Insulin Injection Pen (VetPen): More Questions (and Answers) about this New Diabetic Product

Since the FDA approved the use of a new insulin injection pen (VetPen) made by Merck Animal Health last week (1,2), I've received a number of questions from both veterinarians and owners of diabetic pets. Listed below are some of the most common questions with my responses.

Do we buy a single VetPen and use it forever? Or does the VetPen have to be replaced after a month or two?

The VetPen has been tested for at least 3,000 actuations (i.e., how many times the insulin release button is pressed and released). Therefore, a single VetPen is likely to last a lifetime for the majority of dogs and cats treated with diabetes.

How are the pens and cartridges sold? 
The reusable VetPen is supplied in a Starter Kit which contains everything you need to get started (see below). This included everything except the Vetsulin cartridges, which are supplied separately in cartons of ten, 2.7-mL cartridges.

The VetPen itself is available in 2 sizes. For greater accuracy at low doses, the first option (blue cap) has a maximum total dose of 8 units, allowing for dosing increments of 0.5 unit per injection. If higher insulin doses are being administered, the second VetPen option (tan cap) has a maximum total dose of 16 IU per injection, with dosing increments of 1 unit.

What is in each VetPen Starter Kit?
Each Starter Kit contains either an 8-unit or 16-unit VetPen with an instruction leaflet.

The kit also contains a box of 28-g, ultra-thin needles that feature a silicone coating to help minimize injection discomfort, as well as a needle remover that helps to remove used needles, while minimizing the risk of accidental needle stick injury. There is also a travel pouch to hold all of the components.

The kit also contains two adaptors to assist those with dexterity issues. The dose selector adaptor may be used to provide a better grip when selecting a dose. The release button extension may be used to provide a better grip when giving injections.

Are the VetPens an accurate way for insulin dosing?
The VetPen is ideal for cats and small dogs on low doses of insulin, in which dosing accuracy can be a concern (3,4). A recent study comparing the precision and accuracy of the VetPen to U40 syringes demonstrated that even when doses were drawn up by trained laboratory technicians, syringes were found to deliver at least 20% to 25% more insulin than needed for a 1-unit dose (5).

In contrast, VetPen enables doses to be delivered with accuracy and precision down to 0.5 units. In large dogs, dosing accuracy is generally not a problem.

Do the pens and cartridge need to be refrigerated? Other handling precautions?
The VetPen cartridges should be refrigerated (not frozen) and protected from light before opening.

VetPen does not need to be refrigerated after a cartridge has been started (4), although it probably is best to do so. The loaded VetPen can be stored on its side in the refrigerator.

VetPen should always be stored or carried with the needle removed and the cap on. To clean the device, wipe with a damp cloth. Do not immerse in water.

Are the VetPens expensive? How would the costs of the VetPen compare to those associated with the standard insulin vial/syringe method?

The cost of treatment will depend upon the size of the diabetic pet. For smaller dogs and cats, the price of the VetPen with the Vetsulin cartridges and needles will be similar to the cost of the standard 10-mL Vetsulin vial and U-40 insulin syringes.   For larger dogs, the standard way of administering Vetsulin (via an insulin syringe) would generally be a more economical way to provide insulin treatment.

Bottom Line:

These insulin pen devices are an alternative to the traditional insulin vial-and-syringe method and offer many advantages. In human diabetic patients, insulin pens have also been found to be less painful than the vial-and-syringe method and are often associated with greater patient preference and social acceptability (6-11).  Similar preliminary findings have been documented in dogs and cats (12,13). As a result, this method of insulin delivery may ultimately help to improve glycemic control and should be considered as an alternative insulin delivery method.

Insulin pens are designed to deliver a fixed insulin dose while insulin syringes rely on the ability of the user to accurately draw up the required insulin dose. One recent study reported that for low doses (below 8 units), the VetPens were more precise and accurate than the insulin syringes (5). In particular, insulin syringes tend to over-deliver, compared to the insulin pen, for very low doses (1 unit). For higher doses (16 units), both devices were comparable (5).

Similar findings have been reported in human pediatric patients, in which very low doses of insulin must be administered. One older study looked at the reliability of using U100 syringes for accurately administering low doses of insulin in the hospital by pediatric nurses. In that study, attempts to administer doses of 0.5 U or 1.0 U of U-100 insulin resulted in overdosage of 95% and 66%, respectively (14). Based on this study, it's no wonder that small diabetic dogs or cats are often a challenge to regulate when small insulin doses are needed.

