Sugar diabetes, more correctly know as diabetes mellitus, is a complex disease that is sometimes difficult to control in cats and dogs. Proper treatment requires a significant commitment on your part, usually for the life of your pet. This page describing diabetes disease is very thorough.
A glossary of medical terms will be used in this page:
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euglycemia- normal blood glucose level |
polyphagia- excess appetite |
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hypoglycemia- low blood glucose level |
polyuria- excess urinating |
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hyperglycemia- high blood glucose level |
polydypsia- excess drinking |
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glycosuria- high glucose in the urine |
PU/PD- polyuria and polydypsia |
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ketonuria- ketones in the urine |
DKA- diabetic ketoacidosis |
The ability to use a food source for energy is critical to the success of any species, therefore nature has very sophisticated mechanisms to regulate this process. These mechanisms are extremely complex, and only those mechanisms that relate to diabetes mellitus will be summarized for the sake of simplicity.
In response to a decreasing blood glucose level the appetite center in the brain is stimulated and hunger ensues. A meal is then eaten, which consists of fats, carbohydrates, and proteins in different percentages. When these fats, carbohydrates, and proteins are broken down by the digestive system and absorbed into the bloodstream they are used by the body for differing functions. The main function of the carbohydrates is eventual conversion to an energy source in the form of glucose, the primary energy source for all cells in the body. Some of this glucose is stored in the liver in the form of glycogen, which is released and converted back to glucose when cells need energy in-between meals.
Carbohydrates can be complex or simple. Complex ones are bread and pasta, simple ones are lactose (the carbohydrate in milk). When these carbohydrates are absorbed in the bloodstream through the intestines they are converted to glucose by the liver. The simple ones like lactose are rapidly converted and will immediately raise the blood glucose level. The more complex carbohydrates take longer to be metabolized to glucose by the liver, as a result they raise the blood glucose level more slowly. This point becomes important when treating both hyperglycemia and hypoglycemia.
Once in the bloodstream the glucose that circulates throughout the body is available for use by all cells as their primary energy source. These individual cells can not absorb this glucose that passes by in the bloodstream unless the hormone insulin is circulating in the bloodstream at the same time. Insulin causes a chemical reaction in the cell wall that allows the glucose to enter the cell. The only cells in the body that do not need insulin to absorb glucose are specific brain cells.
Insulin originates in a group of cells called the islets of langerhams that are located in the pancreas. Insulin comes from the beta cells in the islets. It is secreted into the bloodstream in response to an increase in glucose in the bloodstream, a normal occurrence after a meal is eaten. The higher the glucose level the greater the amount of insulin secreted. Since the absorption of simple carbohydrates will cause a more rapid increase in blood glucose there will be a more rapid increase in insulin secreted. The complex carbohydrates will cause a more gradual rise in the insulin level. This fact becomes important in feeding a diabetic patient.
The normal physiology is even more complex. Insulin also has a large effect on fat and protein metabolism. In addition, the pancreas also secretes a hormone called glucagon in response to a decreasing blood glucose level. Glucagon originates from the alpha cells in the islets, and its role is to help the liver convert glycogen back to glucose. As can be expected, glucagon will increase the blood glucose level, and counteracts the blood glucose lowering effects of insulin. Insulin and glucagon work in a negative feedback loop that allows for a very refined system to keep the blood glucose level at an optimal level for the energy requirements of each individual cell. The liver is a major part of this loop, acting as a blood glucose buffer to keep the blood glucose at optimum levels.
In general, brain cells do not need insulin to utilize glucose. A specific area of the brain, called the appetite center (in the hypothalamus), monitors the amount of glucose that circulates in the bloodstream. The lower the blood glucose level in the cells in the appetite center the greater the appetite. Unlike most of the brain cells, the ability of glucose to enter the cells of the appetite center is dependent upon insulin. In diabetes mellitus, with its lack of adequate insulin in the bloodstream, these appetite center cells don't monitor glucose levels properly, thinking the blood glucose is low. As a result, the animal develops polyphagia to correct for this perceived problem. The additional food that is then eaten further increases the blood glucose level.
The pancreas does more than secrete insulin and glucagon into the bloodstream. It is the primary source of enzymes that are secreted into the small intestines (not bloodstream this time). These enzymes are secreted in response to the presence of food in the digestive tract, and are the primary way that many nutrients are broken down and absorbed by the intestines into the bloodstream. The way these energy sources are acted upon by the enzymes, and how they are eventually utilized by the liver, are also factors that effect the blood glucose level.
