Hi, my name's Alice and I'm doing a PhD in the genetics of canine diabetes at the Royal Veterinary College. And today I'm gonna be talking about some tips for managing diabetic dogs and cats in clinical practise. So I'm gonna be talking through a bit of background about what causes diabetes in dogs and cats.
I'm only gonna be talking about diabetes in dogs and cats today. I won't be referring to any other species. I'll then move on and talk about some of the diagnosis, and some management, some monitoring tips, and a bit about managing some of those complicated cases.
It'll be a bit of a whistle stop tour, but hopefully this will be useful. So I'll start by talking a bit about the background of diabetes and causes. So, diabetes, and when I refer to diabetes going forward from here, I'm referring to diabetes mellitus, not diabetes in syphilis.
And the European Society of Veterinary Endocrinology has defined diabetes as a heterogeneous group of diseases with multiple etiologies characterised by hyperglycemia resulting from inadequate insulin secretion, inadequate insulatin inaction, or both. And it's one of the most common endocrine diseases in dogs and cats. So it's useful to talk a little bit about insulin and carbohydrate metabolism in dogs and cats in order to understand what leads to diabetes.
So insulin is a hormone which is produced in beta cells of the pancreas, and it's stored as a pro-hormone pro-insulin in the beta cells until closure of potassium ATP channels in the beta cells results in their depolarization and stimulates the release of insulin into the bloodstream. When it reaches target tissues, insulin causes the uptake of glucose into those cells, thereby preventing hyperglycemia. The action of insulin is antagonised by other hormones, including glucuron, cortisol and progesterone, which act to prevent hypoglycemia.
And these act together with insulin normally to maintain blood glucose, within the normal range. And this is important to prevent the negative consequences of either hyperglycemia, which leads to the clinical signs of diabetes or hypoglycemia, which we'll come on to a little bit later. So it's important to remember that cats are not small dogs, and there are differences in carbohydrate metabolism between these species.
Dogs are typically fed at mealtimes, once or twice or more often daily, and there's a post-perial rise in the blood glucose once they've eaten, when glucose is digested and absorbed, and that then leads to the release of insulin. Cats are less dependent on dietary carbohydrate for their energy, and they're in a constant state of leukanogenesis. Their blood glucose is more constant throughout the day and less likely to see the postprandial rise in blood glucose, although this can still occur in diets high in simple sugars.
The hormonal regulation of blood glucose to keep it in the normal range though is very similar between both species. So, specifically in dogs. There are marked breed differences in the risk of canine diabetes.
Certain breeds are highly predisposed, for example, samoyeds and certain terrier breeds, whereas diabetes is hardly ever seen in some other breeds such as boxers or German shepherd. The dogs? And these breed differences suggest.
Excuse me. And these breed differences suggest that there are genetic factors involved. In the development of the disease, as well as environmental risk factors.
Exactly what those genetic risk factors are is a work in progress. The causes, the disease processes leading to diabetes can be broadly classified into insulin deficient diabetes. For example, immune-mediated B cell destruction like occurs in human type 1 diabetes.
And B cell destruction as a result of pancreatitis or other causes. And the second category is insulin resistant diabetes. So this might result from some of those hormones that we discussed which antagonise the effect of insulin.
It's often said that dogs have a syndrome more similar to human type 1 diabetes and cats more similar to type 2 diabetes. But it's likely that diabetes in dogs has different causes or underlying disease processes between different breeds and even between individuals. So, there's not strong evidence to suggest that it's a type 1 syndrome in all cases.
Cats, however, on the whole, do seem to have a syndrome more similar to type 2 diabetes in humans, resulting from a combination of inadequate insulin secretion and insulin resistance. Some of the factors that increase the risk of diabetes in cats include older age, being overweight, reduced activity, males are much more predisposed than females. Certain drug treatments which antagonise the effect of insulin can also lead to diabetes.
And certain breeds are predisposed, for example, Burmese in Europe and Australasia. So I'll come on to talking a little bit about the diagnosis. And it's often said that diabetes mellitus is fairly straightforward to diagnose because of the characteristic clinical signs and the simple diagnostic tests.
