Pet Health: BG Monitoring

A Rational Approach to Feline Blood Glucose Curves

G.D. Norsworthy, DVM, Dipl. ABVP
Acres North Animal Hospital
San Antonio, Texas
The glucose curve is the most effective way to monitor insulin
therapy in diabetic cats. But curves are expensive, and many consider euthanasia because of the high
cost. In such cases, here are some practical, less expensive alternatives.
From the November 1995 issue of Veterinary Medicine (a peer-reviewed journal)
Diabetes Mellitus in cats is one of the most frustrating diseases faced by veterinarians. Diabetic cats
have certain peculiarities not seen in dogs, including the marked effect of stress on glucose
concentrations. In addition, a cat's response to insulin is much less predictable than a dog's. We know, in
general, what to expect from the different types of insulin. But the same type of insulin may be absorbed
and metabolized differently from one cat to the next.
Assumptions about peak times and duration of action in
diabetic cats are often inaccurate. The only way to
know how any given insulin works in an individual cat is
to perform a glucose curve.
The standard glucose curve and its alternative
A glucose curve is a series of blood glucose
determinations made after a dose of insulin is given.
Typically, blood samples are taken every 1 1/2 to 2
hours until the effects of the insulin injection can be
determined. For ease of understanding, they are often
plotted on a graph (Figures 1 & 2).
I use the term "mini-glucose curve" to describe
blood glucose determinations made just before an
insulin injection is given and at the previously
determined peak time This two-point curve should
identify the highest and lowest, or peak and trough,
blood glucose concentrations. As described below, in
certain situations, the mini-glucose curve is a useful
substitute for the full glucose curve.

Fig 1. This is an example of an ideal glucose. It has its

highest point below 300 mg/dl and its lowest point,
the nadir, above 100 mg/deciliter. The range is from
105 to 297 mg/dl, and the range midpoint is 201 mg/deciliter. The peak time is six hours. These criteria
mean that this insulin type and dose should produce good regulation when given every 12 hours.
 
