DIABETES MELLITUS 0195-5616/95 $0.00 + .

20

HOME MANAGEMENT OF
CATS AND DOGS WITH
DIABETES MELLITUS
Common Questions Asked by
Veterinarians and Clients
Arnold N. Plotnick, MS, DVM, and Deborah S. Greco, DVM, PhD

WHICH KIND OF INSULIN SHOULD I USE?

Insulin comes in three general types: short-acting, intermediate-

acting, and long-acting. Short-acting insulin is used to manage diabetic
ketoacidosis (DKA) and life-threatening hyperkalemia. Both intermedi-
ate- and long-acting insulin may be used for home management of
diabetes; however, long-acting insulins are preferred because regulation
is more consistent.
The species of origin of the insulin should be considered. Commer-
cial insulins are derived from beef, pork, beef/pork combinations, or
recombinant human insulin. Selection should be based on cost, availabil-
ity, and desire to minimize adverse reactions in the patient. Structurally,
pork insulin is identical to dog insulin; human and canine insulin differ
by a single amino acid. Pork and human insulin are both relatively
nonantigenic in the dog, even after long-term use, and either is fine
for home management. Interestingly, beef/pork combination insulin,
although more antigenic because of the bovine component, is also quite
suitable for home management because a limited immune response to
the insulin may delay its metabolism and prolong the insulin's duration
of effect. Beef/pork insulin is more likely to last 24 hours; pork or
human insulin is more likely to require twice daily injections. Rarely
does the species of origin affect the clinical outcome of the treatment.

From the Department of Clinical Sciences, College of Veterinary Medicine and Biomedical
Sciences, Colorado State University, Fort Collins, Colorado

VETERINARY CLINICS OF NORTH AMERICA: SMALL ANIMAL PRACTICE

VOLUME 25 • NUMBER 3 • MAY 1995 753

754 PLOTNICK & GRECO

Feline insulin differs from bovine insulin by one amino acid, from
pig insulin by three amino acids, and from human insulin by four amino
acids. Beef, beef/pork, and human insulin are all acceptable for home
management. Long-acting beef/pork insulin (Ultralente Iletin I, Eli Lilly
Co, Indianapolis, IN) works well in cats. See article entitled "Insulin
Therapy" by Greco et al of this issue.

WHAT ARE THE MOST COMMON CONCERNS

REGARDING HOME MANAGEMENT OF THE DIABETIC
PET?

Much of the difficulty encountered in managing a diabetic patient

at home comes from the handling of insulin and insulin injection tech-
niques. Many veterinarians differ in opinion on whether insulin needs
to be refrigerated. To be safe, it is recommended that insulin be kept
refrigerated. Excessive heat must be avoided; insulin should be kept out
of direct sunlight or excessively high temperatures. Insulin needs to be
mixed well to resuspend any crystals that may have settled during
storage. It has been said that insulin vials should not be shaken vigor-
ously because this can alter the crystaline structure of the insulin; how-
ever, other investigators have suggested that this is a myth and the
concerns about vigorous shaking were to avoid causing insulin to foam
in the vial. Foam could cause inaccurate measurement of -the insulin
dose. In any event, resuspension can be adequately achieved by gently
rolling the vial.
Some insulin preparations come in a 100 U / mL concentration (U-
100), a 40 U/mL preparation (U-40), or both. Insulin syringes also are
available in U-100 or U-40 styles. It is important that the syringe con-
forms to the insulin concentration to avoid underdosing or overdosing.
Drawing up the proper amount of insulin may be problematic for
some clients. Cats and some small dogs often require very small
amounts. Attempting to measure 3 U on a 100-U syringe can be difficult
and frustrating. Having the client obtain insulin syringes that hold a
maximum of 30 U of insulin can help. The calibration marks on the
syringe are more widely spaced so that small doses can be measured
more accurately. An alternative is to dilute the insulin 10-fold (with
diluent supplied by the manufacturer). A 3-U dose now becomes a 30-
U dose, which is easily and accurately measured on any insulin syringe.
One should check to see that the client is measuring the insulin
properly in the syringe. The plunger of the insulin syringe is a potential
source of client confusion (Fig. 1). With the syringe held so that the
needle is upright, insulin is measured from the top of the plunger to the
needle, not the bottom.
The insulin injection site on the pet's body is another client concern.
An area between the scapulae is a commonly recommended location;
however, some emaciated animals have scapulae that protrude from the
body. This makes the interscapular area a more risky target because
 HOME MANAGEMENT OF CATS AND DOGS WITH DIABETES MELLITUS 755

