Good evening everyone. My name is Charlotte and thank you so much for joining us this evening at the webinar vet. I had the pleasure of presenting tonight's webinar, new treatment options in diabetes, notices in cats.
So a bit about our speaker tonight. Ian Ramsey is a professor of small animal medicine at Glasgow University and at our CVS and European recognised specialist in small animal medicine. He has lectured and published extensively on many aspects of small animal medicine, but his main interest is endocrinology.
He's the editor of the BSAVA canine and feline formulary and was awarded the BSAVA Woodrow Award for his for his contributions to small animal medicine in 2015. I wish to let you all know that today's session will be recorded and available on playback and you will receive a certificate for today's attendance also for your CPD. Please use the Q&A box for any questions you may have, and if you run out of time, we will see what we, if we can answer these questions, submitted.
We will email you any responses to you in the next few days. So with no further ado, I'm now allowed to hand over to Ian to start this evening's session. Thank you, Ian.
Thank you very much, Charlotte, welcome, everyone to this, webinar vet, presentation on, treatment options in, diabetes in in cats. my name's Ian Ramsey. I work at the University of Glasgow, where I, obviously, see a lot of, clinical work, but in particular, I run the diabetic clinic, at the University of Glasgow.
Just before we start, as always, a couple of conflict of interest disclosures, the particularly significant one there is actually the, the least, the least amount, which is that, that I have had some hospitality over the years from Bohringer Engelheim, which is, the makers of Sanvego, the, drug that we will be talking about quite a bit today, but, but that's all I, all my contact with with Bohringer is. OK, we're gonna talk about feline diabetesmus, and before we start talking about the new drugs and the options for stabilising and monitoring, we need to just start with a wee introduction. That introduction is important because it tells us quite a bit about when we can choose a particular drug or one or the other drug.
So I, I think just a quick revision on diabetes mellitus is important. In, in 1 or 2nd year of physiology, we learned that insulin was the primary hormone, driving glucose uptake into the liver and the muscle, making glycogen and stopping ketogenesis. But, it doesn't affect all tissues in this way.
Insulin doesn't increase blood glucose uptake from into the brain or the blood cells, and it doesn't drive the uptake of glucose into the beta cells of the islets of Langhans, which is quite important, the part of the regulation, of course, of, of insulin concentrations. but in, in the totality of it, it's better to regard insulin as being a hormone not primarily concerned with glucose uptake, but with the uptake of food. So it's the primary hormone for dealing with a meal.
And that includes things like fatty atti synthesis, amino acid uptake, protein synthesis, fat synthesis, all this is driven forward. By insulin And this is important when you start to think about the cat, because the cat has evolved to live a life that is not dominated by glucose. In fact, cats are evolved to live on a high fat, high protein diet with really very little carbohydrate.
So insulin in the cat needs to be working on the products of digestion of a mouse, i.e., fat and protein, and not to worry too much about the carbohydrate.
OK? When we have a diabetic cat, then there are two competing and additive pathologies going on. The main pathology in the islets is as a is a degenerative condition of the islets of Langerhans by the deposition of amyloid.
This does not kill the beta cells. But renders them very insensitive to that glucose diffusion into them, so they see a hypoglycemia, they see less of what's going on in the body. In addition, cats may develop a degree of pancreatitis on occasions, and that may compound the, the issues of the islet cell amyloidosis.
But immune mediated destruction, genuine type one diabetes, is very rare in the cat. In addition to that, cats will develop peripheral resistance to insulin. Probably the most well known of those, of course, is obesity.
Obesity stops insulin working. But as important is this phenomenon of glucose toxicity and the presence of other hormones that are diabetogenic, so things like growth hormone in acromegaly and cortisol in feline cushings, will act against the insulin. So you have both an islet cell destruction and an insufficiency of insulin production.
Such that insulin production is reduced relative to requirement, and we have diabetes mellitus. What is this glucose toxicity? Before we started to worry about diabetes being treated by a number of different conditions, glucose toxicity didn't matter, but now we really do need to understand glucose toxicity.
We know that diabetic cats do not have enough insulin, but they do have some. What we forget is also that a high glucose concentration inhibit insulin receptor function. This isn't logical.
Actually, your receptors for insulin should work better really, if your glucose goes up, but they don't. High glucose concentration inhibit insulin receptors, and so as a result, that little insulin that you the cat does have doesn't work as well. If you can reduce the glucose for a while, and by a while I mean several weeks, then those insulin receptors may be able to regenerate and therefore, without increasing your insulin concentrations, now those insulin molecules become more effective and so diabetes may go into remission.
