Good evening everyone. Thank you so much for joining us. My name is Charlotte and I have the pleasure of presenting tonight's webinar, individualising care for the cat with diabetes.
Do I use nutrition, insulin, or SGLT2I? So, a bit about our speaker today. Maggie Margie graduated from the On Ontario Veterinary College in 1982.
In 1986, she opened CAT's only veterinary clinic in Vancouver, Canada, the third feline clinic in North America. She became a board certified feline specialist, the first year this specialty became available and has maintained this certification. Since 2008, she has been a consultant and an educator, speaking internationally and teaching online.
She co-edited the Journal of feline medicine and Surgery for 23 years. Margie has serviced extensively in the American Association of Feline Practitioners, as well as other veterinary organisations. Her interest includes all things feline, especially an analgesia, seeing to an end to dechloring, the particularities of the feline digestive system, and enabling more positive interactions with cats.
So the perfect person to be speaking about this case today. I wish to let you all know that today's session will be recorded and available on playback, and you will all receive a certificate for today's attendance, also for your CPD. Please use the Q&A box for any questions you may have throughout the presentation.
And at the end of the session, at the end of the session, we'll see if we can get through any answers, of these questions you may have. If we run out of time with the questions submitted, we will email out any responsive responses to you in the next few days. So with no further ado, I'd now like to hand over to stay out today's session.
Thank you. Thank you, Charlotte, and welcome. I hope that this is a topic of interest to you.
obviously, you, you, are interested enough to attend the, webinar or listen to the recording. So, that makes me very happy because I love cats and I love, diabetes. So the two together are, are wonderful.
Cause I love, old, old cats, but, especially older cats. So back in 2017, there was a, a study, a survey performed, and it was a, a question or, an online survey, that was answered by 1,192 veterinarians. And this was dogs and cats, and 1 out of 10 pets were euthanized at the time of diagnosis.
When I read this, I was shocked because I don't think I've ever euthanized someone with diabetes because of their diagnosis. Additionally, 1 out of 10 who had been treated were euthanized within 1 year due to lack of success or compliance. Now, looking at the cat data, what they found was that treatment of diabetes Malthus was least likely to be stopped within the first month of diagnosis because of lack of success or compliance in cats presented to practises in Australia.
Being presented to a mixed animal practise, as so dog and cat and large animals, increased the risk for stopping treatment within one year in cats, and then risk of stopping treatment within one year of diagnosis was lower for cats presented to a referral or university hospital. So, That's that in and unto itself is not particularly surprising. What they concluded was, given how common euthanasia was, the act that we needed to develop a treatments that had the characteristics of being less expensive, rapidly effective, having a low risk for hypoglycemia, and having a decreased impact on owner lifestyle.
So what I'm gonna go over here, I'm gonna try to get through a lot of these, these things. There are a lot of things here, but I'll start with risk factors. Also, just to let you know, these are some QR codes for some of these resources at the end of the the slides, I've got a lot of resources, as many of them with QR codes as I can make as as have QR codes.
The ISFM consensus guideline, which was from 2015. The Aha American Animal Hospital Association diabetes Management guidelines from 2018, but they were actually updated in 2022, still called 2018 though. And then the AAFP now called the feline VMA diabetes Educational toolkit that is free and available to anyone.
So risk factors increasing age, physical inactivity, being male and neutered, having been on glucocorticoids or progestational substances, drugs, and being Burmese from certain regions. So what's with the Burmese? Doctor Jackie Rand, and, Rhett, Marshall from Australia, they have done lots of work in, in, Diabetes in cats, because in Australia, the Burmese have a different genetic makeup than in other parts of the world.
So these cats are found not only in Australia, but are also found in the United Kingdom, so it, and it is an an inherited trait. The rest of the world that the cats, Burmese aren't at any, a greater risk. Now, the risk factors are, are certainly obesity, and that goes along with being indoors, being bored, having too much access, easy access to food, of course.
They are up to 4 times more likely. To become diabetic. Why?
Because obesity reduces the cell receptor, availability to, insulin. So the insulin receptor is impaired and, therefore reduces insulin sensitivity. Shockingly, for every kilogramme of excess body weight in cats, and we all know lots of cats who are more than 1 kg overweight, there is a 30% reduction in insulin, sensitivity.
So here in this, diagram, what I wanted to show you is under the normal circumstance, there are two re there's essentially two receptors. Well, it's kind of like a lock and key situation. The insulin unlocks at this receptor, which then opens the door for the glucose to get into the cell.
And this is what's normal. When we have Insulin resistance, such as a scene with obesity, such as a scene with obesity or seen with, concurrent illness, especially inflammator other inflammatory conditions, obesity being an inflammatory condition, the cells stops responding to insulin. There's changes in the, the surface receptor.
So concurrent illness, as I mentioned, it impaired, it impairs the insulin effect, and, and there may be increased insulin production and amylin production, and, and also the hormones that interfere with insulin are include glucagon, growth hormone, thyroid hormone, epinephrine, and cortisol, and this is why We'll see, problems in cats with, like acromegaly, which is growth hormone, or thyroid hormone, when you've got hyperthyroid cats, oftentimes, well, I shouldn't say oftentimes, but it's not uncommon to find a cat with both hyperthyroidism as well as diabetes. And ultimately, the, the issue here is that when there's impaired insulin effect and increased insulin production, we end up with glucose toxicity. And what glucose toxicity refers to is the fact that in sus, when there's sustained hyperglycemia, so too much.
Sugar in the blood, that causes beta cell loss in the pancreatic islets, even in healthy cats. And so that's why it's so very, very important to give insulin right, right away, get insulin going, rather than just starting with diet. OK, or starting, one could start with an SGLT2 inhibitor.
More on that in a little bit. How do we diagnose it? Well, certainly, polyuria, polydipsia, polyphagia, weight loss, decreased activity, possibly, decreased jumping.
And while it's the same age group or a little bit earlier, then we tend to be thinking about arthritis, recognising that arthritis starts as young as one year of age. That's a different conversation, a different topic. But, we, if somebody's got decreased ability to jump, rather than assume or attribute that to arthritis, maybe also be thinking about the possibility of diabetes.
Weakness. They may have a gait change with a dropped cock or a dropped carpus. They may be vomiting or they may have diarrhoea.
Of course, with the PUPD, as you can see in these top two images and polyphagia, you also have lethargy because the cells aren't getting the glucose, and unkempt hair coat dehydration and constipation is a sign of dehydration. So those two go together often. We may get muscle wasting.
Because the, the body is having to prioritise where it gets its energy from and, and it's going to take muscle, take amino acids for that. The brain actually functions on glucose, but in cats that, that requires a lot of amino acids to be transformed. Into glucose.