NOT[
this
one

Figure 1. Proper measuring technique

for insulin. With the syringe held so
that the needle is upright, insulin is : !
measured from the top of the plunger 24 13
to the needle, not from the bottom. units units

injections are more likely to pierce through the skin causing insulin to
be deposited on the skin surface rather than subcutaneously. A potential
disadvantage of the interscapular area is that it is an area of low
vascularity. Also, long or thick hair coats make injections more difficult.
Clients are more likely to mistakenly deposit insulin below the hair but
not into the subcutaneous tissue. Shaving a small (1 in X 1 in) square
of hair from the thorax, abdomen, or over the left or right hip area helps
delineate a target for the more timid owner. The owner should be
instructed to rotate the injection site.
If an owner pierces through the skin and injects some (or all) of the
insulin onto the skin, they should be advised not to attempt to guess
how much insulin went subcutaneously. Instead, they should just skip
that dose and give the normal dose at the next appropriate time. An
occasional underdosing is harmless; overdosage may have serious conse-
quences.
One common reason for diabetic animals to present with hypoglyce-
mia is that the pet has been given a double dose of insulin as a result of
miscommunication between family members or caretakers. Owners
should be instructed to designate one family member as the primary
person responsible for administering the insulin, with clear communica-
tion regarding who is the secondary caretaker if the primary person is
unable to administer insulin on a particular day(s).

WHAT SHOULD I LOOK FOR IN A BLOOD GLUCOSE

MONITORING DEVICE?

The ability to rapidly and ·accurately assess blood glucose levels in

a hospital setting is very important in veterinary practice. There are a
number of different glucose reagent strips and reflectance meters cur-
rently being marketed. A comparison of three reflectance meters (Accu-
Chek II [Boehringer Mannheim, Indianapolis, IN], Glucometer II [Miles
Inc, Elkhart, IN], and Glucoscan 2000 [Lifescan Inc, Milpitas, CA])
756 PLafNICK & GRECO

showed all three to be highly accurate in determining blood glucose

concentrations in the dog. Two reagent strips (Chemstrip bG [Boehringer
Mannheim] and Glucostix [Miles Inc]) were also compared and both
were determined to be highly accurate. In terms of accuracy and repro-
ducibility of results, the Accu-Chek II reflectance meter and the Chems-
trip bG gave the highest correlation coefficients.

WHAT ABOUT EXERCISE?

Insulin requirements decrease with vigorous exercise because of

increased delivery of insulin to working muscles. Glucose transport into
the skeletal muscles increases significantly. Because the amount of daily
exercise will affect the daily insulin requirements, athletic activity in the
dog should be kept as constant as possible. Active dogs can remain
active, but less active or sedentary dogs should not have their daily
exercise routines changed significantly. The fact that insulin require-
ments are determined for dogs in a hospital setting in which exercise is
limited is usually compensated by the fact that at home, they tend to
consume a bit more food.

WHAT ARE THE GOALS OF INSULIN THERAPY?

In diab,~tic dogs without cataracts, blood glucose should fluctuate

between 100 to 180 mg/ dL. For dogs with cataracts, 100 to 250 mg / dL
is the goal. Cats are more difficult to regulate, therefore, 100 to 300 mg/
dL is acceptable. More importantly, the goal of therapy is to resolve
the patient's clinical signs. A well-regulated diabetic animal exhibits a
noticeable decrease in water intake and urine output. The rate of weight
loss should slow down, and most well-regulated diabetic patients will
gain some weight. A significant decrease in appetite is the least consis-
tent sign of good glycemic control; even well-regulated diabetics con-
tinue to have excellent appetites. A checklist of topics to discuss with
clients regarding home care of the diabetic animal is given in Table 1.

