows GI transit time,
starch hydrolysis and glucose absorption
• Cellulose in vegetables and grains
– Reduced fats to prevent pancreatitis
• Diets recommended for diabetic dogs in

good body condition:
– Eukanuba Restricted Calorie, Glucose Control, Adult
Reduced Fat
– Hill’s w/d, r/d
– Purina DCO, OM
– Royal Canin Diabetic
• Contraindications to the recommended diet
– Emaciation
– Chronic constipation or obstipation that gets worse
– Severe recurring pancreatitis that needs lower fat, or
other co-morbidities that require a different diet
• If homemade diet is chosen:

– Incorporate pumpkin, green beans, psyllium or wehat
dextrin
– Or these can be added to maintenance diets
– Balance diet at www.petdiets.com
Denise Doolittle
Copper Canyon TX
• Feeding Schedule
– Dogs treated with BID insulin
• Half of caloric intake offered at insulin time
– Dog treated with SID insulin (glargine or detemir)
• Half of caloric intake at insulin time
• Half 8 hours later
– Dogs do not have to meal feed
• munching on food available throughout the day
seems to work well as long as ideal weight is
maintained
• Offer at insulin time, and when it’s gone, it’s gone
Nutrition for Diabetic Cats
• For many years, we fed diabetic cats high

fiber, low fat diets, just like dogs & people
• 2001 - ACVIM – carbs also important
– 31% fed Low Carb diet were able to d/c insulin, and an
additional 46% decreased insulin dose
– None of the High Carb cats were able to reduce or
discontinue insulin
– Confirmed by numerous studies since
– Remission achieved by using low carb-high protein diets
with long acting insulin (glargine – Lantus® and others)
– Some papers have reported remission rates 60-80%
– Chance of remission increases four-fold by feeding low
carb-high protein diet
Ideal diet for diabetic cats

• >40% protein & <10% carbs, as % of calories (AAHA 12%)
• A little different from % of Dry Matter basis (fat is 2x as
calorie dense as protein & carbohydrate)
• Percent Calories Calculator can estimate percent calories
from Guaranteed Analysis
• If a flatter curve is needed, insoluble fiber (Metamucil)
could be added to canned low carb diet to slow GI transit
time without adding carbs
• No studies on doing this
• Hill’s Studies comparing 2 high carb diets with differing
fiber shows diabetics do better on high fiber diet, when
carbs are equal

• Dry diets on the market that fit the bill
– Innova EVO (California Naturals - Natura)
– Wellness Core
– Nature’s Variety Raw Instinct
– Various Boutique Diets
– Purina DM & Hill’s Rx Diet M/D dry (15% carbs),
and Purina OM (18% carbs) are much better than
other dry cat diets (25-35% carbs), but not ideal
• Many commercial canned diets fit the bill (website)
– PFC content of hundreds of commercial foods
– Canned OM high in carbs, Canned DM & M/D low
in carbs

• Effects of high protein, low carb diets on cats:
– Optimized metabolic rate
– Improved satiety
– Limits risk of fatty liver during weight loss
– Prevents lean muscle loss during regulation and
weight loss
– Arginine stimulates insulin secretion
– Carbs contribute to hyperglycemia and glucose
toxicity
– AAHA Guidelines: “high fiber diets are not
recommended for cats with DM”

• If ideal diet is rejected, consistency in food intake and
consistency of diet are important
– Regulate around food the cat will eat
• Diet for the most serious disease should take priority
• NOTE: some feline experts no longer recommend
protein restriction for chronic renal disease.
– Currently no studies for or against
– Most agree phosphorus restriction is appropriate
– It’s difficult but not impossible to produce a high
protein, low phosphorus diet
High protein, low carb, low phosphorus diets

Diet Protein Fat Carbs Fiber Phos
(% calories) (% calories) (% calories) (% calories) (mg/100kcal)
Almo Nature Kitten 42 58 0 0.8 116

Almo Nature Senior Cat 44 53 3 0.9 113
Nutro Natural Choice Salmon & 39 55 6 0.3 150
Ocean Fish can
Orijen Cat & Kitten Dry 38 51 11 0 110
Orijen Six Fish Dry 38 50 12 0 110
Orijen Regional Red Dry 39 49 12 0 130
Wysong Beef All Meat Can 39 61 0 0.1 115
Wysong Seafood Gourmet Can 41 52 7 0.5 136
Wysong Turkey All Meat Can 46 54 0 0 118
Prescription renal diets phos 68-120mg/100kcal & protein 21-27%

Commercial maintenance diets phos 200-700mg/100kcal
Myth #1: Diabetic cats should be meal fed if they are

to be well regulated
• Fresh food BID – allowed to eat ad lib
• Multiple small meals eaten throughout the day and night
• 24 hour glucose curve done (q2h)
• no correlation between blood glucose and the amount of
food consumed over the previous 2 hours
• overnight fast did not significantly alter morning blood
glucose
• Meal feeding diabetic cats who will do so is not a problem,
and “portion feeding” is recommended by AAHA Guidelines
J Feline Med Surg. 1999 Dec;1(4):241-51. Food intake and blood
glucose in normal and diabetic cats fed ad libitum. Martin GJ,
Rand JS.
Myth #2: You shouldn’t give insulin to pets

who aren’t eating
• Type I Diabetics that don’t eat still need insulin – they
just need less (50% dose for complete anorexia)
• If glucose >300 for any period of time, insulin needs to
be given to prevent diabetic ketoacidosis, glucose
toxicity, fatty liver, etc.
• Dogs and cats with DKA will remain acidotic until they
get insulin
• If you are chicken, give small amounts only as needed
• A small amount of insulin can do a great deal of good in
a DKA patient
Myth #3: If the owner is resistant to insulin

injections, it is reasonable to start high
protein diet alone while they weigh options
• Diet alone is very unlikely to reduce blood glucose
significantly in a cat, and can lead to glucose toxicity
• Better to try diet and oral hypoglycemics than diet
alone, if glucose <300
• Allowing any cat with glucose persistently >300 (not due
to stress) to go without insulin risks the cat’s life
• REMEMBER: it is easier to give most cats an
insulin shot than to give them a pill
Cats Are Carnivores
– Cats have carnivore dentition & retractable claws