They may be thin or they may be obese, depending on how long they've been diabetic or have had diabetes. And then, as I said, they may have a plan to great stance in the tarsi or carpi or one of each or just one. It's, it's very variable.
So what are our normal tests that we do? Of course, we do a CBC, a complete blood count, or with a film being read, serum biochemistries. We're going to need to do a fructosamine.
More on that in a moment. And we're going to do also a urinalysis to verify the glucose urea and see if there's infection. If there is infection, then we're gonna culture it.
Otherwise, we're not gonna to culture it. And then active sediment would mean Something, would, would mean we would have, white blood cells and bacteria, indicating the response. Just seeing, just seeing bacteria could just be contamination, but we do need to see white blood cells as well.
A T4, again, this is, these are these, you know, 8789 year old cats, so it certainly could be hyperthyroidism. With the same clinical signs, or as well as having diabetes. And then, what about abdominal ultrasound and FPLI?
Well, as, as, Andy Sparks wrote in the ISFM guidelines, the, he mentioned, or they mentioned that the interpretation of these tests may not be straightforward. So, the diagnosis really relies on documenting persistence of hyperglycemia and glucoseuria with consistent clinical signs. And for this, we need to confirm with a fructosamine, because fructosamine indicates the glycemic control from the previous.
1 to 3 weeks. In other words, not just stress hyperglycemia. So if you've got somebody who's just become diabetic in the last week, it may not be elevated yet, or if it's very mild diabetes.
But it, but this is how we differentiate between, the main way that we differentiate between gluco pardon me, stress hyperglycemia, glucoseuria, and, and, diabetes. So what sorts of things affect fructosamine? Well, fructosamine may vary be variable between individuals.
Oh, let me just, go back to what fructosamine is. Fructose Aine, so a sugar bound to a protein, is fructosamine. So when you've got, you've got too much glucose, it binds to the protein.
If you're hyperthyroid, you're in a Micrometabolic state, so you don't have a lot of protein there cause you're using it all up. As a consequence, you, your fructosamine may actually not be elevated yet. So we need to, or it may not be elevated because there's no protein left to, to use.
So that's can be a, a, a tricky one. Acid-based balance, hydration, it may also affect fructosamine. So we do want to, as I said, the cat may be obese, but they, but they still have muscle wasting.
And hopefully, you're familiar with the muscle condition scoring. I would refer you to the World Small Animal Veterinary Association, which is WSAVA.org, for this information.
On how to muscle score cats. This is obviously an unkempt coat, in an overweight cat, obviously a high body condition score, but I think you can appreciate how very thin this cat is. We've got the muscle wasting in the temporal regions as well.
Now, I do want to bring to your attention the European Society of Veterinary Endocrinology's website, which I've got on the slide, and they've got the a live project. What they're trying to do is to get everyone aligned with the the language being used in veterinary endocrinology. And so they've, they've broken it down.
This goes on to, on this page, goes on further to other conditions, hyperthyroidism and Cushing's and all those other things as well. But I've just taken a screenshot of the issues or the, the, links to, definitions of, regarding diabetes. Now, what they say is that the way we can differentiate stress hyperglycemia from gluco from diabetes is by either making a, a diagnosis in a patient with a random fasted or unfasted elevated blood glucose here.
So, depending on if you're using US units or if you're using international units, with the classic clinical signs of hyperglycemia, with no other plausible cause, or having a hyperglycemic crisis, and at least one of increased glycated proteins, there's your fructosamine. And glucose uria and or glucoseuria on more than one occasion in a naturally voided sample acquired in a home environment at least 2 days after any stressful events. So that's one, that's another way you could confirm if the, the, for whatever reason, you're not gonna do a fructosamine.
The other, in some cases, the clinical signs may not have been reported by the . The other way we can do it is in, in, or pardon me, if a patient has a random fasted or unfasted blood glucose that isn't as markedly elevated, and at least two of the classical clinical signs, it, it increased glycated proteins, and glucose ura again, with the caveat of being at least 2 days, after any stressful events. Additionally, they have this very nice table or scale score that you can use to, the degree, which is going to be very subjective, of course, gonna be, I beg your pardon, gonna be very subjective here, PPD appetite, attitude, and activity.
And so this is the alive diabetic clinical score and our the, unintended weight loss. And the total score is gonna be anywhere between 0 and 12, obviously, 0 being not diabetic. But we want to, the treatment aim, with, with, insulin, diet, SGLT2 inhibitors is to have the lowest score possible without unacceptably high risk of hypoglycemia.
So what do we do? We've made the diagnosis in a CAT. Either the client has seen clinical signs or has not.
We've either seen a significantly elevated blood glucose and an elevated fructosamine, or an elevated a glucose urea two days after a stressful event, or, something in the, in the middle there. And so what are we going to initially do? Well, we're gonna start insulin.
We're gonna start a diet, and we're gonna get the client going on, on a diary with using a diary. So, what I do is I have a demonstration appointment. The, clients, like we make the diagnosis, and then we, we book the client in without their cat, for a demonstration appointment.
And at that time, discussing diet, we, if they're overweight or obese, we, want to talk about, losing, helping the cat lose weight. You certainly feeding canned may help in that they feel fuller and it is lower, calorie, less, less calories in the canned food, for all. And it also has more, protein than dry food.
Feeding small amounts frequently of dry and multiple canned meals, and then monitoring, total amount fed as well as, eating. And, you know, in, in a multiple cat household, that gets to be, somewhat problematic. So they do need to be, may, may need to be, separated, certainly for the Morning and evening feedings, but diabetic cats, unlike other species, should be eating throughout the day because cats are designed to eat 8 to 10 small meals a day.
And when I say small, I mean like this amount of food. That's that is what, which is why puzzle feeders are so useful. Now, what data do we have to, that supports the use of low carbohydrate high protein diets and are they, are they the answer for cats with diabetes or not?
Our data is actually pretty scant. It's pretty flimsy. There were only 9 published studies using low carbohydrate diets, and only 2 of those 9 were controlled and randomised.
The low carbohydrate aspect of it was all over the map, and they weren't comparable. The number of cats in per per study group ranged from as few as 6 to as many as A mass of 55. So not a lot.
And the duration of diabetes at the time of the study ranged from newly diagnosed to, as long as 72 months, and in some cases, it wasn't even reported. The feeding duration ranged from 10 weeks to several years. The remission rate was between 17 and 68%, and I'll talk about remission in a little bit.