And if you can keep the glucose concentrations down, there's enough insulin and not too much of the growth hormone, of the cortisol, of other things going on, then those cats can stay in remission for a very long time. And it's this phenomenon of glucose toxicity, which goes a long way to explaining why this, new drug, called veigliflozin, works. Before we get to the exciting bit about er Velaglofrozen.
We need to just remind ourselves about the diagnosis of diabetes mellitus, because in the cat, diabetes is often a very slow, chronic condition that progresses relatively slowly. We see cats quite regularly that have had diabetes for 2 or 3 months before they've been presented to a vet. They've had clinical signs of an increased thirst, mild weight loss, mild lethargy, mild weakness, and they may have an increase in appetite, or they may have a decrease in appetite, but these cats will do fine for up to 7.
Several months sometimes before an owner actually gets worried enough to bring them to the vet. In some instances, they may develop a neuropathy, and what we will see here in this situation is this low hind limb gait, which is characteristic of a diabetic neuropathy and sometimes this is what owners present the cat to the vet with, even though the cat is polyuric, polyphagic, polydipsic, and so forth. This is in some contrast to the dog.
In in the dog, really the signs of diabetes, once they start, are more severe, more rapidly progressive. Note that this cat here is overweight. This cat looks like it's a healthy cat, and, and it's, if it's eating more and drinking more, many owners don't worry too much about it, and they are actually presenting this cat was presented because of its hind limb gait.
To confirm the diagnosis of diabetes. We need to demonstrate increased glucose in the urine and in the blood. Because just a high glucose in the blood is not enough.
We know that cats can develop stress-induced hyperglycemia, and it's only when it becomes a chronic hyperglycemia that we can diagnose diabetes mellitus. There's no limit to which blood glucose cannot go in a stressed cat. And therefore, we need to demonstrate not just a high blood glucose, but also a degree of chronicity.
And that's, helped by the presence of glucose in the urine and helped by the, increase in fructosamines that we should see as well. Every diabetic cat will have raised liver enzymes. Most will have a high cholesterol.
Those are not indicators of liver disease, they are induced enzymes, the liver is doing fine, the main thing is the diabetes. The renal threshold in cats is 12, so any blood glucose less than 12 is not considered to be a a diabetic or but may be stress. So it's only blood glucose is greater than 12 with urine glucoses with high fructosamines that we would consider as a diagnosis of diabetes in cats.
This this graph here just nicely shows you this, the, the, the, orange box box and whiskers, is the, the, the group of diabetics. And if you look at those and compare them to the cats with, which are sick, then you'll see that many cats that are sick have a high glucose as well. but their fructosamines are within normal range, and that's why it's important to measure fructosamines in these animals.
Note also that when you treat Diabetes with insulin. That the glucose goes down, but the fructosamines do not go down as much. And people have been using fructosamines, somewhat inaccurately, I feel, in using these to monitor the feline diabetic.
But really the evidence is that actually glucose levels nearly normalise compared to, to, to, to, to. To sick cats, but the fructosamines do not. So you see many cats which are diabetic on treatment, successfully treated, but their fructosamines remain high, and, only some cases will get down into reference ranges.
So how do we go about stabilising the feline diabetic once we've decided that it is a diabetic? Well, I think that begs the question, what do we mean by stable? And I think that's a question we need to ask ourselves about what we consider to be a stable diabetic, because until we get that right, we cannot.
achieve stabilisation if we don't know what we define as stable. So one of the questions is, is an animal that doesn't have ketones? Is it an animal that doesn't have hypos, an animal that's not losing weight, doesn't have PUPD has a fructoseamine concentration of, of whatever.
Now that's thing that some labs will tell you that you've got a stable diabetic on the basis of a fructosamine concentration, not true. Is it the human definition of a glycolated haemoglobin of less than 5%? Difficult because there's no measurement of glycolated haemoglobin in animals.
Is it an animal that doesn't come back into your practise except for insulin and needles? The cat's not bothering you, you're not bothering the cat, everyone's happy. Or is it a blood glucose curve like whatever.
Until we answer this, we are always going to be finding ourselves being disappointed. There is no research that shows that anything matters to cats who are diabetic. Except clinical control.
If you have clinical control of the diabetes, i.e., the animal is being treated and its body weight is stable, it's not losing weight, its urine production is normal, it's not PUPD, and its appetite is normal, there is no indication that actually, that is, you need to be better than that.