for holding prey
• Dogs grind their food, cats do not
• Cats have no lateral-medial movement of the jaws
• Cat teeth lack occlusal surfaces for grinding – the
molars and premolars interdigitate and are fewer
• Cats crack their kibble into smaller pieces and
swallow it
– Cats don’t digest starches & sugars well
• Cats lack salivary amylase, so digestion begins in
the feline stomach
• Cats do not have tastebuds to taste sweet
• Feline pancreatic amylase production is 5% of dogs
Cats Are Carnivores
– Cats need double the protein as dogs
• 5g/kg protein daily to maintain nitrogen balance
• The only reason ever to restrict protein in a cat is to
prevent hepatic encephalopathy
• Cats waste muscle when protein is restricted (low
creatinine is a clue)
• Cats do not down regulate proteinases well
• Increased transaminases and deaminases that remove
the amino groups from the amino acids, converting them
to keto-acids to be used for energy or glucose production
• Pyridoxine (vitamin B6) is a prosthetic group of all
transaminases. Feline requirement for pyridoxine is
about four times that of a dog.
• Cats can not convert tryptophan to niacin (vitamin B1), as
an dogs, so they require four times the niacin compared
to dogs
Cats Are Carnivores
– Cats need more taurine and arginine than dogs
• These AA are rich in animal products
• Cats have decreased ability to produce arginine, and
increased need for it
• Taurine is an essential amino acid for cats, but not
for dogs
– Cats have a GI tract adapted to eating protein
• GI tract length in cats is relatively shorter (4:1) than
dogs (6:1), with respect to body length
• short colon that limits their ability do digest and
absorb starches and fiber by fermentation
• Big cats express ingesta from entrails before eating
them
Cats Are Carnivores
– Cats rely on gluconeogenesis (production of glucose
from proteins) for energy, as opposed to producing
glucose from soluble carbohydrates
• Adult cats have very low glucokinase activity in the liver
as compared to dogs
• In dogs, maximum gluconeogenesis occurs long after a
meal is absorbed, and in cats maximum gluconeogenesis
occurs as soon as proteins begin absorption from the gut
• Cats have an alternative gluconeogenic pathway that
uses the non-essential amino acid Serine (found in large
quantities in muscle, milk and egg) to produce glucose
• The intestinal sugar transport system of the cat is not
adaptable to varying dietary levels of carbs
• Cats have low intestinal disaccharadiase levels (sucrase,
maltase, isomaltase)
Cats Are Carnivores
– Cats have the ability to digest and utilize high levels
of dietary fat (as is present in animal tissue)
• Cats don’t get pancreatitis from high fat meals
• Cats have a special need for arachadonic acid,
since they can not make it from linoleic acid as can
the dog
• Animal fats are rich in arachadonic acids
– Cats can not convert beta carotene and other
carotenoids (in plants) to vitamin A as dogs can
• Vitamin A occurs naturally only in animal tissue
– Cats have more significant post-prandial
hyperglycemia than dogs after eating high starch
and high sugar diets.
Weight Loss & Exercise
Obesity causes reversible insulin resistance

• Weight loss can contribute to achieving diabetic
remission in the cat
• Weight loss can improve diabetic control and reduce
insulin requirements in dogs
• Obese dogs and cats are at greater risk for pancreatitis
(4x for the cat), which can be a life threatening
complication of diabetes mellitus (also fatty liver)
• Moderate exercise can increase mobilization of insulin
• Strenuous exercise should be preceded by a reduction
in insulin
• Consistent exercise programs are best
K+ & Phos in DKA Patient
• Monitor PCV, K+ and Phos at least daily until

stable, in DKA patients
– More often if very low or unstable
• Can use 0.5cc lithium heparin tubes to
prevent exsanguination
• Place jugular catheter for patient comfort
– Draw blood without venipuncture
• Replace K+ according to sliding scale
– More K+ supplemented when acidotic
– The lower Phos, the more KPhos:KCl you use
– Don’t exceed 0.5 mEq/kg/hr potassium
K+ & Phos in DKA Patient
• Eating is important to maintaining K+/Phos

– Things usually begin to stabilize when the cat
begins to eat
• REMEMBER
– KCl contains 2 mEq/ml potassium
– KPhosphates contain 4 mEq/ml potassium
– Use half the volume of KCl as KPhos for the same
amount of potassium added to fluids
• Be VERY CAREFUL of bicarbonate therapy
– I almost never give bicarb to DKA patients
– Bicarbonate can exacerbate low Phos and K
Flop
Flop
•Chief Complaint – Not doing well since

treating abscess on a toe 1 week ago,
vomiting blood
– 3 days ago regular vet did a UA and blood

glucose
– UA showed ketones++ and glucose +++, blood
glucose 296
– Has been treating with IV fluids since, getting
worse
– Did not start insulin because cat not eating
Flop
•Exam
– Dehydrated, lethargic
– Icteric
– RR 56
– vomited coffee grounds and collapsed on
abdominal palpation
– HR dropped to 65/bpm
– Responded to atropine IV and fluid bolus
Flop
Diagnostics
•CBC – granulocytes 16,000
•Profile – glucose 200, BUN 41
– TG 500, Chol 297
– Bili 4.2, ALT 148, ALP normal
– Ca 7.0, Phos 1.6
•UA – SG 1.027, ketones ++, glucose +++, inactive
sediment
•Electrolytes – K+ <2.0, Na+ 133, iCa++ 1.08
– pH 7.032, BE -24, HCO3 7, TCO2 8
– pCO2 26.5
•No chest rads or abdominal US done
•Urine culture pending
Flop
•Initial life threatening problems

– Severe ketoacidosis
– treatment – insulin, (bicarbonate), IV fluids
– Severe hypokalemia
– treatment – IV KCl or K-phosphates
– Severe hypophosphatemia
– treatment – IV K-phosphates
– (pancreatitis, hematemesis, abscess on toe)
– (treatment – feed, antacids, sucralfate,
antibiotics)
Flop
Treatment
•IV fluids – 45 ml/lb/day
– Rehydrates & corrects acidosis – which fluids?
– Buffered – LRS, Ringers, Normosol, Plasmalyte,
Hartmann’s, etc.
•Potassium chloride – disadvantage limits phosphates
•Potassium phosphates – no disadvantage
• 100mEq/L (25cc Kphos/L)
Dechra Fluid Chart
(K+ sliding scale) (IV drip rate calculator)
Flop
IV Fluid Na+ Cl- K+ HCO3- glucose Ca++ pH Mg++ mosmol/L

