Feline Diabetes - and Feline Diabetes + CRF, Pancreatitis, Hepatic Lipidosis, and more!
THE FIRST DAY
The initial shock and fear you feel when the vet tells you that your pet has diabetes can be overwhelming. Diabetes is a treatable condition and your pet can live a normal, happy, healthy life. Diabetes is not a death sentence for your pet.
One of the first questions many people ask is "How long will my pet live?" Every pet is different, but very often your pet can live a normal life-span.
Another question that is often asked is "My pet is older, should I put him to sleep?" This is a very complicated issue and depends on the overall health of your pet. Age alone should not be the deciding factor in determining whether to treat your diabetic pet or whether to euthanize it. Many older pets have been diagnosed with diabetes and with commitment and loving care, have lived many more years. There are diabetic cats and dogs that are quite elderly (18 years old or more) who are in very good health.
COMMITMENT, PATIENCE, AND EDUCATION
Caring for a diabetic pet takes a very strong commitment from both the caregiver and the vet. You must provide a very high level of care for your pet on a daily basis. Gone are the days of putting out food and water, giving a quick pat on the head, and hurrying out the door. Every day you will have to give your pet medication, feed a proper diet, and watch his behavior. Don't get the impression that you are now a prisoner....you aren't, but you will have to pay much closer attention to your pet's needs and behavior, and you will have to make arrangements for someone to care for your pet if you leave for an extended period of time. Your hard work and commitment will be reflected in your pet's continuing good health, and hopefully you will be able to enjoy the love and companionship of your pet for many more years.
With a disease like diabetes, it is very important that you have a good working relationship with your vet. Your vet does not have to be an "expert" but he or she should be experienced in treating diabetic patients. If your vet does not know something or is not sure how to treat your pet, he should consult with a specialist or refer you to a specialist. Communication is absolutely essential. You will have a lot of questions about your pet, about diabetes, and about various treatment options. You must be able to ask the vet questions and get thorough, understandable answers.
At times, diabetes can be a very frustrating disease. The veterinary community is always expanding its knowledge about diseases and treatment options, and diabetes is no exception. Although there are standard treatment options for diabetes, diabetic animals can be difficult to treat and every animal responds differently to any given treatment plan. One thing that most vets or owners of diabetic pets will tell you is "every pet is different".
Educating yourself about diabetes is one of the best things you can do for you and your pet. There is a lot to learn about the various aspects of diabetes and its treatment, and all of this information can be intimidating. It is important to learn the very basics early on, but then you can take things a little slower and do more reading. Even after you've been doing this for many months or even years, there is always more to learn. Don't be afraid to ask questions. If you don't understand something, no matter how simple you think it is, you must ask. Knowing the correct answer could save your pet's life. There are many resources available on the internet and in both human and pet health care books. With a basic understanding of diabetes, you will be better able to care for your pet and better able communicate effectively and participate in the decision making process with the vet.
Cost is something owners think of when their pet is diagnosed with diabetes. The initial "sticker shock" can be overwhelming and the financial requirements of caring for a diabetic pet can be substantial. Unfortunately, none of us has unlimited resources, and reality is that money is a factor. If money is limited, many vets will work with you to limit expenses and will allow you to make payments on your bill. Please discuss this option with your vet.
The first few weeks
It is not unusual to spend $200-300 for the initial diagnosis and hospitalization, even if you caught the diabetes early. If you were not aware of your pet's condition and he is in critical condition, the costs can be significantly more. In the first few weeks or months, when you and the vet are trying to get your pet's diabetes regulated, the expenses may still be high. You will have to take you pet to the vet for a few check-ups during the early stages of diabetes. These check-ups are essential to determine how your pet is doing and to make any necessary changes to the medications. In some pets, the diabetes is quickly brought under control (regulated). Other pets are not so lucky, and they require more frequent visits to the vet and adjustments to their medication.
Typical Maintenance Expenses : After the diabetes is reasonably well regulated, the costs decrease dramatically. Supplies typically cost around $30 to $40 per month. This includes syringes, insulin, and a prescription diet. Many people monitor their pet's urine glucose, and the test strips are relatively inexpensive (less than $10 for 50 test strips).
A blood glucose curve done in the vet's office may cost about $100-150. You and your vet will determine how often these tests are needed. After the diabetes is fairly well regulated, a blood glucose curve may be needed only every 6 months, or only when you suspect that your pet's diabetes is no longer under control. If your pet is more difficult to regulate, more frequent blood testing may be required. Home blood glucose monitoring is an option that can significantly decrease your expenses. There are many valid reasons why care-givers choose to do home blood glucose monitoring. A primary reason is that it may provide the most reliable and immediate information on your pet's blood glucose levels. Another reason is the cost savings. If you choose to do home blood glucose monitoring, it requires the support of your vet because the vet will help you interpret the results. The blood glucose meters and test strips vary in price, but rebates are often available. I spent $30 for the meter (after rebate) and the test strips are about $35 for a box of 50 strips. The strips last us for several months.
Another expense associated with diabetes is for vet visits for other suspected health problems. In a way, this is a strange benefit of diabetes. You become very aware of your pet's behavior and are usually able to detect any changes or problems very early. Also, the routine 6 month or annual check-up provides another opportunity to catch any new problems at an early stage.