To further complicate the picture, epinephrine (adrenaline), cortisol (cortisone) and growth hormone also influence the blood glucose level.
This is a picture of the pancreas from a cat. It is directly next to the beginning part of the small intestine called the duodenum. The pancreas is the pinkish tissue directly underneath the cylindrical duodenum. For such a small organ it has an important job. 
Now that you are an expert at normal physiology, lets learn what happens when the normal mechanisms described above go wrong. This is called pathophysiology
The relative lack of insulin causes the blood glucose to go abnormally high. Normal blood glucose in a cat and dog varies from 80 to 150, but can temporarily go much higher (300-400 or more) in stressful situations. When the blood glucose is consistently high, as seen in diabetes mellitus, several negative effects occur.
Inadequate insulin levels force the cell to perform its functions with alternative sources of energy besides glucose. This causes problems for the organ that is made up of these cells and eventually will lead to significant disease and the complications that occur in untreated diabetes mellitus.
The cells of the body (except most brain cells) are deprived of their primary source of energy. This means they do not function at optimum efficiency. Since they are starved of glucose they need to rely on other sources of energy, namely fat and amino acids. These are not as good an energy source as glucose in the long run.
To utilize amino acids as an energy source the body needs to break down protein. A large part of this conversion occurs in the protein in muscles cells, As this conversion from protein to amino acids progresses the body loses its muscle mass and weight loss occurs.
Metabolism of fat as an energy source is a normal response when cells do not receive adequate glucose for their energy. In the short term this process is highly advantageous. Fat has twice as much calories as proteins and carbohydrates, so it is a concentrated source of energy in the short run. If the fat metabolism process goes on for a prolonged period of time it becomes detrimental, and leads to the buildup of byproducts from fat metabolism. The main byproduct is a compound called ketones.
The ketones that build up in this process change the pH of the blood, further dehydrate the animal, interfere with other metabolic processes, and cause fatty infiltration of the liver. Ketones also cause vomiting, which leads to further inappetance and additional dehydration. Further inappetance causes the cells to use even more fat as an energy source, causing an uncontrollable spiral, and sometimes even death. Any diabetic pet presented with ketones in its urine is a medical emergency. These animals have what are termed diabetic ketoacidosis, abbreviated as DKA.
In addition to the liver, the kidneys are another important organ in this disease. The primary role of the kidneys is to filter the blood. As the blood passes through the kidney filters essential nutrients are returned to the bloodstream and waste products are excreted through the urinary system. Glucose is one of the many molecules that is returned to the bloodstream after it has passed through the kidney filters. Once the glucose exceeds 200 mg per deciliter in the bloodstream though, the kidneys can no longer selectively return all of this glucose back into the bloodstream. This is called "exceeding the renal threshold", and is a very important part of diabetes mellitus.
As a result, glucose spills into the urinary tract and bladder in excessive quantities. Since glucose attracts water (called the osmotic effect) it pulls fluid out of the cat and causes polyuria. To compensate for this excess urination the cat drinks more water, and now has polydypsia. It now has the symptoms we abbreviate as PU/PD. Eventually it causes dehydration when the animal can't drink enough water to keep up with the increased urination. In addition, the excess urination pulls important electrolytes out of the bloodstream like sodium and potassium, which leads to lethargy and weakness. The loss of glucose also depletes the body of its primary energy source, so additional weight loss occurs. To further add to a diabetic cat's woes, the excess glucose that builds up in the bladder feeds bacteria that can cause a urinary tract infection.
Why the pancreas stops secreting adequate levels of insulin is a mystery. There is a strong correlation for diabetes mellitus to occur in cats that previously had an episode of pancreatitis. This makes sense because the pancreas is the source of insulin. Yet, many pets that have diabetes mellitus had no apparent pancreatitis in the past. In some cats and dogs the immune system attacks the beta cells in the islets and deposits a compound called amyloid which makes the beta cells unable to secrete insulin. Obesity and genetic factors are also involved as a cause. Genetics can not be controlled, but obesity can.
The pancreas can get a tumor
called an insulinoma. In this case the pancreas secretes too much
insulin and the blood glucose hovers at dangerously low levels. This
problem is very rare in most mammals except for the ferret.
Most people are familiar with the classification scheme used in human medicine. Even though the disease is similar in people and cats, the human classification scheme does not always correlate with diabetes mellitus in animals. Differentiating between Type I and Type II in animals can be difficult.