There's no laboratory test which is more stable than that. You're using these laboratory tests to get to that situation. Once you have good clinical control, then you do not need to, to, to go on beyond that.
And in cats, we have to use a combination of the diet and the treatment to achieve this. That diet and treatment, because the treatment needs to be given every day, it's the same every day. It's important that there's more stability in the day.
So the daily routine for that cat is quite important. It's important that it's fed the same amount, the same type, the same times, that the treatment is given, the same amount at the same time, and we try to keep the environment consistent. It really doesn't matter what the.
It's important that it does have a routine. It's the thing you sacrifice when you lose your insulin is your ability to adapt to change, particularly in the diet, is going to be compromised by the fact that you're giving regular treatment. What should we feed a diabetic cat?
There are a number of diabetic foods on the market, but what's most important is that the cat wants to eat it. Pallatability is all. It needs to also be given the right amount.
If the cat is obese, it needs to lose weight. If the cat is thin, it needs to put on weight, and we need to adjust the amount of food to achieve that. Very much secondary issues are the balance of the fat, the carbohydrates, the protein.
There's some research showing that if you give a high protein, low fibre, low carbohydrate diet, that some of these cats are more likely to enter, remission. But it's a, it's a relatively small amount of research and it doesn't matter. What you're feeding as long as the palatability and the energy are right, that is really the the most important levels.
Having found a food that the cat likes. Then we need to consider the treatment options, and this is where we get into the new stuff because until November of this year, the treatment options were insulin or insulin or insulin. And in the UK there are 2 licenced insulins for cats, a lenty insulin, can insulin.
And a PZI insulin Prozinc. Some of you may have heard of glargine insulin detemir insulin, and all other sorts of insulins, all very interesting, but they're not licenced for use in cats and therefore should never be regarded as first choice. But we now have in the UK a new drug called velalihozin.
It's sold as Sanvelgo, which is an alternative to to insulins. This drug is an SGLT2 inhibitor, and it is one of a family of drugs that has been used for a number of years in human diabetes now. And includes bexaglyphosin, which is likely to be licenced for cats in the UK fairly soon, and also dapoglyphosin, canoglyphosin, and all the other glyphosins, which are licenced for humans in the UK and have had some research done on cats.
So there's quite a family of drugs out there. Senvelgo is just the first. There's many more coming.
If we just look quickly at the insulins just to remind you that that lenty insulin is really quite short-lived in the cat. So if you're going to use can insulin in cats, you really should be injecting twice a day. With PZI insulin, Prozinc, that insulin can last quite a long time in cats.
So some cats you can use once daily insulin, I mean the prozinc insulin, but it also works quite well twice daily, and, and for me at least, I, I try to use Prozinc twice daily in cats if I am going to use it, because I find Lenty is really too short acting. But there are some cats that you can, and I say, get away with. Once daily insulin.
What about these glyphosins, the sodium glucose transporter inhibitors. These are an increasingly common treatment for human type 2 diabetes, remembering that cats are, type 2, type 2 diabetics rather than dogs, which are type 1. And they're proving to be highly successful in the management of diabetes with some interesting benefits on heart function and kidney function in those people who are getting these drugs.
And, and I'm sure we'll be hearing more about that in the years to come on the cat side. As I said, there are several formulations. Been is the one to be aware of because it's licenced in the US, where it's sold as Vaca.
There are some differences in the precise wording of the licence for San Valgo in the USA compared to Europe, and there are differences between Bxaca and Sanalgo. So they're all little subtleties here to be. Aware of, and there's a whole load of other preparations.
And the reason I put these up here is simply that we've had some experience already with dapoglyphosin, and canoglohosin in cats. I've, I've used dapoglyphosin in a cat, and that's something that has helped us move on to San Valgo. How do these things work?
Well, if you, imagine this as the glucose circle that goes on through the kidney and the body, in a normal cat, you can see here that blood entering into the kidney goes into the glomerulus where it is freely filtered, so all the glucose goes through into the convoluted tubule. The blood coming out of the glomerulus is therefore relatively glucose deficient. And the glucose is then taken back up from the kidney tubule by a number of carrier proteins, of which the SGLT2 is the major one, but there is an SGLT1 that's also there.
So that by the time the blood has gone past the renal tubule and is now exiting the kidney, the glucose has been retained. And the Blood circulates around, it may go through the guts where it picks up some food, some proteins, some some amino acids, some, some glucose perhaps and some fatty acids. Insulin acts on these areas and turns the those products.
