TRENDS IN YOUR INBOX: Start Your Diabetic Cat Patients Off on the Right Paw
Start Your Diabetic Cat Patients Off on the Right Paw: Set Your Clients and Patients Up for Success
Each month in NEWStat, we highlight an article from the upcoming issue of Trends magazine.
When I tell people I’m a veterinarian (which we all try not to do, right?), people usually respond with that happy “awwww” noise. But when they find out I’m a feline specialist, I’m usually greeted with a polite silence or maybe even a confused “why?” Even veterinary colleagues seem to be frequently baffled why anyone would want to work with just cats. And I get it. Cats can be difficult, sharp, and ungrateful. Throw a complex disease like diabetes into the mix, and it can drive anyone a little nuts. I’m going to give you some pointers on how to set your clients, your staff, and your patient up for diabetic management success.
The Big Question: Does This Cat Need Insulin?
What? The cat is diabetic. Of course he needs insulin, doesn’t he? The answer is a solid “maybe.” Taking a deeper dive into how long the cat has had clinical signs and symptoms can be helpful in making the decision as well as knowing what a particular cat has been eating. A pudgy cat who has only really had clinical signs for a short time and who only eats dry food is a great candidate for trying a diet change. Eliminating dry food and minimizing carbohydrate intake in a dry-food–junkie cat can reverse the diabetic changes and allow that cat to go into remission. If you decide to start with a food change prior to starting insulin, it is imperative that you follow that cat closely—weekly is best—to see if clinical signs are resolving and the hyperglycemia is being eliminated. If clinical signs and hyperglycemia persist despite carbohydrate restriction, the cat must be started on insulin.
OK, So What Kind of Insulin?
The three main insulin choices for cats are insulin glargine, protamine zinc insulin, and porcine zinc insulin. I personally start all new diabetics on glargine, as do the rest of the authors of the 2018 AAHA Diabetes Management Guidelines for Dogs and Cats. When comparing insulins, factor in the cost per unit, the likelihood of achieving diabetic remission, and your own comfort level. Although it may be tempting to choose the least-expensive insulin, remember that starting one insulin, then having to change to a new one, may negate any financial gains; it also puts the cat at risk of diabetic complications. And don’t forget to factor in the frustration of the owner who wants her cat better now!
Client Education: It’s More than Injection Instruction
The appointment to go over how to administer the insulin may be one of the most important visits your staff ever has with a client. Did you catch that? Your team members can be empowered to help your clients understand the entire diabetic situation. Administering the insulin is the tip of the iceberg. It is crucial to make sure that the client understands how insulin works, what hypoglycemia is and what it looks like, how to monitor water intake and urine output, and most of all, what to do if a problem is identified. Many people are taught to administer insulin without being told how it works. Because of that, when they think the cat is having a diabetic problem, their instinct is to give more insulin. We all know where this can lead. Leverage your staff members and allow them to teach your clients in simple terms. Our clients don’t care about the pathophysiology of ketosis; they need to know that insulin lowers blood sugar.
Make sure to discuss how to handle insulin properly. Owners should know how often insulin needs to be replaced. In addition, one of the most important conversations to have with the owner is what this cat should be eating. There is a much greater chance of getting the cat well regulated, or even into remission, by eliminating as much carbohydrate intake as possible. This may include a prescription diet, but that is not an absolute necessity. Be aware that changing from a high-carb diet at the same time as starting insulin causes significant changes in glucose levels. The cat should be monitored very closely for signs of hypoglycemia. Also note that many cats will do better if they are fed smaller, frequent feedings.
To help your staff become more comfortable, consider having them take the AAHA Diabetes Educator Certificate Course. It’s a great investment in your staff and can help improve their confidence levels.
OK, so you’ve done a great job diagnosing this cat, choosing treatment, and your staff has helped make the client comfortable with living with a diabetic cat. But, as your staff has so effectively educated your client, giving the insulin is just the beginning.
One of the most important things the owner can do is keep a diabetes journal. There is a sample log in the 2018 AAHA Diabetes Management Guidelines for Dogs and Cats, or your client can make her own at home. A checklist showing when the insulin was administered, how much, and who administered the insulin is important as well as a general comment about how the cat is feeling that day. Is the appetite returning to normal? Are there fewer or smaller urine clumps in the box? A bonus is if the owner is able to accurately measure weight (within ounces or tenths of a pound) on a weekly basis. Depending on the client, that may be the only monitoring she is comfortable doing.
In a perfect world, the owner would be willing and able to monitor glucose levels at home. Spot checks on glucose levels are best used only to monitor for hypoglycemia; a single high reading doesn’t give enough information about overall regulation to make insulin dosing changes. Even cats who have spot-checked glucose levels greater than 400 during the day may be getting into normal range or below normal range at other times. Do not increase insulin doses based on a single blood glucose reading.