Type IHas similarities to insulin dependent or juvenile onset diabetes mellitus. Most commonly occurs in middle aged cats or dogs. Insulin is needed to treat the problem. This is also known as insulin dependent diabetes mellitus (IDDM).
Type II
Similar to adult onset or non-insulin-dependent in humans. Obesity is a significant risk factor, especially in cats. Insulin is not needed in all cases. Type II cats can become Type I cats when exposed to significant stress. Fortunately, when the stress is resolved they can revert back to Type I. This is also known as non-insulin dependent diabetes mellitus (NIDDM).
Diabetes can occur secondary to other problems. Some of these problems include hormone imbalances and reactions to medications. A medication called Ovaban, a hormone once used to treat numerous cat ailments, can cause diabetes.
The classic signs of a cat with diabetes mellitus are PU/PD. These signs are subtle at the beginning stages of the disease and are easily missed. This is especially true in outdoor cats who do most of their urinating outside.
Other symptoms include weakness, an increase in appetite, occasionally a decrease in appetite, weight loss, lethargy and rarely, vision problems due to cataracts (this problem is more common in dogs). Cats with a severe liver problem associated with this disease might have icterus (jaundice). An affected cat or dog might even walk abnormally on the rear legs (called plantigrade posture) due to nerve problems as a consequence of this disease.
These are also the symptoms of other diseases commonly seen in cats and dogs, and can only be differentiated by diagnostic tests. These other diseases include, but are not limited to, hyperthyroidism, kidney disease, cancer, liver disease, Cushing's disease and adverse reaction to medications.
The yellow discoloration to these gums is icterus. It is commonly, but not always, caused by liver disease.
By the time a diagnosis of diabetes mellitus is made the disease process has been present for a significant period of time. When the disease process first started the pet did not show any symptoms because of compensatory mechanisms in the body. As diabetes progresses these compensatory mechanisms lose their ability to maintain euglycemia. Eventually, symptoms of PU/PD and weight loss occur and the pet is brought in to be examined. This emphasizes the point that middle aged and older dogs and cats should have a routine blood panel and urinalysis every year once they reach 8.
This is a complex disease, and no specific set of symptoms tells us your pet has diabetes mellitus. It is important to follow the tenets of the diagnostic process closely when making a diagnosis of diabetes mellitus, especially since kidney disease and hyperthyroidism have similar symptoms. We will use the diagnostic process as an example of how we make this diagnosis:
Signalment
Typically this disease is seen in obese cats that are middle aged or older, and more commonly in males (the opposite of dogs). There is no specific breed predilection in dogs or cats.
History
The classic signs of PU/PD, polyphagia, and weight loss occur in many cases, but not all. These signs depend on how well entrenched the disease process is before the pet is brought in for an examination. Sometimes the only thing an owner notices is accidents around the house in a previously housebroken pet.
Since this disease occurs in middle aged and older pets there can be other diseases occurring simultaneously. Some cats have a history of vomiting in the recent past, an indication that they might have had an episode of pancreatitis. Some cats and dogs are borderline diabetics that have had a recent illness, stress, or adverse reaction to medication. There might also be blood in the urine or straining to urinate, an indication of a urinary tract infection.
Cats and dogs presented in DKA might have a history of abdominal pain and distention, vomiting, inappetance, and lethargy.
Physical Examination
The findings of the physical exam depend on how severe the diabetes is, how long it has been present, what caused it, and if there are any other disease processes occurring simultaneously.
Many animals will have lost weight, yet they still could be obese. There might be dehydration, weakness, lethargy, an enlarged liver on abdominal palpation, and an acetone (juicy fruit) smell to the breath. Hypothermia and shock could be present in advanced cases and those with DKA.
Diagnostic Tests
The primary method of diagnosis in dogs and cats requires a blood panel and a urinalysis. The blood panel will reveal hyperglycemia (at least > 200 mg/dl) while the urine sample will reveal glycosuria. In cats, not every case of hyperglycemia means he/she has diabetes mellitus. Cats that recently ate, or those that eat canned foods that are rich in sugar, might have blood glucose levels higher than the normal range. Cats that are on cortisone, are in heat, on phenobarbital medication or hormone medications might also have hyperglycemia.
