Good evening everybody and welcome to another members Thursday night webinar. My name is Bruce Stevenson and I have the absolute honour and privilege of chairing a session tonight with the renowned Daniela Gunmur. I'm sure we are in for an absolute treat.
I cheated and saw her presentation beforehand and I can promise you, you are not going to be disappointed. Daniela graduated from the Royal Dick University of Edinburgh, with the Dick vet Gold medal in 1991. After a year in small animal practise, she joined the Feline centre, University of Bristol, initially as the feline Advisory Bureau scholar, and then as the DA Feline Fellow and completed a PhD study into feline infectious peritonitis in 1997.
After a short period as a lecturer in veterinary pathology, University of Bristol, she returned to Edinburgh to establish the feline clinic and became professor of feline medicine in 2006. Daniela is interested in all aspects of feline medicine. She is an internationally recognised expert in her area, has lectured extensively and published over 130 peer reviewed research papers, plus many reviews and book chapters.
In 2009, she was awarded the BSAVA Woodrow Award for outstanding contributions in the field of small animal veterinary medicine. In 2011, she was awarded the International Society of Feline Medicine Hills Award for outstanding contributions to feline medicine. In 2012, the Royal Dix students voted her as the clinician I would most like to be.
In 2016, the FECAVA awarded her increased vocalisation and elderly cats paper as the most original paper in the European Journal of Companion Animal practise in that year. And in 2017, she became a fellow of the Royal College of Veterinary Surgeons. She shares her home with her husband Frank, a 16 year old Maine Coon boy called Mortlock, which for those of you that don't know, obviously is a single malt Scottish whiskey and a tiny little 16 year old black cat called Sheba Adberg.
Daniel, it is my absolutely pri privilege to welcome you back to the to the webinar vet and it's over to you. Thank you very much, Bruce. Thank you for that lovely introduction and thank you very much and to Dawn for organising everything.
Hello, everyone. It is great to be here. I hope you're snuggled in, sitting comfy, got yourself a glass of wine, something to eat, and I'm gonna keep you hopefully entertained and put some education in there as well.
Cause let's be honest, my job is to do a little bit of both. It's a topic that is very close to my heart. I see a lot of tricky diabetic cases, which makes me think that you guys must see some too.
So, I'm gonna throw in some pictures of cats and I'm gonna base it on a case as I always do. I want to draw your attention to find my pointer. There is, there's my laser pointer.
I can put it on a little scruffy's note, I scruffy. Draw attention to this paper. It's the ISFM consensus guidelines on diabetes.
A couple of years or so old now, but still brilliant. And if you go to the RFM website, there's some really good handouts on for owners on diabetes as well. So definitely help yourself out and, and go and have a look at those.
So this is a great case. This was one of, a great friend of mine, Marge Chandler's pussycat. This is Alex when he was 14.
He had been one of our blood donors. He was a beautiful old soul. And so this is him at 14, and he presented to me, with a couple of weeks peeing outside the box, periura, no blood in it, no obvious smell or anything, but he did seem thirsty.
He had lost a bit of weight. You can see his coat's not great. And he's not sleeping, and it's sorry, he was sleeping a bit more.
He was generally just getting a little bit on the old side, but the, the perurea and the polydipsia was definitely causing much some worry. So here he is all coupled up with Charlie, who was his cousin, he adored him. So physical exam, not too bad, as you can see his body weight is still not too bad, but he does have some pretty significant periodontal disease.
I will make mention of that a couple of times. He's got some pretty impressive arthritis, particularly in both elbows. I haven't met a single Burmese that's over the age of 7 or 8 that hasn't.
They get an enthesophytosis in the tendons around the elbows, so they all end up with these Queen Ann legs. But his major problem, really at this point was periura and polydexia. So if we think of the different causes of periura, it does depend quite a lot on the age of the cats.
Obviously, the vast majority of cats with periura are going to be less than 10, and the vast majority of those are gonna have stress cystitis or plugs, urethral plugs, which are just another form of stress cystitis. That's gonna be the vast majority. But if we're looking at cats older than 10, and remember Alex is 14 at this point.
Then stress bladder is not a really important player. What changes suddenly is the risk of urinary tract infection. And so we know that if a cat is older than the age of 10, and Alex certainly is, then the risk is he's got a UTI.
Clearly, it doesn't just happen on your 10th birthday that you wake up and go, ah, my bladder hurts. It's because of diseases that you're more likely to get. So if we look at our list here, you've got the behavioural neurological.
So yes, that could be cognitive dysfunction, and you'd have to think about that in a pussycat of Alex's age. All the bladder related things and certainly in an older cat and transitional cell carcinoma. No, what have they renamed it urothelial carcinoma.
Why do people change their names? PUPD is gonna be your major player here. And the causes of that are medical causes of PUPD, which will be in the next slide.
But don't forget about musculoskeletal problems. Remember that Alex has got arthritis. So we really needed to check had Marge bought a new litter box?
Did it have higher sides, you know, was it placed further away? Was it just he's having more trouble with higher sided litter box and it's just progressed a bit. Maybe it's winter time and the arthritis is, is just feeling worse.
And then when we're looking at PUPD, yeah, exactly. You're talking kidney disease, you're talking diabetes mellitus, and you're talking hyperthyroidism. They are your top three in cats, head, shoulders, and tail above everything else.
All other causes are much, much less likely. So, given that these are the conditions we're looking at, then the next thing we need to do is really start thinking about some diagnostics. So we really need that full history, and we've got that now.
We need a full physical. Really important is weight and calculate the percentage weight change. If, if you remember just about nothing else from this first bit, please do that.
I mentioned it in most of my lectures. It is such an important indicator. If a cat has lost more than 5% of its body mass, doesn't matter whether it's in a day or a year, adult cats, adult humans, if you're not trying to change weight should be pretty stable.
There's been, think about what 5% of a weight change and you would be. It's actually quite a lot. And it's easy to miss in a cat because if they were only 4 kg, well, they're, they're now, you know, 3.6, that's that's nothing, is it?
Yeah, it is, that's just 10% loss, and that cat's very likely to be dead within the next year. Unless you intervene and change something for them. You also want to think about the body condition score and the muscle condition score.
Really important to do that oral exam because a really bad monkey mouse makes so many things worse. Retinal exam, we're thinking particularly for high blood pressure, which is so common with these diseases, but also things like toxoplasmosis for those cats that have been, you know, hunting, shooting, fishing kind of cats because, you know what, it can come back out as they become older and I see more and more toxoplasmosis. We've got much better tests for blood tests for it than we used to.
Then after you've decided whether or not you've got retinal changes, ideally, you take the blood pressure because what I always want you to do is check the blood pressure before you take bloods in an old cat. Please, please, please, always. If you can't check the blood pressure, then at least do a really quick retinal check because I can tell you about a little cat called Charlie, who's a little black cat when I was a resident.