Fig 2. This glucose curve is not suitable. The highest point is 380 mg/deciliter. The nadir is 160
mg/deciliter. The range is 160 to 380 mg/dl, and the range midpoint is 270 mg/deciliter. The peak time is
at 4 p.m., or eight hours after the insulin injection. Three blood glucose determinations were made after
the nadir, but the concentrations at 4 p.m. and 4:30 p.m. were so similar that it was decided that two
subsequent determinations should be made after those two values to verify that the slope was rising.
Based on these results, the type of insulin is correct because the peak time occurs eight hours after the
insulin injection. The insulin dose be increased because the midpoint of the range is 270 mg/dl and the
nadir is not below 100 mg/deciliter.
Indications for a blood glucose determination
There are three indications for determining blood glucose concentrations:
1. To establish initial insulin protocol at the time of diagnosis
2. To monitor the degree of regulation and
3. To rule in or out rebound hyperglycemia.
Initial regulation
Pet Health: BG Monitoring 1
 The first indication for a glucose curve is to establish the insulin dose dosing interval, and insulin
type during the initial regulation process. The conventional way to regulate a diabetic cat is to choose an
insulin type dose, and dosing interval; adjust insulin for at least three days; and perform the glucose
curve. If the results indicate that any of these variables is inappropriate, the regimen is altered. The new
regimen is then used for at least three more days and the glucose curve is repeated. It is not unusual for
three to five glucose curves to be performed before a satisfactory regimen is determined.
Because of the expense of performing multiple glucose curves, many owners are unable to afford the
initial regulation process. In lieu of that many diabetic cats are euthanatized. To avoid this unfortunate
situation, I have developed an alternative approach in cats that have received the initial conservative dose
of insulin and are still consistently showing signs of diabetes, including polyphagia and polyuria. The initial
dose is presumed to be inadequate if the blood glucose concentration just before insulin administration is
greater than 350 rng/deciliter. In such cases, the serial blood glucose determination is discontinued. The
insulin concentration is increased by 10 to 20% and administered for at least three more days, when the
cat is returned for another full glucose curve. This process is repeated until the initial blood glucose
concentration is below 350 mg/ deciliter. At this time, a full glucose curve is performed.
The goal for regulating a diabetic cat is to keep the blood glucose concentration between 100 and
300 mg/dl throughout the day. If the blood glucose concentration at the time of diagnosis is less than 400
mg/dI, insulin is begun at 1/4 unit/lb given subcutaneously twice daily. An intermediate or long-acting
insulin is given. If the blood glucose is more than 400 mg/dI, 1/2 unit/lb is given twice daily.
Monitoring regulation
The second indication for a glucose curve is to monitor a diabetic patient's level of regulation. A
glucose curve should be performed at regular intervals as determined by the attending veterinarian
(usually every three to six months). A full glucose curve should be performed whenever signs of diabetes
or dysregulation occur (erratic fluctuations in clinical signs or behavior from one day to the next).
However, if the cat is presented for a routine follow-up and appears well regulated or if there are serious
financial constraints that prevent a full glucose curve, I often perform a mini-glucose curve. I recognize
that there is some variation in glucose curves from one day to the next, which limits the effectiveness of
the mini-glucose curve. But financial constraints often become such an important factor with many owners
of diabetic cats that a less expensive alternative to a full glucose curve is often a necessary option.
Documenting rebound hyperglycemia
The third indication for a glucose curve is when rebound hyperglycemia is a consideration. This
phenomenon occurs when blood glucose declines to life-threatening concentrations, generally below 65
mg/ deciliter. In response to this crisis, gluconeogenesis and glycogenolysis occur, resulting in glucose
formation. The blood glucose concentration rises quickly, but the cat is unable to produce the appropriate
amount of insulin because it is diabetic. Within a few hours, the blood glucose concentration may exceed
600 mg/dl and produce the classic signs of diabetes that occur in response to hyperglycemia.1 The best
way to document this occurrence is with a full glucose curve. In this situation, the use of the mini-glucose
curve is inappropriate.
Contraindications for blood glucose determinations
The primary contraindication for performing a glucose curve is a very fractious cat. Because of the
stress response that occurs in cats, blood glucose determinations in such cats are very inaccurate.
Sometimes, this situation can be managed by hospitalizing the cat for a few days to acclimate it to the
hospital environment. During this time, the cat should be isolated from the sights and sounds of dogs and
other cats. The hospital staff should make concerted efforts to befriend the cat. It should be petted,
stroked, and talked to in an effort to ease its fear.
Another approach that may work is to do the glucose curve on an outpatient basis. This is successful
only if the owner lives nearby and the cat does not become agitated by riding in the automobile. In such
cases, the cat is presented for blood collection and taken home. This process is repeated until the glucose
curve is completed. The reception staff should be told that this patient should not be kept waiting in the
reception area, especially if dogs or other cats are there. Upon arrival, the owner and cat should be sent
directly to a quiet, closed examination room, and the blood sample should be taken quickly with as little
stress and restraint as possible.
The other contraindication for a glucose curve is the concurrent administration of any drug that
would affect glucose concentrations. These drugs include dextrose, glucocorticoids, and progesterones.
There is little reason for doing a glucose curve when a cat is receiving intravenous dextrose.
Glucocorticoids and progesterones are contraindicated in diabetic cats.
The glucose curve is the beat tool we have to understand how a diabetic cat reacts to any given type
and dose of insulin. However, it is not infallible. Great emphasis should also be placed on the cat's total
Pet Health: BG Monitoring 2
clinical picture. If the cat is maintaining proper weight or gaining weight and is not polydipsic, polyuric, or
polyphagic, its state of regulation should be considered adequate regardless of the results of the glucose