Cats are unique in that their stress response can cause a tremendous rise (up to 4x normal) in the blood glucose. This is a common occurrence when we take a blood sample in a cat and needs to taken into consideration when we analyze a blood report. This stress induced response is a normal reaction to the release of epinephrine (adrenaline). It is a transitory response and will not persist like the hyperglycemia of diabetes mellitus. These cats sometimes need to adjust to a hospital environment before we are able to determine their true blood glucose level.
Here is a blood glucose report from our lab for a cat that does not have diabetes mellitus. The blood glucose is 317.
This cat has diabetes mellitus, its blood glucose is 390.
How do we differentiate them when both are well above the normal range?
Diabetes mellitus is diagnosed when there is a persistent fasting hyperglycemia along with glycosuria, that is consistent with a history of PU/PD and polyphagia.
Other blood tests are sometimes used in this disease. The two more common ones are serum fructosamine and glycosylated hemoglobin. They are used to to distinguish stress induced hyperglycemia from diabetes mellitus, and to also monitor insulin therapy.
In addition to glucose in the urine and ketones, the urinalysis might indicate that a urinary tract infection is present. This is detected by a change in the pH of the urine, excess white or red blood cells, and bacteria.
This is a urinalysis from a cat that has diabetes mellitus. Its glucose is 4+, fortunately,it is negative for ketones, there are no white or red blood cells present, and there are no bacteria visible either. This cat does not have ketonuria or an infection. 
Some cases of diabetes mellitus are not straightforward. An obese cat can have NIDDM in its normal, unstressed home environment. These cats are secreting insulin but in low levels. As long as they are in a stress free environment they are able to maintain euglycemia. If they encounter a stressful situation, get sick, or are put on certain medications, their blood glucose will increase. If it goes beyond the renal threshold for glucose, PU/PD will ensue.
These cats are then brought to a veterinarian because of the PU/PD and diagnosed as having diabetes mellitus. They are put on insulin therapy and the problem improves. The problem occurs when these cats are returned to their normal environment and the problem that started the increased blood glucose in the first place (stress, illness, drugs) is now gone. In some of these cases these cats will now become hypoglycemic because they are being given insulin injections when they do not need them. Identifying these cats that have converted from insulin-requiring to non-insuin requiring NIDDM is difficult. This is one of the numerous reasons why diabetic cats should be brought to our hospital every 1- 3 months for a urinalysis and blood glucose curve.
Diet
Increasing the complex carbohydrates and fiber in the diet (especially in the dog) will minimize the rise in blood glucose level as the body digests this food. This allows for less fluctuation in blood glucose and easier treatment with insulin. In addition, since many of these dogs and cats are obese, the higher fiber will help minimize this problem. A cat or dog that is underweight from diabetes mellitus should not be put on a high fiber diet.
For some cats with NIDDM dietary therapy with increased protein levels (such as Purina DM diet) might be all that is needed. This type of diet helps slow glucose absorption from the intestinal tract and helps control blood glucose after meals. Since this disease is prevalent in older cats the change in diet might be met with resistance. In these cases mix the special food with its regular diet to get some advantage of the new diabetic diet. Do not feed foods that contain excess sugar like semi-moist foods.Oral Hypoglycemics (Cats only)
The goal of oral hypoglycemic medication is to minimize glucose absorption by the intestines and to also minimize the conversion of glycogen to glucose by the liver. They also help increase insulin secretion from the pancreas.
They are used in cats that are not underweight, have negligible ketones in the urine, no indication of pancreatitis or no history of being on medication that could cause hyperglycemia. In conjunction with diet, oral hypoglycemics can sometimes help us differentiate NIDDM form IDDM. Cats with NIDDM will have significantly lower blood glucose levels when checked several days after initiating this protocol.
Some cats will vomit, not eat, and might even develop hepatitis from oral hypoglycemics. Currently they are falling out of favor due to the drug's numerous side effects.
Insulin
For many years the insulin used to treat cats was derived from a beef-pork combination (90% beef and 10% pork) that was used in human diabetes mellitus. Then the pharmaceutical companies relied on human recombinant (genetically engineered) insulin. Now the insulin we currently use to treat cats PZI and for dogs the first choice is Vetsulin ®.
The goal of insulin therapy is to mimic naturally secreted insulin from the pancreas as closely as possible. The dose of insulin and the type of insulin that is effective will vary from animal to animal. Once a proper dose is initially determined at some point in time in the future this dose will probably change.