I was just too bloody keen. I, I'd already looked in his eyes. I knew he'd got retinal bleeding.
I did his blood pressure. His systolic was 220 over, I think it was 110. So I knew he had high blood pressure.
That wouldn't have been a cause of it that I could have changed in the 34 days that it would have taken me to bring the blood pressure down using amlodipine, but I was too bloody keen and I dived in and started taking blood. He died on the end of the needle. And it was just still want to talk about it.
All the, all the hair at the back of my neck just stands up because I know I killed him. And OK, he was an elderly cat and. Yes, he had turned out he did have hyperthyroidism, but you know what, he could have had years more of quality life, but I was stupid.
So please, elderly cats, check blood pressure first. And don't take the bloods if the blood pressure is above, certainly if it's above 200 and certainly if there's any sign of retinal haemorrhages. And actually starting with urinalysis can be a really good way to go.
So while you're getting that blood pressure back down if they've got high blood pressure, but let's look at the urinalysis because that can give you so much information. Look at the diseases we're wanting to know about diabetes mellitus, hyperthyroidism, and chronic kidney disease. But we can get 2 out of the 3 of those.
So that's great. And then depending on what you find with those, we'll say what other tests you might need to do. So here we are, Alex's results.
We started with a P, that was pretty easy to catch. So you can say, oh look, really nicely concentrated. I don't need to worry about his renal concentrating ability, do I?
Actually, look, 3 pluses on glucose. Look at this little calculator over here. Each plus of glucose is worth 0.004.
On the specific gravity. So actually, Alex's USG is only 1033. So it ain't as good as it should be, is it?
He eats mainly, well, he's wet and dry food, but just the same, he should be doing better than that. So it's really important that you think about the effect of the glucose in the urine affecting the specific gravity. So, can we say, can we make a diagnosis based on all of that glucose?
It's true, it is unlikely to get 3 pluses of glucose just out of stress, but I have seen it. I've also seen 3 pluses of glucose where we've had an acute urinary tract infection, particularly where I've seen leptospirosis or any other cause of acute renal injury, renal infection. So you couldn't rule it out from that.
The urine was sterile. So yeah, you'd be looking at this thinking. Diabetes looks likely, but it's not guaranteed on that.
Thankfully, his BP was beautifully boring, which is I like. Haematology, yeah, white cells down a wee bitty, but the lymphocytes down in an elderly cat, well, they're all down, aren't they? Yeah, it's normal.
The low news, they weren't too bad. They were just on the edge. Glucose 23, could you get 23 from stress?
Yes, you could. So particularly in a very stressed cat, doesn't usually go up that high, but it certainly can. Highest I've ever seen was a little cat who'd had a 4 hour journey to come and see me.
She had, piddled in her box. It was in those days when we used to use those horrible boxes that closed over at the top and turned into a handle. Yeah, some of the old souls in the audience.
You'll, you'll remember them as well. So she peed in a box and the box had gone soggy at the bottom. So after the 4 hour journey, her owner lifted up the box, and of course she just fell out of the bottom of it and she hit the tarmac in our car park and bounced straight on under the wheel arch and onto the engine.
She burned all four pores really badly and her blood glucose was 32. And once we got her all sorted, she wasn't diabetic. She was just the most stressed cat I've ever seen.
So, 23, you could get that, with stress. And if you did, that could result in 3 pluses of glucose. So you'd expect to see a very stressed cat, which Alex wasn't.
And that certainly was, backed up by a, a very high fructose. I mean. Normally.
You'd be less than 350. So that really there isn't a a reason for fructosamine being falsely high that high. It doesn't have a 100% sensitivity and specificity, but really at this high, that would be pretty safe that yeah, we've got a diabetic pussy cat.
Why is the ALT up? Well, lots of reasons could be most likely, this is hepatic lippidosis. You have got an untreated diabetic, they will have hepatic lippitosis.
And this level of lipiddosis would be pretty normal for, you know, an ALT of about 400 and pussycat presenting like Alex. So if I haven't got much pennies, then do I need to do the ultrasound at this point? Nope, I don't.
I could just treat, . And go ahead with that because I'm in a hospital because Marge was one of my colleagues and this is one of our ex blood donors. I am dotting all I's and crossing all theses.
Of course we did ultrasound and his pancreas looked normal. All there was was a slightly enlarged, homogeneous, rather white looking liver or consistent with the paddo libidosis. I didn't think it necessary to do a fine needle aspirate to prove it, but I could have done if I would have been tempted.
So he's a diabetic. What can I tell you about diabetes? Well, you probably all know it's really common.
One of the studies I did a few years ago with one of my residents, we showed that in Britain, it's about 1 in 200 pussycats. And we now know it's increasing. If you look at the data above, you can see that's pretty high.
OK, that's US data, but it's the same over here. It's mainly a disease of older cats, they tend to be old fat boys, is what we always go, old fat boys. It tends to be, those particularly house cats, cats that don't exercise are much more at risk.
In Britain, Burmese are massively predisposed, and of course, Alex is a cream Burmese. That is the same for Australia, New Zealand, and much of Europe. That is not the same for US.
So if anyone is from the US or going back to the US, Burmese are not predisposed to diabetes in the US. Also in Europe, Tonkins, which of course is just Burmese Siamese cross really, and the forest cats are Norwegian Forest cats are also predisposed, whereas in the US it's actually Maine Coons, Russian blues, and Siamese. So you do need to know your risks depending where you are.
I know this is a busy slide, but I really wanted to put it all in and I'm gonna talk you through it. Now, this is the classification of diabetes mellitus as per the WHO. It has been this classification for people for probably 20 odd years.
It has been this classification for cats for probably, I don't know, 15 years. And I don't know why, but some of the doggy focus vets still lecture. In the old fashioned way, talking about insulin dependent and insulin non-dependent.
Come on guys, get with the programme. That's a stupid way of looking at this disease. And a good chance for me to let that sink in and and let some water sink in at the same time.
So let's have a quick look at those different types. So classic type one used to be called insulin dependent, that is because in humans, you are stuck with it. If you are unfortunate enough to develop this disease, this is an immune mediated, insulinitis.
It is an attack on your beta cells. They are wiped out. You do not get them back.
Until we get to the point where we're doing pancreatic transplants and we're getting close, then there is going to be no cure for this disease. And certainly, thankfully, it doesn't happen in cats, or if it does, it's so rare that we really don't recognise it. We don't have to worry about that in cats.
Obviously, dogs do do this. And if you've got a dog with type 1, it is going to be diabetic all its life. Whereas type 2, which is the vast majority of pussycats.
This is peripheral resistance. OK, this is impaired insulin production. Initially, because of the insulin resistance, they actually produce more insulin than they used to.
