Best Practice

Guidelines

Feline Diabetes Mellitus

Basics
Definition

Diabetes mellitus (DM) refers to an absolute or relative insulin deficiency leading to hyperglycaemia and a
reduced ability of tissues to utilise glucose. This causes an array of different clinical signs.

Pathophysiology

Type 1 DM: Sometimes called ‘juvenile onset diabetes’ – caused by immune-mediated destruction of
pancreatic β-cells. While the most common form of DM in dogs, it is very rare in cats.

Type 2 DM: Sometimes called ‘adult onset diabetes’ – caused by peripheral insulin resistance, generally in
combination with pancreatic β-cell dysfunction. Most cats appear to suffer from this type of diabetes.

Type 3 DM: Sometimes called ‘secondary diabetes’ – where diabetes is secondary to another endocrinopathy
(e.g. acromegaly) or drug therapy (e.g. progestogens) that cause insulin resistance.

Prolonged hyperglycaemia itself may contribute to both insulin resistance and impaired β-cell function
(‘glucose toxicity’). Diabetes may be complicated in some cats by the presence of pancreatitis or other
concomitant diseases.

Systems affected

• Pancreas – reduced numbers and/or impaired function of β-cells

• Peripheral tissues – impaired ability to utilise glucose effectively, hyperglycaemia
• Increased production and utilisation of ketones as an alternative energy source

Genetics

Male cats are predisposed to DM as they have lower insulin sensitivity than females. Burmese cats are at a
higher risk of DM.

Incidence/prevalence

The prevalence in first opinion practice is ~ 0.2-0.5%

Geographic distribution

N/A

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Signalment
Species

Cats

Breed predisposition

Seen in all cats, predisposition in Burmese

Mean age and range

Prevalence increases with age, mainly cats >7 years old.

Predominant sex

Males, but females also affected

Signs
General comments

Clinical signs vary according to the severity and duration of disease.

Historical findings

• PU/PD (due to glucosuria-associated diuresis –may not always be obvious to owners)

• Weight loss
• Lethargy
• Increased appetite
• Less common signs include:
- Dehydration
- Plantigrade stance (diabetic neuropathy)
- Weakness
- Apathy
- Anorexia and vomiting (potentially with diabetic ketoacidosis)

Physical examination findings

• Variable body condition (from obese to thin)

• May have large bladder (diuresis)
• May be dehydrated
• May have ketotic odour to breath
• Other findings may reflect underlying or concomitant disease

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Causes

With type 2 DM there is usually pancreatic amyloidosis caused by deposition of amylin (a counter-regulatory
hormone co-secreted with insulin, that is amyloidogenic in humans and cats). This is partly an age-related
change but is much more severe in cats with DM and contributes to β-cell dysfunction. Insulin resistance
is also important (obesity and inactivity often contribute significantly). Other diseases may affect β-cell
function (e.g. pancreatitis, immune-mediated destruction) or cause insulin resistance (e.g. acromegaly,
hyperadrenocorticism, glucocorticoid or progestagen therapy).

Risk factors

Age, gender, obesity, inactivity, neutering (probably related to obesity), breed (Burmese)

Diagnosis
Differential diagnosis

• Hyperglycaemia: stress hyperglycaemia

• PU/PD: CKD, hyperthyroidism, hypercalcaemia
• Weight loss: CKD, hyperthyroidism, neoplasia, GI disease
• Polyphagia: hyperthyroidism, GI disease

CBC/Biochemistry/Urinalysis

• Hyperglycaemia
• Usually increased serum fructosamine
• Glucosuria
• DM is a risk factor for urinary tract infections

Other lab tests

• Acidaemia may be present

• Ketonaemia and ketonuria may be present
• Elevated feline pancreatic lipase immunoreactivity may be present with pancreatitis

Imaging

• Abdominal ultrasound valuable to look for pancreatitis

• Ultrasound/radiography may be valuable to look for concomitant or underlying disease (e.g. acromegaly)

Other diagnostic procedures

• Stress hyperglycaemia may be excluded by demonstrating persistent hyperglycaemia, elevated

fructosamine or persistent glucosuria (e.g. with home urine samples)
• Urine culture and sensitivity indicated if there is an active urine sediment
• May need to assay growth hormone or test adrenal function if acromegaly or hyperadrenocorticism
suspected

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Gross and histopathologic findings