Plasma 135-145 100-110 3.5-5 22-26 4-7 5 7.5 1.5 280-295
0.9% NaCl 154 154 0 0 0 0 5 0 308
Ringers 148 156 4 0 0 4.5 6 0 309
LRS 130 109 4 lactate 28 0 3 6.5 0 273
Plasmalyte A 140 98 5 acetate 27 23 0 7.4 3 294
Plasmalyte 148 140 98 5 acetate 27 23 0 5.5 3 294
Hartmann’s 131 111 5 29 0 2 6 0 270
5% dextrose 0 0 0 0 50g 0 4 0 252
Units are mmol/L unless otherwise designated

Flop
IV Fluid Na+ Cl- K+ HCO3- glucose Ca++ pH Mg++ mosmol/L

Plasma 135-145 100-110 3.5-5 22-26 4-7 5 7.5 1.5 280-295
0.45% NaCl 77 77 0 0 0 0 0 154
2.5% dextrose 0 0 0 0 25g dex 0 0 139
½ Strength LRS 65 54 2 lactate 14 0 1.5 0 137
Plasmalyte 56 40 40 13 acetate 16 0 0 5.5 3 110

2.5% dextrose +
½ strength LRS
65.5 55 2 lactate 14 25g dex 1.5 5 0 263
2.5% dextrose +
0.45% NaCl
77 77 0 0 25g dex 0 4 0 278
Plasmalyte 56 +
50% dextrose 40 40 16 acetate 16 0 0 5 3 362
Unites are mmol/L unless otherwise designated

Flop
Treatment
•Insulin – not yet
– Advantage – corrects ketoacidosis
– Disadvantage – makes hypokalemia and
hypophosphatemia worse (K <2.0, Phos 1.6)
•Bicarbonate – not given
– Advantage – corrects acidosis
– Disadvantage – will make hypokalemia worse
•Cefazolin 100 mg IV TID
•famotidine 5 mg IV BID
•Cerenia 1cc IV SID
Flop
Reassess in 2 hours
•No longer laterally recumbent – sitting up
•Glucose - 310
•PCV – 28%
•K+ 2.9
•Gave 1 unit NPH SC
Flop
Reassess in 2 more hours (4 hours total)

•Glucose - 99
•PCV – 23%
•pH 7.228, HC03 10, TCO2 11
•pC02 23.9
•iCa++ 1.07, Na+ 130, K+ 2.3
•Phosphorus 0.7
•Red tinged urine, serum icteric
•Hydration normal, general condition slightly
improved, no vomiting, not eating
Kathy Crouch
Lubbock TX
Flop
2 days later (1-2U NPH SC PRN)

•Glucose - 325
•PCV – 20%
•pH 7.403, HC03 18.8, TCO2 20
•pC02 30
•iCa++ 0.92, Na+ 134, K+ 3.7
•Phosphorus 3.4
•Urine clear, serum slightly icteric
•Hydration normal, general condition greatly
improved, eating small amounts, no vomiting
•Began the process of regulation via weekly visits
Hypoglycemia
Signs of Hypoglycemia
• Make sure client knows what to look for
• Mild (glucose 50-80)
– Lethargy, weakness
– Poor appetite
• Moderate (glucose 30-50)
– Vomiting
– Head tilt, ataxia
• Severe (glucose <30)
– Seizures, coma
– Blindness – temporary or permanent
– Signs can be relatively mild when insidious and/or
chronic (Teddy)
Hypoglycemia
Treatment of Hypoglycemia
• Skip the next dose, then no insulin until
hyperglycemia returns
• Reduce insulin dose when resumed
• Asymptomatic - reduce insulin by 10-20%
• Mild – Feed, reduce insulin by 20% when resumed
• Moderate - Karo syrup or 50% dextrose PO
– Monitor blood glucose by curve until recovered
– Reduce insulin by 20-50% when resumed
• Severe - Dextrose IV immediately
– If life threatening, consider glucagon, epinephrine,
dexamethasone
– Monitor blood glucose by curve until recovered
– Reduce insulin by 50% when resumed
Regulation
Weekly to Bi-weekly rechecks
• Weight and exam
• If still showing clinical signs of DM, do
glucose curve without fructosamine
• If clinical signs under control, do
Fructosamine (FRA)
– Resolution of PU-PD and weight stabilization are key
• If FRA high or low, do glucose curve
– Adjust insulin and recheck 1-2 weeks
– Sooner if problems
• If FRA acceptable, no curve needed
– send home on that dose and recheck in 1 month
– Sooner if problems
Regulation
Fructosamine – glycosylated serum protein
• Averages blood glucose levels over the past 1-3
weeks
• Not affected by acute stress hyperglycemia
• Falsely decreased by
– Hypoproteinemia, Hemolysis
– Hyperlipidemia
– Azotemia
– Prolonged storage at room temperature
– Hyperthyroidism, thin body condition
• Falsely increased by
– Hyperglobulinemia
– Hypothyroidism
• In house – HESKA, Idexx, Abaxis
• Or send out (freeze until shipped)
Regulation
Fructosamine Low (<200)
• Mild to moderate hypoglycemia
• Not enough to cause Somogyi (glucose 65-80)
• Decrease insulin by 10-20%
Normal range (200-350)
Good diabetic control (350-450)
Fructosamine High (>450 mcmol/L)
• >600 – danger zone
• Significant periods of hyperglycemia
• Not enough insulin, or too much insulin
– Hypoglycemia, rebound hyperglycemia
Regulation
Low FRA with poor glycemic control – check T4
Remission is defined as normal FRA w/o insulin
• Regulation using FRA can work well when
curves are not practical
– But keep in mind that FRA is ideal in only 60%
of diabetic pets with good clinical regulation
Why Do Glucose Curves?