The problem is in humans and cats, I think of humans as being a really good model for for diabetes and the cat, because it's the same. Only cats, humans and raccoons for some reason actually do is amyloidosis, which I'll mention again on the next slide. So, Obesity plays a big role here, and this is the major reason obesity and lack of exercise are the major players for this disease in cats and in people, along with our very high density food.
And obviously, this starts as not being in requiring insulin. Certainly in people, in cats, it's almost always too late by the time we first recognise it. But if you can get them into remission, then they are no longer insulin dependent.
So It's because if you've got disability for insulin from for diabetic remission, it's a very, very different disease from type one. So some people and it tends to be the doggy focus people talk about type 2 becoming type 1. That just doesn't make any sense.
Let's stick with the WHO guidelines. I think it makes it easier for all of us to get our heads around. But we also see a lot of what's other types of, so secondary to something else.
Pancreatitis, we know, is a massive player. Over 60% of diabetic cats at point of death have got pancreatitis. Now, clearly, that doesn't mean that 60% of diabetics are caused by pancreatitis.
That would be daft. But if you've got pancreatitis, then that does often become a cause of diabetes and particularly younger cats, where you've got a diabetic young cat, it tends to be that they've had acute pancreatitis. And if you're an unstable diabetic, because of all the oxidative injury that's going on, it really is a risk of pancreatitis.
And you know that if you inflame cats anywhere really, then, what can become inflammation can then Mutate and become carcinoma or lymphoma. That's just cats you can have a whole discussion about that. And certainly in one pm study of diabetic cats, then about 20% did have pancreatic carcinoma, which is why in an unstable diabetic, it is important to do that abdominal ultrasound.
Let's look at what that pancreas is looking like because if you've got a mass in there, you really need to aspirate it and find out because if you've got a carcinoma, unless it is resectable. You're not gonna get that cat back under control. The endocrinopathies are playing ever and ever more important roles.
This is in humans as well, and this probably relates to all the toxins we are putting into our environment. We know, complete aside, you know me, I like to digress occasionally, keeps everyone awake. We know that we have a global pandemic of hyperthyroidism in cats.
And it's more and more it is looking like it relates to exposure to polychlorinated, hydrocarbons, etc. Particularly pot lining pop cans, plasticizers, flame retardants, etc. We're also seeing a lot more thyroid carcinomas, so it's the same in humans.
And interestingly, acromegaly, which obviously starts off as hypersommatotropism, which is the production of too much insulin-like growth factor and growth hormone from a pituitary carcinoma, pituitary cancer, sorry, adenoma, and then again mutates. It becomes acromegaly, which means acro edge, and megaly, big, big edges, big head, big feet. So you start off with just the biochemical things happening, but no physical change, you don't look any different.
And then with time you start showing dysmorphic body formation. So we used to call acromegaly, but it makes sense to call it hypermatotropism because that explains why a lot of these cats with resistant or unstable diabetes, and they can just be unstable when this starts up, that they look perfectly normal. But we're seeing more of this in humans too.
And this appears to be again being caused by these different toxins we've put in the water. And as a complete aside, I discovered, two days, yeah, two days ago that the last live birth of orca around the British Isles was in 1985, the year I went to university. There's been none since then.
We're gonna die out because we've poisoned the whole bloody lot. So yeah, that's my little soapbox, but it means that these, so many of these diseases that we're dealing with, we have caused them, not intentionally, but I'm hoping that while some of these diseases were first found in my academic lifetime, if we can therefore find hormonal blockers, we might have a chance of actually preventing them before I have to retire. That would be really good.
So a little bit of debate about just how common typesmatotropism, but it's probably around 20% of diabetic cats, and you can see this adds up to more than than 100%. So you can see that things there's got to be some, some wriggle room in here. Hypercortisolism, which could also become hyperdrenal corticism, which is otherwise known as Cushing's like syndrome, potentially up to about 15% and then obviously exposure to some drugs can do this too.
These are the ones you really like because these guys are likely to go into remission pretty quickly. Look like cyclosporin is got a game to play here as well. I know I spent a bit of time on that slide.
I hope. It wasn't boring for you. I know I haven't got a picture on it and I like my pictures, but I think if you can understand the causes, you've got a much better idea about understanding what's going wrong when we're gonna try and turn around those resistant ones.
Just a quick mention of amyloidosis. This is, it's the amylin protein. It's not the same amyloid to get in brains or you get a secondary to you reactive problems, reactive amyloid.
This is a protein that is co-seed with insulin by the beta cells. Unfortunately, it builds up around those beta cells and it's toxic to them. So anything that causes high demand for the production of insulin automatically produces more amylin and makes the whole thing worse.
It's a really bad design fault. So yeah, you know, I think cats completely perfect in every way. They just evolve one or two little silly things, and this is one of them.
We know the role that genetics can play, and I've already said about obesity, and we know that the reduction in insulin sensitivity that you get with obesity causes a 5 times increased risk of diabetes in cats, which is pretty high. And obviously, the fat of the cat, the worse the risk. And it amazes me about people who've got fat cats.
They're proud of them. Like, you know, it's like, why would you be proud that you've made your cat so fat and it's now got a massive risk of diabetes, joint problems, allergy problems, breathing problems, heart problems. Oh, let's get the cats back to a proper weight.
Yeah, I see so many cats come in that are 6 7 8 kg, where when you look at them, you know they should be more like a 4 kg cat. That is a big percentage increase. And just also a little mention of the pancreatitis being so common, chronic pancreatitis can result in both diabetes mellitus and exocrine pancreatic insufficiency, in which case you've got a cat that really is very, very hungry because everything they eat is either pooped out in the litter box because they couldn't absorb it because the EPI.
And if it actually gets absorbed, then because there's no insulin to let get it into the cells, then they just pee it out and whoops, yeah, back into the litter box. These guys are very hungry. To go with this as part of the triitis problem, then they're quite likely to have cholangitis.
And or inflammatory bowel disease, which can result in a whole load of problems too. So don't forget about that risk. So, let's think for a second about insulin remission or for insulin is a good one.
I love that. But let's try diabetic remission. Depending on who you read, we'll tell you it's really easy to do and over 80% can be can achieve this too shit, you know what, I can't get 20% to do it.
If you actually look at normal clinic conditions, you are probably looking more like 50 to 60% as being achievable. All right, these 80% pluses that I'm gonna come back to it because there's a serious risk when you do this. It is not to be undertaken lightly.
So it means you basically have reversed the glucose toxicity and you've managed to get that poor limping along pancreas back functioning. So you've got to get it for at least 4 weeks to be declared as a diabetic remission. Not surprisingly, quite a few cats that you get into remission do then relapse.
And that is maybe because they had pancreatitis and they develop pancreatitis again, or because they were fat like little Sally here. And this, this owner, this owner was, thought it was funny to show how fat this cat is. This cat's fatter than me.