curve.
The steps in the procedure
The cat should be fed immediately before leaving home. Upon arrival at the hospital, the owner
should be escorted directly to an examination room, or the cat immediately admitted to minimize waiting.
The first blood sample should be taken without delay. It is important that this step not be skipped
because, generally, this sample will yield the highest concentration on the glucose curve - a value you
need to know and record. This approach differs from the standard recommendation of fasting the cat until
after the first blood sample is taken and the insulin is administered. I prefer this approach because of the
difficulty I have getting the cat to eat the proper food in the amount that it would at home. If the owner
cannot bring the cat to the hospital immediately after feeding it (e.g. because it eats at 6 a.m. and your
hospital does not open until 8 a.m.), the conventional approach should be taken.
I prefer using the cephalic vein when collecting blood for a glucose curve. Use of a small tourniquet,
alcohol to wet the hair, a 25-ga. needle, and a heparinized syringe will permit repeated blood collections
from most cats, I take my first sarnple from the right cephalic vein just above the carpus. Subsequent
samples are taken from alternating legs and slightly proximal to the previous one. By using this rotational
pattern, 10 samples or more can be taken in one day from most cats. Other clinicians prefer the jugular or
femoral vein. I find the jugular vein harder to see without clipping hair, which most clients find
objectionable. The femoral vein is much smaller than the cephalic and tends to form hematomas very
easily. However, in some cats it is necessary to use a combination of all of these.
Some clinicians prefer to place a jugular catheter so that multiple blood samples can be taken
without repeated venipuncture. The advantages of this approach are that blood collection is very easy and
inflicts minimal or no stress on the patient. The disadvantages are the cost and technical difficulty of
placing this type of catheter.
Treating a diabetic cat for several years may require that several hundred blood samples be taken.
Because of the small size and limited number of accessible veins in cats, it is important that you minimize
trauma to the veins. Generally, I do not place a cephalic catheter in a nonketoacidotic diabetic cat because
an intravenous catheter will render the vein unusable for blood collection for several days to weeks. To
minimize hematoma formation, I cover the venipuncture sites with tape after each sample. Another
disadvantage of using the jugular or femoral vein is the inconvenience of applying appropriate pressure;
these veins should receive direct pressure for five minutes or more to avoid hematomas.
Next, insulin is given. It should be the same dose and type as has been used for the last three days.
It is highly preferable to have the owner bring his or her bottle of insulin to prevent adding another
possible variable.
The blood glucose is then measured every 1 1/2 to 2 hours until the nadir (the lowest point on the
glucose curve) is reached. After that, one or two blood glucose determinations are made to be sure that
the blood glucose is on the increase. The second sample is taken because of possible variation in blood
glucose determinations, regardless of the method used, as discussed below.
The ideal way to perform a glucose curve is to continue taking blood samples until it is time for the
next insulin injection. This is feasible in hospitals staffed at least 12 hours a day, if insulin administration
coincides with the hospital schedule. But most private veterinary hospitals, including mine, are not open
12 hours a day. So, because the key determinants have been made once the nadir is passed and because
glucometers can produce variable readings, I prefer to make two blood glucose determinations, at 30-
minute intervals, past the nadir.
Laboratory methods for making glucose readings
Several means for making blood glucose determinations are available. You can submit the samples
to a reference laboratory. However, this is the most expensive way, and it will not allow you to know when
adequate samples have been taken.
Blood glucose determinations can be made using dry chemistry machines, which are found in many
veterinary hospitals. This method is much cheaper than using a reference laboratory, and it will permit
readings to be made as the glucose curve is in progress. Some of these machines perform best using
serum instead of whole blood or plasma. If so, larger blood samples are needed, and more time is
required for clotting and separating the serum from the clot.
A third option is a hand-held reflectance meter. This instrument is designed for use by human
diabetics. Its retail price is about $100, but it is often heavily discounted. Reflectance meters have been
shown to be accurate for veterinary use. They require only two or three drops of whole blood and about
60 seconds in operation time. They are less expensive to operate than a dry chemistry machine, both in
Pet Health: BG Monitoring 3
labor cost and cost of the operating supplies. However, newer models, calibrated for capillary blood are
not as accurate when venous blood is used. These models should be avoided since we use venous
samples.
Regardless of the method used, glucose determination by laboratory methods is not an exact
science. One study found that glucose concentrations above 180 mg/dl could vary as much as + or - 90
points from one machine sampling to another. Reflecters can be misused so there is a greater degree of
inaccuracy interposed. There are several ways to increase the accuracy of reflectance meters. (These are
listed in Table 1) This frightening degree of variability is something that we have to recognize and consider
when interpreting the glucose curve. Glucose curves with values that do not seem to be in context with
the others in the curve may represent the variation that occurs in blood glucose testing. Because of this
variation, we should not try to regulate a diabetic cat too closely.
TABLE I
Ways to Increase the Accuracy of Reflectance Meters*
 Use test strips properly.
 Store at room temperature.
 Do not remove the strips from the bottle until ready for use.
 Keep the lid on the bottle lightly.
 Do not use strips if they are outdated.
 Do not use generic strips.
 Use only the right code number on the glucometer.
 Use only the strips that are made for the reflectance meter chosen.
Keep the glucometer in good condition.
 When the light transmission window gets dirty, clean it with water.
 Store and use the glucometer at room temperature.
Recognize disease influences.
 Anemia causes abnormally low or high readings.
 Dehydration causes abnormally low readings.
 Elevated bilirubin causes abnormally low readings.