• Early detection of occult hypoglycemia
• Ensure that dose changes are effective
• To document dysregulation as the first step to
correcting it
Regulation
Glycosylated Hemoglobin (AAHA)
• Average blood glucose over past 2-4 months
• HbA1c alone is used in diabetic people
• “A1c” alone is not helpful in dogs – there are 2
other fractions (HbA1a, HbA1b) that must be
measured
• Need all three fractions in dogs
• In house assays for people are all A1c alone
– Must send out – not widely available
• 1-4% - normal (ave dog 3.3, ave cat 1.8)
• 4-6% - good diabetic control
• >7% - poor control
• >8% - danger zone
Regulation
Glycosylated Hemoglobin
• A1c only – dogs and cats

• $99 MSRP
• Overnight results
• Need the in house test kit – let dry for at
least 3 hours prior to shipping
Glucose Curve Protocol
• Owner feeds and gives insulin
• Bring pet to clinic within 2 hours
• Glucose (+ fructosamine) on arrival
• Glucose every 2 hours when >100
– Once you know the insulin duration, you may be
able to take the first glucose 4 hrs after insulin
• Glucose every hour when <100-150
– Can miss nadir (low point) if you don’t do this
• Continue until you get 2 values 2 hours apart
that are upwardly trending
– If nadir not <120, it’s difficult to determine duration
• Usually can be completed in a business day,
but not always
– Some require 12-24 hours - finish at home or EC
• Dogs on Lantus® can often do q3-4 hrs
Home Glucose Curves
• Really are better than “in clinic”

• Stress increases glucose
– Especially in cats
• Many owners can learn to do it
• It’s very helpful for owners to be able
to check blood sugar in an emergency
• Entire curve does not have to be
finished the same day
• Have owners come in for appointment
to discuss the glucose curve
Home Glucose Curves
1. Warm the ear

• Lateral to the ear vein in cats, or inner surface
• No need to warm lip, foot pad, elbow callus
2. Apply vaseline if area is haired
3. If you use alcohol, allow it to dry
4. Prick with human lancet
• Can use 27 gauge needle
• Use roll of gauze inside the ear for cats
Cat - Ear Prick
Dog – Lip, Elbow, Footpad, Ear
Home Glucose Curves
Choosing a glucometer
• Low sample volume
• Inadequate sample volume prevents sample
from running
• EDTA (purple top) and LiHep (green top)
blood are fine
• Plasma calibrated rather than whole blood
𝒑𝒍𝒂𝒔𝒎𝒂 = ____ 𝒘𝒉𝒐𝒍𝒆 𝒃𝒍𝒐𝒐𝒅___
. −( . × %)
• Auto-calibration of test strips
• Calibrate to in house machine
• Enter species code for veterinary meters
• Glucometers are most accurate <100mg/dl
Continuous Glucose Monitoring
(CGM) Systems (Flash)
• Probe measures glucose in interstitial
fluid continuously to plot a curve
• Wireless transmission to a pager size
display
• Human device validated in dogs 2016
• Previous devices worn in a vest
– Freestyle Libre is disposable
– Available in the US as of Dec 2017
– Requires a prescription
– Approved for people – off label for pets
• Shave fur over the dorsal neck
• Clean with alcohol and let dry
• Apply sticky disc this size of a quarter
• Secure with a light bandage
• Stay on dogs pretty well – often fall
off cats in 2-3 days
• Disk stores data for 8 hours
• Wave reader over the disk to read &
save up to every 8 hrs, for 10 days
• Disk $75-100, Reader $50
Dr. Greg Matt, Houston TX



Interpreting Glucose Curves
Duration of the curve
• If your curve is 12 hours or less, you
need to give insulin BID, not SID
Glucose range
• If all values are 100-250, leave it alone if
symptoms are controlled
• Avoid values above 300 and below 80
• Average of 6 values taken in a 12-hour
curve should be less than 250
Interpreting Glucose Curves
Glucose nadir
• If < 80 reduce the insulin dose
• If >130, consider increasing insulin dose,
unless all values less than 250
• Ideal nadir is 80-130
Glucose Peak
• If nadir 80-130 and peak too high,
change to longer duration insulin
regular < NPH < Lente
< PZI < glargine < detemir
Somogyi Effect
• Rebound hyperglycemia follows blood
glucose < 60
– usually within 12 hours
– Lasts 24-72 hours
– Often >400 mg/dl
• Due to epinephrine and glucagon
release (counter-regulation)
• A cyclic response of 1-2 days of “good
control” followed by several days of poor
control should increase suspicion
• Fructosamine usually >500 mcmol/dl
• Reduce insulin and recheck FRA +
curve in 1 week
Home Urine Testing
• I don’t use urine strips for glucosuria

• Renal threshold can vary
• Many well regulated diabetic dogs and
cats will have daily glucosuria
• It is reasonable to have owners keep
KetoDiastix
• Ketonuria indicates seeing the vet
ASAP
• Increasing insulin based on glucosuria
can result in Somogyi effect
Spot Checking Diabetics
If you were only allowed two

glucose checks in every 24 hour
period, when would you want to
take them?
At Insulin Time?
5-7 hours after insulin?
One of each?
• Which values in a glucose curve are

used to determine dose?
– Nadir (lowest glucose values - insulin peak)
• Which values on a glucose curve are

used to determine interval and insulin
type?
– Peak glucose values (insulin nadir)
– If glucose nadir is ideal, and glucose peaks
are too high, then you need to give insulin
more often, or you need a longer acting
insulin
Quiz – Glucose at insulin time
1. 250, 260
1. 250, 260
1. 250, 260
• Need to decrease insulin
2. 350, 335
1. 250, 260
2. 350, 335
Jane Kennedy
Atlanta TX
1. 250, 260
2. 350, 335
• Increasing insulin would probably make this
dog or cat hypoglycemic
• Need to change to longer insulin instead
3. 245, 265
1. 250, 260
2. 350, 335
• Need to change insulins instead
3. 245, 265
1. 250, 260
2. 350, 335
3. 245, 265
• Need to increase insulin
4. 200, 200
1. 250, 260
2. 350, 335
3. 245, 265
4. 200, 200
1. 250, 260
2. 350, 335
3. 245, 265
4. 200, 200
• Insulin should not be changed
Maintenance
Recheck Every 3-4 months
• Exam, weight, urinalysis
Every 6 months
• Exam, weight, UA
• CBC, panel electrolytes, urine culture
• fructosamine
• Blood pressure
Yearly
• Thyroid testing for middle aged to older cats
Regular dental cleanings
Glucose curves only when clinical
problems or FRA abnormal
Long Term Goals
• Learn home blood glucose testing

• Achieve ideal pet weight
– Especially important in cats
• Transition pet to ideal diet & feeding
program
– Especially important in cats
• Institute regular exercise program
• Never, never, never run out of insulin
Remission
• Not uncommon in cats