So as always, it's important to consider the signalments, so for example, breeds that are predisposed and the fact that diabetes is more likely in older animals, both older dogs and older cats. And then the characteristic clinical signs include polyuria and polydipsia because hyperglycemia above the renal threshold will lead to osmotic diuresis causing this polyuria and compensatory polydipsia. It also, because of the lack of insulin and the inability for glucose to be taken up into cells.
Causes weight loss or muscle wasting, and polyphagia as well. So animals are typically drinking a lot, weighing a lot and eating a lot, but may also be losing weight. Likely also to be losing weight.
When it's severe, it can also cause inappetence, lethargy, and vomiting. And when it becomes chronic, it can lead to peripheral neuropathy and also cataracts, and cataracts can be quite common in dogs, diabetic dogs. So according to the American Animal Hospital Association, clinical diabetes is diagnosed on the basis of persistent hypoglycemia, persistent glucosuria, and the presence of characteristic clinical signs.
So once we've noted the clinical signs. It's common to carry out blood glucose, which can just be done on a handheld glucometer to demonstrate hyperglycemia. Typically fasting hyperglycemia or repeated measures to demonstrate that it is a persistent hypoglycemia.
And urinalysis will be carried out and often a urine dipstick is sufficient in order to demonstrate persistent glucosuria. Some other tests can be carried out, for example, serum, biochemistry, and fructosamine or further evaluation, although these aren't always necessary in order to demonstrate the persistent hypoglycemia, glucoseuria if you've got consistent, characteristic clinical signs. So some differential diagnoses to bear in mind for hyperglycemia include stress.
So stress hyperglycemia can be a particular problem in cats, especially in clinic settings. And this should be ruled out by demonstrating a persistent hyperglycemia either by repeated measures once cats are settled, either at home or in a, in a kennel, or. Through measurement of fructosamine to demonstrate a lasting hypoglycemia.
Other conditions resulting in hyperglycemia may result from those hormones which counteract the effect of insulin, these can be drugs being given or . Endogenous hormones, pancreatitis and other rare causes as well. So one particular presentation that occurs in some diabetic patients, which it's important to be aware of, is diabetic ketoacidosis.
So this is a life threatening condition and should be treated as an emergency, and it can occur either during treatment or this may be the first presentation of a diabetic patient. So insulin is required for the metabolism of ketones. But when there's a deficiency of insulin.
And ketoacids accumulate, this can lead to the metabolic acidosis, and then patients will enter this diabetic ketoacidosis, with clinical signs including vomiting, depression, weakness, anorexia and collapse. Lab findings typically will show the hypoglycemia, ketonemia, ketonuria, and electrolyte abnormalities which indicate metabolic acidosis. But be aware of false negatives on urine dipstick for ketones because these urine dipsticks won't always pick up beta hydroxybutyrate.
Another thing to bear in mind is that observing ketones on your own dipstick doesn't always mean that these animals are in metabolic acidosis. So treatment consists of fluid therapy to correct electrolyte abnormalities, as well as administration of soluble rapid acting insulin and later IV glucose if required to prevent hypokalemia. Practises will typically have a protocol for dealing with diabetic ketoacidosis or an emergency manual can be consulted for precise treatment protocols of this condition.
And it's important to remember that diabetic ketoacidosis often occurs because of a precipitating factor. For example, if a patient develops a urinary tract infection or something upsets the glycemic control, and so correction of these factors is important for resolving the ketoacidosis. So moving on to discuss the management of your diabetic patients, and management is long term, so it's gonna be a long term condition for owners to manage.
And so it's really important to set owner expectations and to establish good communication with them so that they are happy with the treatment. And this will help to ensure that good management continues long term, and the owners are happy, with the treatment going forward to reduce problems later down the line. So it's important to be clear with owners that good control of diabetic patients is possible, but complications are not unlikely so that they need to be aware of this, they can be picked up on early, but also not to be surprised if they occur, and they should be reassured that these complications can be reassured, sorry, can be resolved, .
So, and good control can be restored. So routine is really important in managing diabetic patients. This should be incorporated into the owner's routine, it can be helpful sometimes to talk to the owners about what their routine is and discuss with them about how to fit the .