• Pancreas most commonly shows reduced β-cell numbers and islet amyloidosis

Treatment
Inpatient versus outpatient treatment

• Cats presenting with ketoacidosis need intensive management as inpatients

• Most cats with uncomplicated DM can be managed as outpatients

Activity

• Encourage activity (e.g. playing with toys) as may improve insulin sensitivity

Diet

• Carbohydrate content has not been found to be a risk factor for development of DM, but feeding dry
food was found to be a risk factor in one study (Öhlund et al 2017)
• Once DM is present, feeding a low carbohydrate diet improves glycaemic control, may facilitate diabetic
remission
• Feeding a wet diet may reduce risk of dehydration
• Calorie restriction is important if overweight – normalising bodyweight will reduce insulin resistance

Client education

• Disease is often long-term/permanent

• Good management generally requires insulin injections (usually twice daily) and monitoring, but often
results in excellent quality of life
• Support from veterinary staff is invaluable
• Remission is possible in some cats (temporary or permanent)

Surgical considerations

• If cats with DM are to be anaesthetised, give 50% normal insulin dose that morning.

Medications

Overall aims are to:

• Minimise or eliminate clinical signs
• Avoid hypoglycaemia and other complications
• Use a treatment regime that fits with the owner’s abilities

Oral hypoglycaemics

• Glipizide (sulphonylurea, not licensed for veterinary use*) at 2.5 mg/cat PO q12h (doubling dose if needed)
• Some efficacy in ~40% of cats but results often poor and may exacerbate amyloidosis.

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Insulin choices

Optimum diabetic control is likely to be achieved in most cats by using insulin with a longer duration of
action (e.g. PZI) administered twice daily, 10-14 hours apart.
• Protamine Zinc Insulin (PZI), a longer-acting insulin
o Typical peak activity in cats: approximately 2-6 hours
o Typical duration of effect in cats: approximately 13-24 hours
• Lente insulin, a medium-acting insulin
o Typical peak activity in cats: approximately 2-8 hours
o Typical duration of effect in cats: approximately 8-10 hours

Aim of insulin therapy

• Control clinical signs

• Maintain blood glucose (BG) below 14 mmol/l for as much of the time as possible
• Avoid hypoglycaemia

Initial insulin therapy

Starting dose ~0.25-0.5 IU/kg q12h (≤2 IU/cat). Higher dose (0.5 IU/kg) may be appropriate with BG >20
mmol/l
• Insulin requirements may reduce in first 1-2 weeks with reversal of glucose toxicity
• If hypoglycaemia not encountered, reassessment may take place every 1-2 weeks initially.
• Adjust insulin according to clinical signs and BG (ideally BG curves, measuring BG every 3 hours for 12
hours after insulin).
• Insulin should generally not be increased more frequently than every 5-7 days
• Aim for peak BG <14 mmol/l and nadir >4.5 mmol/l.
• If nadir <4.5 mmol/l, usually reduce insulin by ~50%
• If peak >14 mmol/l usually increase insulin by ~0.5-1.0 IU

Long-term management of DM

Encourage owners to keep detailed diaries:

• Daily water intake (measured) – valuable as corresponds closely to average BG
• Daily demeanour and activity level
• Daily amount and type of food offered, and eaten
• Daily insulin dose
• Daily urine production
• Weekly bodyweight
• Intermittent urine glucose (if able to collect urine)

If stable, in-clinic reassessments every 1-4 months depending on the case.

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Home monitoring of BG

• Some owners can very successfully monitor BG at home using an ear-prick or paw-prick technique and a
low volume glucometer
• Can more accurately assess glycaemic control, less affected by stress
• Depending on owner, this may allow for occasional BG samples, or occasional BG curves
• With a conscientious owner and compliant cat, home BG monitoring may allow for tighter glycaemic
control (e.g. aiming for BG <11 mmol/l), but care is needed to avoid hypoglycaemia.

Fructosamine monitoring

• Fructosamine concentrations vary between cats. The change in an individual cat over time is generally
more important than the absolute value.
• Fructosamine <350-450 µmol/l generally suggests good to excellent glycaemic control
• Fructosamine >550 µmol/l generally suggests poor glycaemic control

Follow-up
Patient monitoring

• Every 1-2 weeks ideally until stable

• Every 1-4 months when stable, depending on the patient

Unstable patients

• Unstable diabetic cats should have their insulin and insulin injection regimes carefully checked
• Cats with DM that are difficult to stabilise or become unstable should be evaluated carefully for
concomitant or underlying diseases such as pancreatitis, acromegaly and hyperadrenocorticism
Prevention/Avoidance
• Keep cats in optimum body condition – avoid obesity and encourage exercise