Of food into glycogen, into protein, into fat, and the blood carries on back round to the kidney. So that's what happens in a normal cat. In a cat with an untreated diabetic cat.
Then you have no insulin. And you have glucose toxicity. Such that the products of the digestion from the food.
Increase the blood glucose, but there is no removal of glucose, amino acids and so forth from the from the blood and all the glucose goes into the kidney, where the SGLT2 reabsorbs it again and maintains blood glucose at the 25 millimo per litre or whatever that diabetic cat is running at. And there's a lot of glucose also coming out in the urine. If you treat that diabetic cat.
With an SGLT2 inhibitor, then what happens is it blocks the uptake of glucose from the tubule. Such that only a small amount gets back into the blood. And therefore only a small amount exits the kidney and almost all the.
Glu is therefore, almost all the glucose in the blood, therefore exits in the urine, not so much is reabsorbed. SGLT21 can do a bit. So it reabsorbs up to about 8 millimoles per litre, something like that, but cannot do the full job.
Food comes in, adds glucose back into the mix, goes into the virus, same problem. Note that SGLT2 is only glucose. It doesn't do anything about the amino acids, the fatty acids, and so forth.
So on the principle of this, that actually, at this point, you'd say this isn't a terribly good drug. But what happens over time is that because the blood glucose is now much lower. That phenomenon of glucose toxicity is reduced.
And because the form blood glucose toxicity is reduced, now insulin receptors are better, and so insulin now does its job. And now it can take the products of digestion out into glycogen, into protein and fatty acids, and the blood, therefore, though it still accumulates some, some glucose, is Lower in, in glucose and the other things, and you still get blockage of the SGLT2, so you're still getting a failure to reabsorb, so there's still urine glucose. There's still quite a bit of urine glucose coming out here, but the overall blood glucose has gone down, and that's how this drug works.
Let's go and look about how to decide now between insulin and STL2, and that really does depend on this idea of general health of the cat. Does the cat have any insulin left? And, and the really big marker for having no insulin at all is the presence of ketones.
If the cat has ketones in its urine or in its blood, then probably it has gone beyond the stage where it has a little bit of insulin left to, to, to work. Are there any concurrent conditions? How adaptable is the animal?
Is the animal able to take insulin injections? That could be a big factor in here. How good is the owner at giving injections?
That could be a big factor here. And, possibly finances, and, and you may think that, that, this all sounds like SGLT2 inhibitors might be more expensive or cheaper, and actually there, there are arguments both ways, because once you start SGLT2 inhibitors, you're on them for life. So, although the initial cost may not be that high, it's going to carry on.
Whereas if you start insulin and you can reverse the glucose toxicity more rapidly, more successfully, you may in fact make this cat into remission and so the insulin is no longer needed. So, although it may seem like one is more expensive than the other initially, the outcome of these cases is going to determine which is more expensive, and that's going to depend on how you use these drugs. So having established that we have these two drugs, how do we go about stabilising them?
Nothing's really changed on, on the, the insulin front. I still use PZI twice daily in quite a few cats. I will then, the, the easiest, cheapest monitoring tool I have is to look at the.
Urine glucose is, if, if owners can get the urine glucose and to measure it, then I can, they can do that. So I will adjust the dose by 1 or 2 units at a time, depending on the average urine glucose over 3 or 4 or 5 days, something like that. And I keep on doing this process until I get a degree of stability.
I'm very mindful that I have to be careful that the presence of no glucose may indicate that this cat is going too low, so I don't want persistent no glucose. I just want maybe 345 days a week, having no glucose, because you can't tell between a good curve and an overcontrolled cat using, glucose ura. And equally well if there is a bit of glucose in the urine, it's not too, too much, but if there's a lot too much glucose, then you're, you're going to, to, to find that that er er adjusting the insulin may help.
The problem with er using glucose is if you're only using once daily insulin, because if you're doing that, then you're gonna get a curve that that looks like this and so if you're measuring the glucose a long way away from the injection of insulin, then you've got a problem, which is why I say you should use twice daily insulin if you're going to use glucose in the urine as a monitoring tool. Another option might be to use insulin once daily or twice daily and then use fructosamines to, to monitor, monitor these cases. But again, the problem with that is that .
If you have a low fructosamine, fine, you're probably overtreating. And if you have a very high fructosamine, you're probably, under treating. But if the glucose is, if the insulin is too short acting, it can be only acting for a short time, so the overall effect is high fructoseamines, but you will risk a hypoglycemic episode.