Initially, insulin is dosed conservatively in order to see an individual animal's response and to minimize any chance of hypoglycemia.
Here are the 2 main types (there are 40 different types of insulin) of insulin we use to treat IDDM in our hospital.
PZI (cats) Vetsulin® Long- acting 90% beef
Intermediate- acting Porcine (pork insulin)
Note that the use of these insulins require special U-40 syringes for administration with 26 or 27 gauge needles.
Idexx PZI (for cats) contains protamine and zinc to delay absorption and prolong duration.
Vetsulin® (for dogs) is considered a porcine insulin (pork is most similar to canine insulin).
Regular insulin may be used initially to treat an animal if it has DKA. Once the ketoacidotic state has been reduced we use the intermediate or prolonged lasting insulin. Your veterinarian will let you know which one might be most appropriate in your situation. Sometimes we need to try more than one type of insulin. What is just as important as the type of insulin used is the familiarity a doctor has with a specific protocol.
Ketoacidotic Diabetes Mellitus
Animals presented with DKA need immediate medical attention. They need regular insulin due to its ability to rapidly lower the blood glucose level. They also need fluids and electrolytes to correct dehydration, electrolyte imbalance, and acidosis (a change in the pH of the bloodstream). They must be monitored closely in the first 12-24 hours. Our goal is to return your cat or dog to a relatively stable state within the first 1-2 days after initiating this therapy.
Regulation in the Hospital
Most diabetic cats and dogs need to be regulated (the correct dose of insulin determined) in the hospital. Starting this can take 5 days and sometimes longer. Most cats and dogs have well entrenched pathology that is not conducive to rapid change. The dose has to be given in small amounts initially to prevent hypoglycemia. It takes at least 3 days for a cat or dog to respond to a change in dose. This initial regulation only gives us a starting point for your pet's insulin dose since there will be numerous mitigating factors that will affect insulin levels when your he/she returns home.
During its hospital stay your pet's blood glucose level will be checked frequently. This is called a blood glucose curve, and it is a critical part of determining the proper insulin dose. It is such an important part of monitoring that we use a special blood glucose instrument called an Accucheck.
Since it takes several days for an animal to show a decrease in blood glucose due to insulin we might not start this curve immediately. The blood glucose curve will give us an idea of how it is reacting to the type and amount of insulin we are using. Every animal is different, so this trending is needed to understand specifically how he/she will react.
Our goal is to get the blood sugar level down to somewhere between 100-250 mg/dl. Some pets are regulated fine even if the blood glucose peaks at greater than 250 mg/dl. It is much better to have a pet that has a slightly high blood glucose level than to try and refine the dose so closely that hypoglycemia is risked.
To monitor your pets blood glucose we take frequent samples. To prevent the constant irritation from obtaining this blood sample we put a catheter into one of your cat's veins. This eliminates discomfort and also minimizes the stress response. This cat has jugular catheter -- to learn more about catheters click here. 
The first step in the process of running a blood glucose test in our hospital involves taking blood from your pet and putting it on a special strip.
The blood has to spend 60 seconds on the tip of the strip before it can be inserted in the blood glucose machine. Here we are at the halfway point (30 seconds have elapsed) in the process.
After 60 seconds we wipe away the excess blood on the strip.
Now the strip is inserted in the machine for 2 minutes
This cat's blood glucose reading is 63 mg/dl. It is hypoglycemic at this point.
In addition to starting insulin therapy we will feed your pet a special prescription food. As was previously described, this will help minimize the fluctuations in blood sugar level. Also, pets that exercise need less insulin. In cats this is not as much of a factor as in dogs.
The typical cat or dog needs anywhere from 2-10 units given from once to twice daily. Of course this dose depends on the weight of your pet, the type of insulin used, its diet, its exercise level, and its individual response.
After we have an idea of how your pet is responding to insulin in the hospital we will send him/her home for you to refine the dosage. It may take up to a month to find the optimum dose. The ultimate goal of long term insulin administration is to achieve a blood glucose level as close to euglycemia as possible. Doing so will minimize the symptoms of diabetes mellitus and minimize the chance of long term complications due to the disease.
We recommend you return for a blood glucose check in 7 days to assess your home therapy. Feed your pet and give it its insulin 7-8 hrs prior to bringing your pet in. We may need to perform a blood glucose curve later on in the course of therapy, especially if we feel that the animal is not responding well to insulin treatment.