Yeah, she's even got fat around her tail head. She's actually a little cat. Look at the size of her, her face and her pores.
So type ones will not go into remission. Type 2s, if you can resolve the obesity, they can go into remission. And the second is if you can sort the pancreatitis, sort that really bad gingival disease, there was a very interesting paper in humans that came out a month or so ago, and it showed it basically did a a a very rigorous, and repeated.
Control of the gingivitis, stomatitis, particularly gingivitis in these people. And the people who had the really tightly controlled, gingival disease did much, much better and their diabetes was in much better control than those that either had no maintenance of their, their, their gum hygiene or, or minimum. So if they've got that, and we know that little Alex did, maybe we should have been quicker in in addressing that, particularly as if you've got periodontal disease, every time you bite and chew, you're gonna have a good bacteremia going, which is going to go around the cat, particularly risking getting to the kidneys and you're gonna get a secondary renal problem.
And we know that UTIs are common. You tract infection is common in these cats, not surprising. You've got high blood glucose, and then you've got glucose in the urine, which you can grow bugs on.
So, yeah, and they've got low urine specific gravity, so not surprising at all. I've already mentioned the endocrinopathies and clearly, if you can resolve any of these, then you can get your cat back into remission again. And the best chance of remission is if you've given your pussy cat some corticosteroids, maybe be a sort of depot because it had harvest mites, and now it's gone diabetic.
There's a really good chance that you get strict with that cat, and it will go back into remission, which is great because then they don't need to have daily insulin. So an appropriate diagnosis requires the appropriate history. It amazes me.
I do get some cases, every now and again that have no history of polyuria, polydipsia, polyphagia. I know they're easy to miss, particularly polydipsia if cats go outside, because people Don't see them drinking from puddles, polyuria because they don't see them going outside and peeing. So it, it can be easier to miss in a cat than a dog, but it is an important thing that there should be weight change, there should be something more, to go on than just glucose in the urine.
Then persistent fasting hyperglycemia, classically, people would say greater than 11, but remember that stress can easily take you up there. Jackie Rand and her team in from Australia do talk about a pre-diabetic state where they're working mostly with cats that are actually research cats who of course are very used to being handled, etc. And if they, these cats, they're, they're they're looking for Burmese, the Burmese cats, so we know they've got a risk of developing diabetes and she can start seeing that they're starting to be at risk if they're going above 7.5.
But you know what, that's so many of the cats in my clinic that would be me getting very excited about prediabetes on a daily basis. And then you've got glycosuria. Remember the renal threshold for most cats is bit cat to cat dependent, but it's about 15, so you can easily get glycosuria with stress.
So it's got to be persistent. Other things you might see, polyphagia, weight gain, weight loss. If you truly document weight gain in an unstable diabetic, you have got acromegaly.
All right? So weight gain in an unstable diabetic is an acromegalic. I've already mentioned the problem about seeing these clinical signs because they could be hidden with outdoor access.
If you've got ongoing pancreatitis, you could have signs of anorexia, vomiting, GI signs. It is unusual to get a little cat like little Ellie, who really was pretending to be a German Shepherd dog with EPI. She even looks like a German Shepherd dog with the right colouring in the greasy coat.
Obviously, easy enough to, to diagnose, but you need to have it on your list to recognise it. I've already mentioned about the risk of UTI. Some of these, particularly its E.
Coli, present with signs of dementia. E. Coli hasn't got out of the bladder, but the toxins they're producing have.
So you've got a cat that presents as a cognitive dysfunction type case. And just remember, this could be a UTI. Climbed your hip.
All this clinical signs that you might, might expect from that. Heart failure, particularly we see this if they are acromegalic. Hypersmatotropism here is beautiful ginger, modelling a perfect acromegaly with great big head, big paws.
You can see the separation of its teeth. And then this is a little case of mine. This is little Molly, and she's got very thin skin.
You can see it's paper thin and it's all folding up. And yeah, she had, hypergenic corticism. It's not easy to diagnose in the cat, whether you do an increased urine cortisol creatinine or you do depression, it's your own choice and thankfully it's not at all give too often because the data out there is not that great.
So, what do we do next? They're your clinical signs. Go and look at all of those and if any of those things light up and give you a bit of a warning, then follow those down because they really aren't that rare.
None of these complicating factors. Then blood, yep, serum fructosamine. Remember that reflects about the last week only in the cat.
If the cat has lowmen, the fructosamine can be falsely low. That is because it's a combination of blood glucose and blood proteins. So if your blood albumin is low, your fructosamine will also be low.
Also, if you've got hyperthyroidism, it will be low because of the increased protein turnover that occurs with hyperthyroidism. So if you're unlucky enough to have a diabetic that's also a hyperthyroid, really hard to diagnose, just send those to me. They are weird because the fructosamine is low, because of what I've just said.
The glucose, blood glucose is high. The, T4, which you'd expect to be really high, that is brought down because of your thyroid sick effect, so it's only in the top third. And that can then make it a bit strange.
So you've got serum fructosamine is just at the top of the reference range, and so is your your your thyroid function. You're going, what? So those weird ones, but they will be really polyphagic, polyuric.
They will look like they are the worst diabetic, the worst hyperthyroid you can get. And yet the bloods aren't that exciting. That should be the clue that what you've actually got is a concurrent diabetic hyperthyroid.
On the urine, so you see blood glucose being spilled into the urine, after about 15. Ketones, less than 40%'s actually quite a bit lower than that in most studies. So cats don't seem to do ketosis as easily as dogs, which is something at least.
You're in culture with the UTI varying different papers, but certainly up to 25%. So to not look for it is pretty daft. I know you'll find the London team will push on and say you've got to look for an increased IGF one first thing straight away because you've got maybe they keep going on about the 25% chance of having acromegaly or hypermatotropism, but they really were the complicated cases they were looking at, and you can't do anything about acromegaly at the minute.
Well, it's thousands of pounds for brain surgery, thousands of pounds for radiation treatment, thousands of pounds for the posrioide, if you can get hold of it, or you just treat them as an unstable diabetic. So that's not really going to change what you. And certainly not when you first make your diagnosis.
But whether the cat has a urinary tract infection, whether or not it is ketotic, or whether or not it's got pancreatitis, or make a difference on day one. So I really do recommend that you do look for all of those things. And then whether you need to go on further, ultrasounds, etc.
Will depend on the case. I do always look for hyperthyroidism because so many cats that seem to end up with me have got hyperthyroidism and diabetes. So what about treatment then?
We've got our diagnosis, yay, let's treat. Well, you basically want to limit clinical signs, and important, avoid hypoglycemia cause that is what kills. A lot of people will say push for a diabetic remission.