So again, you have to think about the choice of insulin here if you're going to use fructosamines. So I guess the gold star method, gold standard method, would be to perhaps use insulin twice daily or once daily, but then use something like a continuous glucose measurement system or possibly a blood glucose curve. And I do measure glucose in these cats when they come in, but I'm very careful that the only interpretation I put on them.
Is that if they are the blood glucose is between 5 and 25, 30, it really doesn't help me because it could be anything going on there because you don't know exactly which curve they're they're on there. One single glucose does not, is not interpretable if it's over 5. But if it's under 5 millimoles per litre.
If it's under 5 milli per litre, you are definitely overtreating. So if you ever take a blood glucose from a diabetic cat that's been treated with insulin and you've got less than 5 milli per litre, back off the insulin because you are risking hypoglycemia. What about blood glucose curves?
Well, unfortunately, research has shown that blood glucose curves in cats are very difficult to interpret. And even when you think you know what you're doing, if you repeat the curve the next day, you get a different result. So they're not repeatable.
And the reason why they're not repeatable is stress. Stress causes blood glucose curves to be changed on the day you do them. The act of taking the curve itself destroys your chance of getting a curve that actually is representative of what's going on in the owner's house.
So when I hear that blood glucose curves are the gold standard, I disagree. I think they're tedious, stressful and expensive, and I only use them if I'm actually trying to investigate a problem, and it's the stress that causes the problem here. So if I'm using insulin, then I try to make sure that my first point is to get to know the owner, get to find out what they need in their individual routine.
Are they shift workers? Do they have children in the house, do they have? Other cats, can they get urine sample, and so forth.
And I very much emphasise the basic approach of getting the diet consistent, get the insulin consistent, and I emphasise the point about home monitoring. These cats have got to be stable at home, not, in, in your vet's surgery, and they have to be stable when they're not stressed. What about stabilising with SGLT2 inhibitors?
Well, here it gets really complicated because you've got to give the cat the dose in the food. Once daily That's it. I've got nothing more to say on that, it's so easy.
There's no storing in the fridge, there's no injections, no dose titrations, no dose changes. This is why this is such a game changer. Is because it really does make it much easier for owners to treat a diabetic cat.
You don't have to spend a lot of time in consultations teaching them to inject. You don't have to talk to them all about making sure they resuspend the insulin like that. It's just a fixed dose.
In the food And that's it. But it is not for every cat, which cats are a good choice? The Clinically well diabetic, so the ones that are eating well, drinking well, urinating well, they may be obese, they're happy, and you can manage them as an outpatient.
There's no anorexia, no lethargy, no dehydration, diarrhoea, and particularly no signs of diabetic ketoacidosis. There is no ketonuria, there's no ketones in the blood, and there's no history of having had a ketotic episode in the past. So Josh here On the left is a bad choice.
Josh has kidney disease, Josh has diabetes, Josh has hyperthyroidism. This is not a cat to try and treat its diabetes with Cymbalgo. Whereas Lucy here on the right.
Looks pretty smug about life. She's happy, she may be diabetic, but my goodness, she doesn't look it, does she? And that's the cat to treat with envulga.
Here's an example of of one of our cats, this is Tula. She's an 18 year old female neutered domestic short hair. She's losing weight, she's polyuric polydipsy, but she's happy.
She's eating well. She does not tolerate. Anybody fiddling with her, she is a tortoiseshell, orange and black all over, including in her behaviour.
Sometimes she's lovely and sometimes she's not. She will not tolerate insulin injections, and trust me, we, we did try. And the only way until we started the Sanvego that she could be managed with her diabetes and had been managed with her diabetes for about 2 months was by using one of these diabetic diets, a low carbohydrate diet, and that just about did OK, but she was still losing weight, she was still poly polydipsy, she was still slowly fading away.
We started her on San Valgo Pyros, liquid in the food mixed in once daily, no dust adjustments, and the owners were delighted to know that actually there's no dietary recommendations with these things either, so they could go back to her old diet rather than using the diabetic diet. What's important at this stage is that Tulip was monitored very carefully for the first few weeks. We made sure the owners were doing some sort of home monitoring of her urine, so we had a litter tray, we had two litter trays actually, one with holes drilled in it, which litter goes in and one underneath to catch the, the urine.