Diabetic management routine in with their routine, and so it's less of a burden for them, and also encourage them that regular monitoring is important, both to pick up on any problems early and just to keep a record of how their diabetic control is early. So this ongoing good client communication can be really important for starting treatment well and ensuring that any complications that occur later down the line. Are less of a a a problem both for the animal and for the owner.
The aims of management should be kept in mind right from the start. So we're aiming to reduce clinical signs of the condition, and also reduce complications, which includes avoiding hypoglycemia. And achieving both of these things will improve the quality of life.
Of both the animal and the owner. So one particular treatment aim in cats is diabetic remission. So diabetes in cats is a potentially reversible condition if there are functional beta cells remaining, and this should be the aim of treatment when it's started in most cases.
So starting an appropriate treatment with insulin early to maintain optimal glycemic control throughout the day, including, incorporating a suitable diet into that. To help with maintaining optimal glycemic control is the best way to achieve remission, and this can be a real incentive for owners to control the animal diabetes well, because obviously it would be advantageous for them if they didn't have to administer the insulin anymore. So, .
This is a real incentive for owners to treat the diabetes and establish a good routine, hoping that their cats can enter remission and no longer need insulin treatment. It is less likely to occur in chronic cases or if there's a concurrent untreatable condition, however, so if that is the case, then aiming for diabetic remission is, is probably unrealistic. Remission is also quite rare in dogs.
This is because the prolonged hyperglycemia leads to glucose toxicity, which is damaging to beta cells, and therefore it exacerbates, the problem and there's less likely to be functional beta cells remaining. It can occur in some cases that are picked up early, for example, those with, dire form of diabetes, due to the hormones in dire or during pregnancy. So early neutering of dogs, of female and tired dogs.
Which have a tress form of diabetes can result in remission, it is early correction of the blood glucose, however, this is seen less commonly than in cats. So insulin treatment by injection is the mainstay of treatment of diabetes in dogs and cats. There are different types of insulin available or different formulations with different characteristics.
So neutral or soluble insulin is the most rapid acting form, and this should be used in treatment of diabetic ketoacidosis, but not for longer term treatment of diabetes. Then we have the intermediate acting. Insulin form and lente forms, and also the longer acting forms, including, the protamine zinc insulation, which insulin formulation, which has a delayed onset and a longer peak and duration of action.
There are other longer acting forms as well, for example, deimy and glargine, but these aren't licenced in the UK and are used less commonly. They are, however, used more commonly in other countries, so, it's important with insulins to check which ones are licenced, . In your particular country if governed by sort of regulatory requirements that need these products to be licenced.
For example, in the UK you might have to use neutral or soluble insulin off licence in order to treat, diabetic ketoacidosis. It's the only human forms available. So, for example, .
In dogs fed twice daily, it may be that a lentate insulin administered twice daily around the time of feeding is effective. And in cats, because of their, their less likely to have that protoranio glycin rise in blood glucose and more consistent blood glucose throughout the day, protamine zinc insulin, which has a longer peak in duration may be more suitable. But, it's very individual and so it's important to find out which .
Insulin treatment is best suited to that particular patient. Once you've started a particular protocol, it may be that it needs changing, later down the line, so it's important just to make. Owners are aware of that as well, that the dosing product that you start with may not be optimal for treatment, long term.
And also really important to check that the syringe and the pen are calibrated for the type of insulin that you're using, in order to ensure, correct dosing using, those, dosing products. Diet is also a really important part of managing diabetes in dogs and cats. So diet is important for optimising body weight, and, and a routine with feeding, balance with.
Exercise is really important to help maintain that optimal glycemic control because of the impact of food and exercise on blood glucose. So try and encourage owners to establish a routine early on. Some cats will need to be fed ad lib if they won't conform to feeding, once or twice a day.
And that's OK so long as it, remains, routine for them and that's, that's optimal for managing them. So the diet needs to be palatable. Regular intake, like I said, is really important and the best way to ensure that animals eat what you give them is to ensure that it's, it's palatable.
It should also be low in simple sugars to reduce the risk of that, postcranial rise in blood glucose and complex carbohydrates can ensure a more gradual absorption, which is also helpful for avoiding peaks and troughs in, in the blood glucose. High protein is important because of the muscle wastage and weight loss which we talked about previously, and a moderately increased fibre and reduced fat levels have also been found to be beneficial. So some owners will inquire about oral hypoglycemic agents, for example, those used in the treatment of human type 2 diabetes.