References: 

1. FDA website. FDA Approves First Insulin Product for Use with Automatic Injection Pen in Cats and Dogs.
2. Press release. Merck Animal Health Receives FDA Approval of VetPen  
3. Merck Caninsulin website. Caninsulin® VetPen® helps make pet diabetes management easier 
4. Pet Diabetes website. What you need to know about the Caninsulin VetPen. 
5. Burgaud S, Riant S, Piau N. Comparative laboratory evaluation of dose delivery using a veterinary insulin pen. Proceedings World Congress ASAVA/FECAVA/BSAVA 2012;567.
6. Molife C, Lee LJ, Shi L, et al. Assessment of patient-reported outcomes of insulin pen devices versus conventional vial and syringe. Diabetes Technol Ther 2009;11:529-538. 
7. Pearson TL. Practical aspects of insulin pen devices. J Diabetes Sci Technol 2010;4:522-531. 
8. Wright BM, Bellone JM, McCoy EK. A review of insulin pen devices and use in the elderly diabetic population. Clin Med Insights Endocrinol Diabetes 2010;3:53-63. 
9. Cuddihy RM, Borgman SK. Considerations for diabetes: treatment with insulin pen devices. Am J Ther 2013;20:694-702. 
10. Davis EM, Foral PA, Dull RB, et al. Review of insulin therapy and pen use in hospitalized patients. Hosp Pharm 2013;48:396-405. 
11. McCoy EK, Wright BM. A review of insulin pen devices. Postgrad Med 2010;122:81-88. 
12. Burgaud S, Guillot R, Harnois-Milon G. Clinical evaluation of a veterinary insulin pen in diabetic cats. Proceedings World Congress ASAVA/FECAVA/BSAVA 2012;499.
13. Burgaud S, Guillot R, Harnois-Milon G. Clinical evaluation of a veterinary insulin pen in diabetic dogs. Proceedings World Congress ASAVA/FECAVA/BSAVA 2012;568.
14. Casella SJ, Mongilio MK, Plotnick LP, et al. Accuracy and precision of low-dose insulin administration. Pediatrics 1993;91:1155-1157. 

FDA Approves First Insulin Automatic Injection Pen for Diabetic Dogs and Cats

VetPen, for use with Vetsulin (in USA) and Caninsulin (outside USA)

The U.S. Food and Drug Administration (FDA) has approved the first insulin injection pen (VetPen, Merck Animal Health) for diabetic cats and dogs, the agency announced today, March 19, 2014 (1).

2 Sizes of VetPens

The VetPen may now be used to administer Vetsulin insulin cartridges, also made by Merck Animal Health. The refillable VetPen automatically measures the prescribed insulin dose and provides the owners of diabetic dogs and cats with an additional option for insulin delivery.

There are two sizes of refillable VetPens. One (tan cap) dispenses insulin doses from 1-16 units per dose in full unit increments. The other (blue cap) dispenses 0.5-8 unit doses in full or half unit increments. Both pens use 2.7 ml insulin cartridges which hold a total of 108 units (IU) of U-40 Vetsulin (or Caninsulin).

Vetsulin is an FDA-approved insulin for use in dogs and cats (2). This insulin is identical to Caninsulin, the brand name of the insulin sold in Europe (3).

Merck said the VetPen is easier to dose and administer and is more accurate than traditional delivery systems, such as syringes and vials (4). “For years, insulin pens have made managing diabetes more convenient for human diabetics,” the company said. “Merck Animal Health has now brought the same technology to veterinary medicine.”

An informational website (2) provides tools for both veterinarians and pet owners to make managing pet diabetes easier. More online information about the VetPen can also be found on the Caninsulin website (5); the Pet Diabetes website has an informational brochure that can be downloaded (6).

Administering insulin to a cat with the VetPen

For questions on how to obtain Vetsulin or the VetPen, please contact Merck Animal Health Customer Service at 800-521-5767.