We checked her at 1 week and 4 weeks, again, measuring urine, measuring blood, ketones, clinically examine her body weight, measuring fructosamine once a month, and then we see her once every 3 months. And what we saw in in in Tulla was that the fructosamines, which started at about 460, fell to about 300 over the course of, the, the, the first two months. Her weight came down from 5.6 to 4.7 kg, and she looked a lot better.
For those of you who are interested, we, we actually checked cause she's one of the first. We checked her with one of these freestyle Libras, these continuous glucose monitoring systems, and you can see here that her, her, her, her skin glucose is trundling along there very nicely within the, the, the normal range. Note that this is her skin glucose, it measures low compared to her blood glucose.
So she's not going hypoglycemic hair, she's just low. OK, these are, these freestyle Libras are calibrated for human skin, not for cat skin. To be aware of?
Cats treated with Sanvego will quite commonly develop diarrhoea in that 1st 2 months, and that may last for 2 or 3 weeks. This happens because there are SGLT one. transporters in the gut, and SGLT2 in the gut as well, and because you're blocking SGLT2 in the gut, you're getting an osmotic type of diarrhoea.
I've never had a problem with this, but potentially, because there's glucose in the urine, you may get urinary tract infections, slightly more commonly than you would with insulin. We see weight loss, but that's often a good thing. Some owners report that the polyuria polydipsia, whilst it improves, there is still a very small element of polyuria polydipsia left.
I think it's probably more that they're attuned to it than actually a serious problem, and a few counts of hyper salivated. This all sounds very good and it's it's something that I think a lot of people are very excited about in the world of endocrinology. But, question, do we want to change cats from insulin to SGLT2?
Sanvelgo in the UK is licenced for this, but other SGLT2s are not. And I think we should be aware that the reason why they're not is that there is an increased risk that when you take the insulin away, because the normal insulin has been suppressed by the exogenous insulin, you don't get immediate recovery of the beta cells, even if they're capable of it. And of course you don't know, because these animals have often had extended periods of of insulin treatment.
You don't know that their disease, their primary amyloidosis has not progressed. So when you take away the the the exogenous insulin, there is a period when you're going to find out just how much insulin they have left. And if it's not much, you're going to be in problems, so these cats.
We really, because they, you don't know that they're not diabetic ketoacidotic, they are at increased risk of developing that. And therefore you need to monitor them closely. This is, this is Clive.
He was treated for 3 years on insulin, without problems, and the owner was happily injecting him, but, didn't like injecting him, heard about this new Sanalgo stuff and insisted to a vet that she wanted to change. So they changed, they stopped the insulin one day and started to send Valgo the same day. Within 3 days.
Clive had developed extreme diabetic ketoacidosis. He had no insulin. He vomited.
He aspirated, and sadly he died. This is not a drug that you want to do that to. This was a, a, a, and, and I don't in any way blame the vet, they were forced into it by the owner.
But, if you have an owner come to you and say, I want to change, tell them about Clive. I think it's different if you've had a cat on insulin for a week. Because obviously you haven't had that time for the amyloidosis to progress.
But if you've had the cat on insulin for 6 months, then taking them off and putting them on this drug is probably a bad idea. So, summary on on SDLT2 inhibitors, these are a game changer. They, they are in human medicine, and they, they change the paradigm of treating diabetes in cats because there is, so much easier without the dose changes, without the injections, without all the monitoring of the glucose curves and so forth.
But they're not risk free. You can expect and warn owners about diarrhoea for the 1st 2 or 3 months. You can't see if the cat's gone into remission or not.
So at the moment, the advice is you have to just keep treating these cats for the rest of their life. And there is a significant risk of ketosis, even in those cats that have just started. I say significant, not in terms of numbers, but in terms of the seriousness if it happens.
So it's really, really important that we watch these cases. Only a small percentage will develop ketosis, unless they've been pre-insulin treated. They've been pre-insulin treated, the risk of ketosis is higher.
But in the healthy, happy, diabetic cat. The risk of ketosis is low, but if it happens, it's a problem. So monitoring these cases closely, especially during those first few weeks.
And care with switching stable patients, especially the cat's been on insulin for a long time, and if you do get into problem, stop and transition to insulin if the cat becomes unwell. If the cat becomes unwell for another reason, for example, pancreatitis, or it has an accident or something, it, it's stress hormones will be that much higher. The insulin that you're relying on to, to, to keep the ketosis at bay may not be sufficient.