Possible complications

• Diabetic ketoacidosis
• Hyperosmolar diabetes
• Diabetic neuropathy
• UTI

Expected course and prognosis

• Much depends on the owner

• DM can be overwhelming, especially initially, and owners should be given extensive support initially –
most are able to manage cats well long-term
• Most cats enjoy good quality of life with appropriate management
• Successfully managed cats often die of unrelated diseases

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Miscellaneous
Associated conditions

• Acromegaly
• Hyperadrenocorticism

Age related factors

Mostly older cats (>7 years old)

Pregnancy

• Breeding is not appropriate in cats with DM

Abbreviations

BG = Blood glucose
CKD = Chronic kidney disease
DM = Diabetes mellitus
GI = GI disease
PU/PD = Polyuria/polydipsia
UTI = Urinary tract infection

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References

• Aptekmann KP, et al. Owner experiences in treating dogs and cats diagnosed with diabetes mellitus in
the United States. J Am Anim Hosp Assoc. 2014 Jul-Aug;50(4):247-53
• Bjornvad CR, et al. Obesity and sex influence insulin resistance and total and multimer adiponectin levels
in adult neutered domestic shorthair client-owned cats. Domest Anim Endocrinol. 2014 Apr;47:55-64
• Callegari C, et al. Survival time and prognostic factors in cats with newly diagnosed diabetes mellitus:
114 cases (2000-2009). J Am Vet Med Assoc. 2013 Jul 1;243(1):91-5
• Caney SM. Pancreatitis and diabetes in cats. Vet Clin North Am Small Anim Pract. 2013 Mar;43(2):303-17
• Martin GJ, Rand JS. Comparisons of different measurements for monitoring diabetic cats treated with
porcine insulin zinc suspension. Vet Rec. 2007 Jul 14;161(2):52-8
• Nelson RW, Henley K, Cole C; PZIR Clinical Study Group. Field safety and efficacy of protamine
zinc recombinant human insulin for treatment of diabetes mellitus in cats. J Vet Intern Med. 2009 Jul-
Aug;23(4):787-93
• Nelson RW, Reusch CE. Animal models of disease: classification and etiology of diabetes in dogs and cats.
J Endocrinol. 2014 Sep;222(3):T1-9
• Niessen SJ, et al. Evaluation of a quality-of-life tool for cats with diabetes mellitus. J Vet Intern Med. 2010
Sep-Oct;24(5):1098-105
• Norsworthy G, Lynn R, Cole C. Preliminary study of protamine zinc recombinant insulin for the treatment
of diabetes mellitus in cats. Vet Ther. 2009 Spring-Summer;10(1-2):24-8
• O'Leary CA, et al. Investigation of diabetes mellitus in Burmese cats as an inherited trait: a preliminary
study. N Z Vet J. 2013 Nov;61(6):354-8
• Öhlund M et al. Environmental Risk Factors for Diabetes Mellitus in Cats. J Vet Intern Med. 2017
Jan;31(1):29-35
• Palm CA, Feldman EC. Oral hypoglycemics in cats with diabetes mellitus. Vet Clin North Am Small Anim
Pract. 2013 Mar;43(2):407-15
• Prahl A, et al. Time trends and risk factors for diabetes mellitus in cats presented to veterinary teaching
hospitals. J Feline Med Surg. 2007 Oct;9(5):351-8
• Smith JR, et al. A survey of Southeastern United States veterinarians' preferences for managing cats with
diabetes mellitus. J Feline Med Surg. 2012 Oct;14(10):716-22
• Sparkes AH, et al; ISFM consensus guidelines on the practical management of diabetes mellitus in cats. J
Feline Med Surg. 2015 Mar;17(3):235-50
• Zeugswetter FK, Rebuzzi L, Karlovits S. Alternative sampling site for blood glucose testing in cats: giving
the ears a rest. J Feline Med Surg. 2010 Sep;12(9):710-3

Acknowledgements

Kindly prepared for Companion Care & Vets4Pets by:

Andy Sparkes BVetMed PhD DipECVIM MRCVS, RCVS Recognised Specialist in Feline Medicine, Boehringer
Ingelheim Ltd and the International Society of Feline Medicine (ISFM)
January 2018
[email protected]

An educational service from Boehringer Ingelheim Limited, Animal Health, makers of ProZinc®. ProZinc 40 IU/ml suspension for injection for
cats contains protamine zinc recombinant human insulin. UK: POM-V IE: POM. Further information available in the SPC or from Boehringer
Ingelheim Limited, Animal Health, Bracknell, Berkshire, RG12 8YS. Date of preparation: October 2017. AHD10381. Use Medicines Responsibly.

Best Practice Guidelines

Feline diabetes mellitus