You can do that by really aggressive early treatment. There is a protocol where you can hospitalise the patient, give it IV insulin, and then, monitoring with, you know, one of these, subcutaneous, long-term monitors and It has been shown in one paper that if you do that for a week and you basically clamp the cat's insulin into the reference interval and you keep that cat's blood glucose just where you need it all week, then it goes home being treated as a diabetic. The likelihood is that cat is gonna go into a remission better, quicker, more effectively and stay there than if you don't treat us aggressively.
But you've got to manage your client expectations. If you've got an owner like you, for example, having had a diabetic cat, I can tell you, I couldn't give my cat insulin twice daily for love or money. I wasn't home.
I'm working there. And so you have to work with your clients. What is really important to them?
Do they need a very practical day to day treatment that is not going to, it's not likely to remove the diabetes, but it's also not likely to kill the cat with hyperglycemia. Or would they really, really like to go for an intensive, therapy in the hopes that the cat is no longer diabetic? And you can talk with the cat through the different things that can be involved in treatment, and there's the list there.
So, tips. The most important when you're treating diabetic cats, be realistic, be flexible. Sit down with the owner.
You need a long consult to do this, or you need two consults to do this. Ideally, you have a nurse, because nurses are much more approachable than we are, and owners will tell them things that they won't tell us. Who's always on the end of a phone or an emails to help with the support for this because this is a big thing to make a diagnosis of.
You need to provide good websites. We did a study recently which I'll show you some data on in a second. And it showed that generally the websites that owners tend to find themselves are far more useful than the ones that vets have tend to give out.
We can do better on that clearly. You need to talk through the different causes. Treatment options prognosis.
They need really clear handouts with clear potential expectations. Yeah, this is tricky. Nothing is guaranteed.
What came out very strongly from our study is that vets weren't talking about the role of diet. Very quickly, and they weren't talking about home monitoring very quickly, if at all, and the owners were very cross about that. So that study should should don't be, should come out pretty soon, I think.
I hope that will help, will help with some of us. Explain the chances of transient diabetes, etc. But you've got to work with that owner.
If that owner works 12 hour days. Then you know what, you're not gonna be aiming for or for remission. So exercise, can it really help?
Yeah, here are all my guys modelling it for you. As much as just 5 minutes of play twice a day can actually make a big difference, not just on weight loss, but it actually increases the metabolic activity. And my good friend, Sarah Kaney runs Caprofessional.com.
She writes some beautiful little books, which are good for owners, vets, vet nurses, etc. There's one which is called Caring for the Overweight cat. She's working on the one for hyperthyroid.
Or is that one out now? I think she's working on the diabetes one. I must, I must speak to her.
But certainly have a look at our website and I know the overweight one really helps here. With diet, it used to be high fibre, and that is still used obviously in dogs. You will find some people who will still use a high fibre, for example, in a cat like Arthur, because they worry that it's hard to diet a cat when they're quite that big.
I have successfully dieted cats on the preferred high protein, low carb diet, the wet one. So I would still prefer to go down that route. And the reason that these high protein, low carb diets work, it's because if you bear with me, it's only a little bit of pathology path for you.
Insulin tells allows glucose from the food to get into the cells. Now that would just diffuse straight back out again once the blood sugar falls after the food, if the phosphorylation didn't actually stick a phosphate on the glucose and prevent it from diffusing back out of the cell. Now in dogs and people, We use a glucachinase and the glucachinase can work at high blood sugar, which means we can eat a high sugar meal and our glucachinase can stick on that phosphate, which means when our blood sugar then falls, we don't feel immediately so hungry, at least most of us, and it means that the glucose stays in your blood, stays in your cells.
The problem is cats don't have glucochinase. They only have a hexachynase and it can't work at high blood sugar. Well, why would they have that to, to, to have a system like that?
Because if you eat high protein meals, many and often a day, you never get a blood glucose rush. So you don't need an enzyme system that works at a high blood sugar. So that means if you feed a cat, that gives it high blood glucose after feeding, then it will not phosphorylate that glucose, which means as soon as its blood glucose goes back down again, it's gonna just diffuse straight out of the cell and the cat's gonna be hungry and it's diabetic because it didn't get any of the benefit of that blood glucose getting into its body.
Does that make sense? I hope so. I hope I explained it OK.
So we know that with a high protein meal, you get a reduced and markedly delayed postprandial glucoseage if you get one at all. If you can stop the high . So this is what it means this feeding high protein makes the hexainnase is much more effective.
If you can stop high blood sugar, it means no glucose and sugar gets above the renal threshold of about 15. If you haven't got sugar in your urine, you don't lose the energy into your bladder and hence into your litter box. You're not losing, so that you're not losing your water as Well into the litter box because you get that osmotic diuresis.
So the blood sugar getting into your urine means you lose all that energy and you get polyuric and then secondary polydipsia. And because you've peed all your energy out, you are gonna have polyphagia. So by feeding high protein, you reduce the signs of diabetes and for mild cases of diabetes, this can be enough, the diet, if you catch it early.
Little study, small study. Cats started on a high fibre diet after they had been, on that for a couple of months, they were switched over to a high protein, low carb diet. This was the wet version, which is the, the, the best one of the prescription diets.
It was a significant reduction of insulin in 8 of the 9 cats with 3 of the 9/3 going into remission. There was an overall 50% reduction in insulin and it wasn't because the food tasted so disgusting. They didn't like it and hence they didn't eat anything and they lost weight.
That wasn't the case, OK. The weight stayed the same. Obviously, the urea in the blood went up because they were fed a high protein diet.
One of my very good residents, Carolina Albuquerque has been helping me up, update all the data that's coming through on this. So these are the diets which are designed for diabetic cats. So you've got the Purina, veterinary diet, the wet one, the dry one, hills, wet and dry, Royal Cannon, dry, sorry, I forgot to put the wet one in.
I'm very sorry, and then two which are designed for. The higher fibre way of looking at things. I hope I'm gonna show you why they don't work.
We know, if you look at mouse, which is obviously what a cat has evolved to eat, then it is less than 5% carbs, because the only carbs are entailed in the entrails of the the mouse. It is about 55% protein and about 40% fat. And that is what else is.
So if you look at the Purina wet version, that's pretty much what that is. Some authors would now suggest, and I think there is some reasonable data for this, that you need to aim for less than 12% metabolizable energy from carbs in order to try and put a cat into remission. So if that's where you're aiming and you're aiming for less than 12.
That is the only diabetic diet that's actually gonna do that for you. Pretty scary, hey. The dry diets, you can never get them, as low, you can't get them below 15 because you need that much carbohydrate just to make kibble.
The royal canon one is made with less protein. So this is kind of a halfway house if you've got a cat maybe with kidney disease, you might want to think about. But I think what's interesting to look at now is with the increase of low carbohydrate diets and some no carbohydrate diets, particularly you've got applause and Lily's kitchen.