So you may have to temporarily transition these cats onto insulin and then switch them back. What happens if you do find out that when these cats are on Sanalgo, they develop ketones in their urine, by which I mean anything positive on the dipstick, or ketones in the blood, and by that I would say anything over about 1.5 millimo per litre of beta hydroxy butyrate is probably significant, to start worrying about.
Well, the obvious thing is you switch to insulin, but When you start injecting insulin into these cats, their blood glucose is currently normal. So actually you're gonna drive the glucose down really hard. They've got ketones, but they've got normal glucose and therefore you're going to need to give a lot more glucose, and that means you're going to have to give it IV.
And you're gonna have to give that glucose IV for probably 2 to 3 days before the San Valgo has worn off. And once the cat's eating, once the, the blood glucose has gone up with your glucose infusion and stayed up, then you can say, OK, the San Velgo's gone now, now I can switch on to normal insulin treatment and they the cat can leave the hospital, but it might take 2 or 3 days. If you have a Sovalgo treated cat that has ketones in its urine, simply switching to insulin and stopping the evalgo is not something you can do on an outpatient basis because you are treating a cat that has currently a normal glucose and is excreting a heck of a lot of glucose in its urine.
So insulin will make them hypoglycemic. If they're actually acidotic, then you need to talk about giving a a soluble insulin infusion to get rid of the ketones quickly. You're going to need to monitor the blood glucose very carefully.
Again, lots of IV glucose is going to be needed and it might take longer for you to get this cat back into a state where it can be treated as a normal diabetic ketoacidotic, with all that that entails. What about monitoring these cases? Well, monitoring feline diabetics, home records are key.
Urination, thirst, appetite, demeanour, any evidence of hypos. On clinical exam, when we see them, weighing the cats, really important, to keep an eye on weight. Insulin is the bodybuilding hormone.
By a chemical assessment, yes, that spot glucose is useful, but fructosamines can be useful, particularly in the Sanvalgo treated cat. I do encourage owners to do urine testing. There's a number of tricks for getting urine out of out of cat, including those two litter trays with one drilled with holes, including using catcall litter and so forth, and, monitoring the.
These cats, and in, in the insulin treated cats, you want to look at glucose and ketones. In the SGLT2 treated cats, these cats are always going to be glucose uric, so there's not much point in looking at the glucose in the urine there. So we would just recommend using ketone sticks for those, which are really cheap.
And make sure the owners are keeping home monitoring records. The real best way of monitoring, I think, insulin treated cats is probably using one of these continuous glucose monitoring systems. These are sold as freestyle Libras and are widely available now through Amazon and through local pharmacies.
Do please watch when you buy these that you are getting them from the UK because you do need a UK freestyle to match with a UK phone. If you buy it, Freestyle's cheap from Amazon and you don't check this and you end up with some Swiss freestyles, I think we had at one point, they don't work on UK phones. and of course the advantage of these, freestyles is they give you days and days and days of, skin glucose, which allow you to look at the average pattern in a stress free environment for the cat.
There are plenty of, documents out there about how to apply freestyles. This is the new Freestyle 3, so it, it comes as an all in one unit. we, we normally, Prep the skin by clipping it and by wiping it down with with a clinal wipe and then drying it off really, really thoroughly, and, we usually do this clipping over in cats over the, the, upper thorax, .
And then we then apply a small drop of tissue glue, to the surface of the freestyle. We put it on and push firmly down to get the thing stuck, and then slowly disengage it by a rotating action, and then cover that with a a a a a string vest and elasticated stocking stocking. And these really are excellent for, for insulin treated cats.
I would not recommend them for a Sanalgo treated cat. The limitations are, of course, with these Sango treated cats, sorry, with these, these continuous glucose monitoring . systems is that they are, not responsive to rapid changes, so things are happening very quickly in a diabetic ketoacidotic and so forth, then they are not a substitute for blood glucose in that circumstance.
They are human devices and they are therefore, their thresholds are different. They are less accurate in the hypoglycemic range, and they underestimate in the glycemic range, and it's quite often the, the, the, the monitor, the freestyle will say the, the skin glucose is 4 millimo per litre, and you go and actually test the cat, and it's more like 8, 1012. and, and that's how, how much difference it is.
So it's all about the pattern with these things, not about the actual concentration. severe dehydration will stop the glucose getting into the skin, so that, that, that, that's a contraindication. And of course in cats, they are masters of getting these things off and given these things are sort of 70 to 80 pounds each.