Insulin Injections
It is imperative that you administer the precise amount of insulin required since small changes can have dramatic effects in the body. Be consistent and give the insulin the same time and at the same location every day. If your pet is on twice daily insulin injections give each morning and evening dose at the same time every day. Always feed your pet in the morning prior to giving the insulin. If it does not eat its food skip the morning dose of insulin. Giving a normal dose of insulin to a cat or dog that is not eating greatly increases the risk of hypoglycemia. You must always err on the side of hyperglycemia instead of hypoglycemia.
Most cats eat small bites of their food throughout the day. This is not advantageous in a diabetic cat because of the manner in which the insulin that is administered peaks. If possible, feed your cat or dog twice each day, feeding part of its daily meal when you give the insulin in the morning. Make sure it has access to this same food when the insulin level is peaking later in the day.
A record should be kept of your pet's food intake to note any changes. It should be kept as consistent as possible. The same thing holds for its water consumption. As a basis for comparison, the average cat drinks 3-4 times per day. For a dog, you will need to ask us what the normal water consumption is per day based on his/her weight.
The actual administration of insulin is very straightforward. As a matter of fact, it is easier to give insulin injections at home than it is to give SQ (subcutaneous) fluids to cats that have chronic renal failure, a common finding in our hospital. This is because an insulin injection takes 1 second to give, whereas fluids take 5 minutes.
You will never be forced into doing something that makes you feel uncomfortable. While your pet is in the hospital with us you can observe how we give the insulin injections. One of our nurses will demonstrate its proper administration when we release your pet from the hospital. You can return to our hospital for assistance in giving the insulin at any time.
In order to simplify the process we will give you an insulin syringe that has been designed to be used with the specific type of insulin your pet requires. You will be giving insulin in a measurement called "units", and not in ml (milliliters) or cc (cubic centimeters) as is commonly used in most syringes. A typical insulin syringe is called U-40. If you look back at the 2 insulin bottles above you will notice that they have 40 units per ml, which is why we use the U-40 syringe with them. Another type of insulin syringe is called U-100. A U-100 syringe is used if the insulin bottle contains 100 units per ml.
Some cats require such a low dose of insulin that we have to dilute it for proper administration. A special diluent is needed for this, and diluted insulin should not be used longer than 2 months. A special syringe is sometimes used for dilute insulin.
This is what a U-100 syringe looks like. The needle is very small and sharp so your pet will not feel it during its injection. 
Insulin should be kept refrigerated at all times to preserve its freshness, although this is not mandatory. Prior to use it should be gently warmed in your hands. Gently roll it (never shake it vigorously because excess bubbles will form) between your hands for 1-2 minutes to bring it to the proper temperature for administration. Storing the insulin bottle on its side in the refrigerator will help in mixing.
Make sure you are in a relatively calm location when you give the injection. Hold the insulin bottle upside down and draw out slightly more than the number of units your pet requires. Tap the syringe a few times to remove any air bubbles-this aids in accuracy (a few tiny bubbles are OK). Push the plunger in the syringe slightly forward until you have the exact number of units you need to administer is in the syringe. Put the cap back on the syringe and put the insulin bottle back in the refrigerator. Do not reuse the syringe. 
Give the injection in the scruff of the neck just as you would when giving SQ fluids described above. Your pet should not feel anything because the needle is so tiny and sharp. The whole process, from warming the insulin to giving the injections, should only take a couple of minutes. As you get confidence it is recommended to rotate your injection sites. We can shave a section of hair to make this whole process easier. Also, feeding your pet a treat during the injection helps to make it a more pleasant experience for all involved.
Improper administration of insulin is one of the most common causes for improper regulation. Please do not hesitate to contact us at any time for assistance in this vital procedure.
Home Monitoring
Determining the daily dose of insulin required at home is not an easy task. The best way to monitor your pets blood glucose at home is to perform the blood glucose yourself. Ears and pads are areas in which a small prick will give sufficient amount of blood to run an in home blood glucose.
Most people prefer to monitor the glucose in their pet's urine because it is simpler. Monitoring of the glucose in your pet's urine will give you at best a rough idea of its blood glucose level. There are significant limitations to home monitoring using urine glucose as a criteria.
Urine glucose measurements do not necessarily correlate with blood glucose measurements, the more important of the two. Also, if the blood glucose level is below the renal threshold a negative glucose in the urine can not differentiate between euglycemia and hypoglycemia. If you note a significant amount of glycosuria consistently for several days your cat needs a blood glucose curve.