*Adapted from Hoyson, P.M.: Diabetes 2000: Oral Medications. RN 58(5):34-39; 1995.
 
TABLE II
Interpreting the Glucose Curve*
To determine the dosing interval or the type of insulin given, evaluate the peak time.
If the peak time is:
< 5 hours: change to t.i.d. (3/day) administration or administer a longer-acting Insulin.
5-8 hours: continue b.i.d. (2/day) administration.
> 8 hours: change to s.i.d. (1/day) administration.
To determine the dose of insulin or if dysregulation is a problem, evaluate the nadir and range
midpoint.
If the nadir is < 100 mg/dl, decrease the insulin dose.
The ideal range midpoint is 200 mg/dI, and 150-250 mg/dl is acceptable. If the range midpoint is:
1. < 150 mg/dl: reduce the dose of Insulin.**
2. 150-250 mg/dl: don't change the dose.
3. > 250 mg/dI: several possibilities exist:
o The cat may have been stressed when the blood glucose curve was performed.
o The Insulin dose may be too low.
o There may be an insulin problem (inactive insulin, insulin not mixed property, poor
injection technique, poor absorption).
o Insulin resistance may be occurring due to concurrent disease (systemic Illness,
hyperthyroidism, hyperadrenocorticism, acromegaly) or insulin antibodies.

*Based on twice-daily dosing of insulin.

**The nadir also should be below 100 mg/deciliter.
Interpreting the curve
Four values are important in interpreting the glucose curve (Table 2). They are as follows:

Pet Health: BG Monitoring 4

 1. The highest blood glucose concentration, which is usually the one taken just before
insulin is given. In some cases, the morning meal and the stress of riding in the car will cause the
blood glucose concentration to rise slightly on the second sample, but it should decline from that
point.
2. The nadir, which is the lowest blood glucose concentration.
3. The peak time, which is the time from the insulin injection until the nadir. It is
expressed in hours.
4. The midpoint, which falls halfway between the highest and lowest blood glucose
concentrations in the range.
Once these values are determined, they can be used to determine the dosing interval, the type of
insulin, and the dose. The guidelines below are based on the assumption that insulin is being given twice
daily.
To determine the dosing interval and the type of insulin, follow these steps:
 If the peak time is less than five hours, a longer-acting insulin is given, or the current
insulin is given more frequently, generally three times a day.
 If the peak time is five to eight hours, the current insulin is continued on a twice-daily
schedule.
 If the peak time is greater than eight hours, the current insulin is continued, but is given
once daily.
To determine the dose of insulin or if dysregulation problems exist, use these guidelines:
 If the nadir is less than 100 mg/dI, the dose should be decreased. You should assume that
the nadir in the hospital is somewhat higher than what it will be at home because of stress. If this
assumption is incorrect, you will err so that the blood glucose concentrations are too high. This is
always the better way to err. Hypoglycemia can be fatal; mild to moderate hyperglycemia is not.
 The ideal midpoint of the range is 200 mg/deciliter. However, the midpoint is satisfactory if
it is from 150 to 250 mg/deciliter. If the midpoint is less than 150 mg/dI, the dose of insulin is too
high and should be reduced. The nadir also should be below 100 mg/dl when the dose of insulin is
too high.
 If the midpoint is greater than 250 mg/dI, several possibilities exist: 1) The cat may have
been stressed when the glucose curve was performed. Recount the cat's attitude during the blood
sampling process and the hospital stay. 2) The dose of insulin may be too low; if so, increasing it
will solve the problem. 3) If increasing the dose does not bring the midpoint into the desired range,
insulin problems should be considered. These include inactive insulin, insulin that is not mixed
properly, poor injection technique, and poor absorption. 4) If this does not seem feasible, consider
concurrent infectious disease. Many infectious diseases can cause temporary insulin resistance. A
two-week course of a broad-spectrum antibiotic should be considered if your physical examination
and other laboratory tests do not indicate a specific problem. 5) If these approaches are
unsuccessful, you should consider insulin resistance due to hyperthyroidism, hyperadrenocorticism,
acromegaly, or insulin-antibody formation.
Summary
Regulating a diabetic cat can be difficult, and the glucose curve is the foundation for understanding
how any given insulin works in an individual cat. It is one of the first steps in achieving regulation. It is
used to determine proper insulin type and dose and proper administration interval. The glucose curve is
also used as a monitoring tool for regulated cats and as a diagnostic tool for cats in dysregulation. Four
values are used to interpret the glucose curve: the highest concentration, the lowest concentration
(nadir), the midpoint of the range, and the peak time. Generally, these values can be determined in six to
eight hours. Taking the time to properly perform a glucose curve can save a great deal of time and money
for the client.
REFERENCES
1. McMillan, F.D.; Feldman, E.C.: Rebound Hyperglycemia Following Overdosing of Cats with
Diabetes Mellitus. JAVMA 188: 1426-1430:1986.
2. Joseph, R.J. et al: Evaluation of Two Reagent Strips and Three Reflectance Meters for Rapid
Determination of Blood Glucose Concentrations. J. Vet. Intern. Med. 1: 170-175; 1987

Pet Health: BG Monitoring 5