– Endogenous insulin production varies with the state of
chronic pancreatitis
– Type II diabetes is possible
• More common with glargine or detemir
insulin in combination with high protein/low
carb diet
– 50-60% or more with Lantus® and Levemir®
– 38% for ProZinc, and 25% for Vetsulin®
• Rare in dogs, except after recovery from
severe acute pancreatitis or OHE
• Temporary or permanent
• Short or long
Remission
• Individual cat can have multiple remissions,
but they are more common early in disease
– Most common in the first 6 months after Dx
Insulin Resistance
• Normal amount of insulin produces
subnormal response
– Insulin binding antibodies
– Insulin resistance (decreased receptor binding)
– Insulin signal transduction
• Greater than 2-3 units/lb, with all curve
values remaining very high
– No glucose values below 300, FRA >500
– **Any dose is fine if pet is regulated**
– >0.5 U/lb warrants investigation for co-morbidities
– >3 U/lb warrants investigation for insulin resistance
• Glycemic control is erratic
• True insulin resistance is very rare
• More often a co-morbidity causing temporary
insulin resistance (dysregulation)
Insulin Resistance/Dysregulation
1. Check for the Obvious
• Make sure females are spayed
• Check insulin
– Expired? Discolored? Cloudy?
– Exposed to extreme heat or freezing?
• Check Administration
• Make sure females are spayed
• Check insulin
– Expired? Discolored? Cloudy?
– Exposed to extreme heat or freezing?
• Check Administration
– Check for skin thickening at injection site
– Make sure they have the correct syringes (form)
– Make sure they are administering regularly
“How many doses do you miss monthly?”
• Exam & Check History for co-morbidities
– Dental infection, skin or other infection
– Heart murmur, GI symptoms, neoplasia
– Endocrine alopecia (polyendocrine co-morbidity)
– Variation in diet, exercise, stress
• Eliminate insulin antagonistic drugs
– Glucocorticoids, progestagens
– Glucosamine, theoretically
– Try cyclosporine, azathioprine for immune mediated
disease
– Try Apoquel® or Cytopoint® for pruritus
• Check regulation of co-morbidities
– ACTH stim for adrenal disease
– TT4 for thyroid disease
– GI panel for IBD, lymphangiectasia, pancreatitis, etc.
– Renal panel for renal disease
– Chest x-rays + echo + ECG if heart murmur
– Obesity in cats, severe obesity in dogs
2. Look for new Co-Morbidities
• CBC, panel, lytes, UA
– Elevated liver enzymes – hyperadrenocorticism?
– Azotemia – renal disease
– Low albumin + globulin – PLE
– Hyperlipidemia
• Urine Culture, thyroid testing, HW Test,
FeLV/FIV
– Hypothyroidism in dogs – TSH, fT4, TT4
– Hyperthyroidism in cats – TT4, fT4
• cPLI, TLI, B12, folate
– Chronic pancreatitis
– Exocrine pancreatic insufficiency
– Inflammatory bowel disease
2. Look for new Co-Morbidities
• Abdominal ultrasound + chest x-rays
– Neoplasia
– Chronic inflammation
– Chronic infection
– Hyperadrenocorticism
– Hepatobiliary disease
– Kidney disease, pyelonephritis
– Pancreatitis
– Inflammatory bowel disease
• Rule out Somogyi Effect
– Check mid-day glucose daily for a week
• ACTH stim, Low Dose Dex, urine cortisol
– atypical Addison’s, occult Cushing’s
3. Look for Zebras
• Insulin binding antibodies
• IGF-1 - acromegaly in the cat
• Glucagon – glucagonoma
• Pheochromocytoma
4. Change Insulin
5. Long term – weight reduction
REMEMBER TO DECREASE INSULIN
AND WATCH FOR HYPOGLYCEMIA
WHEN CO-MORBIDITIES ARE
CORRECTED
Insulin Antibodies
• Can result in erratic glucose curves and poor
glycemic controls
• Diagnosis
– MSU Endocrine Lab will assay for insulin
antibodies
• Normal – 15% or less
• Significant antibody problem if >40-50%
– Insulin antibodies can increase insulin assay
just as Thyroid antibodies do
• Insulin typically <50 mcU/ml 24 hours after
insulin in diabetic dogs
• Will be >400 if insulin antibodies
Insulin Antibodies
• Treatment
– Switch to a different insulin
– Vetsulin is least likely to cause antibodies
• Pork insulin = canine insulin
– Recombinant human is less likely to cause
antibodies, but usually too short acting
– Insulin analogs (glargine, detemir) are
unlikely to create antibodies
– Avoid protamine containing insulins (PZI
and NPH)
– Beef-pork and beef insulins (not on the
market now) are most likely to cause
antibodies.
Erratic Glycemic Control
“Brittle Diabetic”
• Rule out Somogyi
• Rule out difficulty with injections
– Frequent skipped doses
– Difficulty with injection technique
• Rule out absorption problems and
antibodies to insulin
• Type II diabetes, pancreatitis
– Sometimes all we can do is monitor and
respond
– Make sure clients understand signs of
hypoglycemia and hyperglycemia
– Astute clients can make minor adjustments
on their own
Erratic Glycemic Control
“Brittle Diabetic”
• Type II diabetes, pancreatitis
– 25-50% of diabetic dogs & cats have chronic
pancreatitis
– Ultra low fat diet, antioxidants and support of
hydration can minimize pancreatitis flares
– Treat hyperlipidemia if present
• Can cause insulin resistance and pancreatitis
• Chronic kidney disease
– Insulin requirements can fall
• Decreased renal clearance of insulin
• Decreased renal gluconeogenesis
– Cannot rely on PU-PD as an indicator of
glycemic control
Willie
Willie
• 17 year old DLH, has been a diabetic for about 3
years
• Had an “insulin vacation” for about six months
during the first year
• Was taking 2 units NPH BID for about a year
prior to boarding for 10 days
– Eats Innova EVO dry free choice (crunchy junkie)
– He doesn’t eat well when he boards
• Since coming home from boarding a month ago,
Willie has felt terrible
– PU/PD
– Doesn’t eat chicken jerky snacks as voraciously
– Very lethargic
Willie
• In the past month

– Weekly visits to regular vet for spot checks at
insulin time
– Fasted overnight and no insulin prior to coming in
for glucose checks
– Insulin given at clinic, Willie doesn’t eat all day
– All glucose values > 400
– Insulin gradually increased to 6 units BID
– Willie just keeps getting worse, now he won’t eat at
home, still PU-PD
• No new findings on exam, except weight loss
of 1.5 lbs over past year
– Other than glucose, last bloodwork done 2 yrs. ago
Willie
• Bloodwork at 2pm (insulin 7am)