These have been investigated in dogs and cats, and some have found to be, have been found to be useful as an adjunct treatment, particularly in cats, however, None are currently recommended for use in preference to insulin, and so only you should be encouraged that insulin and diet are the majority of treatment for dogs and cats, but if anyone does want more information on these, there are there's more information the references at the end of the presentation. Now in any patient receiving insulin treatment, there is a risk of hypoglycemia, and owners should be reassured that although this can be very severe, it's also treatable. So owners should be made aware of signs to look out.
For have sugar or sugar solution or honey available, and they should know what actions to take. Some owners will be very worried about hypoglycemia as a potential risk and so they should be sort of, you should make sure that they're happy with recognising it and what action they should take if if it does occur. Clinical signs will vary with severity, so if mild, might result in some aggression, lethargy, increased vocalisation, just not quite being themselves, and when it's more severe will lead to a weakness, a texture, and seizures.
And so treatment aims to store glycemia. If animals are able to eat, then they should be fed. Otherwise, sugar solutions should be applied to the mucous membranes, but in more severe cases will require admission to the clinic and IV dextrose solution to correct that blood glucose.
So a bit about monitoring of diabetic patients. So the initial stabilisation, like I said, it's really important to establish good client communication and ensure that they are happy, try and get them to start at home monitoring checklists. Reassure them that no single protocol is effective in all cases, like we discussed.
So, it's mainly adjusting as you go along. Prompt ovarian hysterectomy for entire few more dogs will help to establish control of the diabetes. It can be very difficult to establish good control in entire females which aren't neutered.
Any concurrent conditions should be treated, for example, urinary tract infection or dental disease. And they should also be gradually started on a suitable diabetic, diet as soon as possible. Insulin treatment can be started at home or in the clinic, but they should be closely monitored for hypoglycemia.
Blood glucose curve is recommended in the 1st 24 hours, but not to ensure that blood glucose control is perfect over that time, but just to monitor for any occurrence of hypoglycemia. And in the longer term, the owner records of how they're doing and how the animal's doing is really helpful, to pick up on any problems early. Blood glucose curs are really important for monitoring.
Serum fructosamine gives us a view of a longer term glucose control, but we're aware that it will average out peaks and troughs. So if periods of hypoglycemia are occurring, but these are brief, it may not be picked up. By the fructosamine, and urinalysis can also be useful, but generally shouldn't be used as a sole monitoring method, it can be useful, but the above factors are also, should be used alongside this.
So blood glucose curves are really important for some aspects of control of diabetics, as it indicates blood glucose fluctuations throughout the day. But it's important to think about what the blood glucose curve is being used for in a well-controlled patient with, where the aims of treatment are being met. Glucose cles may not be necessary, but they are useful for the initial stabilisation or if aims of treatment are not being met or after any particular dose adjustments.
It can be carried out at the clinic or at home if the owner is happy and competent, if if the the animal is more relaxed at home, to give a more accurate reading. And typically it's carried out using a handheld glucometer with measurements every 1 to 2 hours. Although continuous glucose monitoring devices are becoming more common, and can give more of a, continuous picture of how the blood glucose is fluctuing with, throughout the day without the 1 to 2 hour gaps.
So blood glucose curves and clinical signs might indicate that a change in insulin dose is required, and dose adjustments should be gradual and allowed to stabilise for a few days before a blood glucose curve is carried out to assess whether the dose adjustment has been effective. Be aware of this moja effect. So this is when too high an insulin dose causes a hypoglycemia and then a rebound rebound hyperglycemia because of compensatory mechanisms.
So in this case, because it, the insulin dose is causing a hypoglycemia. The Insulin dose is too high and therefore should be reduced. But just be aware that there's sometimes the hypoglycemia is not always observed on the glucose curve.
Sometimes only the hyperglycemia is seen, and then the reaction might be to, increase the insulin dose, but that would be the wrong reaction to treat this, physiological effect. And lastly, just er coming on to management of complicated cases. So as I said, there can be some complications in managing diabetic patients.