So really what we have here is not a lot of data, but I do, you know, we, what has been recommended is to feed this amount and that wet is preferable over dry, low carbohydrate over just regular dry. So regardless of low carbohydrate or higher protein diet, I think is, is a good type of diet for any cat because it, it is palaeolithic, it is their native diet. But we can we can control them on any type of diet, as long as it's the same every time, or every meal.
And that doesn't mean that it It has to be brand A, 8 to 10 times a day. It can be brand A for the morning breakfast every day, and then, brand B or, or 5 treats of the same type, at mid-morning every morning, and then it can be brand E at lunch or whatever. So.
OK. So, are there other ways, rather than, you know, looking at, at diet and insulin, can we perhaps avoid doing, avoid doing that? Well, a lot a bunch of oral hypoglycemic agents have been looked at and really, they're not advisable because there's a better chance of reducing that glucose toxicity and achieving remission, if that's your goal, with early insulin.
We do not want to be avoiding that. So what about SGLT2 inhibitors? SGLT-2, you know, in other words, why should we consider bexoglyphin or a glyphlazin, which are bexoca and sanvalgo?
And well, they don't need insulin. SGLT2 inhibitors are are once daily and they're oral. There's no home glucose monitoring, and there's no risk of hypoglycemia, which there is with insulin, especially when you're using a long acting insulin either like like Levemir or largine.
So what are SGLT2 inhibitors and how do they work? So, glyplizins are specific. They're in they're co-transporter inhibitors.
So they stop the the sodium glucose transportation, and, and the glyphins are specific to SGLT2. It's used in, these are used in people with type 2 diabetes, which is what most cats get. It's the type 2, meaning they're still making some insulin.
They inhibit renal tubules from reabsorbing 40 to 50% of glucose, which therefore decreases the blood glucose. So the the, the glucose gets peed out, well, it doesn't get peed out, it gets filtered by the kidneys into the ultrafiltrate and then it gets reabsorbed from there under normal circumstances. But when the SGLT-2, co-transporter inhibit are inhibited, then they can't, they, they can't reabsorb.
that glucose. So there's a low risk of hypoglycemia because there, there's still some glucose there. And because, and this is the big reason, SGLT one, SGLT one co-transporters, increase their glucose reabsorption.
They're generally found in, in the, in the gut, but they are also found in the tubules. This results in increased urine glucose, regardless, you know, because if you're, you're not reabsorbing that glucose from the, ultrafiltrate into your body, you're peeing it out. So you're gonna have increased urine glucose, but decreased serum glucose.
So that's gonna be, you're gonna have very lots of sugar in your urine. So you get increased glucose urea, but you are normal glycemia. So without going too much into detail here, the SGLT2s work in the proximal, the proximal tubule, at the very first part of the proximal tubule sections, and the SGLT2, work, a little lower down.
So what we've got then is normally, you have the renal tubules. This is the tubule, and this is the, the, the, pardon me, these are tubule, cells, and this is the tubule. So this is where the, the urine goes.
So normally the SGLT2, in, it reabsorbs the glucose. So 97% of the glucose, is reabsorbed with the sodium glucose, co-transporter, sodium, glucose co-transporter. And, but when you have the SGLT2 inhibitor in the early section of that proximal tubule, then that doesn't happen.
So you're not reabsorbing all of that sugar. But you are still reabsorbing some because the SGLT1, which absorbs only a small amount, is going to increase so that you still have, lower down in the, proximal in, in the tubules. You're going to reabsorb, enough sugar that you're not gonna be hypoglycemic.
So SGLT1 is functional when the SGLT-2 is inhibited, and the percentage reabsorbed by the SGLT-1 increases. They must have some insulin production though, because if they're not making insulin, then they're gonna get into trouble. So they have to have an insulin source to prevent DKA, diabetic ketoacidosis, or euglycaemic diabetic ketoacidosis.
So that's, that's diabetic ketoacidosis, where you're actually have normal blood glucose levels. So how do I choose diabetic patients for SGLT2 inhibitor inhibitors? Newly diagnosed diabetic who's not on insulin.
They shouldn't have already been on insulin. They're otherwise healthy and have a good appetite, so no concurrent conditions. We've got to check their ketones, and we must, and, and the ketone levels need to be normal.
And the ketones that we're checking are beta hydroxybutyrate, not the standard acetoacetic acid on, or acetate that we see in the, in on that we can measure on our urine dipsticks. That's not relevant. We need the earlier one, which is beta hydroxybutyrate.
So there, there needs to also be no significant renal or hepatic changes. As I said, the beta hydroxybutyrate should be less than 25 milligrammes per decaliter or 2.4 millimoles per litre.
The SEC FPL, if you're measuring that needs to be less than 5.3 and there needs to be no clinical signs suggestive of pancreatitis. Whatever those might be.
If they are well and there are no blood ketones, we're looking at the ketones in the, in the serum, then you can start an SGLT2 inhibitor. What about, if they are an unhappy rather than a happy diabetic? So somebody who may be vomiting, diarrhoea, anorexia, dehydration, achexia, lethargy, hepatic disease, we do not want to be using SGLT2 inhibitors in them.
Or if they have ketones in their blood, beta hydroxybutyrate, then we need to choose insulin. Once they're healthier and I still have no ketones, we do not want to consider an SGLT2 inhibitor in them. These are not candidates.
So this could also be, they're also recommending not in cats with chronic kidney disease. So it is beta hydroxybutyrate. Well, when you metabolise fat, it produces ketones in response, especially to starvation or insulin deficiency.
Beta hydroxybutyrate is the first one produced in the blood and then spills into urine, but our urine strips only measure acetoacetic acid and acetone, not beta hydroxybutyrate. So what can we do then? We can use plasma, so blood on the urine dipsticks that we normally use for in our urinalysis.
It is sensitive for detecting ketones, but it is not as good as using a blood ketone metre, but it's better than using urine on urine dipsticks. Now, this blood ketone, metre is very inexpensive, the one that's being talked about that, that the endocrinologists recommend using is this one by Abbott. And it is designed for blood.
And it is, there are different strips. This isn't the most current one. The most current one has two different types of strips, one which is for ketones and one which is for glucose.
So it's very nice for the clients to be able to check both. So how do you initially monitor a cat whom you've put on an SGLT2 inhibitor? You're gonna monitor the, this is very important.
The first two weeks are the critical time. You won't need to monitor beta hydroxybutyrate, so blood ketones or beta hydroxybutyrate. In the, in the, you could use the urine strips with plasma on them or you better still, just don't fiddle with that.
Just use the, ketone monitor at home on days 237, 14, or if clinically, not well. On day 7, you want to recheck them in the clinic as well as day 14, perform an exam, check a body weight, obviously get a history. Look, look at the blood ketones and the glycemic control, meaning a fructosamine.