• CBC – NSAF
• Profile & electrolytes – BUN 68, creat 4, phos 9, glu 31
• UA – SG 1.015, no bacteriuria
• Urine culture negative
• TT4 – 6.5, fT4 – 63
• No chest x-rays or abdominal US
– This may have sent Willie over the edge
– Sedation might compromise the kidneys
• New Diagnoses – hyperthyroidism, CRF, insulin
overdose
Willie
• Plan
– 100 ml LRS SC (owners not ready for home fluids)
– No insulin tonight, reduce insulin to 4 units BID
– Recheck in 1 week, or sooner if problems continue
– Provide owner with list of canned moderate protein,
low carb foods – wishful thinking
• 1 week later, Willie “is a new cat” ;-)
– Eating well and happy, but still PU-PD
– With CRF & hyperT4, we likely won’t be able to use
PU-PD as a marker for good regulation
– 2 pm glucose 67, BUN 49, creat 2, phos normal
– Reduce insulin to 3 units BID, recheck 1 week
Michael Dodd
Atlanta TX
Willie
• 1 week later, Willie still feeling good

– still PU-PD
– Fructosamine high
• BUN 59, creat 5, phos normal
– Glucose curve
• Time 0 – 365
• 2 hours – 71
• 4 hours – 143
• 6 hours - 310
– Change to Lantus 3 units BID, recheck 1 week
Willie
• 1 week later, Willie still feeling good

– still PU-PD
– Fructosamine within normal range
– Begin methimazole 2.5 mg PO SID
– Decrease Lantus to 2 units BID, recheck 1 week
• Why?
• Hyperthyroidism causes relative insulin resistance
Willie
• We eventually weaned Willie down to 0.5 unit

every other day
– If we stopped, he got hyperglycemic and did not
feel good
– If we increased, he got hypoglycemic and did not
feel good
– We continued this for 2 years, until he suffered an
episode of acute renal failure at 19 years of age
– His temperament was not suitable for
hospitalization, and he was humanely euthanized
Willie
Lesson from Willie

– PU-PD in an unregulated diabetic does not always
mean more insulin is needed
• Insulin overdose can cause PU-PD, due to rebound
hyperglycemia
• Other problems can cause PU-PD – CRF & hyperT4
in this case
– Regular rechecks can nip problems in the bud and
prevent illness from dysregulation
– Glucose curves are not always necessary – one
mid-day value can tell you a great deal
Willie
Lesson from Willie

– I prefer owners to give insulin and feed prior to
bringing in for glucose curve
– In-house fructosamine can preclude need for
glucose curve
SPOT CHECKING GLUCOSE

ONLY AT INSULIN TIME
SUCKS BIG TIME!!!!!
Sequellae of Diabetes Mellitus
• Blindness – most common canine sequella
– Cataracts – dogs >> cats
• 14% at the time of diagnosis
• 25% at 60 days
• 50% at 6 months
• 75% at 1 year
• 80% at 1 year 3-4 months
• Vision restored by surgery in 80% of diabetics
• Aldose reductase inhibitor (Kinostat®) can delay
diabetic cataract formation – not yet available
– PRAA > Diabetic retinopathy
• OcuGlo® can delay onset
– Glaucoma secondary to uveitis
– Severe hypoglycemia
• Kinostat® Trial – no longer taking
patients
– Dr. Mary Glaze, Dr. Robert Munger
– http://therapeuticvision.com/kinostat-study/for-
pet-owners/
– Eligibility:
• Diabetes recently diagnosed
• No cataracts present
– Requirements:
• Eyedrops TID
• 6 visits in 9 months
• May get placebo
– Medication, eye exam and bloodwork paid
for by the study
• Lens induced uveitis
– Lens proteins exposed during cataract
formation
– Must be controlled prior to surgery
– Diclofenac (Voltaren®) or flurbiprofen
(Ocufen®)
• Corneal ulcers
• Chronic pancreatitis
• Recurring infection
• Ketoacidosis
• Hypertension – 50%
– Start hydralazine or amlodipine if >160mmHg
• Diabetic neuropathy (cats 10% >> dogs)
– Risk factors: obesity, hypertension, hyperlipidemia
– Segmental demyelination, then remyelination
– Pelvic limb weakness, inability to jump
– dropped hocks, plantigrade stance
– Loss of muscle tone and atrophy
– LMN reflexes
– Rule out hypokalemic weakness
– Treatment:
• Best is optimizing glycemic control
• Pain control – gabapentin
• Antioxidants: alpha lipoic acid, acetyl-L-carnitine,
benfotiamine
• Aldose reductase inhibitors have been tried with
little success
• Diabetic nephropathy
– Occasionally seen in the dog and cat
– Protein losing nephropathy
• UPC >1 is diagnostic
• UPC >5 = grave prognosis
– With progression, azotemia, which can result in drastic
reduction in insulin requirements
– Monitor diabetics for proteinuria (rule out UTI)
– Treat with ACE inhibitor
– Benazepril 0.25-0.5 mg/kg/day
– Can increase to 2 mg/kg/day if tolerated
Severity of Diabetic Neuropathy
Criteria
Severity
Gait & Stance Neuromuscular Status
•Base-narrow gait •Neuro exam normal
Very Mild •Difficulty jumping
•Not plantigrade
•Base narrow gait •Mild postural deficits
•Feet sensitive to touch •Normal tendon reflexes
Mild •Partially plantigrade & crouched
walking
•Base narrow gait •Moderate postural & spinal
Mild- •Feet sensitive to touch reflexes
Moderate •Partially plantigrade walking & •Normal tendon reflexes
standing
•Feet sensitive to touch •Decreased postural & tendon
Moderate •Plantigrade walking & standing reflexes
•Mild muscle atrophy
•Feet sensitive to touch
Moderate •Obvious pelvic paresis & ataxia
•Plantigrade walking •Severe postural deficits
-Severe •LMN reflexes – areflexia (0)
•Palmigrade & plantigrade standing
to hyporeflexia (1)
•Feet sensitive to touch
•Obvious general paresis & ataxia •Generalized muscle atrophy
Severe •Palmigrade & plantigrade walking &
standing
Prognosis
• Depends on owner commitment, co-

morbidities, glycemic control and
avoiding DKA
• Dogs & cats that survive the first 6
months are likely to do well for several
years
– Median survival for cats is 2 years
– Shorter survival rate if elevated creatinine
– Longer survival if remission achieved
• Dogs - 1st visit fatality was 40% in 1970
– 10-12% in 1999 (similar for cats)
Diabetic Pearls
• Rolling Lente insulin is passé