References: 

1. FDA website. FDA Approves First Insulin Product for Use with Automatic Injection Pen in Cats and Dogs.
2. Merck Vetsulin website. www.vetsulin.com
3. Merck Caninsulin website. www.caninsulin.com
4. Press release. Merck Animal Health Receives FDA Approval of VetPen  
5. Merck Caninsulin website. Caninsulin® VetPen® helps make pet diabetes management easier 
6. Pet Diabetes website. What you need to know about the Caninsulin VetPen. 

What's the Best Insulin for Treating Dogs with Diabetes Mellitus?

I am writing you regarding my 11-year old male Weimaraner, Duke. He has always been in good health but over this past week he has had 2 ”accidents” where he has urinated in the bed. He has also been drinking a lot more water than usual and urinating more too.

I  took him to the vet because I had a feeling he might be diabetic. My veterinarian confirmed that it was indeed diabetes mellitus and started him on 10 units of NPH, once after breakfast and once after dinner.  He has improved since starting the insulin, but remains quite thirsty and continues to urinate excessively.

Now I know that this will not give very good control alone because NPH is only a long-acting insulin. I am a Type 1 diabetic, diagnosed when I was 12 years old, so I have quite a bit of experience dealing with this disease. I want my poor puppy to be as controlled as possible so he does not feel like I do when my sugars are out of control— lethargic, nausea, headaches, unquenchable thirst, urinating all the time, and just plain crappy! Not to mention the stress this puts on the on the rest of the body.

If dogs are anything like people, I believe that Duke needs an insulin mixture that will bring his blood glucose down to normal and keep it leveled out. I have been giving him the rapid-acting insulin analog Humalog (insulin lispro) along with the NPH and that seems to be working really well, with marked improvement in his thirst and urination.  The only problem is that he needs 4-6 injections of Humalog each day. I was hoping you have had experience with something that would give him the same control as Humalog but with less injections daily.

In the past, I have used short-acting Regular insulin (before Humalog was invented) but I do not remember how the dosing went. I do have much better control with the Humalog but I am also on an insulin pump, so NPH insulin is no longer necessary.

Any help you can give to allow my dog Duke better control long term without so many injections would be greatly appreciated.

My Response:

In dogs, veterinarians commonly start with an intermediate-acting insulin (NPH or Vetsulin) twice a day (1,2). In some dogs, I find it necessary to add a short-acting insulin to the longer-acting insulin preparation, but many dogs can achieve adequate glucose control without giving more than 2 injections per day.

Insulin of choice for canine diabetics
In my opinion, the insulin of choice for most dogs is Vetsulin (porcine insulin zinc suspension; Merck Animal Health) (3). The main advantage of Vetsulin (known as Caninsulin outside the USA (4), is that it is actually composed of both short- and long-acting insulin components (see Figure below, showing the duel peaks of activity) (5,6). So giving Vetsulin is like administrating NPH together with a second, short-acting insulin preparation, like you are doing now.  However, Vetsulin works better than NPH for most dogs because it has a longer duration of action than NPH.

Timing of meals and insulin injection
The short-acting amorphous fraction of the Vetsulin, which composes 35% of the insulin activity, acts like regular insulin or Humulog, mainly to control the rise in blood glucose after each meal (6).  To help prevent severe rises in glucose after meals, however, it is also important to give the insulin before meals, instead of after the food is ingested, as you are doing now. This protocol will allow the short-acting insulin to be absorbed into the blood stream and ready to act to lower the blood sugar as soon as the food is absorbed from the gastrointestinal tract (7).

The only time I don't do this insulin-feeding protocol is in dogs that don't always eat their meal well; but even in those dogs, I never wait long after the meal is finished to give the insulin. Instead, I always give the insulin injection as soon as possible, once the dog has eaten a sufficient amount of food.

Vetsulin (porcine insulin zinc suspension), with it's 2 peaks of insulin activity

References:

1. Nelson RW. Canine diabetes mellitus In: Ettinger SJ, Feldman EC, eds. Textbook of Veterinary Internal Medicine: Diseases of the Dog and Cat. Seventh Edition ed. St. Louis: Saunders Elsevier, 2010;1449-1474.
2. Davison LJ. Canine diabetes mellitus In: Mooney CT, Peterson ME, eds. BSAVA Manual of Canine and Feline Endocrinology. Fourth ed. Quedgeley, Gloucester: British Small Animal Veterinary Association, 2012;116-132.
3. Vetsulin website. www.vetsulin.com 
4. Caninsulin website. www.caninsulin.com
5. Monroe WE, Laxton D, Fallin EA, et al. Efficacy and safety of a purified porcine insulin zinc suspension for managing diabetes mellitus in dogs. J Vet Intern Med 2005;19:675-682.
6. Fleeman LM, Rand JS, Morton JM. Pharmacokinetics and pharmacodynamics of porcine insulin zinc suspension in eight diabetic dogs. Vet Rec 2009;164:232-237.
7. Cobry E, McFann K, Messer L, et al. Timing of meal insulin boluses to achieve optimal postprandial glycemic control in patients with type 1 diabetes. Diabetes Technol Ther 2010;12:173-177. 

U-40 Insulin Syringes Recalled

Med-Vet International Issues Recall of 1/2-cc U-40 Insulin Syringes Due to Mismarked Syringe Barrels (1).  

On February 14, 2014 , Med-Vet International initiated a voluntary nationwide recall of 140 boxes of 1/2-cc U-40 insulin syringes (1). The syringes are incorrectly labeled as 40 units per 1/2-cc syringe, whereas they should be marked with only 20 units per 1/2 cc. Obviously, this could potentially result in a lower-than-prescribed dose of insulin being administered, and lead to relapse of signs of diabetes, as well as development of ketoacidosis.

Consumers who have these insulin syringes should quarantine all products subject to recall. In addition, if you, as the veterinarian, may have sold these syringes, please inform the clients at once about this product recall so they can change to another insulin syringe.

The following 1/2-cc U-40 insulin syringes have been recalled:

• 140 boxes of 1/2-cc insulin syringe U-40 with 29g x 1/2” needle. Lot Number: 20120610
• The product can be identified by Item number: MV1/2CCINS-40 or 1/2CCINS-40 by Oasis.

Med-Vet International is arranging for return of all recalled 1/2-cc U-40 insulin syringes. Consumers with questions may contact the company via telephone at (800) 544-7521 or via e-mail at customerservice@shopmedvet.com.

References:

1. FDA website (www.fda.gov). Med-Vet International Issues Nationwide Recall of Veterinary 1/2cc U-40 Insulin Syringes Due to Mismarked Syringe Barrels

Managing Addison's Dogs with Concurrent, Uncontrolled Diabetes

I have a 10-year old male Terrier dog named Scooter who now weighs in at 11 pounds (5 kg). He was originally diagnosed diabetes mellitus that we could not get regulated with Vetsulin, even at doses as high as 8 units twice daily. 

Scooter was subsequently diagnosed with with pituitary-dependent Cushing's disease and was treated with mitotane (Lysodren). Once we got the Cushing's disease under control, his daily insulin requirements fell to 3 units twice a day, and the diabetes was well regulated based on glucose curves done at my vet's hospital. However, after a few months of treatment with mitotane, it was apparent that Scooter had been severely overdosed with the medicine, which resulted in complete adrenal insufficiency and threw him into a severe Addison's crisis. It was a near death experience for him, but he has pulled threw and is now doing much better off of the mitotane and on treatment for his iatrogenic Addison's disease. 

Now we have spent the last 3 months trying to stabilize his iatrogenic Addison's disease and concurrent diabetes. Currently, he is on 2.5 mg of fludrocortisone (Florinef) twice day along with 1.25 mg of prednisone twice daily. The Florinef dose has had to be gradually increased to keep his serum electrolytes (sodium and potassium) within their proper ratio and ranges. Based on his last blood test, we may have to increase it yet again, since his serum potassium remains slightly high. 

To make matters even worse, his diabetes is now completely out of control, as evidenced by his intense thirst and excessive urinations with heavy amount of glucose in the urine. Serial blood glucose monitored done at my veterinarian's clinic confirms that the blood glucose readings remain very high throughout the day. We have gradually increased the insulin dose back up to 7 units twice daily, but it just doesn't seem to be working at all at this point. 

What do you recommend that I do? We need to get the Addison's disease controlled but as we have raised the doses of the Florinef and prednisone, Scooter's diabetes is getting worse! My vet has suggested that I transition Scooter from the Florinef tablets to Percorten injections in order to stabilize his serum electrolytes. He also told me that the Florinef contains some steroid activity which may be contributing to his high insulin doses.  Is the steroid in Florinef any less hard on him than the prednisone?   