SHOULD OWNERS BE ADVISED TO MAKE INSULIN

DOSE ADJUSTMENTS THEMSELVES?

In the past, clients were instructed to monitor their pet's urine

glucose levels and either increase, decrease, or continue the same dose
of insulin the next day based on presence or degree of glycosuria. It is
no longer recommended that owners adjust insulin dosage themselves
for several reasons. First, the danger of inducing hypoglycemia followed
by rebound hyperglycemia (Somogyi effect) precludes this practice. Sec-
ond, fairly rapid resolution of clinical signs (polyuria/polydipsia, sub-
normal body weight, possible ataxia from diabetic neuropathy) allows
the degree of severity of these signs to be an effective indicator of
glycemic control. And finally, after a period of time, clients often com-
 HOME MANAGEMENT OF CATS AND DOGS WITH DIABETES MELLITUS 757

Table 1. CHECKLIST OF TOPICS TO DISCUSS WITH CLIENTS REGARDING HOME

CARE
1. Proper insulin handling and storage
Refrigerate; avoid excessive heat or sunlight
Mix well by gently rolling the vial; do not shake
2. Proper injection technique
Make certain client knows how to draw up correct amount
Appropriate injection sites
What to do if an isolated incidence of improper injection occurs
3. Hypoglycemia
Recognition of signs of hypoglycemia (ataxia, confusion, weakness, seizures, and so
forth)
Treatment of hypoglycemia (karo syrup or maple syrup orally or poured on gums,
then contact veterinarian)
4. Feeding
Schedule
Type of food
5. Exercise
Avoid significant changes in pet's normal routine
6. Home monitoring
Improvement or resolution of clinical signs
Keeping a record of pet's water intake (optional)
Occasional monitoring of urine glucose (optional)

plain of the inconvenience of daily urine monitoring and the difficulty

obtaining urine samples from pet cats, especially if the cat spends most
of its time outdoors or is in a multicat household . (The recent develop-
ment of cat litter with color-sensitive indicators of glycosuria has made
this practice easier; however, adjusting insulin dose based on glycosuria
is still discouraged.)
Pet owners should not necessarily be discouraged from measuring
urine glucose levels, especially if they are conscientious and highly
involved clients. Measuring the presence of glucose and ketones and
keeping a monthly log is helpful in alerting the veterinarian to the onset
of a lapse in glycemic control. Clients can also measure their pet's daily
water intake before insulin therapy has begun and again when serial
glucose curves show glycemic control. Recurrence of polydipsia can
then be objectively confirmed by the owner before bringing the animal
to the hospital for re-examination. If a client suspects that their pet's
glycemic control is becoming compromised (i.e., clinical signs of poly-
uria/polydipsia, polyphagia, ataxia, or weight loss return), adjustments
in insulin dosage are to be based on the results of serial glucose curves.

HOW ACCURATE IS A GLUCOSE CURVE IN A

HOSPITAL SETTING?

Glucose curves can be affected by many variables, such as failure

to eat consistently while in the hospital, the stress of hospitalization,
and the need for multiple venipunctures. Stress causes the release of
758 PLOTNICK & GRECO

the counter-regulatory hormones, epinephrine and glucagon, making

diabetes harder to regulate and causing glucose curves to vary some-
what from day to day. Despite' these pitfalls, the glucose curve detects
important trends and shows the most important information regarding
a patient's glycemic control, namely, time of peak effect, duration of
effect, whether the patient is receiving enough insulin, and whether
there is hypoglycemia followed by rebound hyperglycemia (Somogyi ef-
fect).

WHEN IS AN ANIMAL SAID TO BE "RESISTANT" TO

THE EFFECTS OF INSULIN?