Caring for a diabetic pet can be frustrating and emotionally stressful for everyone involved. At first, you wonder how much you are upsetting or hurting your pet by giving pills or injections, feeding a new diet, and doing all the other things you will have to do. The changes are difficult at first, and your pet may be upset or not acting as lovingly as usual. But these new activities are life-saving necessities and they soon become part of daily life, both for you and your pet. With all the extra attention and care that you give your pet, you will probably find that the bond between you and your pet becomes even stronger.
There may be times when your pet's diabetes is uncontrolled, or when other illnesses arise. The extra effort and commitment you give to your pet makes these set-backs even more heart-breaking and stressful. Every health crisis can be an emotional drain. Exhaustion, frustration, anger, sadness, fear, and guilt are all normal feelings that are part of caring for an animal with a chronic health condition. Don't ignore these feelings, but don't dwell on them either. Be sure to take some time for yourself and rely on your friends and family for emotional support. The bad times usually pass quickly and you learn to cherish the little things even more. And don't forget to celebrate the progress that you make, even if it is just a small step forward. I believe that animals are very perceptive of our emotions, and the healing power of love should not be underestimated. Never lose sight of the joy that your pet brings to your life.
PEOPLE THINK YOU ARE CRAZY
Friends, relatives, and co-workers may make insensitive comments that you are crazy to care for a chronically ill pet. Although it is difficult, try to ignore the unsupportive people - they do not understand the special bond of love that you share with your pet. Their inability to have compassion for an animal means that they will never experience the pure and unconditional love that can be shared between a human and a companion animal. Only another pet lover will understand your choice to give such dedicated care to your pet. Your good friends will understand your choice and be supportive, and one of them may even be suitable to be a back-up caretaker. Try to find a group of other pet-lovers who will be supportive of your decisions. There are many internet mailing lists and web sites for care-givers of pets with chronic illnesses. The people there will understand and be supportive of your choices.
YOUR SOCIAL LIFE
Caring for a diabetic pet will place restrictions on your ability to spend time away from home. Your pet must be given insulin or other medications, fed properly, and observed every day. With some advance planning, diabetic dogs can often accompany you on weekend trips or extended vacations. Unfortunately, most cats don't travel well, so they usually require special arrangements. Before spending any extended period of time away from home, you must make arrangements with a well trained care-giver to take over the care of your pet. This is not a job for a neighborhood child or someone you don't completely trust. The care-giver must be able to properly administer medications, ensure feeding, observe your pet's behavior, and be able to call the vet or take your pet to the vet in case of emergency. A close friend or family member may be suited to this serious job. Another commonly used option is to check with the technicians at your veterinarian's office - they are well trained, and often available to do in-home care for a reasonable fee. Boarding you pet at a competent boarding facility, or the vet's office is another option.
THE BOTTOM LINE
By making the decision to care for a pet with diabetes you are taking on a huge, but very rewarding challenge. There is a lot to learn and do, so be patient with yourself. Whatever decisions you make for the care of your pet, a decision based on love and the welfare of your pet is the best decision for everyone.
CHRONIC RENAL FAILURE AND DIABETES IN CATS
What is Chronic Renal Failure?
Chronic renal failure (CRF) occurs when 70% of kidney function is irreversibly destroyed. The kidneys consist of tiny units called nephrons, which are responsible for filtering out toxins and wastes from the blood. These toxins and wastes become concentrated in the urine and eliminated from the body. When the kidneys no longer have enough functioning nephrons to effectively rid the body of toxins, uremic poisoning results.
As one of the most common causes of death in the geriatric cat, CRF can occur as a result of:
The normally functioning kidney is able to rid the body of toxins and wastes by storing them in the bladder as concentrated urine. However, the failing kidney is unable to use a small amount of water for the toxins (concentrated urine), and because of this failure in water conservation, more water is needed to flush the toxins from the body. Consequently, the most common symptoms of CRF are polydipsia (increased drinking) and polyuria (increased urination). These are also the two most common signs of diabetes.
As CRF progresses, other
physical signs include:
Diagnosis and Testing
Diagnosis of CRF can be made by a variety of methods. Physical examination findings of abnormally small or large kidney(s) may initiate further testing of kidney function. Tests most commonly utilized to assess kidney function include a urine specific gravity test to determine how well the kidney is concentrating urine and blood work to determine the levels of toxins in the blood. The two most significant blood test results are the BUN (blood urea nitrogen) and the creatinine levels. BUN is a protein metabolyte and although lab values differ, the approximate range is between 14-36 mg/dl (5-12.9 nmol/L) for healthy kidneys. BUN is related more to diet, and if dehydration is present, will show increased values. Creatinine is thought to be a more reliable indicator of kidney function as it shows how well the kidneys are filtering out the toxins and is less dependent on dietary factors and hydration status of the cat. A normal range for creatinines value for the healthy kidney is 1.0-2.2 mg/dl (88.4-194.5 umol/L). Additional blood values used to diagnose renal failure include phosphorus, potassium, calcium,and packed cell volume.
Other tests to determine kidney function include x-ray of the kidneys, kidney ultrasound and biopsy.