Any advice would be greatly appreciated. 

My Response: 

With Scooter, we need to address both his poorly-regulated Addison's disease and his uncontrolled diabetes, as well as the increased thirst (polydipsia) and urination (polyuria). There is a lot going on with Scooter, so let's take one problem at a time.

Mineralocorticoid replacement: Florinef vs. Percorten-V? 
For mineralocorticoid replacement for dogs with Addison's disease, either oral fludrocortisone acetate (Florinef) or injectable desoxycorticosterone pivalate (DOCP; Percorten-V) can be used successfully (1-3).

In your dog, however, I would definitely make the switch to Percorten-V. Some dog's just don't respond very well to treatment with Florinef, and it's not uncommon for dogs to require increasing doses of daily Florinef over time to control the serum electrolyte concentrations (1-3). With high doses of Florinef, this can lead to signs of increased thirst and urination, and may also lead to problems with management of diabetes, as you are seeing in Scooter.

Since you are having problems controlling the serum electrolytes, I'd recommend starting with the label dose of 2.2 mg/kg, injected every 25-30 days (4). If this drug works to stabilize the serum sodium and potassium levels (and I expect that it will), then we can try to gradually lower the Percorten dosage after a few weeks to months (e.g., I generally try reducing the dose by 10% or so each month). Many dogs will maintain normal serum electrolyte levels on doses between 1-1.5 mg/kg per month, and a few will even need less (1,5).

Glucocorticoid supplementation in Addison's disease
Now let's next turn to your dog's glucocorticoid needs. Dogs with Addison's disease, either spontaneous or iatrogenic (that is, drug-induced, as it was in Scooter), will require replacement glucocorticoids (e.g., prednisone or prednisolone) in addition to the mineralocorticoid supplementation (1-3). Some dogs will do fine without any glucocorticoid supplementation, but the vast majority of dogs will feel better with a small daily dose of glucocorticoid administered daily. Since we know that these dogs cannot secrete normal amounts of cortisol, it certainly makes a great deal of sense to use low-dose glucocorticoid replacement.

Unfortunately, many dogs with Addison's disease are treated with too much glucocorticoid. Remember that our goal with glucocorticoid supplementation is to provide the same amount of steroid that the dogs would normally produce if their adrenals had not failed.

For dogs, the daily glucocorticoid maintenance dose for prednisone is only 0.1-0.2 mg/kg/day (3), so that calculates out to only 0.5-1.0 mg per day for Scooter, quite a bit lower that what you are currently giving (2.5 mg per day). That would certainly be enough to cause an increased thirst by itself, but would also contribute to glucocorticoid-induced insulin resistance, making the diabetes uncontrollable despite the higher insulin doses.

Therefore, we should try to lower the prednisone dosage first down to 1.0 mg once daily (or divided). If he is doing well clinically (i.e., normal appetite and no vomiting), then the dose can be lowered even further, down to 0.5 mg per day. Prednisone or prednisolone are available in 1-mg tablets, as well as an oral solution, making it possible to administer these smaller dosages (6,7).

Florinef also contains significant glucocorticoid activity
In addition to the fact that Addison's dogs are commonly overdosed with prednisone, it's very important to realize that fludrocortisone acetate also possesses moderate glucocorticoid activity, as well as having marked mineralocorticoid potency (2,3). By comparison, fludrocortisone has 10-times the glucocorticoid activity and 125-times the mineralocorticoid activity of cortisol, the glucocorticoid hormone secreted by the adrenal gland. In this regard, fludrocortisone is very different than Percorten-V, which possess no glucocorticoid activity (2,3).

For the dog with Addison's disease, a glucocorticoid is a glucocorticoid —it makes no difference to Scooter if this glucocorticoid activity comes from prednisone or from the Florinef.  This potent glucocorticoid activity of fludrocortisone explains why some dogs will develop polydipsia and polyuria, common side effects associated with higher-dose glucocorticoid treatment in dogs (8). This is another reason why we need to get Scooter off of the Florinef and switch to the Percorten-V.

Glucocorticoid-induced insulin resistance
In all likelihood, the reason for Scooter's poorly controlled diabetes is related to insulin resistance associated with glucocorticoid excess (9,10). By stopping the Florinef and providing mineralocorticoid replacement with Percorten-V instead, we will remove one source of excess glucocorticoid. Lowering his daily prednisone dose will also help.