Monitor their body weight, their blood glucose, and their beta hydroxybutyrate, just repeating what I just said, although at home that could be done as well. Remember this equipment has two different types of strips, one for blood glucose and one for beta hydroxybutyrate. And a blood beta hydroxybutyrate concentration of 1 to 2.4 is in the grey zone.
We really would like it to be less than 1. If the beta hydroxybutyrate is greater than 2.4, you must stop the SGLT2 inhibitor, because otherwise, we run the risk of that we're developing, diabetic or euglycemic, diabetic ketoacidosis.
Glycemic control occurs within the in 7 days of starting, so it's pretty darn quick. And we want to monitor the serum or urine beta hydroxybutyrate, intensely for the 1st 2 weeks of treatment, as this is most likely when e glycemic DKA or DKA can occur. So, long term, what we're looking at doing is rechecking them at 4 weeks.
And, and that hopefully is that. Do I have to curve them? An 8 to 10 hour glucose curve should ideally be done once a cat seems to be improving on Bxoat or evalgo to ensure that they're under control, well controlled.
And after this, as long as clinical signs are controlled and kitty's doing well, follow the serum fructosamine. So when do you stop them? Well, if they're hyperexic, anorexic, lethargic, dehydrated, or losing weight, i.e.
Sick, immediately assess them for DKA regardless of their blood glucose. As I said, you know, doing ketones, blood glucose, electrolytes, acidosis, and, because, as well as their pardon me, because their blood glucose could be absolutely normal because they're peeing out the excess, so they're eugglycemic DKA. But they can also have DKA and start insulin if there's poor glycemic control, such as weight loss, blood glucose from an eight-hour blood glucose curve averaging more than 250 or 13.9, depending on which units you use, and or having a fructosamine indicating poor glycemic control after 4 weeks of treatment.
So, let's remind ourselves what, how do we treat DKA while we discontinue the SGLT2 in to inhibitor immediately. Start them on IV fluids and if the blood glucose is low, then we want to add dextrose to the fluids. Start a short-acting insulin such as regular, regardless of blood glucose, even if it is normal.
They need insulin. They need insulin. We're gonna place a flash monitor, an interstitial glucose monitor, and, and monitor and supplement potassium with without phosphorus as needed and make sure that they have food.
So what the heck is eugglycemic DKA? It's DKA that occurs despite normal serum glucose, and it occurs almost exclusively in patients on SGLT2 inhibitors. Insulin administration is critical to these patients despite the normal glycemia, and they'll need dextrose along with the insulin to prevent hypoglycemia, nutritional support, and then monitor serum beta hydroxybutyrate.
So treating these guys, immediately stopped. They have normal blood glucose, they need insulin despite the normal glycemia treat like decay, so fluids with with dextrose, constant rate infusion and insulin, monitor potassium, and in people or pushing oral carbs. So, after the 1st 8 weeks of Bexicat or Cinalgo, we're going to dose, you know, dose the either the 1 the 15 makes pero per cat or bexicat once a day.
It's a flavoured tablet or using the liquid 1 milli algo 1 milligramme per kilogramme. You've got to weigh them because as they're getting better, their weights are gonna go, are likely going to increase unless they're obese to begin with. The weights are gonna increase and they're gonna need more of them.
Of their SGLT2 inhibitor. So we need physical exam with body condition score and muscle condition scoring. We're gonna do 8, we're gonna do a blood glucose curve, check a serum fructosamine, and again, beta hydroxybutyrate to monitor for euglycemic DKA.
So with either, as I, cats with decay often have disease concurrent with the diabetes. Once it resolves, you should not use these. We should start insulin, we should manage concurrent illnesses, and we want to, if we've taken them off the GLT2 inhibitors, keep monitoring the glucose for pardon me, keep monitoring the beta hydroxybutyrate for a couple of weeks after stopping because they may develop decay or glycemic DKA during that time period.
Side effects, I'm not gonna, you know, go, go through all of these. You can read the slide just as well as I can. So, you know, you've got clinical side effects.
And then we have some biochemical side effects as well. Possibly a mild increase in creatinine, BUN, phosphorus, sodium, whether or not they already have CKD within a few weeks of starting therapy, and it is recommended, sorry, and it is recommended in certainly in the European Union, the San Valgo says do not use if they have chronic kidney disease. The FDA also says that.
So persistent increases in serum calcium should prompt investigation as it is associated with risk of of calcium containing neolith formation. And this other than Sanalgo is from Bexicat, in the Bexicat cats who receive Bexicat, rare, very rare, but as I'm talking about this with at veterinary meetings, I'm hearing from people that they have also seen it with San Valgo as well. OK.
Now, as I'm racing through here, we've got what about insulin? So we have, of course, and, and if you're in the United Kingdom, you have to follow the cascade, anyways, which means that you would be starting with can insulin or prozinc in other parts of the world. They don't have to start with those, and they may decide in fact, to start with Daimir or glargine.
Which I would not be recommending to do because we actually they can actually result in prolonged hypoglycemia because they last for longer than 12 hours, so you're always giving insulin on top of some that's already in their system. A very nice paper that's not too old now, looked at, you know, recommending which type of insulins PZI glargine detemir. We want the longer acting insulins, as you can see here, that can insulin or vetsilin, are in fact, Lanta, they're, whereas, as opposed to ultralante, but I've had very good success with, with any with either of them.
We do need to, they should be dosed at ultimately at 0.25 to 0.5 units per kilogramme twice daily.
And that's gonna be based on an estimate of their ideal weight. So if they're extremely overweight, that's not what we're doing. If they are very, very underweight, then we, then we really should dose based on what they've got there rather than what they should have.
Very important, to use the appropriate syringe, if as you can see from the, these images here, a U100 FCC syringe, they're both have CC syringes. A U 100 has a lot more lines than a U40, meaning that a unit of a of a U40 insulin is a large, much larger volume. And can insulin and prozinc are U40, whereas the human, these human ones are U100.
The, this is much more concentrated than than this, which is why these are easier to use and and dose. Important to use the right type of syringe because if that it's too easy for miscommunication to occur. Care of the insulin vial.
I used to be very concerned that, you know, even leaving a vial of insulin out on the kitchen counter overnight would mean that it was dead. That's not true. We want to avoid extreme temperatures, so don't put it in the, in the oven.
Don't put it in the freezer. And we don't want to use an insulin vial for More than 3 months, because the, every time you, puncture the, the rubber stopper, there's a risk of contamination. And were you to use alcohol on it, then you're driving alcohol in as well, which will denature the, the insulin cause insulin is a protein.