Special Considerations for
Because many of the same symptoms present in diabetes (e.g., PU/PD), are also indicators of renal failure, CRF can be easily misdiagnosed as poorly controlled diabetes. Elevated BUN and creatinine levels can also occur with diabetes alone, so a diagnosis of CRF can be complicated.
This misdiagnosis resuls in delayed treatment and therefore faster progression of CRF as well as mismanagement of diabetes. If the owner is assessing diabetes control by measuring fluid intake and outtake only, the cat can be inappropriately overdosed with insulin.
Because the diabetic cat is prone to CRF as well as other illnesses, it is advisable for the cat to undergo periodic examinations including a comprehensive bloodwork panel and urinalysis. If at all possible, periodic blood pressure of the diabetic cat is also recommended as hypertension can results from poorly controlled diabetes, and untreated hypertension can lead to CRF.
CRF is a terminal illness. However, with specialized treatment, many CRF cats are able to live months to years before succumbing to the disease. The goal of treatment is to ease the work done by the kidneys and to prevent dehydration. Thus, management to slow the progression of the disease revolves around two mainstays of treatment, diet and fluid therapy, both of which are controversial.
Up until very recently, the recommended diet was both low in protein and phosphorus. Although most veterinary practitioners are still recommending such a diet, there is new evidence suggesting that the amount of protein is of less importance than the "quality" of the protein source. Consequently, there are now two schools of thought, one advocating the traditional low protein CRF foods and the other proposing a higher or moderate protein diet using high quality proteins such as cooked eggs, boiled liver, chicken, turkey, heart, etc. At a recent conference on renal failure, it was also suggested that too low of a protein diet (e.g., Hill's K/D) could contribute to increased muscle wasting in the CRF cat.
Both sides concur with one aspect of the CRF diet: it must be low in phosphorus.
Prescription foods for CRF
that are both low in protein and phosphorus include:
For drinking water, distilled water is recommended because tap water and bottled water with added minerals can be hard on the kidneys.
The second controversial issue in CRF treatment is the administration of subcutaneous fluids. Some experts believe that periodic hydration will slow the progression of the disease by helping the kidneys to flush out the toxins while keeping the cat consistently hydrated. With this approach, fluid therapy is given once a week to daily depending on the needs of the cat as determined by both renal values and overall well-being. Other experts believe that fluid therapy should only be initiated when the cat is dehydrated, the belief being that chronic administration of sub-q fluids can actually hasten the progression of CRF because the kidneys have to work harder, expending more energy. Another concern with chronic administration of subcutaneous fluids, especially in large amounts, is the danger of inducing hypertension. Hypertension is a common consequence and precursor of CRF. However, fluid therapy has been shown to significantly reduce BUN and creatinine values (levels of toxins in the blood), and progressive renal failure is also responsible for hypertensive disease.
Administering Subcutaneous Fluids To Your Cat is an excellent site for illustrating the technique of home administration of subcutaneous fluids.
Other CRF Treatments
Calcitriol: there is increasing evidence that Calcitriol (vitamin D3) will delay progression of CRF by restoring calcium balance. Some experts are promoting the use of Calcitriol as long as a parathyroid hormone test determines that the cat is a candidate. If the calcium value multiplied by the phosphorus value exceeds 60, Calcitriol should not be given. Other experts would like to see more clinical trials before approving this adjunct to standard CRF treatment.
Potassium supplementation: in CRF, potassium depletion is common. Many experts believe that potassium supplementation should be initiated before the potassium values reach the low end of the normal range. The most widely used potassium supplement is Tumil-K, available in tablet, powder and gel form. Potassium added to sub-q fluids is also an option but often causes discomfort to the cat during fluid administration.
A phosphate binder (AlternaGEL, BasalGel, PhosLO, or Tums) may be used to bind phosphates in the diet, reducing phosphorus intake and normalizing blood phosphorus levels.
Hypertension is a common result of CRF and must be treated so that strokes, heart disease and blindness are prevented. Currently, the drug of choice for hypertension in CRF cats is amlodipine (Norvasc).
Epogen: as CRF progresses, anemia results due to erythropoietin deficiency. Erythropoietin is made by the kidneys and is responsible for stimulating red blood cell production by the bone marrow. In chronic renal failure, erythropoietin is depleted causing anemia as reflected in a low packed cell volume value. Severe anemia is life threatening as there are not enough adequate red blood cells to deliver oxygen to the body tissues. Unfortunately, because the only erythropoietin drug available (Epogen) is human based, many cats quickly develop antibodies to it causing the packed cell volume to fall even lower. Therefore, erythropoietin therapy is not initiated until the packed cell volume falls dangerously low, and the cat's life is in immediate jeopardy.
Anorexia is common in the CRF cat. Appetite stimulants are often given to help promote appetance and help the cat maintain a stable weight. Drugs to stimulate appetite most commonly prescribed are Valium and Cyproheptadine (Periactin).
Another drug used for inappetance as well as to promote and help maintain muscle mass is Winstrol, an anabolic steroid.
Gastrointestinal distress: To counteract gastric upset in the CRF cat, small amounts of Pepcid-AC can be given (1/4 tab morning, 1/4 tab night.)