As we remove the cause of the insulin resistance, the dose of insulin will again fall. You should monitor Scooter closely during this period to ensure that insulin overdosage and hypoglycemia do not occur, and lower the insulin dose as needed.

Don't forget to rule out urinary tract infections
Finally, don't forget that diabetic dogs, no matter what the cause, will commonly develop urinary tract infections. Think about it: a bladder full of sugar-laden urine is a perfect breeding ground for bacteria to thrive! Such urinary tract infections will also commonly contribute to insulin resistance (9,10) but can also lead to kidney failure, if the infection ascends from the bladder up to the kidneys.

For this reason, I always recommend checking a complete urinalysis and urine culture in all dogs (and cats) with insulin resistance. However, even if the diabetes is well-controlled, I still recommend doing a urinalysis with culture twice yearly in all of my diabetic patients.

References: 

1. Kintzer PP, Peterson ME. Treatment and long-term follow-up of 205 dogs with hypoadrenocorticism. J Vet Intern Med 1997;11:43-49. 
2. Church DB. Canine hypoadrenocorticism In: Mooney CT, Peterson ME, eds. BSAVA Manual of Canine and Feline Endocrinology. Fourth ed. Quedgeley, Gloucester: British Small Animal Veterinary Association, 2012;156-166.
3. Kintzer PP, Peterson ME. Canine hypoadrenocorticism In: Bonagura JD, Twedt DC, eds. Kirk's Current Veterinary Therapy, Volume XV. Philadelphia: Saunders Elsevier, 2014; pp 233-237.  
4. Lynn RC, Feldman EC, Nelson RW. Efficacy of microcrystalline desoxycorticosterone pivalate for treatment of hypoadrenocorticism in dogs. DOCP Clinical Study Group. J Am Vet Med Assoc 1993;202:392-396. 
5. Bates JA, Shott S, Schall WD. Lower initial dose desoxycorticosterone pivalate for treatment of canine primary hypoadrenocorticism. Aust Vet J 2013;91:77-82. 
6. Peterson ME: Treating small-breed Addison's dogs with low doses of prednisone or prednisolone. Animal Endocrine Clinic blog, December 14, 2013. 
7. Plumb, DC. Plumb's Veterinary Drug Handbook. Seventh Edition, Wiley-Blackwell. 2011.
8. Melián C, M. Pérez-Alenza, D, Peterson ME. Hyperadrenocorticism in dogs, In: Ettinger SJ (ed): Textbook of Veterinary Internal Medicine: Diseases of the Dog and Cat (Seventh Edition). Philadelphia, Saunders Elsevier, 2010;1816-1840.
9. Hess RS. Insulin resistance in dogs. Vet Clin North Am Small Anim Pract 2010;40:309-316. 
10. Peterson ME. Diagnosis and management of insulin resistance in dogs and cats with diabetes mellitus. Vet Clin North Am Small Anim Pract 1995;25:691-713.  

Combining Rapid and Long-Acting Insulin Analogs for Dogs with Diabetes

I am the owner of Coco, a 6-year old male Poodle who has been diagnosed with diabetes mellitus. I noticed the symptoms myself, as I too am a Type 1 diabetic (I was diagnosed 42 years ago at the age of 7 years). 

My dog's blood sugar was slightly more than 400 mg/dl when I brought him in for testing. That’s terribly high. I am a man with deep concern about this disease, and I personally keep myself in very good control (my A1-C tests are always in the 6’s). And thus, I am interested in having excellent control of my dogs health too. 

I’ve been directed by my veterinarian to give ”Coco” 2 daily injections of long-acting type insulin (I give him glargine (Lantus) since that’s what I use for my diabetes). So I started him 5 units of Lantus twice a day but still found him to be drinking far too much water and still having high sugar levels. So, I then added in small amounts of insulin lispro (Humalog) to better control his sugar. I’ve not yet taken him back in for spot checking of his blood, but I do notice the Humalog is helping decrease his water drinking and urinating at normal levels. So now, I give him 2 shots at breakfast and 2 at dinner—5 units of Humalog and 10 units of Lantus twice per day. And I watch him closely but find he is doing well. I see no signs of low blood sugar. 