They're very palatable, they are very high in protein, they're not good for cats with kidney disease. Just make sure when you're talking to owners about this, this is a really good calculator that you can use. A lot of the applause ones are only oh what's the word, supplementary foods.
They're not complete. Something like, I think there's 17 different diets and only 3 are actually complete. So make sure when you're recommending things to owners, they must be using at least some complete diet every day.
So if you have questions about that, come back to me. Vitamin E could certainly help reduce stress and carnitine can be helpful to reduce the risk of lipiddosis. Assisting those hexainnases by little and often and regular feeding is definitely the best way to go.
And what I do actually prefer for my diabetic cats is maybe 2 or 3 wet meals a day. And then I want them to have kibble down the whole time as long as they're not obese cats, so that, if I'm home late, except if the owners are home late, they've still got something to eat and it gives them that trickle feed the whole time. Clearly, if they are a kidney cat that is not gonna work with those you have to accept that it's the kidney diet you usually need to go to, you could add in psyllium husk and or acabose that will reduce that post-perennial surge, which glucose surge, which will help.
I'm not gonna see massive about insulin because I think we could probably do a whole lecture on it, but that the numbers that you will recognise I'm just gonna underline some things that maybe some people aren't quite so sure on. Obviously, Lenty, can insulin, Petillin, this is always twice daily. PZI really it needs to be twice daily.
If you're gonna try to go once daily, you get away with it with a few cats, and so you said potentially 30%. Glarine is a much better way to go if you have to go once daily, for example, because you've got owners who have such long shifts. And it's not a lot of data really on data.
Your starting doses are gonna be 0.25 to 0.5, and you really need to be thinking about what the cat's ideal weight would be per injection.
You don't treat them as for an 8 kg cat when they're actually a 4 kg cat. And quite a few people, myself included, I tend to start low, particularly when the blood glucose isn't that high and higher when we have got high blood glucose, but with a maximum of 3 international units per cat, per insulin injection initially. Adjust by I tend to do 0.5s unless I'm really not getting any response at all.
And then really, I'm just gonna check the Nadia, to make sure that I'm not going too low and you only just the insulin doses up every 5 to 7 days. Obviously, if you've got a hypo, you need to drop it straight away. But if you need to increase insulin, don't do it quicker than once a week.
It takes that long for the cat's metabolism to balance out and you're aiming initially. To be somewhere between 5 and 14. All right.
Make sure that you match the type of insulin with the strings because Lantus, which is your glargine, is 100 international units per mL, whereas PZI and insulate are 40. And obviously if you model those syringes, you're gonna make a mess. Don't dilute insulin.
And then this is kind of what these were two diabetic girls, gorgeous girls, both Burmese, of course. Cats are not very predictable, either cat to cat or even within a single cat. On day one, I just make sure that the nadir isn't too low, and I send them home.
But some owners, I think it does help if you clip a little patch on the back of the neck so they can really see what they're doing. But once they've got it sussed, I say move around because you can get one patch, which gets quite thickened and then that will slow down absorption. And then usually after about a week, we do a blood glucose curve.
And how frequently you do them, whether you do it every 12 or 12 hours, whether you do it for 24 will depend on what the owner can do. Certainly most times it's gonna be a 12 or just a bit longer. If there's no change in glucose, then obviously you're gonna increase the insulin and reassess later.
You're really looking for trends and remember, blood glucose curves cannot be interpreted in a really stressed camp. I've already mentioned that intensive 7 day protocol with subcutaneous constant glucose monitoring and obviously that is something that you could put in at this point. So the sort of thing you're usually looking for is there's your renal threshold, and this would be with lenty.
So it starts up high and as soon as it comes below the renal threshold. Remember, now the cat is comfortable, it's not peeing for Britain anymore. It's not thirsty for Britain anymore.
It's not hunger for Britain anymore. As soon as you get below the renal threshold, you've got rid of the clinical signs. Now, clearly long term, it doesn't help to live at this level, you will get damage to nerves and to retina, etc.
So you do want to pull them down here, but that is your aim initially. Glarine has kind of a cumulative effect. So we describe as peakless and certainly I do much prefer it to to Lenta.
I don't have a lot of joy with Lenta, but obviously in Britain, you're gonna have to start with Lentay or PZI and my, my preference now is to start with PZI. You're much more likely to succeed with that with cats than you would with a standard Lenty can insulin just because it's not long enough. So start with PZI if that doesn't work, then obviously you can move on to lay.
That's Cascade being used appropriately. Really important, particularly if you're doing an intensive protocol, is you need to make sure the owner is really clued up for signs of hyperglycemia. What is important to remember is, one, the way the glucometers are set, but two, cats, normal healthy cats, when they're fasted, they'll go down to 2 all the time, and they're completely happy with that.
It's when they go lower, you start getting into trouble. And the problem is that cats just hide. Yeah, they don't do all the things they should do, like eating.
So if the cat is hiding or shaky, then it's really important the owners have some glucos stop or something similar at home that they can put on the cat's scans and get the cat quickly and to see you. I'm not gonna say much about the oral hypoglycemic drugs because they don't tend to be used very much. I'll be interested to know how many of you use them.
I've certainly used glipizide quite a bit. One study showed it could be as good as can insulin, but long term it's not a good move because it does push the pancreas pretty hard. Acabose is something you mix into the food and it will slow down the glucose release, postprandials that could be useful if you've got a cat with kidney disease, for example.
Quite a lot of the veterinary diets have got things like chromium added. Watch this space for the increins. These are funky, funky, hormones.
These are the hormones that are triggered when you eat food. This is why glucose added to your body via the gut is so much more effective than if you give it IV. And that is because if you get a release of all these other, hormones, particularly gluca glucagon like peptide one.
That's not easy to say. And so work in humans and now in cats with these extended release versions are looking quite promising. This at the moment is looking like an injection that's going to be once a week.
Clearly, that would be a nice way to go. So watch this space on that. So treatment, remove any causes, drugs, particularly steroids or let that get out of the cat's system.
Look for those infections, pancreatitis, bad gingivitis, UTI. Good current diseases, get the cat's weight down. Make that diet change, and then I do go routinely straight to exogenous insulin unless the owner is terrified of needles.
So that means I'm gonna go with an oral hypoglycemic. And then you've got to monitor this kitty cat because nothing stays the same, that's for sure. All of these things can help changes in the appetite, body weight, body condition, well-being, muscle strength, cook quality.
And your owners are the best people here. Get them to keep a diary with the diabetic cat so they can mark, you know, smiley face, sad face, you know, those those buttons you get outside toilets in municipal places and airports and things, you know, green for smiley face to red with a grumpy face. If they do that kind of thing for the cat, that can really help to monitor the cats and see quite which way you're going.
You've got urination and drinking, certainly monitoring how much water is being drunk, even if you've got two cats in the household, if it's being put down in a bowl. One cat is likely to be stable if the other cat is diabetic. If you've got 2 diabetics, it's gonna be really tricky.