An accurate blood glucose curve can be invaluable for adjusting insulin doses. We are all aware of the pitfalls of in-hospital blood glucose curves and the inaccuracy of these curves in so many cats. The travel to the hospital, the repeated poking, the cage, the noise, and the bustle all contribute to significant stress hyperglycemia. However, home glucose curves may not be that much better. Cats are creatures of habit who thrive on routine. Trying to do a blood glucose curve at home may end up being incredibly stressful. If the owner has to find the cat, fumble around with getting a sample, and disturb the cat again in another few hours and projects her own stress and nerves onto the cat, the odds of getting accurate readings decreases. There is a place for home curves, but remember to interpret the readings as part of the whole picture of the cat’s diabetic state.
An underutilized tool for monitoring diabetic cats at home is measuring urine glucose levels. Urine glucose test strips, available at local pharmacies, can provide some insight into how well a cat is regulated. There is a useful chart in the AAHA guidelines, but the main takeaway is that if the urine glucose is negative, the cat needs to be monitored carefully for hypoglycemia or overregulation. If the urine glucose remains at the highest level, the cat needs to be reevaluated for increasing the insulin dose. Urine glucose levels in the midrange can be harder to interpret, but they are still useful in putting together the whole picture of diabetic regulation.
One of the coolest things to come along for diabetic patient monitoring is not approved or calibrated for animals. However, it gives us a valuable look at blood glucose trends in the animal. The FreeStyle Libre system, a continuous glucose-monitoring system developed for human diabetic patients, provides real-time glucose readings with a handheld reader. A small sensor applied to the cat just lateral to the shoulder blades stays attached for up to 14 days. The owner scans the cat at least two to three times a day, but the reader stores continuous glucose readings. This device is a game changer. Besides being just plain fun to use, it allows us to have glucose-level information for times we would never have had otherwise. For example, one patient of mine seemed to be doing pretty well, but when we placed a sensor on her, we realized that her blood glucose was dipping every night at about 2 a.m. Further investigation led us to reduce her insulin dose, and she improved dramatically. Again, this device is not specifically for animals, but it can be a very effective tool to help in overall diabetic management. It should not, however, be used as your exclusive means of monitoring.
Looking at the big picture is important when monitoring your diabetic cat patients. Cats are notorious for not following the rules. Discordant monitoring results in cats really aren’t that unusual; a clinically well-regulated cat may have elevated fructosamine. A cat with fructosamine in the 300s may not clinically seem well regulated. A minimal amount of glucosuria is OK. In the hospital, a blood glucose curve that doesn’t curve is not the end of the world. You absolutely cannot make insulin dose-change decisions based on one monitoring parameter. It is imperative to have an in-depth conversation with the owner: Is the cat eating more normally (calculate the calories that cat is eating)? Is he less polydipsic? Is his weight stable (maybe he’s gaining a little initially)? If there was any neuropathy to start, is it resolving?
As an example, we recently saw a cat in hypoglycemic crisis on emergency from another hospital. His insulin dose had been increased by 40% based solely on a fructosamine measurement of 540. He was not polyuric, polydipsic, or polyphagic, he was feeling good, and he had gained a little weight. Clinically, the cat was doing extremely well. After a few weeks on the new dose, he was near death, seizing. After 48 hours in the hospital, he was able to go home, but that was a scare (and bill) that the owner didn’t need.
Feline diabetics do not need to be as tightly regulated as humans need to be. It would be great if they were, but in reality, this is not usually the case. Thankfully, cats are less likely to have the catastrophic consequences of less-than-perfect regulation. Remission in cats is possible and is a realistic goal. At minimum, the goal of regulating diabetic cats is to minimize their clinical signs, improve the cat’s quality of life, and maintain the owner’s quality of life.
Remember that managing diabetic cats is truly a group effort, requiring the doctor, the staff, and the owner all to communicate well. Make sure that you consider all the pieces of the puzzle when making treatment decisions; this will make everyone’s life easier as things go forward. But most of all, know that you are not alone. Don’t be afraid to reach out to a boarded feline specialist or internist for help. It takes a team to help these cats, and when you get things right, the results are pretty sweet.
Renee Rucinsky, DVM, DABVP, is a graduate of the University of Missouri, a board-certified feline specialist, and owner of AAHA-accredited Mid Atlantic Cat Hospital. She is a frequent speaker on feline endocrinology, geriatrics, and complex disease management. When she’s not wrangling cats or laughing with her staff, you’ll find her outdoors on her bike or in the woods with her dog, who shares her philosophy that things are always more fun when there is mud involved. Rucinsky is always available to chat about diabetes or whatever cat things are on your mind, and can be reached at [email protected].
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