Special Considerations for
Diabetes and CRF are intricately involved; the progression of one impacts on the progression of the other which makes control of each disease difficult to manage. CRF puts immeasurable stress on the cat's body, making diabetes regulation difficult, if not impossible. In turn, poorly controlled diabetes will contribute to an accelerated progression of CRF, especially if hypertension and urinary tract infections (UTIs) are present and inadequately addressed. In the diabetic cat with or without CRF, it is important to have regular screenings and treatment for any UTIs and periodic blood pressure testing if at all possible.
The diet typically indicated for CRF cats can be contraindicated in the diabetic. Some diabetes experts are recommending higher protein diets, and many owners have found that a higher protein diet can significantly reduce blood glucose levels. However, standard CRF diets are low in protein, so for difficult to regulate diabetics, a decision must be made as to which diet to choose. A good compromise may be to offer the lower protein/phosphorus diet with the addition of a high quality protein source such as boiled chicken, turkey, liver, or eggs.
Questions for your vet:
Ask your vet what he or she recommends concerning screening for CRF in the diabetic cat. Especially if your cat's diabetes is well controlled and you still see signs of PU/PD, have a blood panel done to rule out CRF (as well as other diseases such as hyperthyroidism) as well as a urinalysis for urine specific gravity and to check for any concurrent urinary tract infections.
If your cat is diagnosed with CRF, ask your vet about his beliefs concerning diet and home administration of subcutaneous fluids. Discussing the other treatments for CRF would also be advisable.
If your vet does not have
access to blood pressure monitoring equipment, see if he will refer you to a
vet with this capability.
Frequently Asked Questions
What is Pancreatitis and how does it relate to diabetes?
Diseases of the Pancreas (extracted from The Cornell Book of Cats)
Acute Pancreatitis. Acute pancreatitis is uncommon, but can occur in obese cats that get little exercise and may have eaten a meal with high fat intake. Steroid administration and a decrease in the blood supply to the pancreas each may play a role in the production of acute pancreatitis. When pancreatic cell damage takes place, pancreatic enzymes are released and begin breaking down the fat in other adjacent tissues, resulting in bleeding, shock, endotoxemia (bacterial toxins in the bloodstream), and possibly death.
Clinical diagnosis is based on intuition and speculation. A cat that has had an episode of vomiting, fever, and anorexia, which responds to supportive care in forty-eight to seventy-two hours, may indeed have had acute pancreatitis. Many cases are not diagnosed until after the cat's death, when a necropsy (autopsy of an animal) is performed.
Traumatic Pancreatitis. This is usually caused by an accident such as being hit by an automobile, or falling from a height, as in high-rise syndrome. The trauma or injury to the pancreas allows leakage of the enzymes into the surrounding tissues and abdomen, resulting in same clinical picture as in acute pancreatitis.
Chronic Pancreatitis. Chronic pancreatitis usually results from recurrent bouts of acute pancreatitis. It is usually subclinical (symptomless), found at necropsy in older cats. Chronic pancreatitis may lead to diabetes mellitus and exocrine pancreatic insufficiency, but the typical signs of maldigestion are extremely rare in cats. Pancreatic insufficiency results from a decrease or near absence of the digestive enzymes to break down fats, carbohydrates. and proteins, causing malnutrition.
Pancreatic Neoplasia. Primary neoplasias or tumors of the pancreas, are uncommon. When diagnosed they are usually adenomas, adenocarcinomas, or islet cell tumors. Secondary neoplasia occurs more commonly as lymphosarcoma associated with feline leukemia.
Nodular Hyperplasis. This is a common finding in old cats, at necropsy. It appears as lumps or thickenings in the tissue of the pancreas. It is not a malignancy and probably has little clinical significance.
What is Hepatic Lipidosis?
Hepatic lipidosis, also known as "feline fatty liver syndrome," is the most common form of liver disease in cats in North America. Cats that are obese appear to develop this disease most frequently. While the most common form of this disease is idiopathic (of unknown origin), it can occur with another liver disease.
Stress appears to play a significant role in the development of this disease, even minor stresses. The most common presentation of this disease is an overweight cat that, due to a stressful event, stops eating, starts to lose weight, and begins vomiting. The failure to eat usually lasts more than two weeks, but it can cause hepatic lipidosis in as little as one week. There is no age or breed disposition. It is often associated with a low-grade pancreatitis.
Diagnosis can be made by blood tests, an abdominal ultrasound and a liver sample.
The primary treatment of this disease is feeding the cat. Frequently this entails placing a PEG (Percutaneous Endoscopically placed Gastric) feeding tube. This is a semi-permanent tube that is surgically placed by your veterinarian. It allows the cat to be syringe-fed directly through the tube. The tube is easily removed when it is no longer needed.
With tube feedings, approximately 70% of cats will recover from hepatic lipidosis.
What is Hyperthyroidism?
Located in the neck, the thyroid is a butterfly-shaped gland that regulates many aspects of the cat's metabolic rate. Hyperthyroidism is the most common hormonal disease of cats. The overproduction of thyroid hormone can be the result of hyperplasia (increased activity of the gland for unknown reasons) or cancer. A small percentage of the cancers are malignant. This disease was not commonly recognized prior to the late 1970s. The reason for the increase in prevalence is not known.
