The Preventive Vet

Did you know that November is National Diabetes Awareness Month? Yup, one month out of every year… diabetes gets the spotlight. Given the importance of this disease and the debilitation it can cause, you’d think it would at least deserve a month with 31 days. But I guess it could be worse, it could be in February. Besides, November is probably a very appropriate month - given that it comes right after Halloween, includes the holiday most often associated with overeating, and precedes the month with the over-indulgent holidays of Christmas and New Years too. So… November it is - this year and every one to follow.

Regardless of which month diabetes gets the spotlight in though, its just important that it gets it. Why? Because it is one of the most debilitating and one of the most common chronic disorders affecting people… and pets. That’s right, cats and dogs can develop diabetes. And, as this blog post will highlight (at least as regards cats), they can do so with alarming frequency, and with potentially devastating consequences.

So, please read on to help protect the health and safety of your cats, as well as the ‘health’ of your bank account. It’s November… so prepare to become aware of feline diabetes - what it is, when you should suspect it, and what the potential emergency complications of it are. Also included, and it wouldn’t be a Preventive Vet blog post without them, are tips on how you can prevent it and how best you can manage it to avoid the associated emergency complications. Remember to come back to and share this post in other months of the year too, diabetes doesn’t respect the ‘boundaries’ of the calendar… it can strike in any month!

What is diabetes?

In the most basic sense, diabetes mellitus is a disorder of glucose (‘blood sugar’) metabolism. Though there are several hormones within the body that play important roles in glucose metabolism, and insulin is one of the most important and the one that is most central to the development and control of the diabetic state. It is, of course, far more involved and complicated than this, but this gives the basic knowledge for the purposes of this blog post.

Insulin is important because, amongst other functions, it is the hormone charged with getting glucose into most cells within the body. This ‘metabolic fuel’, glucose, is vital to the normal and efficient longterm functioning of all cells and organs within the body. This is not to say that all is lost without glucose in the cells - life likes itself too much to risk putting all of it’s proverbial ‘eggs’ in the ‘glucose basket’. Failsafes have evolved within the body to keep life going in the absence of glucose, but they are only effective and life-sustaining for a relatively brief period of time.

So back to insulin and its role in diabetes, and this is where the ‘distinction’ between ‘Type I’ and ‘Type II’ diabetes comes in. In ‘Type I’ diabetes there is an insufficient production or release of insulin from the pancreas (the organ in the body where insulin is produced). Conversely, in ‘Type II’ diabetes there is an appropriate amount of insulin available in the body, but there is an ineffective cellular response to it. In veterinary medicine dogs more commonly get ‘Type I’ diabetes and cats typically get ‘Type II’. The lines can get a bit blurred, and its often not as straightforward as this, but that’s the basic difference.

Which cats are most at risk?

Diabetes is a very common disorder in cats. One commonly cited study put the incidence at 1 in every 400 cats being affected, but the actual incidence may indeed be far higher. The condition is most common in overweight, male neutered cats over 8 years of age, and in particular in those that eat a high carbohydrate diet exclusively (this is pretty much any dry cat food). Additionally, Burmese cats seem to have an inherited higher risk of developing this disease.

What signs could indicate that your cat has diabetes?

Although the actual diagnosis of diabetes requires a thorough physical exam and laboratory testing (of both blood and urine) by your veterinarian, certain signs that you might notice at home should indicate the presence of a problem that warrants a trip to the vet. None of the clinical signs listed below are specific for diabetes, and in fact many of them are common amongst several of the common disorders of cats, but the presence of any of them is enough for you to know that its time to bring your pet to your vet for evaluation. And if you want to avoid the litany of complications that can result from many of these disorders, and likely minimize your out of pocket expenses in the process, you should do so sooner rather than later.

Earlier signs of diabetes mellitus in cats:

• Excessive thirst: Known as ‘polydipsia’, this sustained increase in thirst is often an obvious early sign in diabetic cats. Many owners report starting to notice their cat drinking from the dog’s water bowl, or the sink, bathtub, or toilet. This sign is also often present with kidney disease, certain liver disorders, and other hormonal disorders - regardless of its underlying cause though, a persistent and marked increase in your cat’s thirst should prompt you to bring them for veterinary evaluation.
• Excessive urination: The medical term for a marked, sustained, increase in urinary volume is ‘polyuria’. Many pet owners first indication that their pet is urinating excessively is that they are finding more and larger clumps of urine in the litter box, or sometimes these cats start urinating outside of their litter boxes. Similar to the case with polydipsia as discussed above, polyuria can be associated with several different underlying disorders. But also similar to the case with polydipsia, it is also important that pets with polyuria be evaluated by a veterinarian to determine the underlying cause.
• Ravenous appetite (‘polyphagia’) often accompanied by weight loss: Many diabetics have a ravenous appetite, often pestering their owners for more food after clearing out their bowl. This is often a blatantly obvious sign for owners that something has changed - but it may not be as obvious if you just periodically fill a bowl full of dry cat food and only check it sporadically. What many owners may also not immediately realize, especially if their cat has long fur, is that in spite of their cat’s ravenous appetite, they are actually losing weight. As with polyuria and polydipsia, polyphagia with concurrent weight loss is not, in and of itself, diagnostic for diabetes - so if you are noticing this sign, have your cat evaluated by your veterinarian - sooner rather than later.
• Generally speaking, the likelihood of these aforementioned signs indicating diabetes in your cat is increased if your cat is overweight/obese (or ‘big-boned’ or whatever else some people may call it to avoid the problem) and eating predominantly or exclusively a dry food diet. Such cats are often referred to as ‘pre-diabetic’ in many veterinary circles. These cats are just waiting for for an excuse - illness, medication, stress - to push them over the line into full blown diabetes.

Later signs of diabetes mellitus in cats:

• Walking flat on the back of their hind legs. This is referred to as a ‘plantigrade stance’ or ‘dropped in the hocks’. This is a result of damage and dysfunction to the nerves that feed the back legs. This is typically obvious when you view your cat from the side. Normally in cats, the hock/ankle (the point at the back of a cat’s hind leg) is off the ground when they walk. In cats with a plantigrade stance however, they walk with it in contact with the ground.
• Many diabetic cats will lose the interest in or their ability to jump. This can sometimes be a very subtle sign and it can be indicative of several other conditions as well, but it should prompt veterinary evaluation.
• Very late signs of diabetes, and ones that typically indicate the presence of a diabetic ketoacidotic state (see below) include vomiting, lethargy, and lack of appetite. If these are the first signs of diabetes you are noticing in your cat, they and your pocketbook are in serious trouble.

Why you should care about and try to prevent diabetes in your cats?

While diabetes is often easily diagnosed and there is a range of options available for its control, when undiagnosed or poorly managed, diabetes will certainly shorten your cat’s life (and frustrate your’s). Poor regulation of diabetes can result in a variety of debilitating, expensive, and potentially fatal conditions. Some of the most common are listed and discussed below…