In fact, it's not unusual and so owners should be made aware and are really kept on board throughout the investigation and management of any particular complications or instability. So perhaps if the treatment aims are not being met or if they have a very, High insulin requirement, then this should be investigated. So as always, it's important to take a thorough history and clinical examination and to use this to create a problem list, then identify differential diagnoses, and then plan how to rule in and rule out each of the differential diagnoses and keeping owners on on board and informed with this.
Can be really key as you kind of work out what's going on, what might have destabilised their diabetic patients, diabetic pets, control. And that way, they might feel reassured that they're able to get on top of it. Cause owners can be quite frustrated sometimes if good control suddenly, suddenly is gone and they're not sure why.
So working through this with them can help to, keep those good client relationships and sort of positive outcome for, animals and their owners. So some causes of diabetic instability can include management factors, so check that owners are happy that they're storing and administering the insulin correctly. They should be keeping a good log at home and check that periods of hypoglycemia aren't being missed.
Check that they're on a suitable diet and they'll say that they're able to stick to a routine. Sometimes things like a change in the home environment, even if everything else is consistent, it might cause, destabilisation of diabetic patients. So, ask owners about any particular changes.
Patients can also respond. Differently to particular insulin treatments, for example, they may not absorb it as well or as quickly, . So bear in mind those individual patient factors.
Infection or inflammation, for example, development of a urinary tract infection or dental disease or, other, these hormones which antagonise the effect of insulin, for example, exogenous drug treatment or endogenous hormones, can also cause a destabilisation. So I'll briefly talk about three potential concurrent diseases which can be complications for the management of diabetes. So pancreatitis, the first one, is suspected to be underdiagnosed in diabetic dogs and cats, partly because it's difficult to, identify and diagnose, but should be considered, and tested for in all unstable patients where other factors have been, ruled out.
And because of the flare-ups of pancreatitis, it's likely to result in fluctuating insulin requirements. For example, a flare-up in the pancreatitis would lead to insulin resistance and therefore need a higher insulin dose so cause these changes in . Insulin requirements, and appropriate management of the pancreatitis, through, pain relief and fluid therapy and appropriate diet will help to manage this complication and restore control of the, the diabetes.
Secondly, Cushing's disease, so hyperrealcorticism is more common in dogs, but, common, probably underdiagnosed in cats. And as we talked about before, the cortisol causes insulin resistance, and therefore, in hyperadrenal corticism, you're more likely to see a persistently elevated insulin requirement. And so, the the, diabetes is life threatening and so that should be treated first, and ensuring that the diab the control of the diabetes gets started will then help with diagnosis of.
The hypoaddrenocorticism, which is more challenging to diagnose than diabetes. If you do suspect the hypoaddrenocorticism in a diabetic patient, look for clinical signs which can be attributed to the Cushing's disease, alone, which can't be explained by the diabetes, for example, or potbelly or alopecia. And lastly, I'll just touch on acromegaly in cats.
So this is a common cause of insulin resistance diabetes in cats. So for example, in those with a very high insulin, requirement, this should be considered. The growth hormone, most commonly produced by an adenoma of the pituitary causes insulin resistance, resulting in this high insulin requirement.
And although physical changes may not all be, may not always be visible, it should be always kind of in the back of your mind when, treating diabetic cats as, as, as a possibility. Diagnosis requires, . Demonstration of elevated growth hormone or IGF one, and ideally demonstration of this pituitary mass on CTR MRI, but this isn't possible in all cases, and so it's considered sufficient for diagnosis if there are consistent clinical signs and the demonstration of elevated growth hormone or IGF one.
So we just bear acromega in mind when treating diabetic cats if they have a a consistently high insulin requirement. And that's it, just to say, enjoy managing your diabetic patients. It's a long term management process and it can be complicated and difficult, but it can also be really rewarding and owners can be particularly happy when you stop their diabetic dog being all over the carpet.
So these can be really rewarding cases, to manage and take forward, so, with the right approach, enjoy managing them. These are my references if anyone wants further information about anything I've talked about today. And I'd just like to say thank you to the Royal Veterinary College, to my PhD supervisors, and also my PhD funders, and also for the invitation to speak today.
Thank you.