You don't want to overuse them, but they're still much cheaper than doing, repeated blood glucose curves. Before finishing today, I'd just like to remind you that with diabetic cats, the presence of other diseases is an important co-factor in the management of these cases. These include things like pancreatitis, acromegaly, Cushing's, chronic renal failure, hyperthyroidism, the, the list, the, the, the list goes on and on and on.
Particularly acromegaly is important because it induces insulin resistance. the clinical signs of acromegaly are subtle. Many cats can be acromegalic and look fairly normal.
This is an acromegalic cat in this picture. I wouldn't say it's particularly overtly acromegalic on physical or presentation, but they do create a fairly significant insulin resistance. And we can use, insulin-like growth factor one, IGF one to diagnose this condition.
And if we do diagnose it, then there are now some, options for the treatment of it. The cheaper options don't work very well, but sometimes they, they work OK. And there are some more expensive options, that are available as well.
Feline Cushing's disease, feline hypercortisolism is another important cause of insulin resistance. The classic presentation of the cat with the, thin skin, diabetes mellitus, spontaneous tearing, is probably well, well known to, to, to several of you. It is not that common.
But when you do see it, it, it, it needs to be treated because these cats are often, fairly unstable diabetics. Unlike dogs with Cushing's where diabetes is uncommon, in cats with Cushing's, diabetes is really very common, and if it hasn't already got diabetes, it shortly will do so. So if you see a diabetic cat with an open gaping wound like this and thin skin.
Think about Cushing's disease and diagnose it using an ACTH stimulation test or a low dose dexamethasone suppression test, reminding you that it's a higher dose of a to do a dexapression in a cat. So When we see a feline diabetic in summary, we want to look at the whole patient with the owner. Be adaptable on what we do, you can't just use Sanvego, you can't just use insulin.
You're going to have to have a conversation about which is better for that particular owner, for that particular patient. Whatever you choose, you need to have agreed targets on what you're going to look at, what you're going to monitor, how you're going to achieve stability, and when you're going to say that it's not working. This new treatment option is gonna take time to get used to.
So don't pick the sick cats first. Don't pick the difficult ones. Don't start trying to go off the reservation with your first case.
Stick to a nice, healthy, happy, diabetic. Start the veloglohozine, see how it goes, monitor it carefully, and when you've done 2345, you'll start to get more confident. And we will then be able to answer some other questions, which I'm sure people have about how else we can use these drugs, how we can adapt these things to certain situations.
I think it'll be really, really interesting in the next 5 to 10 years, looking at what we can do with these drugs, but right now, let's start carefully. Use home records. If owners are treating a diabetic, get them keeping some home records.
This is going to go on for months or years. We are going to have to make sure that we've got a good consistent recording method because owners will forget what they've. They get blase, they get, into a routine and they forget things.
And if you're only seeing the case once every 2 or 3 months, you can't expect the owner to remember everything that's happened in the last 2 or 3 months. At the very minimum, get them weighing the animal. Get them recording the diet, doing some urine testing, it's probably more valuable to do this, to assess stability than to measure anything, including fructosamines.
Fructosamines are great at identifying stress induced hyperglycemia. They are not so good for assessing stability in insulin treated cats, and they may. And, and the jury, they may be better for, for, Sanalgo treated cats, but we still don't know that for sure.
So fructosamines are something that you don't need to do so much and you can save quite a bit of money if you don't do them as much. Continuous glucose monitoring systems have, in my view, completely replaced doing blood glucose curves. I have not done a blood glucose curve in a cat to assess stability in more than 56 years.
I'm really not bothered with them at all. They really don't . They're just too expensive, too stressful, too difficult to interpret, and they're too variable day to day.
I do monitor blood glucose very, very carefully in very sick cats, obviously, but as a method of assessing stability, frankly, continuous glucose monitoring systems have replaced blood glucose curves, but. It's the pattern that matters, not the absolute value. You cannot diagnose hypoglycemia looking at the continuous glucose monitoring system.
OK. That's a quick run through, what we know on these new treatments for diabetes and where they sit in the, the whole feline diabetes thing. I hope that talk was useful.
I'd be happy to take any questions. And if you're listening to this on recording, you can contact me on this email address. As I say, we, we run a diabetic clinic, it might not be me that answers you, but one of us will get back to you.
Thank you very much for listening. Thank you, Ian, for, the session. What such an informative presentation on one of my favourite subjects, the cat with diabetes.
We hope you all can start introducing these recommendations in practise if you aren't already. We hope you all enjoyed this evening's webinar and we hope to see you all again soon. So thanks for watching.
Good night.