– Study on Vetsulin - shaking Lente
vigorously
• No impact on insulin action
• More uniform dispersal than rolling
• Currently recommended
– No data on NPH and PZI
• ProZinc recommends rolling
– Lantus and detemir do not settle out
• no shaking or rolling needed
Diabetic Pearls
• Lantus does not need to be thrown

away after 28 days
– No loss in activity for at least 6 months
when stored in the refrigerator
– Use until expiration date
– Discard if it becomes cloudy
– 2017 AAHA Guidelines extends this to all
insulins
**TELL OWNERS NOT TO RE-USE NEEDLES**

Diabetic Pearls
• Leaving insulin out of the fridge

overnight does not inactivate it
– Keep in fridge for uniform storage and
longer life
– Discard glargine/detemir if it becomes
cloudy
– Discard if discolored
– Discard if frozen or temp >100oF
Diabetic Pearls
• No need to hospitalize diabetics,
unless they are sick
– Keep overnight or have come back the
next day for 3 checks if BG <80 after the
first dose
– It’s rare to get <80 the 2nd day
– Insulin needs change greatly during the
initial weeks – don’t tweak until later
– Eating/stress levels are different at home
• normalize these factors as soon as possible and as
much as possible
– Multiple consecutive curves are stressful
• 1 curve every 1-2 weeks works better
– A little bit of insulin does a lot of good
Diabetic Pearls
• No need to dilute insulin
– Diluted insulin is not as stable
• Replace every 4-8 weeks
– Diluted insulin is not as uniform
– Choose U-40 if tiny doses are needed
– Use 0.3ml syringes for low doses
• Even U-100 0.3 ml syringes are relatively
easy to read
– Use pens to dial up dose
– Syringe magnifiers are available
• Snap on the syringe
Diabetic Pearls
• No need to dilute insulin
– Diluted insulin is not as stable
• Replace every 4-8 weeks
– Diluted insulin is not as uniform
– Choose U-40 if tiny doses are needed
– Use 0.3ml syringes for low doses
• Even U-100 0.3 ml syringes are relatively
easy to read
– Use pens to dial up dose
– Syringe magnifiers are available
• Snap on the syringe
Diabetic Pearls
• Thumb Rules for insulin

– Give BID insulin 10 - 14 hours apart
– If you are not sure whether a dose went in, skip it
– If >14 hours, either skip it or gradually work back
to the most convenient injection times
– Skipping 1-2 doses a month rarely causes harm
– Never skip 2 doses in a row if you can help it
– If you double dose by mistake, feed and check
blood glucose at peak insulin time, then skip the
next dose
• Call vet if <50
• Expect rebound hyperglycemia for a few days
– Give SID insulin 20 - 28 hours apart
Diabetic Pearls
• Regulating the fractious cat
– Rely on fructosamine to tell you whether control
is adequate (Smutt)
– If control not good, glucose curves at home are
ideal
– If that is not possible, mid-day spot checks may
rule out severe hypoglycemia
• Medial saphenous vein
– Or consider placing a jugular catheter + e-collar,
or try Freestyle Libre. Jug Cath:
• Sedate and place catheter 1-2 days prior to
the curve
• Add extension set for the most fractious cats
• Remove 5-6cc blood, take a drop for testing,
replace 5-6cc blood, flush
Diabetic Pearls
• IV Jugular Catheter
Juanita Duel
Salado TX
Diabetic Pearls
• Delay elective surgeries until well
regulated
– Control must be near ideal for cataract surgery
• Especially brachycephalic dogs
– Use discretion for procedures that can improve
glycemic control
• OHE
• dental
– Proceed with emergency surgeries and hope for
the best in the sick diabetic
• Aggressive treatment with antibiotics due to
immunosuppression
• Be aware of delayed healing
Diabetic Pearls
• Peri-anesthetic management
– Fast for 12 hours as usual
• Do not withhold water until 1-2 hours before
– Give half the usual dose of insulin
– Blood glucose monitoring
• on admission and every 2 hours until surgery
• 1-2x per hour during surgery
• every 2 hours until recovered and fed a small
meal
– Treat hypoglycemia (<80) with 2.5-5%
dextrose to keep glucose 100-250
– Treat >300 with regular insulin at 20% regular
dose IM every 4 hours
– Watch for dysregulation for 1-2 weeks
Diabetic Pearls
• Encourage owners to keep a written
diabetic log, regardless of level of
care
– home glucose testing or not
– Record:
• each feeding and how much is eaten
• insulin dose given or skipped
• glucose results (urine testing)
• Water consumption and urinations
• any symptom of illness
– The log always comes in with the pet
Diabetic Pearls
• Regulating the Cushingoid Dog
– Lysodren is more likely to achieve good
glycemic control than Trilostane
– Starting dose for insulin is higher for
Cushingoid dogs – 0.5 U/kg BID
– Goal for glucose nadir is higher: 100-150
mg/dl
– The best control that can be achieved in
many dogs is nadir 150-200 mg/dl.
– Most diabetic Cushingoids remain PU-PD,
despite the best possible control for that
individual.
– Most of these dogs develop cataracts.
Hyperlipidemia
• Elevated triglycerides and gross lipemia
– Gross lipemia at triglycerides >200 mg/dl
• Assess only after a 12-hour fast
Clinical Signs
• GI upset, abdominal pain, pancreatitis
• PU-PD
• Ataxia, weakness, behavioral changes, seizures
– Danger value - >1000 mg/dl
• Lipemia retinalis, lipemia aqueous, corneal lipid
Hyperlipidemia
– Gross lipemia at >200 mg/dl
Clinical Signs
• PU-PD
• Xanthoma
Hyperlipidemia
– Gross lipemia at >200 mg/dl
Clinical Signs
• PU-PD
• Xanthoma
Hyperlipidemia
DDx High Triglycerides
• Post-prandial elevation
• Primary hyperlipidemia
– miniature schnauzers, shelties >> cats
• Secondary hyperlipidemia
– Endocrine – hypothyroidism, hyperadrenocorticism,
diabetes
– Pancreatitis, cholestasis
– Liver disease, nephrotic syndrome
• Drugs
– Glucocorticoids, estrogens
– Phenobarbital, bromide
– Megace in the cat
Hyperlipidemia
Hyperlipidemia
Diagnostic work-up
• First Tier Tests
– CBC, serum profile with electrolytes, UA
– cPL or CPLI
– Thyroid panel: canine TSH, TT4, fT4; feline TT4, fT4
• Second Tier Tests
– If signs of hyperadrenocorticism - Low Dose
Dexamethasone Test or ACTH Stim
– If hyperglycemia needs further investigation – fructosamine
– If proteinuria – Urine P:C ration x 3 days
– If signs of liver disease – bile acids
• Trial Therapy for primary hyperlipidemia (vet handout)
(Client Handout)
Hypercholesterolemia
DDx high cholesterol
• Hypothyroidism
• Hyperadrenocorticism
• Diabetes mellitus
• Liver Disease
• Protein losing nephropathy
• Drugs – corticosteroids, methimazole, phenytoin,
thiazide diuretics, phenothiazines
Summary
– PowerPoint - .pptx, 1 slide, 6 slides per