What can be very useful is urination. Owners can do this by what is the weight of the litter box at the end of the day, if you've got 1 cat, or if you've got 2, you can still do it, so long as one cat is stable. What I found actually owners are pretty good at is with clumping litter, them measuring the diameter of the urine ball.
And one owner was so clued up, she could, it was actually one of Marge's house sitters, and she said, Alex's urine is always 6 centimetres across on his urine ball, and he is 8.5, something like that, centimetres across this morning. I'm sure he's getting di he's getting pancreatitis again.
Can I bring him straight in. She was right. So that can be really useful.
Urine testing Some people still have this idea that it could be useful to look for glucose in the pee. This is only useful really right at the start of monitoring a cat because pretty quickly, you should get the blood glucose below 15, in which case, you know what, they're not going to be going above the renal threshold. Glucose is going to be negative.
It could also be useful for looking at recurrence of diabetes if you've had an insulin, a diabetic remission. But generally it's not the most helpful thing. Ketones, I will have owners have ketone monitors monitoring if the cat has had, for example, chronic or recurrent pancreatitis, that can be a good early warning system.
And obviously, yes, for looking at culture. Fructosamine, I've already mentioned this, so sensitivity is very good. Specificity is not always as quite as good as I'd like it, but it's, it's not bad.
So what about glucose curves? I really prefer this done at home. I really prefer them done using ear veins or feet.
I really prefer them being done with EmA. I should have put a little stick of the Emla picture. So you put Emla on the ear or the pad.
1, it's gonna anaesthetize it. 2, it stops that lab of blood running into the fur, and then you lose it. I really, I know they're more expensive, but the alpha track, you can ask me about it, but it really is very much more sensitive, very much more specific.
It is designed for cats. And it makes a huge difference using ones designed for humans, get it, gets it wrong, really low sensitivity, really low specificity. And you know, how you set about doing your curves.
Obviously, we can talk more about it in questions, but usually you're gonna do as many hours as you can get and they're gonna be 12 hours apart from, sorry, that's, I'm keeping you awake. You're gonna be 2 hours apart until you get close to the Nadia. If you can do them every hourly close to the Nadia, that, that will help.
What has been shown repeatedly is You can have the same cat in the same hospital situation, or same cat in the same home situation and curve them 2 or 3 days in a row, and about 30% of the time, you would make completely different decisions based on those curves. So please treat them with the cynicism that they require. There's some good YouTubes for doing poor sticks.
And Alpha Track has got, great pictures and things of this beautiful, Maine Coon sitting there having his glucose sticks done. The other thing about the Alpha track is it takes the tiniest, tiniest splodge of blood, and, you know, even, or, you know, there's really no blood there and sometimes you can get a result just about. And this is boo, and he's being tested by his owners.
He had really unstable diabetes because he had chronic pancreatitis, as you can see, and he had to have his blood checked before every insulin requirement because sometimes he could have nothing and other days he would need quite a lot. And they kept him alive for 3.5 years, good quality life because of brilliant home monitoring.
So it really is important. And what is improving now are these continuous glucose monitoring. There's there's a few available.
These are some lovely pictures that Steph Layla has given me from the Guardian real time. I've tried to use this one and not really got on with it very well. The one that really seems to be doing best is the freestyle Libra.
And good reason is it is calibrated in the factory. These other ones, you need to keep calibrating them in the cat, so you still got to do a blood glucose test every 23 or 4 hours, which means, come on, you're just not doing the curve anyway, which I find a pain in the butt, and they don't last very long. Whereas the freestyle Libra, actually, it lasts 14 days, which is pretty good.
So I prefer that one. But I'm still not 100% about any of the main cats, much better to use in the dog. And I just wanted to throw this in, and I, I am sorry, I'm gonna overrun a little bit, so I know some of you have to leave if you do.
I'm sorry, but catch the last 5 minutes at some point if you can, and thank you so much for spending time with me. So this is some data from a really good study that my resident and two of my project students have done. And these are the preferred methods of monitoring, and you can see actually, and yes, it might be a slightly biassed population that they were owners from an online questionnaire, but 71% were happily doing home blood glucose monitoring, 71%.
And only 40% had had that even vaguely mentioned in their consult with their vet, and they were cross about that because then they found out online how useful this could be. The other thing that came out of this study is us not talking about the importance of diet, and that makes owners cross too, because there's really good resources out there for them. So to kind of give you the heads up, that is what owners want to know about.
So, last few slides, what about those tricky responses? The standard flat line, don't we love it? That's the most common thing you get in a cat.
No response. Stress, in which case. Let it calm down, home glucose monitoring, try that.
Insulin resistance. Classically, it said that when you have over 2 international units per kilo every 12 hours or every injection, then that denotes insulin resistance. But more and more people are saying if you're getting above 1 international unit, you should start looking for reasons why the cat isn't controlled as it should be.
Because if you can catch whatever's happening early, that's a much better way to go. So think about doing something when you're actually at one international unit. Don't wait till you get to.
Obviously, the ones you always hope it is, is the owner isn't managing things well. They're leaving the the insulin out of the fridge. They're letting it lie down so it sticks to the stopper, injecting through the coat, etc.
Etc. Easy things to sort by talking them through. And then the true resistance, this comes back to that slide I spent time on at the beginning and why I thought it was so important to put it much more at the beginning, that one that has the World Health organisation logo on it.
You need to think about all the potential causes of true resistance in order to be able to address them. So, OK, insulin absorption wasn't mentioned. That's particularly going to be where owners have stayed in one little position all the time, which is why it's best to inject in different places.
Where there's been weight gain, definitely look for hypermatotropism for that, because that is usually what is happening there unless the owners are really going guns and giving the cat every treat it wants on the ground. Oh, poor kitty. He diabetic I've got to give him like extra sweeties and God knows what else that we do see it.
Infections, particularly urine, particularly gums, pancreas, hyperthyroidism, all the things we've talked about. OK. So really important slide.
I can't do justice with it as quick as I, I need to, but think about all those things that can be underlying and say check early, catch them early. This one, the standard overdose. It is important to remember though, this down and up can occur much quicker in the cat than it can in the dog.
They can go all the way down and up again in under an hour. Which means if you're only doing hourly, you'll miss it. But at least if you're doing hourly at that idea point where the insulin should be most potent, then you should be able to at least see, hang on, it did seem to be going down and now it's got much higher.
And this is one that a lot of people miss. If the blood glucose goes down 10 millimoles of glucose per hour. OK, per litre per hour, you will hit a smoggy, which means if you poor cats started the morning at 28, now we've all seen plenty of cats up there, and you've used a very potent insulin like, cat insulin, and you've gone from your 28 down to maybe 15, that can be enough to trigger a samoy.