And if the insulin is cloudier than normal or discoloured, it should be discarded. So, we have guidelines for the starting dose of insulin. I'm also gonna just sort of use a bit of my gut impression, degree of based on the degree of their clinical signs and the fructosamine, but you really don't know how sensitive and, a given individual is going.
To be how sensitive their cells are to seeing insulin. So it's usually about 1 to 3 units. But ultimately, the ideal dose for that patient, the, the, that we're, that we're aiming for is the dose, to, resolve their clinical signs.
Cats need twice daily injections regardless of the type of insulin. So again, I had showed you this, this image and you can use this while, while the cats not only to make a diagnosis, but also to see, as I said, the we don't wanna to have the risk of hypoglycemia. Now, diabetes is a dynamic process, and so the response to an insulin dose and even the type of insulin may change in an individual's lifetime.
It also differs between cats, so you can't just have, there is no one best insulin. You can't just have one type of insulin in in your practise. Be, you know, you may have the one that you'd like to start with, but be aware you need to have more types of insulin there.
Now, insulin adjustments should be made cautiously. We do not want to be making them, frequently. These, these guidelines had recommended no more than every 5 to 7 days.
I think that, unless they're hypoglycemic, I do, think you may get away with every 7 to 10 days. Now, most cats are gonna need a total 0.5 to 6 units of insulin twice daily.
There is no one best insulin to achieve diabetic control or remission. The actual pharmaconamics of various insulins in cats are similar, but, there's more cat to cat variation than insulin to insulin variation. With respect to these, these pens that exist, they may be very helpful for dosing accuracy and facilitating compliance.
So I mentioned diary. We've talked about diet, we definitely want to get, get them going on a diary. I, want them to, you know, and we want to, find out, we want to train them to be really observant.
So, in other words, the date, how much, how many units of insulin they got, at what time. How their appetite is, what their water consumption is, presumably if there's gonna be a decrease in, water consumed, it's not gonna be more than even in a multiple cat household, it's not gonna be, the other individuals. You're in quantity, size of clumps, number of clumps in 24 hours.
So again, depending on what we've got, even in a multiple cat household, and we started out with grapefruit sized clumps, as well as other smaller clumps, from the others, and now there are no more grapefruit sized clumps, but the clumps are all mandarin orange size or something like that, then that's, we won't know necessarily whose they are, but we know that the Quantity, or the quantity of urine is, has decreased. Bowel movement, yes or no. Having said that, you know, they may not know whose it is, if they pay attention, like with in, in my home, I've got, we live with 3 cats, and I know which corners of each litter box different cats prefer to use.
And then behaviour and activity level, you know, attitude, energy, that should also be made note of. All right, so, ongoing management, is remission the ultimate goal? Yeah, I wish I could call you to see what you think.
Remission is a, is an interesting beast, occurs in people as well. And this systematic review that, Ruth Gostolo published in 2014, she looked at all of the different, insulins and, what's been documented, all the different papers. So there was no single factor that predicted remission and success.
For mission has been documented with a variety of insulin types and protocols, dietary carbohydrate reduction might be beneficial, but requires further study. A lack of well-designed trials, prevents reliable remission rate comparison. Factors associated with remission resemble those in human medicine and support the hypothesis that reversal of glucotoxicity is a major underlying mechanism for remission.
So get them going on insulin, or if they're a happy diabetic, an SGLT2 inhibitor right away, rather than fiddling around with, do diet at the same time, but don't rely on diet. I mean, if a person says, well, I don't want to give injections, then, you know, work, work with that and, and you could, if the patient has, has not got beta hydroxybutyrate, and they want to do. Some fairly intensive monitoring.
It's not, onerous, but some fairly intensive monitoring over the first two weeks that may be the way to go. Now, here's the key, is with what Dr. Goslo found in 2014, is that in fact, the, some of the papers define remission as not needing insulin for 7 days, 7 days.
That's not remission. That's a, you know, I call that a vacation. So what the Alive Project, the the European Society of Veterinary Oncology defined diabetic remission as a patient previously diagnosed with diabetes using alive criteria which ceases to receive exogenous insulin therapy and shows no evidence of diabetes according to these criteria after 4 weeks.
So they're at least saying 4 weeks. So we now have something to hang our hats on, as it were. So up to 60% of cats enter remission if started early on insulin and dietary therapy.
It's rarely permanent. It might be considered pre-clinical diabetes, although the alive criteria don't think that such a thing really exists, namely, pre-clinical diabetes. So, it's remission is not magic.
I'm not a huge fan because they are gonna come out of remission, and that may be very disheartening for the client. When they become diabetic or start showing signs of diabetes again. So remissions can be successful with every type of insulin.
We need more trials, etc. Etc. Etc.
All these other things on this slide from Doctor Shelly Oen, which, you know, you can see what's been looked at there. So there are two treatment philosophies. There's standard versus intensive control, and the, what we really want to look at is minimising the risk of hypoglycemia and tolerating periods of hyperglycemia.
So hypoglycemia is very, very dangerous. But, as As opposed to, minimising the periods of hyperglycemia and tolerating periods of hypoglycemia, which is, sort of where we've gone, unfortunately, with glargine in many cats, glargine or, or, Levemir, deimir in, in many cats. So, remember the definition of a controlled diabetic is someone who is whose clinical signs are absent and lack of hypoglycemia.
So we really don't want to go in that direction. I did want to mention here, there's a very nice paper of, from a few years back that was looked at loose control, lose control using prozinc, and in a decent sized paper, 185 cases to identify. The goal was to identify factors that influenced the likelihood of remission and survival.
And they had domestic short hairs on a pro zinc followed, who were followed until death, lost to follow up or at the end, were outliving the end of the eleven-year study. And they made insulin dose adjustments based on clinical response, clinical response, rather than monitoring them super, super carefully. So super tight control can be misleading, and given that cats don't live long enough, to deve and don't develop glomerul nephritis or .
Cataracts associated with diabetes, that and, and, and gangrene, pardon me, and, you know, gangrene and, and the like, it's It's not gangrene. Anyways, the, they are, we don't need to control them quite that, that, tightly. What they found in this study that the remission probability using this schema, you know, here, if, if the blood glucose was less than 180 milligrammes or 9.9 millimo, they stopped the insulin for 2 to 4 days, then recheck the blood glucose blood glucose.
It was normal, discontinue insulin. And this is being done at home because if you bring them in, of course, they're gonna get stressed again. Survival range is, it's 56%, half of them were more than half of them were likely to go into remission.