Most cats who develop hyperthyroidism are older cats. In hyperthyroidism (hyper="high"), too much thyroid hormone is being produced, so your cat's metabolic rate is too high. Hyperthyroidism affects virtually every organ system, and can result in behavioral changes, weight loss, excessive or decreased appetite, hyperactivity or lethargy, fever, rapid or irregular heartbeat, shedding, increased water consumption (polydipsia) and urination (polyuria), vomiting, diarrhea and osteoporosis. In some cats, the disorder produces atypical signs such as depression, inappetance or weakness.
The increase in thyroid hormone causes the cat's heart to beat faster, often > 240 beats per minute. Heart murmers may be present. Heart failure will occur in up to 10% of cats and heart damage occurs in most, although it is usually reversible with treatment of the hyperthyroidism. The haircoat may look scruffy. Enlarged thyroid glands may be found. Effects on the kidneys from the circulatory changes can make existing kidney disease worse or cause the appearance of kidney disease in some cats.
Diabetes, kidney disease, liver disease and other conditions that also affect older cats need to be ruled out prior to settling on a diagnosis of hyperthyroidism, even if tests indicate it is present. In older cats, this disease is common enough that routine screening is considered to be necessary by many veterinarians. Due to the potential for numerous secondary complications, such as heart disease and digestive problems, early diagnosis is a good idea. Consider asking your vet about tests for hyperthyroidism if your cat is over 10 years of age.
Testing for hyperthyroidism is done by measuring the T4 (one thyroid hormone) levels in the blood stream. In most cats with hyperthyroidism, these levels will be above normal. In some cats, they will be in the "normal" range, despite the presence of the disease. This is particularly true of very old cats. In these cats, repeating the test in a week or so is often diagnositic. If not, more specialized testing must be done, such as T3 (another thyroid hormone) suppression tests or thyroid releasing hormone (TRH) testing.
The effects of too much thyroid hormone on the body are so devastating, the condition is fatal if left untreated. An untreated cat will live on average about two years. There are currently three commonly used treatments for this problem. Surgery, radioactive iodine therapy and medical treatment using methimazole (Tapazole ®). Treatment choice will depend on a number of factors, including your cat's general health, finances, and personal preference.
Anti-thyroid drugs (Tapazole):
What is the Somogyi Effect?
Glucagon and insulin are released by the pancreas. Glucagon and insulin have opposite effects: insulin makes the blood sugar go down and glucagon causes blood sugar to go up. They work together to balance blood glucose levels. Glucagon can increase blood glucose levels by causing the liver to release its stored glucose to the blood stream. Insulin lowers blood glucose by allowing tissues to use or store glucose.
When too much insulin is given the blood glucose drops rapidly and hypoglycemia (low blood sugar) results. This can trigger the body to release glucagon (and other hormones) and the result is that glucose is dumped into the blood. This can lead to hyperglycemia (high blood sugar). So, you have hyperglycemia induced by hypoglycemia, or the Somogyi effect. (Somogyi was a scientist who did research on glucose production by liver during times of stress.)
The method of determining if Somogyi effect is occuring is to do a blood glucose curve. Your cat will have a specific pattern of hyperglycemia if the Somogyi effect is occuring. Although at first it seems odd, the treatment for this type of hyperglycemia is to DEcrease the insulin dose. This prevents the hypoglycemia from occuring and triggering the Somogyi effect.
How do I adjust the insulin dose according to blood sugar levels?
A blood glucose curve is periodic testing of the blood sugar levels to see what effect the insulin is having. The values will ALWAYS vary; you are looking for values outside of acceptable ranges, which will be approximately 100-200 or maybe up to 300 depending on your cat.
In the initial stages of therapy the usual recomendation is to test blood glucose (BG) three to four times per day. See the section on urine testing for suggestions on when this testing should occur. After regulation has been achieved, routine tests before the morning meal two to three times weekly will be enough to let you know if your pet is staying regulated.
BE VERY CAUTIOUS WHEN MAKING CHANGES IN YOUR CAT'S INSULIN DOSE WITHOUT CONSULTING YOUR VETERINARIAN. My recommendation is to always consult a veterinarian before making a change. Also, once a dose change is made, give your cat 3 to 4 days to adjust to the new dose before considering another change.
Here are some rough guidelines:
1.If ALL of the BG readings
are HIGH, an approximate 10% INcrease in the insulin dose can be made.
2.If ALL of the BG readings are LOW, an approximate 10% DEcrease in the insulin dose can be made. If your cat is symptomatic, the dosage may be reduced further.
3.If the readings are HIGH only before insulin is given (or around the time of the morning meal) OR at the time the insulin duration is almost over, do NOT change the dose.
4.If the readings are HIGH at BOTH the morning and evening readings, consider Somogyi effect and DECREASE the amount of insulin.
Here is a table taken from an article in Veterinary Medicine, Nov 1995, by Gary Norsworthy, DVM: 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:
<150 mg/dl, reduce the
dose of Insulin.**
150-250 mg/dl, don't change the dose.
>250 mg/dI, several possibilities exist:
The cat may have been stressed when the blood glucose curve was performed.