To help in the urine monitoring process your cat's normal litter can be replaced with special litter that will not absorb urine. You can also use regular paper, newspaper, or even plastic wrap in the bottom of the cage. There is even a special litter that reacts with the glucose in the urine. With dogs, it is best to collect a fresh morning sample in a cup (free catch sample) prior to the first insulin injection of the day.
One of the more common urine dipstick kits is the Keto-Diastix. In addition to monitoring glucose it also monitors for ketones. 
This is the chart on the Keto-Diastix bottle. The box to the far left is negative, which is the goal. The next box to the right is 100 mg/dl. Its OK to have this urine glucose value on occasion.
On the same bottle there is a chart to monitor for ketones in the urine. Your goal is to have negative with an occasional trace.
What is just as important as urine glucose is your subjective interpretation of how your pet is doing. If the original symptoms are greatly reduced then you are probably giving an accurate dose.
One of the ways the urine dipstick can be particularly helpful is in monitoring ketones. Occasional trace ketones is no cause for alarm. Consistent ketonuria in a pet that is not feeling well requires immediate veterinary care.
Another good method to monitor your pet at home is the amount of water it is drinking.
Do not make any changes in insulin dose unless you talk with one of our doctors. Do not make daily changes in insulin doses either, wait 3 days to determine if the new dose is having any effect.
Warning signs that necessitate an exam and blood glucose curve in the hospital:
- Lethargy or significant increase or decrease in appetite
- Significant increase in drinking or urinating
- (100 mg/dl) or more glycosuria for > 2 days
- Significant ketones in urine for > 2 days
It must be understood that insulin administration does not cure diabetes mellitus, it only controls it. As you learned above in the physiology section, the body has very sophisticated and refined mechanisms to keep the blood glucose at optimum levels. This can not be replicated easily by giving insulin.
To minimize problems we should monitor your pet's blood glucose level in the hospital and perform a urinalysis every 3 months. Since cats can exhibit an exaggerated stress response causing a profound hyperglycemia a glucose curve or fructosamine test may be necessary to ensure accuracy. Every 6 months we should also perform a complete blood panel to look for changes in other organs caused by the diabetes. A further reason to run a complete blood panel every 6 months is to monitor routine age related changes like hyperthyroidism and kidney disease.
This long term monitoring is important for another reason. In almost every diabetic pet insulin requirements change, necessitating the need for close monitoring and communication with us. If your dog or cat goes into heat (another reason to spay females and even neuter males) its insulin requirements might change. In some diabetic pets the problem goes away and they no longer have a need for insulin. Giving insulin to these pets can cause hypoglycemia, which if it is severe enough, can lead to seizures.
Hypoglycemia
One of the more alarming side effects to insulin administration is hypoglycemia. You should be ever vigilant about its appearance and always be ready to treat it at home.Symptoms include shaking, a starry eyed appearance, lethargy, shaking, greatly enlarged pupils, muscle tremors and even seizures. If the problem is serious and persists long enough coma and even death can occur from depression of the respiratory system. Some pets don't show any obvious symptoms except subtle behavior changes like sleeping more than usual. Since cats sleep most of the time anyway this can easily be missed.
In most cases the cause is an overdose of insulin. A common scenario involves a pet that eats significantly less than its normal amount for the day. Hypoglycemia can result if the dose of insulin is not adjusted to take this into account. If your pet is not eating well and you are unsure, either give less insulin that day or do not give any at all. A blood glucose test in the hospital will let us know for sure.
Other causes of hypoglycemia include improper insulin administration resulting in an accidental overdose, along with pets that spontaneously recover from their diabetes and no longer need insulin.
If the symptoms are mild feed your pet some of its normal food. For many pets this will suffice. If the problem is severe use Karo syrup, a simple carbohydrate. It is readily available at the supermarket and should be kept on hand at all times. Give it in small amounts or rub it on the gums. Pancake syrup, honey, sugar water or any fluid that has high amounts of sugar can be used also. These high carbohydrate remedies only last a short time so you might have to keep on repeating one of them. Also, it is a good idea to have a source of simple carbohydrates in your car or other important locations when traveling or even just going for a walk. It pays to be prepared.
In the rare case that your pet has a seizure from hypoglycemia it is imperative that you do not put anything into its mouth, including your fingers. Do not attempt to pour any fluids into its mouth, If feasible, rub Karo syrup on the gums without exposing yourself to harm. These pets need to be seen by a veterinarian immediately.