They lived like a median of 1,488 days, all the way up to 3800 days, recent corticosteroid use before they developed diabetes, lower mean blood glucose during treatment and lower mean insulin significantly increased the likelihood of remission. They recommended, you know, like, they, low carbohydrate diet, that remission had occurred, lack of DKA at diagnosis, lower mean blood glucose during treatment and lower blood glucose at diagnosis were significantly associated with increased survival time. So I thought that was a very interesting study.
Now, in the interest of time, because I really don't have all that much time left, I'm not gonna go through the uncontrolled diabetic. Rather, what I would like to do, the acromegalic or cats with these other things, I would rather prefer to spend these last few minutes on how to interpret curve data and where we're at with flash monitors. So, we started the diary.
We're, we're gonna, after 10 to 14 days, I'm gonna do a curve in clinic. I'm gonna adjust the dose. Now, I'm gonna teach clients how to do the ear prick.
Until then, we've not. They're already, they've learned how to give insulin, their new diet, filling in a diary, that's enough on their plate and, and for them to wrap their heads around. So now we're going to, teach the ear prick when they go home and add blood glucose monitoring to the diary.
And, then, at 10 to 14 days later, I'm gonna do a curve. We're gonna now do a fructosamine cause we're 22, 28 days out. Therefore, it's gonna give us some valuable, glycemic control information and adjust the dose.
All of the Subsequent curves will be done at home. And we're gonna recheck them, 3 to every 3 to,, pardon me, every 4 to 6 months, exam, a fructosamine and urinalysis, unless they're unstable, in which case, of course, we see them at that time. So glucose monitoring is preferable to in clinic.
But here's our target range for most, you know, for most of the day. There's a typo there. Anyways, we, I don't like using paw pads.
I much prefer using marginal ear veins cause we don't want them to be walking on, a pricked pad in the litter box, for instance. The alpha track is what is the glucometer that has been validated for cats. we've got the next, point being about the diarizing, here, spot blood glucose can be measured once weekly, but I don't, that we should not be doing spot blood glucose is only useful when, when A cat on insulin, if you've got them collapsed and you're concerned, like the client is concerned, is called, their cats, they've come home, their cat's collapsed, and they don't know whether their cat's hyperglycemic or hypoglycemic.
There, it's critical because they, with that value, they can then call you and on the phone, they can then say, this is what his value is, and you can say, He's hyperglycemic, you know, stop the insulin, bring him in. He may be in DKA, or if it's too low, then you say, you know, give him some honey, give him some sugar. and, I, I just actually get them to, you know, can give it up their butt, you know, with a, with a, a syringe without a needle on it.
It can go up their butt and be absorbed without a risk of the cat, choking on it. And, then, and then bring the cat in so that we are not losing that, that cat's not gonna go into a coma from being hypoglycemic. Curves, until the weekly or every two weeks until the cat's condition is stable, then every 4 to 6 weeks.
And then here you can see what the therapeutic goals are. As, as, I've put higher up. So at the demonstration appointment, we booked the blood glucose curve and the reevaluation appointment for 10 to 14 days later.
We're gonna call them daily for the 1st 3 to 4 days so that to get progress reports. At the blood glucose appointment, weigh, hospitalised with food and water, determine what time and how much insulin was administered. Get the diary sheets to review them.
If there's a problem, curve, a flat line, watch the client administer the insulin. Don't assume anything. You know, even, even we may think that, well, the client is, is a doctor or has, you know, whatever, is a, is a nurse and has, has done this before, don't assume anything because they may be going intradermal.
They, I've had all kinds of crazy things. So, looking at glucose curves, what we need is that, that, measure of blood glucose immediately to get a starting point. Ensure food and water are available at all times.
We just use a 25 gauge needle. I don't like lancets cause they make a clicking sound, with, you know, no syringe attached and do an ear prick. We have to measure ideally every hour, but it might be as infrequently as every 1.5 hours.
And then we're gonna plot the values. Now, this is these are the units. That we use in Canada, and the ideal range would be would be between 3.9 and, and 8 or something like that.
But in clinic because of the stress, I'm gonna say that it's, it's in this zone here. OK, so what we learned from a blood glucose curve is, is the insulin being absorbed? Are the cells seeing it?
When is the Nadir or the, the peak peak effect of the insulin, the lowest value of the blood glucose? How low is that Nadir? How long until from when the insulin was given until the Nadir, how long does the insulin last?
What is the delta or glucose? Differential and what we can guess, you know, we, well, as we go through this game, what would you, you think the fructosamine would be? What do you, would you expect glucose uria and what would you recommend?
So we get a lot of information from a blood glucose curve. So here for instance, are 3 cats all starting at 300. Now we're back into US units, or part again to US units, normal being up to about 150.
And you can see that they're all responding differently to the same dose of despite how they started in the same insulin they're getting. All right. So if we look at this curve here, here, the normal is in range is in green.
Anything, this is good glycemic control. This is where you would ideally want an individual with or without diabetes to be all day long. So the cat gets the insulin at 8 a.m.
And, and what we look at here is, is the insulin being absorbed. Here's our blood glucose curve and we'd say no, or it's not being seen by the cells because the glucose is remaining unaffected. So what would you recommend with this one?
Would you recommend increasing the dose? You could to try and see if that you can, maybe it's just, you're gonna definitely observe the client's technique. Maybe it's going into the fur.
Probably not gonna decrease the dose. We're gonna increase increasing frequency, decreasing frequency. We don't know that yet.
Changing insulin might be a little bit early to, to be be thinking that that would be the way to go. OK, so what about this curve? Here we've got, we've got is the insulin being absorbed.
Absolutely, the cells are seeing it. There's that drop in glucose. When is the Nadir?
Well, the Nadir is the lowest value, so it is right here, and it is about, it's around noon, about 4 hours after the insulin's been given. How low is it? It's about, 7.2 millimoles per litre or 130 milligrammes per decaliter.
It's in the normal range, but, it's, certainly still, most of the curve is above the normal range. How long does the insulin last? Well, the insulin was given at 8 and it reached that same level again at, at 7 p.m.
So that's 11 hours. What is the glucose differential or delta, and that's gonna be from 300 on the left or 16.6 down to the nadir value.
So you can see here, it's either 9.4 millimoles or, or 100, sorry, I, pardon me, it's either 300, you, you can see here what, what I've done. So will there be glucoseuria?
How is, is the glucose in the blood going to exceed the renal threshold? Yes, it will, because the renal threshold is somewhere in here. So, and, and what do you think is gonna happen with fructosamine?