The Insulin dose may be too low.
There may be an insulin problem (inactive insulin, insulin not mixed property, poor injection technique, poor absorption).
Insulin resistance may be occurring due to concurrent disease (systemic Illness, hyperthyroidism, hyperadrenocorticism, acromegaly) or insulin antibodies.
*Based on twice-daily dosing
**The nadir also should be below 100 mg/deciliter.
I cannot overemphasize the importance of consulting with your vet before making insulin changes. A mistake on your part could result in the death of your pet. Use the information on this page only as a guideline to understand the changes that your vet suggests.
Adjusting Insulin Dosages Using Urine Strip Results
Some people prefer to check glucose levels in their cats by testing the urine. Note that once the blood glucose is within the normal range, no glucose will show up in the urine. Also, please be aware that urine strips cannot tell you if your animal is becoming HYPOglycemic. Once your pet is well regulated, you may want to consider switching to home blood glucose testing. As always, please consult with your veterinarian.
In the initial stages of therapy the usual recomendation is to test three times per day. After regulation has been achieved, routine tests before the morning meal two to three times weekly will be enough to let you know if your pet is staying regulated.
Suggested times for doing urine glucose tests are:
1.Directly before the morning
meal (e.g. 7-8 a.m.)
2.Around the time of the 2nd meal (e.g. 3-4 p.m.)
3.In the evening when the insulin action declines (familiarize yourself with the insulin curves for your particular type of insulin so you will know when to expect this decline, usually 9-10 p.m. if you give an insulin shot in the morning)
From the results of urine strips, the insulin dose can be adjusted. PLEASE DO NOT MAKE RADICAL CHANGES IN YOUR CAT'S INSULIN DOSE WITHOUT CONSULTING YOUR VETERINARIAN. Also, once a dose change is made, give your cat 3 to 4 days to adjust to the new dose before considering another change.
What is a blood glucose curve?
A blood glucose curve is periodic testing of the blood sugar levels to see what effect the insulin is having. The values will ALWAYS vary; you are looking for values outside of acceptable ranges, which will be approximately 100-200 or maybe up to 300 depending on your cat.
Once you're getting fairly consistent results with blood glucose (BG) levels, just spot check now and then (once or twice a week at one or two times in his cycle that you feel will give you the most valuable information). Or, of course, if your cat acts strangely and you want to know if it's a hypoglycemic reaction.
If your cat is well-regulated (staying within the desirable range of blood sugars), you only need to do a mini-curve once a month or so.
A good mini-curve is:
1.An hour after eating, to determine how much of a postprandial (after eating) rise in blood sugar is occuring.
2.At the expected time of insulin peak action, to determine the lowest BG.
3.Halfway between (2) and the next injection, to determine how well the insulin is controlling the BG.
4.Just before the next injection, to determine the duration of insulin effectiveness.
How much drinking/peeing is too much?
From "The 5 Minute Veterinary Consult: Canine and Feline":
Cats - urine output greater than 40 ml/kg per day.
Dogs - urine output greater than 45 ml/kg per day.
Cats - water intake greater than 45 ml/kg per day.
Dogs- water intake greater than 90 ml/kg per day.
For folks in the US, the (rounded) metric conversion is:
30 milliliters = 1 fluid
ounce (2 Tablespoons)
1 kilogram = 2.2 pounds
In general terms, that would mean, for example, that a normal 4.5 kg (10-lb.) cat would be expected to have a typical daily urine output of around 180 ml (6 fluid oz.), or less. A typical daily water intake would be in the area of 202 ml (6.75 fluid oz.), or less.
Of course, each individual cat's normal input/output will probably vary a bit from this. But at least it gives us some kind of idea of what is considered typical water input/urine output.
Help! My Cat is Peeing Everywhere!
Urinating outside the litter box occurs frequently in diabetic cats, especially in the early stages of the disease. If your cat's blood sugars are not yet regulated she still has polydipsia (drinks too much) and polyuria (pees too much). She may just not be able to hold the urine until she can make it to a litter box. Another problem may be a urinary tract infection making it difficult for your cat to hold her urine. Have your vet check her for an infection.
Elimination near the box indicates the rejection of the litter or box. Urinating elsewhere is probably a preference for the location or substrate.
Here are some suggestions:
Have lots of litter boxes! Have a minimum of two, more if your house is large. If you have more than one kitty, make sure you have one box for each additional kitty, preferably in separate rooms. You might also try giving him a choice of another brand of litter, cats really do have preferences. Keep them clean. You can use deodorizers, but overuse can result in rejection of the box. Cats hate to pee in dirty litter boxes, so of course when they have polyuria, the litter boxes seem to always be dirty. This may mean changing or scooping the litter every day (or even more), but it beats the alternative.
Does your cat always return to the same areas to pee? If so, be aware that even a healthy cat who has been peeing outside the litter box may return to the scene of the "crime" and continue to pee there, as it now smells like a place to urinate. (A cat's sense of smell is so much more sensitive-- you may not smell it at all, but she does...) You may need to reclean these areas with an enzyme treatment that actually eliminates any residue. And if the pee was on the carpet, you may need to lift the carpet and treat the pad underneath.