• Diabetic ketoacidosis (DKA): A common complication of undiagnosed/unregulated diabetes mellitus, DKA results when the diabetic animal’s body has to rely too long on burning fats for energy. This fatty-acid metabolism pathway generates substances called ‘ketone bodies’ which are a viable cellular fuel source for only a limited period of time within the body. When this ‘period of time’ expires, the metabolic and systemic changes brought about by such metabolism are so severe as to prevent the normal and efficient functioning of the body as a whole and vomiting, anorexia, lethargy, and dehydration ensue. If DKA is left untreated your cat will suffer seizures, coma, and eventually death. Prognosis for DKA is typically good so long as it is caught and correctly treated early. DKA is a dire metabolic pet emergency which can itself lead to a variety of other systemic problems. Treatment for DKA is best achieved at a 24 hour pet ER with true ICU capabilities, appropriate nursing staff (around the clock), and doctors with a true grasp of the pathophysiology of the disorder. Attempting to treat DKA ‘conservatively’ - i.e. in a regular veterinary hospital with no nursing support staff available overnight or a nursing/doctor staff that is not familiar with the treatment of this disease - will more likely lead to treatment failure and your cat’s death. Ideally you should have your DKA cat’s treatment overseen by a board-certified specialist in either emergency and critical care (DACVECC) or internal medicine (DACVIM) or their residents. (This is not to say that other veterinarians cannot treat DKA, it’s just that, given the often complicated and multifaceted nature of this disease process, your cat’s prognosis for full recovery is often improved by having doctors with this level of advanced training involved in their care.) Treatment for DKA centers around restoring your cat’s circulating fluid volume, correcting their electrolyte imbalances, and helping their body switch its metabolism back from fats to glucose. Appropriate treatment for DKA is not cheap, often costing in the $3,000-5,000+ range, depending on how sick your cat is and how well they initially respond to treatment. This is not to scare you off from perusing treatment, because it is often successful when done correctly. This is to highlight that, in addition to the debilitation that DKA will cause your cat, there should be a strong financial incentive for you to strive for prevention of this condition as well. 
• Hyperglycemic, hyperosmolar, non-ketotic syndrome (HHNK): An uncommon complication of undiagnosed/unregulated diabetes, HHNK occurs when your cat’s blood sugar rises so high as to cause the production of urine at a rate higher than your cat can drink water to keep up with. This leads to a severe imbalance in the osmolarity (solute:fluid balance) within the blood and other tissues of the body. Similar to the complications of DKA discussed above, HHNK often results in lethargy, weakness, and mental depression, progressing to seizures, coma, and death if not treated. Fortunately this is an uncommon complication of diabetes in cats, but it highlights the importance of seeking correct diagnosis and appropriate treatment for it should it occur. As is the case with DKA, treatment for HHNK should happen with the involvement of a board-certified or residency-trained veterinary criticalist or internist at a 24 hour veterinary ER/ICU center to have the greatest chance of a favorable outcome.
• Hypoglycemia: Sadly a relatively common emergency complication of diabetes in cats (and dogs), hypoglycemia literally means ‘low blood sugar’. If your cat’s blood sugar drops below a certain threshold they will suffer seizures with the potential for permanent brain damage, coma, and death if not appropriately managed in a timely fashion. Hypoglycemia in diabetic animals typically results from one of two situations. The first is when the diabetic pet’s caregivers don’t have a good system of communication established regarding the administration of insulin and the pet receives a double dose of their insulin - one from each caregiver. The second common scenario for hypoglycemia in diabetic pets is when they receive their insulin at the prescribed dose, but it proves to be too high a dose at that particular time either because the pet hasn’t eaten their normal meal (due to a variety of potential underlying reasons) or because their insulin requirement has decreased (typically due to a change in their diet or the resolution of an underlying infection or other predisposing factor). The potential for hypoglycemia is the reason why every owner of a diabetic pet should have a handy bottle of Karo syrup on hand. Rubbing Karo syrup on the gums of a pet that is seizing because of hypoglycemia can help to halt the seizures while on the way to the veterinarian - just be careful not to get bitten when doing so and NEVER try to pour the Karo syrup down your pet’s throat or get them to drink it, this will most likely result in Karo syrup getting into their lungs (often proving to be a fatal mistake). Depending on your cat’s degree of hypoglycemia, the length of time they have been seizing, their hydration level, the amount and longevity of the insulin administered, and other factors, costs for treatment of hypoglycemia will typically run anywhere from $500-3,000+. As with many emergencies, the sooner it is detected and appropriately treated, the better the prognosis and the lower the costs. It is vitally important to monitor your pet’s urine dips for ketones on a daily basis - seek veterinary attention at the first sign of ketones in the urine.
• Urinary tract infections: Because of the presence of glucose within the urine of a diabetic pet, these pets are at increased risk of bacterial infections within their urinary tract. Whats more is that because of this abundance of ‘food’ (glucose) for the bacteria, such infections can be more difficult to eradicate and are more likely to recur as well. This can set-up a vicious cycle, as infections (anywhere in the body) can make diabetes regulation more difficult, leading to more glucose in the urine and a greater risk for infection. If such infections affect the kidneys, rather than just the lower urinary tract (bladder and associated structures), then acute kidney failure and long-term kidney damage can result. Have your diabetic pet’s urine checked for infections regularly with your veterinarian.
• Hypertension: Pets with diabetes mellitus are at increased risk of developing high blood pressure (hypertension). This can lead to organ damage, including your cat’s brain, kidneys, and eyes. Have your veterinarian check your diabetic pet’s blood pressure regularly.

What you can do to prevent diabetes in your cats:

• Help your cats achieve and maintain an ideal body condition. This is more than just their weight; it also takes into account their amount of muscle mass and body fat. Ask your veterinarian to help you assess your pet’s body condition. You can get a sense for it by looking at this Body Condition Score chart by Purina.
• Feed your kittens and cats a diet that more closely approximates what their system has evolved to handle - this typically means a higher protein and lower carb canned diet. Long-term feeding of a high carbohydrate and protein depleted diet, which describes almost all dry cat food diets, increases your cat’s risk for obesity and diabetes (and isn’t good for their kidneys and urinary tract health either). Check with your veterinarian first to ensure that a high protein/low carbohydrate diet is safe and appropriate for your cat(s). And see this excellent article by Dr. Lisa Pierson, DVM on the relationship between your cat’s diet and their risk for diabetes (she also provides great tips on her website for transitioning dry food ‘junkie’ cats onto a more appropriate canned food diet).
• Provide your cat with playtime and sources of environmental enrichment to decrease their stress and keep their weight down.
• Regardless of your cat’s vaccine schedule, bring them for annual examinations and evaluations by your veterinarian. A thorough physical examination and history taking can uncover the first, sometimes very subtle, signs of disease. Additionally, this is often the only time you cat gets weighed – and trends in their weight gain/loss can be an indicator of an underlying problem. The annual (and sometimes even twice annual) veterinary examination is a key step in the prevention of many pet diseases and emergencies. It can actually save you money in the long run too, as many diseases are easier to manage and regulate when they are caught earlier.
• Discuss with and have your veterinarian perform regular routine blood and urine screening tests. Both blood AND urine are necessary to diagnose diabetes. Even if the results of such tests are normal, it will be money well spent… you will rule out diabetes as well as a whole host of other disorders, and you will be establishing your pet’s specific normal baseline of laboratory indicators which will be invaluable in the event of future problems.
• Be careful with the use of steroids (especially depot injection preparations) in obese cats when treating other chronic conditions. Steroids are commonly used in the management of feline ‘asthma’ (also known as feline allergic bronchitis), inflammatory bowel disease, and chronic skin allergies. Glucocorticoids (steroids) decrease the effectiveness of insulin in your cat’s body, creating an insulin-resistent state and diabetes. Especially if your cat is overweight, thoroughly discuss the use and potential side effects of such medications carefully with your veterinarian before their administration. When used appropriately and in the right circumstances, the glucocorticoids can be life-saving and quality-of-life improving medications, but it is important to note that they are not without their risk for side effects too.

Important factors in the proper management of feline diabetes to achieve control and avoid the associated emergency complications of the disease:

What to do at home:

• Help your cat achieve and maintain an appropriate body condition.
• Keep a log book at home to note changes in your cat’s appetite, thirst, eliminations, energy level as well as to record you cat’s insulin injections and their ‘urine dip’ and/or blood glucose monitoring results.
• Keep your cat’s diet consistent - as regards food type, quantity, and timing of meals. This can help to ensure that their insulin requirements aren’t changing on a regular basis and can help with regulation.
• Communicate well with the other pet caretakers in your house to ensure that the correct dose of insulin is administered when it is due, and that you do not ‘double-dose’ your cat. Consider keeping a cheap calendar near the fridge where the insulin is stored to mark off when injections are given.
• Appropriately store, handle, and rotate out your pet’s insulin. Obtain refills one to two weeks in advance of when you will need them to ensure that you always have your cat’s insulin on hand.
• Ensure that you always pair the correct size and type of insulin needle for the type of insulin you are using (U-40 vs U-100). Not doing so can lead to either underdosing and a seeming inability to gain regulation over your cat’s diabetes, or overdosing and an emergency episode of hypoglycemia. Neither are desirable.
• Have Karo syrup on hand.
• Be sure that any pet sitter or kennel staff that you leave in charge of your diabetic cat’s care when you leave town is well versed in the management and complications of diabetes.

What to do at your veterinarian’s office:

• Maintain a close working relationship with your veterinarian and their support staff – be honest about your capabilities (both practical and financial). Stick with the recommended in-clinic monitoring plan discussed with your veterinarian.
• Ask the veterinary staff to show you how to monitor your cat’s ‘urine dips’ and/or blood sugars at home.
• Work with your veterinarian to ensure that your cat doesn’t have any underlying medical conditions or infections that can predispose your cat to diabetes or complicate its management.
• Talk with your veterinarian to ensure that your cat isn’t on any medications or supplements that can predispose them to diabetes, or make its management more difficult.
• In cases that are difficult to gain or maintain control over, the involvement of a veterinary internal medicine specialist can often help. Speak with your veterinarian about referral to a local board-certified veterinary internal medicine specialist. You can also locate these specialists by searching the database on the website of the American College of Veterinary Internal Medicine.

Diabetes in cats happens commonly, but it doesn’t have to be that way. There are many simple steps you can take to decrease your cat’s risk of developing diabetes, and achieving such prevention will save you a lot more that just money. Routine veterinary care and evaluation are important, but equally as important is achieving and maintaining an appropriate weight in your cat and feeding them a more ‘biologically appropriate’ diet. Should your cat develop diabetes though, or have already been diagnosed, know that it does not need to be a ‘death sentence’. Many of the steps you can take to prevent this disease are also helpful in managing it, and in a good percentage of well managed cases, cats can actually resolve their need for insulin.

Have you had any experience with feline diabetes or any of its complications? If so, what has your experience been? Leave a comment here or share on our Facebook page.

As always… Be proactive, be preventive, be prepared, and be safe!

Jason Nicholas, BVetMed(Hons)

The Preventive Vet™

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