Is it gonna be normal, elevated, or low, and it's going to be, remember the, the fructosamine reflects the time that it's out of the g glycemic range, so it's gonna be elevated. So what would you recommend on, and what would you recommend on this one? Would you want to increase the dose, decrease the dose, increase the frequency, or decrease the frequency, change the insulin, redo the curve.
Well, in this case, it's lasting a good, it's lasting 11 hours, which I'm happy with, so I'm not gonna touch frequency. with the increasing or decreasing the dose, that's gonna depend on how low it goes because if it's, if it's going too low in here, I absolutely can't increase the dose. So, do I decrease the dose?
Probably not. I have wiggle room if I give a higher dose of insulin here, this is what a whole thing is theoretically. Anyway, it's gonna come down.
Change the insulin? Maybe, but probably Not, and redo the curve, and that's a nice curve. So increasing the dose, we could, we, is, is probably what I do here.
And what the delta tells me is essentially this curve is like a bowl. It's a, it has a narrow delta. And that's what we want because that way we can, lower, lower the whole curve when we increase the, insulin.
Whereas with a, with a, wide delta, I can't do that. OK, so what about this one? This one, the, the, the, staff were asked to do every 2 hours, to measure every 2 hours, and they did, except at 12, they couldn't because clients were coming in and people were going on lunch, etc.
Etc. So they did it at 1 and then they caught up at 2 and went every 2 hours after that. So the insulin's being absorbed.
We can see that. The Nadir is around 10 o'clock or 2 hours after the insulin was given, which is pretty darn fast. How low is it?
It's not low enough. You could see there. Is, how long does the insulin last?
It lasts about 7 hours. What is The delta. It's not a bad delta.
It's pretty nice. Similar to last night, will there be sugar in the urine? Absolutely.
How would this be reflected by fructosamine? It's gonna be increased, isn't it? OK.
It's gonna be very high indeed. And what do you recommend here? So, do you want to increase the dose?
Well, the risk of that is we may be having a samoji here because look at how quickly we got to the nadir, even, how quickly we got to the Nadir. And, it's, it's, as well as this overswing here. So if we increase the dose, we could really get into trouble.
We decrease the dose, yeah, we're not gonna have enough of an effect. What about increasing frequent. Possibly, possibly decreasing the dose and increasing the frequency cause it's not lasting very long.
We don't want to decrease the frequency. Changing insulin maybe redo curve. Yeah, very likely, because look at how it's, we don't have a lot of points on it, do we?
So, increasing the dose, decreasing the dose, I definitely, you know, with increasing the dose, I wouldn't, I wouldn't be happy with that, redo the curve. What about this one? Is the insulin being absorbed?
Yes. Nay, dear, 11 a.m., 3 hours after the insulin, still kind of fast.
How low is it? Too low. How long is it lasting?
Again, not very long, so think about frequency. What's the delta too big? Can't use this insulin cause I don't have the, I, I don't have enough control over the curve.
Will there be glucose ura? You bet. Fructosamine's gonna be, you can see it's the, everything outside of the normal range, it's gonna be very high.
Now, here's the key. So what would you recommend on that one? Increase the dose?
Absolutely not. Decrease the dose, Maybe, but that's not gonna get us into the, you know, it's not, still not gonna last long enough, increased frequency, decrease frequency. I'm gonna change the insulin.
I mean, this is, this is, this is just a, a mess, quite frankly. So, those two curves that I showed you were exactly the same curve. I just removed some points.
And I say this because I want to show you how if you're only doing, if you're only doing them infrequently, you're the spots you're gonna miss how low this nadir goes. In fact, the nadir may be over here, the nadir may be over here. This is, you know, where you have continuous monitors, you can see a lot, a lot more.
Now, the, not, not saying that everybody should have a continuous monitor, but this is, this is why we have to give them, we have to get more points on them. Some people have recommended in the, in the past I've, just doing urine glucose and doing fructosamine. Now, in both of these situations, remember, the urine glucose is gonna be elevated.
It's gonna be spilling above the renal threshold with both of these curves. And the fructosamine is gonna be elevated. The fructosamine is gonna be elevated, which therefore means that, if you're, if you're using urine glucose and fructosamine, you would increase the dose.
And that would be the wrong thing for this cat, wouldn't it? So we do need to have curves. Now, I've got it it in the a handout which I will send to Rebecca so that she can get it to everybody.
Blood glucose curves made easy so that it goes through all of all of this stuff. There's also a blood glucose curve generator that vetsilin, in the US makes, and you might like that. And if you're on Veterinary Information Network, they do curves as well.
OK, so somoji or glycemic variability, I'm gonna skip this right now just in the interest of time. But, so I'm gonna essentially start either an insulin or prozinc, 10 to 14 days, do a curve adjust dose, teach them how to ear prick, add blood glucose monitoring 10 to 14 days later, clinic blood glucose curve, fructosamine adjust dose. So even if a client doesn't want to do curves at home, and that's fine, and we're gonna put interstitial monitors on them, that's fine, but I do need them to be able to do ear pricks so that they can, they'll know if the, if the cat's getting into trouble.
So subsequent BG curves, etc. Etc. The initial curve is only to identify hypoglycemia and duration of action, not to fine tune the dose.
If you're using glargine, it's more complicated because you need to measure a blood glucose every 2 hours for at least 12 hours for 3 days, 3 consecutive days. And then you adjust based on after that, it's easy to adjust based on the pre-insulin blood glucose. Again, clients have to be able to do blood glucosis.
There's at this URL you can go through a curve just as I've shown you now, a diabetes case challenge if you wish. Pastward, but before we reaper. Like there's one that goes around the rim on the outside.
We'll see if we can visualise it better on the other one. Let me just start that again. Whoops, go back.
Towel or toilet paper there and around the rim of his ear is a little blood vessel. Now, part of it, you might be able to see it a bit better on the inside. There's one that goes around the rim on the outside.
We'll see if we can visualise it better on the other one. Yeah. OK.
And it's really, it really just is a line in a bump that you can see around there, and you can see it there too. See how it's darker right across there. If I move his fur back, you can see it's right there at that fold.
OK, OK. Takes practise. All right, I'm gonna do it on this here.
OK. Just gonna pause there for a second. I'll also take the otoscope or aphthalmoscope head and just shine light under the ears so they can see it.
So I'm just gonna take his, I'm just checking his BG level. And I'm going to make a prick with it. He was a good state.
Mhm. And the the great thing about this is that I can just fold it over and hold off because I want to hold off and make it stop, right? And it really is a drop, so.
And no growth reaction to it. OK, so that's also available at veterinarypartner.com.