If your cat is really a problem, you may want to confine her to an easily cleaned, no carpets portion of the house until she gets better regulated, and/or until you reclean any areas. (This way you can also test if the problem is with her diabetes and lack of regulation, or if these pee'd on areas are simply designated "litterbox" because they retain the pee smell and need to get recleaned.
Here are some reader suggestions for dealing with your pesky little cat:
A number of diabetic pet owners use and like Nature's Miracle, others have their favorites.. These treatments do not harm carpets, and are great to keep around to quickly care for accidents. They are great -- we buy them by the gallon!
2 liter club soda (minus 1/2 cup) add 1/2 cup white vinegar; soak the area with this solution, then wet a towel large enough to cover the area with solution and cover area. Walk on towel to pick up surface odor/stain. Replace with another towel. The first day you may need to replace the towel 2 or 3 times. When the towel comes up clean with no stain or odor the treatment is done. It is a pain but seeems to work - you might want to try a small area first. Good luck.
Most importantly, it will almost certainly just be a matter of time. Reward him with a little treat when you see him using the box. Put something perfumey (kleenex soaked in aromatic oil works really well) wherever his favorite "NO" spots are. Hang in there!
Cats hate banana and orange peels. Put these peels in the "no" spots (works well for keeping cats off the counters, too). There are also citrus based sprays that kill odors and help deter cats. They are a bit more attractive than banana peels laying around your house!
Melissa & Popcorn offer
the following suggestions:
1. Pull up the carpet where he pees and either (a): soak the padding in Simple Solution (or other enzyme-based odor eliminator) or (b): replace the padding (should be inexpensive)
2. If the cat box has a lid, remove it.
3. If the cat box is a "deep" one, get him a shallower one - some cats simply don't like to climb in. If he has any weakness in his back legs, climbing in might be difficult for him.
4. After soaking (and I mean drenching) the area with Simple Solution and allowing it to dry somewhat, put newspapers covered by a towel in the spot he likes to pee.
5. Check your cat a possible urinary tract infection.
6. Change litters.
7. After your carpet has dried from the Simple Solution, place a paper towels down over the area and douse with any citric scent (lemon oil, lemon juice - I heard that cats don't like citric smells, but I could be wrong).
8. Place the litter box directly over the area he pees on. Then, slowly move it to the desired location.
9. If at all possible, cut out the peed on carpet area and padding, replace it with new (patch it) carpet that matches somewhat and attach the pee carpet piece on the inside of the cat box.
HELP! My cat's back legs are weak!
One cause : Neuropathy is nerve damage caused by uptake of high levels of glucose.
Nerves, cells in the eye, and kidney cells are particularly sensitive to damage since these cells do not require insulin in order to take up glucose from the blood. Where blood glucose is very high in poorly regulated diabetics these cells take up lots of glucose which causes internal damage.
The only way to avoid this type of cellular damage in diabetics is to manage the diabetes such that blood glucose levels are as near normal as possible.
Many cats will improve tremendously when their blood sugars come under control. In these cases, the hind leg weakness may be caused by electrolyte imbalances (e.g. low potassium levels) related to excessive urination. Also, diabetes that is not under control causes muscle wasting (diabetes is a CATABOLIC or "breaking down" disease) and your cat's hind leg problems may be due to extreme muscle weakness.
This is a common problem and a heartbreaking one. If the problem seems to come on rapidly, consider having a blood glucose curve done to make sure your cat is still regulated, and have a potassium level checked. And make your cat exercise!
How Much Insulin is Too Much?
The Cornell University Feline
Health Center has addressed the topic of high insulin doses in cats. Excessively
high insulin doses are
those greater than one to two units of insulin per pound per day. Felines who use more insulin than this should be evaluated more
intensively. Other diseases may be underlying or complicating the diabetes mellitus and as a result, necessitate high insulin
dosages. Problems with insulin injection, poor absorption or too rapid metabolism of insulin, or even insulin overdose are potential
causes of an apparently excessive insulin requirement.
Symptoms of Hypoglycemia
Symptoms of hypoglycemia
(dangerously low blood sugar) are, in order of * ascending severity * (not of
Immediate oral application of a glucose solution (1 gram per kg body weight) such as corn syrup (Karo), maple syrup, or honey by the owner can alleviate this condition. Rub the solution on the gums or place it underneath the tongue to prevent obstruction of the airway in the impaired animal. Following this emergency measure, food must be provided as the glucose solution has a short duration of effect. Food must be given repeatedly with intervals of 1-4 hours until the effects of the insulin have been eliminated.
Trust your instincts! If you are at all concerned that your cat is hypoglycemic, especially if the cat is shivering or worse, GIVE SUGAR!!! Temporary hyperglycemia (high blood sugar) will not harm your cat. HYPOGLYCEMIA KILLS.
If your cat is having convulsions
or a coma, it is imperative that you take your pet in to an emergency veterinary
clinic for intravenous glucose solution. Always call your vet if you have any
For those who need instructions on injections, or a refresher course, on injection technique, we present the following.
1.Try to establish a PLEASANT
You should be injecting at about the same time every day.
Begin with petting or grooming or maybe even a little high-fiber, low sugar treat. (Or a tiny amount of anything they love.)