Close observation of your pet's appetite will go a long way towards preventing this problem. Monitoring its urine for glucose will help since a negative glucose in the urine should be noted. If the urine test for glucose is negative you need to pay particular attention to your insulin administration.
Liver Disease - Cats
Cats with diabetes are forced into using an energy source that will eventually cause a fatty infiltration of liver cells. As a result the liver will not function at optimum capacity, a potentially serious problem since the liver is such a vital organ. The liver enzyme test on the blood panel will alert us to this complication. When the diabetes is treated this problem might resolve.Radiography might reveal an enlarged liver (hepatomegaly) due to the fatty infiltration. This liver is larger than normal-it is extending towards the right far beyond the margin of the ribs. The 4 white arrows on the bottom outline the lower edge of the wedge shaped and enlarged liver.
One of the most important disease syndromes associated with a fatty liver is called hepatic lipidosis. It occurs in overweight cats that are exposed to a stress that causes them to stop eating. This lack of appetite can become so severe that a feeding tube needs to be put in.
Keeping the blood glucose level as close to euglycemia as possible will help minimize this complication. Again, the need for periodic blood glucose monitoring along with a routine blood panel every 6 months becomes obvious.
Somogyi Effect (Insulin Induced Hyperglycemia)
Overdosing the morning dose of insulin can cause hypoglycemia. If the hypoglycemia becomes severe enough (< 60 mg/dl) the body will go through complex compensatory mechanisms to raise the blood glucose level. These mechanisms involve the liver, glucagon and epinephrine. If these mechanisms are unable to raise the blood glucose rapidly enough then the symptoms of hypoglycemia described above might occur.When these mechanisms are able to correct the hypoglycemia they can cause the blood glucose level to go quite high later in the day and persist through the night. If the urine glucose is measured just before the morning dose the next day there will be significant glycosuria due to the previous afternoon and evenings hyperglycemia. This will cause many people to increase the insulin amount in the morning dose. This overdosing will again cause hypoglycemia some time during the day, and the cycle will repeat itself.
This problem is diagnosed by a blood glucose curve in the hospital. A pet with the Somogyi effect will have a blood glucose level that is abnormally low some time during the day. This emphasizes the need for a blood glucose curve to monitor your pet's problem because only one blood glucose test during the day might miss the hypoglycemia episode that is causing this problem in the first place.
Insulin antagonism
Pets that are not regulated in spite of higher than normal insulin doses might have this problem. This problem can mimic improper storage, handling, and administration of insulin.There can be many causes to insulin antagonism. Hormones, cortisone, the Somogyi effect, adrenal gland disease, infection, chronic pancreatitis, kidney disease, cancer, anti-insulin antibodies, and even ineffective insulin all could be involved.
Infections
Diabetic animals are prone to infections, especially of the urinary tract. These infections makes them more prone to DKA and insulin antagonism. Good dental hygiene is critical also since many pets with diabetes have dental disease.
It is always preferable to keep your diabetic animal in its normal environment. When this is not feasible special precautions need to be taken if your pet is boarded. Pets that board away from home are at an increased risk of becoming unregulated as to their correct insulin amount. They will frequently have a diminished appetite, increasing their chance of hypoglycemia if their insulin dose is not adjusted. Your pet should be boarded only at a facility that is adept at treating this disease and can run a blood glucose test in case of a problem. One of the more common reasons we board pets at our hospital is because they need this type of medical monitoring for their problem.
You should bring your food and your insulin to the boarding facility. A feeding schedule with amounts of food and water consumed and at what times should be provided. Also include a timetable when insulin is given and at what amount.
Since diabetic pets should be monitored with a blood glucose curve periodically this is an ideal time to run this test. When your return to pick up your pet we will review this curve with you and adjust doses as needed.
It is obvious that this is a complex disease that requires diligence on your part for proper control. Since every pet is different your doctor will make a custom plan that will work for you and your pet, and will not necessarily follow any pre-established protocol. Be prepared for constantly changing insulin requirements and potential complications. The more consistent you are with feeding the same food in the same amounts at the same time(s) every day will add to a successful outcome.
The majority of diabetic cats and dogs on insulin therapy have a significantly increased quality of life. This usually makes the time commitment and economic commitment necessary for proper regulation well worth the effort.
There are several good websites that can help you with managing your diabetic dog or cat for more information click on the link button below.
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