A diagnosis of insulin resistance is made when the animal shows

persistent hyperglycemia despite receiving more than 2.2 U / kg per day.
Before embarking on a diagnostic evaluation for insulin resistance,
problems with the handling of the insulin (improper injection technique,
improper amount given by the owner, insulin left unrefrigerated) need
to be ruled out. If the animal truly seems to be insulin resistant, a logical
approach should be used to rule out commonly recognized causes of
resistance. These causes are concurrent use of progestogens or corticoste-
roids; obesity; concurrent disease, infection, or ketoacidosis; hyperthy-
roidism (mainly cats); poor absorption of subcutaneous insulin; hypera-
drenocorticism; acromegaly; insulin antibodies; and "idiopathic"
resistance of no known etiology.

WHY ARE CATS MORE DIFFICULT TO REGULATE

THAN DOGS?

Cats are more difficult to regulate for several reasons. Cats are
easily prone to stress and have a well-developed fight or flight response.
A eat's physiologic response to stress can elevate its blood glucose to
more than 300 mg/ dL. Cats in multi-cat households and sick cats in
general often shQw stress-related hyperglycemia, which can make regu-
lating them difficult. Regulation of glycemic control based on serial
glucose curves obtained in a hospital setting is affected by the stress of
boarding, inconsistent diet, and possible presence of the sight, sound,
and smell of dogs in their vicinity.
Some cats require fairly small amounts of insulin for regulation. It
is not unusual to have a small cat remain unacceptably hyperglycemic
on 2 U of insulin, yet become dangerously hypoglycemic when increased
to 3 U. In this situation, it is recommended that 100 U / mL insulin
formulations be diluted 1:9 to yield a 10 U / mL concentration. This
makes it possible to give incremental doses accurately. (Diluents and
vials may be obtained directly from the insulin manufacturers on re-
quest. Diluted insulin has a shelf life of 30 d ays. Sterile saline or lactated
Ringer's solution is not an appropriate diluent, except in emergencies.)
 HOME MANAGEMENT OF CATS AND DOGS WITH DIABETES MELLITUS 759

Another difficulty encountered in regulating feline patients is their

finicky eating habits. Ideally, diabetic cats should be fed multiple small
meals of a high fiber diet. The frequent feedings, coupled with the
slower digestion of the dietary fiber, minimizes postprandial hyperglyce-
mia and controls fluctuations in glucose. Cats, however, are often reluc-
tant to switch to the high fiber diets recommended for optimal glycemic
control. Gradually mixing the new diet with the old diet often does not
fool a determined cat. If the cat refuses to eat the new diet, it is best to
let them eat their regular diet rather than risk inconsistent food intake,
which can further compromise glycemic control. An exception to this is
the feeding of semi-moist diets. These diets are unacceptably high in
sugar and cause wide swings in blood glucose levels, making glycemic
regulation difficult.

CAN A CAT'S DIABETES RESOLVE?

In a small number of cats, the insulin requirements may wax and
wane. Initially, they may require insulin. As time passes, their require-
ments may decrease, the condition resolves, and the cat no longer
requires insulin to achieve glycemic control. Often these cats present to
a clinic with signs of hypoglycemia. (A few of these "resolving" cats,
however, may become permanently insulin-dependent weeks or months
after the resolution of the prior diabetes.) An explanation for this is
based on the realization that there are two types of diabetic conditions
now recognized in cats: type 1 (insulin-dependent) and type 2 (non-
insulin-dependent). Concurrent use of high fiber diets and resultant
weight loss may cause a type 2 diabetic that is also receiving exogenous
insulin to become more responsive to endogenous (and exogenous)
insulin, causing the insulin requirement to decrease completely and
resolve the diabetes.

SHOULD HIGH FIBER DIETS BE FED TO ALREADY

UNDERWEIGHT DIABETIC PATIENTS?
Overweight diabetic animals should be fed high fiber, high complex
carbohydrate diets at a caloric intake designed to correct obesity. The
low caloric density nature of these diets is inappropriate for underweight
animals because this may result in further weight loss. High calorie, low
fiber diets can be used until normal body weight has been achieved with
glycemic control and then switched to the high fiber diets. Correction
of obesity may reverse or resolve obesity-induced derangements in
carbohydrate tolerance.
Address reprint requests to
Deborah S. Greco, DVM, PhD
Department of Clinical Sciences
College of Veterinary Medicine
and Biomedical Sciences
Colorado State University
Fort Collins, CO 80523