Keep the syringe hidden or disguised. Cats do not have the clearest eyesight, so you have some leeway here. As long as the syringe is not initially in my hand (I hold it sideways by the barrel in my mouth!), Austin is OK with my approach.
If hiding the syringe while you play is too hard, consider using the CAPPED syringe to rub all over your cat. Austin likes to have his face scratched with it. I do have a little trouble getting him to leave the syringe alone once I uncap it for the injection, though. Monica tells us that she puts the needle where Tigger can sniff it a little. The insulin has such a strong smell and Tigger seems to enjoy making sure that he is receiving the right stuff.
2.Get on the same level as your cat: you down on the floor, cat up on a bed or counter, or in your lap. Don't assume a threatening posture (e.g. looming over the cat.)
3.Make sure you are comfortable and your body is in a postion relative to the cat that makes injection easy. For example, if you plan to inject in the neck with your right hand, make sure the cat is facing toward your left or at a right angle to you.
4.Keep your movements smooth.
5.Grasp the cat's skin between
your thumb and index finger (fingers about an inch apart) and pinch firmly to
tent the skin and provide some anesthetic. Most people use the skin from between
the shoulders up to high on the neck, but you can try the hips, too.
Make sure you can see the skin. Austin is long haired, so I try to brush aside his hair to expose a bit of his skin prior to the pinch. This is where he starts to get suspicious, but I often do the pinch several times before I actually inject.
Once you are ready to inject, try to be as quick and smooth as possible. (Practice makes perfect!) If you have more than one cat, consider going through this routine with the non-diabetic first, doing a pretend injection only, but letting your diabetic cat see the syringe near the other cat. Austin will get jealous of the attention being given to Eugene and comes running to me when I do this.
6.Make sure the bevel of the needle is UP. This ensures a clean, quick puncture instead of a drag through the skin.
7.Hold the syringe almost parallel to the cat's spine. You want the insulin to be injected just under the skin (subcutaneous) NOT intramuscular (IM) which hurts!
8.Do the puncture quickly. Most of the pain nerves are at the very surface of the skin, so once you get past them, things improve. And remember that firm pinch to help with anesthesia. Once the needle is through the skin you can slow down a bit.
9.Once you are through,
give the cats lots of hugs, kisses, praise, and maybe another tiny treat.
Tips and Tricks from Pet Owners
I have a friend who is an
RN, and she had advised me to hold the fluid-filled syringe in my fingertips
to warm up the insulin for a couple minutes prior to injecting it, as the insulin
temperature from the refrigerator is very bothersome to human patients and warming
it up makes it easier to take. Also, use the ultrafine needles.
We had a terrible time with
Scooter when we tried to inject using the 'tent' method, which was taught to
us by the animal health technician at the local vets office. On a subsequent
visit with the Vet, himself an owner of a diabetic cat, he displayed a different
technique which works VERY WELL with Scooter, and she displays much less reaction
and definitely less pain. The technique is to pinch some of the skin (for me
using my left hand) between your thumb and forefinger (trying to avoid grabbing
muscle underneath) and ROLL your hand sideways (for me, rolling my hand over
to the left) pulling the skin over your finger.. this makes the cats skin MUCH
TIGHTER than pinching it up into a tent, and the tighter the skin, the easier
the needle penetrates without pulling. The technique literally meant the difference
between night and day, success and failure in our commitment to do what needed
to be done to keep Scoots going. Just thought it worth sharing, some people
might find it makes the difference for them.
(Pat and Shelley and Scooter)
As you fill the syringe, it is important to make sure that there are no big bubbles in the syringe (some of the itty bitty ones just don't go away). This is crucial, considering the very small dosages that many of us are using 3 units from a 100 unit/mL product like Humulin, is only 3/10 of an milliliter; just a drop. You want to make sure that kitty gets the full dosage. Usually, pulling back on the plunger slowly, avoids big bubbles. If you get a bubble, push the plunger back in and try filling the syringe again. Sometimes, it takes more than one or two trys.
I highly recommend that
the syringe be used only once. The syringes are designed for single use (I used
to work for a company that made disposable syringes). It is the best way to
be sure that you are not contaminating your bottle of insulin with and that
kitty gets a fresh, sharp needle with each injection. Needles do get dull and
develop burrs which can make shot time a little more difficult. Used syringes
are best disposed of in a "sharps" container; drugstores that carry insulin
should have them and they are relatively inexpensive ($2-$3); just ask the pharmacist
for it. The filled containers can be turned into the vet for proper disposal
(incinerated, at least in California). A hospital or doctor's office may also
be willing to help with proper disposal.
I do have one trick my fiance
taught me about the injections (he's a physician so that has certainly helped!!):
Hold the syringe with your ring and middle finger and keep your index finger
on the "handle" by the plunger and use the syringe like a dart. Once the needle
is in it's a very simple thing to just lift your index finger onto the plunger
and inject! You may already know this, but it was news to me!! I'd never given
a shot and was more than overwhelmed at the idea of doing so!! This technique
has made things much easier and the syringe is kept very stable so it doesn't
hurt Isaac at all. You've also got a really good grip on the syringe so there's
no way to mess it up as long as you keep a little forward pressure on the syringe.