With everything that happens and with cats, that long high tail can last up to 3 days. So if in doubt, reduce the insulin and see what's happening. So I always, I've got this flat line high, my first thought is, is this is the moggy?
Let's pull it down while I'm talking the owner through all the different management things they might have been doing wrong. Then I can decide where I need to go. And then this is your your standard duration of action to short.
Mostly we see this with can insulin. So, in which case switch to a longer acting one, so prozinc or glargine or give the can insulin 3 times a day if the owner is, and I mean Q 8 hours, not 3 times all within 1 hour. So it's very important Q 8 hours or as near as you can to it.
Dealing with that, you've got to work with your owners. So what happened with the beautiful Alex? Well, we put him onto a high protein, low carbohydrate diet.
We did put him onto Lentex, that's what we're using in those days. And he was actually pretty well controlled for a year and went into remission. Interestingly, after he'd had a dental.
And I do worry that we should have done that dental earlier. And in retrospect, if a cat like Alex came in sooner, knowing the data from human studies, I would take the risk and do that dental earlier to try and get that mouth as clean as I could. With time, he did develop kidney disease as is unfortunately so common in our older cats.
And the prognosis, unfortunately, the prognosis for cats is nowhere near as good as it is with the dog. We find 50% are dead within 12 to 18 months. Yeah, means survival time 1 to 2 years, which is not great, is it?
But that said, I have had really complicated cats get out to 3 and 4 years. If you've got owners who are really willing to work with you and particularly that home glucose monitoring, really, really important. So in summary, I'm gonna take you straight back to those notes by Andy Sparks.
They are brilliant. So diabetes is common in older cats. Most of them are type 2, but remember, which is insulin resistance, but remember all of those secondary ones, all the ones that can complicate type 2, your pancreatitis, your UTIs, etc.
Do you consider hypersommatotropism? Do you consider hyperadrenal corticism. Clinical signs can be very subtle to really severe.
You need to be looking at what those other signs might be. Have you got a concurrent hyperthyroidism, which is so treatable. Ideally, you want to treat with insulin and diet and I hope that new idea about getting those proteins in the diet really low and aiming for less than 12% protein and metabolizable energy.
So from the, the carbs, that's what you're aiming for. Look for those concurrent diseases and yeah, the prognosis is variable, but with good owners, good cats, and more importantly than anything else, a really good veterinary team. This is a real teamwork.
You've got to have the vets, ideally a nurse makes such a difference. They're way better at managing these cases than us vets are keen owner. Malleable cat.
So I hope there's been something useful in there for you. I am sorry I've overrun, that's because I'm just so passionate about this subject, and I'm very happy to take any questions. Thank you again for listening in this evening, and as always, a huge thank you to Webinar vet for putting this webinar on.
Daniela, that was absolutely fantastic and I know I said you wouldn't disappoint and I was right you didn't. It was fabulous. Thank you so much for that.
You're welcome. I can also say to you that nobody is left, so the running over has not affected or dampened the enthusiasm that you show. Thank you.
Christian wants to know, and I'm gonna read it to you. It says, I remember a study evaluating glucose concentration in cats after eating. And they found that compared to dogs, cats have no postprandial hyperglycemia.
Can you comment on this and does this mean that our caribose is not so effective in cats as it is in dogs? There is somebody who is very switched in. Yep, you do not get such a significant post-perial glucose surge in cats, although it does depend on the formulation of the diet.
If you are using one of these really crappy dry diets that you can get from a supermarket, some of those can be up to 60% carbs. That will give you a postprandial glucose surge. And actually some amino acid, some amino acids and some amino acid combinations can trigger a higher postprandial glucose surge as well.
So it's not that cats don't do it, but they don't do it anywhere near. As significantly as dogs. And yeah, it means that Acabos really doesn't work as well in cats.
And the problem you've got with that or using syllium for that matter, is both syllium and Acabos are pretty sticky. And by the time you've mixed in with the cat's food, it's gone there. I don't want to eat this.
So, I really want to see when the incurins come online. I think they're going to be much more useful. Good question.
Excellent. We have lots of comments coming through, fascinating, packed with new information. Thank you very much indeed.
Ashraf has asked a question which I think you've answered, but it might be a nice summary. How do I recognise a good clinical control of diabetes mellitus in feline patients? Combination blood glucose curves versus UG measurement and BG alpha tracks.
You know what, I've got, I try to get my owners to do it. I try to get them to get cat waist scales. And I get them to check weight owners can get pretty good with the diaries such that they, the size of the urine ball can be very good.
The strength of the cat, whether or not you can jump onto their knee can be a really good indicator of a well controlled cat, whether the coat is lying down. If the coat gets sticky, that's as likely to be high blood glucose as low blood glucose, because either way, they feel a bit sick and don't groom. So if I've got a really good owner, I'm gonna have them doing.
Reasonably regular, initially weekly blood glucose curves and then I'm gonna get them to probably doing once a month and I'm gonna throw in, I'm gonna see the cat maybe every initially 1 month, 2 months. I'm gonna do a fructosamine and check the pee for. Urinary infections, etc.
Etc. Yeah, and obviously it's gonna be, the alpha track. I think with time, we will start using more of these subcutaneous monitors as they get better and more feline friendly.
But at the moment, yep, that's where we are. Typical of cats, isn't it, that they don't follow the rules or these subcutaneous monitors like everybody else does. No.
That's why we love them. Daniela, we've come to the end of yet another fascinating webinar and I cannot tell you how much I've enjoyed it and I agree with all the comments that are coming through. Really nice concise webinar, new information, new things to consider, and just little nuances about what to watch for and And trusting our owners more, I think is very important.
I think if there's one take home message is you've got to, this is not something that a vet can do on their own. This isn't just us and our patient. If the owner isn't willing to work with us, then you know what?
I have, and I hate to admit this, it was an elderly lady, she already had pretty early. Dementia. She was very confused, and when her cat I diagnosed with diabetes, I did tell her that diabetes was not a treatable condition in a cat.
Because it would have destroyed her to have tried to do it and got it wrong. So we just changed the diet and knew that the cat wouldn't last very long. And I, I feel bad that I did that, but she had no one who could help her.
And for me to have suggested rehoming, the cat would have meant that it was telling her that she couldn't cope. And she and the cat were very bonded. So I felt this was, that was the kind of thing to do.
So, yeah. Know your owner as you've said repeatedly with your owner with this disease. If you work with your owner, then the prognosis for these cats is so much better.
Well, on that fabulous note, Daniela, thank you and once again, I so look forward to seeing you back on the webinar. Thank you, Bruce, and thank you to Dawn, and thank you everybody. Go and get yourself a glass of wine if you haven't had one already.
Folks, that's it for tonight for another fabulous members webinar to Dawn in the background for making everything run seamlessly. Thank you as always and good night. Good night.