There's lots of things on YouTube, but make sure you can spot check if the kitty's not quite right. So, minimises in clinic stress for everyone, it's more accurate. You're using capillary versus venous blood, which is what the, this equipment is used, is Designed for, it's where the cells are actually getting their sugar.
We're gonna do curves, continuing care fee, and they still need some follow-up visits. So the alpha track has been validated for cats, as well as for dogs, and it was, compared to the glucose exokinnase method that's used in labs. So here's an example of a curve that a client sent in to me way back when.
Here's the times on the left. Here's the, what, the blood glucose readings were in, in, millimoles per litre. And here it says, wet food with bacteria given.
I'm thinking, what on earth is that? She was using a probiotic. Here's where she gave the insulin.
I have no idea why she, made these measurements as well, but hey, then you can see here that it's hard to get this one and that's very helpful because you can see how it, went up and then down again. And then she gave insulin here again. So might ask her the same questions are still seeing the insulin.
Yes, how long does the insulin last? 11 hours. It's the 19.1, and it's going down, going to, 18.7 here or 19.1.
So that's lasting a nice, lasting a very nice, 11 hours. When is the nadir? When is the lowest?
Here it is at 3 o'clock, arguably 2 or 3. What is the delta? So that would be 19.1 minus the lowest, 10.2.
8.9 and she's getting 4 units at this time. And so, how would we adjust the insulin dose, keep on this insulin, increase the dose to 5 units subQ VID subcu VID.
So very quickly, I wanna just talk about continuous blood glucose monitoring. A whole bunch of, you know, early on, it was being reported in 20 in 2018, all these various different pieces of equipment that were being used and can give you an awful lot of garblygook, which is, is difficult. So, just as with the curves that we do in clinic, we really need to sort of stand back and squint and sort of get the overall impression of what's going on and smooth it out.
And the way these work is the capillary glucose flows through the interstitial space to the cells, and there's a chemical reaction between glucose and glucose oxidase, which forms an electrical signal that occurs in the continuous glucose monitoring sensor. And so you get, you, you can see the, how this, how this works there. And these continuous glucose monitoring systems or flash technology, is, is, there's been some, some good work on them now, very helpful indeed.
And the, we know that the dorsal neck is more accurate, or just on either side, the shoulder rather than the lateral chest wall or the knee fold, when compared to a portable blood glucose, using, using the standard of a portable handheld blood glucose monitor. The hydration status may influence accuracy, because with DKA, the, the, in both dogs and cats, the, accuracy, or will be lower. So the freestyle Libra, of course, it's gone through multiple iterations.
This is an older version, supposedly it doesn't need additional blood glucose measurements for calibration at home. The sensor lasts 14 days, they're relatively easy to put on. Certainly, you do want to shave a large enough area and clean it, but be careful not to nick the skin, of course, and use an adhesion, a, an occlusive, sticky, material over it.
They're, you know, really quite, quite comfortable with these, on them. These are, this is in clinic. This is without the oposal on it, but they will fall off if you don't attach them, well.
So using the freestyle Libre in clinic or at home, better at home, and it's made managing diabetic patients easier, but it's still challenging. So, remember what our management goals are with diabetes. We want to eliminate the clinical signs.
We want to use a treatment regime that fits into the caregiver's routine. So, and if they, if they say, well, I can't be home every 12 hours, fair enough, that's realistic. If it's 10 hours or if it's 14 hours, that's fine.
If it's not within that time, Frame 10 to 14 hours, then skip that dose of insulin. It's important to avoid hypoglycemia and prevent other complications, and we want to maintain the blood glucose between 180 and 252 or 10 to 14 millimo per litre, having a nadir of about 80 to 140 or 4.5 to 8.0.
Now, the other thing is we can, the treatment regime may be using an SGLT2 inhibitor. Remember, we have to screen our patients appropriately so that they don't have beta hydroxybutyrate in their bloodstream. And work with with that.
Alive emphasises that serial glucose assessment shows substantial day to day variation. Fructosamine evaluation suffers from reliability problems, and the use of the same validated assay in the same patient is recommended if this parameter is chosen to be used. Negative urine glucose can indicate periods of hypoglycemia in a treated diabetic.
Patients. So, in other words, someone with, who's getting insulin, there should still be a little bit of sugar in there. We don't want them having no glu urine glucose.
Comorbidities are common and should especially be considered when there are clinical signs that are not classic clinical signs of diabetes, and specific blood glucose targets are not Really, really a goal. Rather, control clinical signs, optimise quality of life, prevent complications. Data is part of the picture, but the big picture is the total patient, which is why I presented you the, loose control as another option to make it easier, for, to make it easier for clients.
So as I promised up front, there are number of resources, these ones I've already alluded to, there's in this, in the, the 2018 guidelines or the 2022, only they didn't change the name. They have some nice, . Handouts or nice tables, monitoring blood glucose levels, managing hypoglycemia, and troubleshooting, cats, who have, the upper range of insulin doses, which is where we would get into the, acromegaly sort of scenario.
In 2022, what they also updated there was the, was the, Some algorithms, we've got the, you know, quick reference algorithms, insulin formulations, home monitoring, etc. Oops. Again, this is the ESVE site that I encourage you to look at.
Here's the blood glucose curve generator and also the one that's on Veterinary Information Network. And then these are some nice, articles too, protocol for blood glucose curve evaluation, the role of the blood glucose curve, and then I will make sure that, Rebecca gets this so that this can be available to all of you. I'm very happy to answer any questions should, should you, have some, and I will invite, I will stop sharing and I will invite Charlotte to tell me what she's, what she's got.
Thank you so much. But I'd just like to say, what a great session. It's so informative, and it's just, it shows how far we've come in leaps and bounds, of what is available, in regards to, you know, diabetic cases and what we can.
Actually do for these patients, I think it's, it is such a, an amazing, You know, opportunity that we have got before, you know, we, we were not able to do, any, sort of . Without, without this sort of research. So I think it's we've come a long way.
Yeah, we've come a long way, that's it, that's it, and, I think it is absolutely great. Obviously, you know, we, it's owner compliant. Is, is, is, another, another, thing to go through.
And obviously that is another obstacle, obstacle. We have a number of, number of paths that we can use now. Yes, exactly.
So I think, you know, that is the next steps in regards to this as well. But, I'd just like to say it was such a great session. And obviously anyone can obviously contact you with, further questions, but thank you so much again.
We hope that everyone has enjoyed today's webinar. And thank you everyone for joining us at the Ave, and we hope to see you all again soon. So thank you for if I, if I don't respond to your email, please email Rebecca because it may be that it's gone into my spam folder and I would hate to miss it.
Yeah. All right. Thanks everyone for watching.