page)
– Client Handouts
• Canine Diabetes
• Feline Diabetes
• Diabetic Ketoacidosis
• Home Glucose Testing – Ear Prick –
Lip Prick
• Hyperlipidemia
• Instructions for Diabetics
• Hypokalemia
Summary
– Vet Handouts
• AAHA - Commonly Used Insulins Chart,
Monitoring Diabetics, Managing Hypoglycemia,
Troubleshooting Regulation
• Baycom - HbA1c Information
• Blount - Bicarbonate Administration, Insulin
Conversion Chart, IV Potassium
Supplementation, Hyperlipidemia, IV Fluid
Content Chart
• Feldman & Nelson - Protocol for Regulation of
Non-Ketotic Diabetic Cats, Algorithm -
interpreting glucose curves
• Dechra - Fluid Rate Chart
• Willard - Algorithm for Diagnosing
Hyperlipidemia
Summary
– Clinic Forms
• Insulin CRI Form
– Poster
• IV Fluid Rates
– Drug Handouts
• Fish Oil
• Glipizide
• Insulin
Summary
– Articles
• AAHA Guidelines for Diabetics
• ASVCP Glucometer Guidelines
• AJVIM – Flash Continuous Monitor
– Laboratory Information
• MSU Endocrinology Form & Protocols
• MSU Lab Fees
• MSU Reference Ranges
– Web Resources
• Cat Diet PFC Chart
• Percent Calories Calculator
• IV Drip Calculator
Summary
– Hidden PowerPoint Slides
• Pancreatic pathophysiology
• Breed predispositions to diabetes
• Clinical presentation of diabetes
• Oral hypoglycemics
• Chromium and vanadium
• Why cats are carnivores
• Glycosylated Hb – HbA1c
• CGM Systems
• Home Urine Testing
• Glucose curve peaks and nadirs
• Feline diabetic remission
• Kinostat® study – Dr. Mary Glaze
Acknowledgements
Richard W. Nelson. Canine & Feline

Endocrinology, 4th Edition. Ch 6 – Canine
Diabetes Mellitus.
Claudia Reusch. Canine & Feline

Endocrinology, 4th Edition. Ch 7 – Feline
Diabetes Mellitus.
AP Mizisin, et al. Neurological complications

associated with spontaneously occurring
feline diabetes mellitus. J Neuropathol
Exp Neurol 61:872, 2002.

PowerPoint DiabetesMellitus

Uploaded by

Copyright:

Available Formats

PowerPoint DiabetesMellitus

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

PowerPoint DiabetesMellitus

Uploaded by

Copyright:

Available Formats

What are some of the clinical signs of diabetes mellitus?

What are some of the clinical signs of diabetes mellitus?

What are some high and low risk dog breeds for diabetes mellitus?

What are some high and low risk dog breeds for diabetes mellitus?

Sweet Success:

Managing the Diabetic

Wendy Blount, DVM

• Islets of Langerhans dispersed in the

1. Diagnosis & Stabilization

2. Insulin Regulation & Treat

3. Maintenance & Insulin Adjustment

cPLI is the best test for pancreatitis in

Ultrasound is the best test for

7. Dogs with endocrine alopecia

2. Pancreatitis pattern – need fluid support

2. Pancreatitis pattern – need fluid support

3. Fatty liver pattern – feed cats

4. Fatty liver pattern – feed cats

• For every insulin, the starting dose of 0.5 U/kg is

Regular Insulin (Humulin R®, Novolin R®, Lispro®) –

Glargine – insulin analog (Lantus®, Basaglar®, Toujeo®,

NPH – neutral protamine hagedorn (Humulin N®, Novolin

Glargine – insulin analog (Lantus®, Basaglar®,

Original PZI and ProZinc are not the same insulin

• Virtually all dogs and cats do better on BID insulin

Type I Diabetes – IDDM – Insulin

Type II Diabetes – NIDDM – Non-Insulin

Type II Diabetes – NIDDM – Non-Insulin

Sulfonylureas – stimulate beta cells to secrete

Criteria for Glipizide

Typical response to Glipizide

Glinides also increase insulin secretion

DPP-4 (dipeptidyl peptidase) inhibitors

Incretins (GLP-1 – glucagon-like peptide 1)

Chromium – enhances tissue insulin sensitivity

Vanadium –insulinomimetic properties

• High complex carbs (>50% dry matter)

• Diets recommended for diabetic dogs in

• If homemade diet is chosen:

• For many years, we fed diabetic cats high

Ideal diet for diabetic cats

Ideal diet for diabetic cats

Ideal diet for diabetic cats

Ideal diet for diabetic cats

High protein, low carb, low phosphorus diets

Almo Nature Kitten 42 58 0 0.8 116

Prescription renal diets phos 68-120mg/100kcal & protein 21-27%

Myth #1: Diabetic cats should be meal fed if they are

Myth #2: You shouldn’t give insulin to pets

Myth #3: If the owner is resistant to insulin

– Cats have carnivore dentition & retractable claws

Obesity causes reversible insulin resistance

• Monitor PCV, K+ and Phos at least daily until

• Eating is important to maintaining K+/Phos

•Chief Complaint – Not doing well since

– 3 days ago regular vet did a UA and blood

•Initial life threatening problems

IV Fluid Na+ Cl- K+ HCO3- glucose Ca++ pH Mg++ mosmol/L

0.9% NaCl 154 154 0 0 0 0 5 0 308

Ringers 148 156 4 0 0 4.5 6 0 309

TELL OWNERS NOT TO RE-USE NEEDLES