Do you find my plan a good one? Am I overreacting by giving him Humalog in addition to the Lantus? I’m not a doctor, but I think a blood sugar curve should be between 70-150 mg/dl to keep him healthy, just like in human diabetic patients. Is this correct? Is there something better I can do? 

Finally, is there a simpler way to give the injections? I use a small needled Pen for his injections between his shoulders in a pinch of skin. Is there a needle-free ”Jet” type injection system that would be better than the needles? 

Thank you very much for any help advice you can share. 

My Response: 

Although insulin glargine (Lantus) can be used to treat diabetic dogs (1-3), it doesn't always work well as the sole insulin preparation, as you have discovered in your dog. Therefore, I don't usually start with glargine in dogs, but I use either NPH (Humulin) or lente (Vetsulin) insulins, which give us a higher success rate (4,5).

Your approach to combining a long-acting insulin analog (glargine; Lantus) with a rapid-acting analog (lispro; Humalog) is certainly an acceptable one. Insulin lispro has been proven to be effective in dogs (6) and combing Lantus with Humalog  has been recommended as an option by some investigators (1). If you use Lantus and Humalog yourself, this may be a good option for you. The rapid-acting Hunalog insulin will lower the blood sugar rise that occurs after meals, whereas the longer-acting Lantus will act as a background insulin to maintain glucose levels between meals.

You mention that you would like keep your dog's blood sugar well-controlled. That is a good idea, especially if you want to prevent the formation of diabetic cataracts, which are common in dogs with diabetes (7,8). However, to do that, the use of "spot checks" of his blood glucose concentration will not be enough. You are going to have to do periodic blood glucose curves, either done at home or in the hospital (9-11). 

Finally, our current options for insulin injections are either use of an insulin needle and syringe or an insulin pen, such as the Lantus SoloStar pen (12).Use of needle-free, jet injector for insulin delivery has been reported (13,14). However, to my knowledge, such jet injectors are not yet available commercially, and they certainly have not been tested in diabetic dogs.

References:

1. Mori A, Sako T, Lee P, et al. Comparison of time-action profiles of insulin glargine and NPH insulin in normal and diabetic dogs. Vet Res Commun 2008; 32:563-573. 
2. Fracassi F, Boretti FS, Sieber-Ruckstuhl NS, et al. Use of insulin glargine in dogs with diabetes mellitus. Vet Rec 2012;170(2):52.
3. Peterson ME. Treating diabetic dogs with insulin glargine. Blog post. May 3, 2012.
4. Palm CA, Boston RC, Refsal KR, et al. An investigation of the action of neutral protamine Hagedorn human analogue insulin in dogs with naturally occurring diabetes mellitus. J Vet Intern Med 2009;23:50–55. 
5. Monroe WE, Laxton D, Fallin EA, et al. Efficacy and safety of a purified porcine insulin zinc suspension for managing diabetes mellitus in dogs. J Vet Intern Med 2005;19:675-82.
6. Sears KW, Drobatz KJ, Hess RS. Use of lispro insulin for treatment of diabetic ketoacidosis in dogs. J Vet Emerg Crit Care (San Antonio) 2012;22:211-218. 
7. Beam S, Correa MT, Davidson MG. A retrospective-cohort study on the development of cataracts in dogs with diabetes mellitus: 200 cases. Vet Ophthalmol 1999;2:169-172. 
8. Wilkie DA, Gemensky-Metzler AJ, Colitz CM, et al. Canine cataracts, diabetes mellitus and spontaneous lens capsule rupture: a retrospective study of 18 dogs. Vet Ophthalmol 2006;9:328-334. 
9. Wiedmeyer CE, DeClue AE. Glucose monitoring in diabetic dogs and cats: adapting new technology for home and hospital care. Clin Lab Med 2011;31:41-50. 
10. Cook AK. Monitoring methods for dogs and cats with diabetes mellitus. J Diabetes Sci Technol 2012;6:491-495.
11. Davison LJ. Canine diabetes mellitus In: Mooney CT, Peterson ME, eds. BSAVA Manual of Canine and Feline Endocrinology. Fourth ed. Quedgeley, Gloucester: British Small Animal Veterinary Association, 2012;116-132.
12. Association AD. Insulin administration. Diabetes Care 2001;24:1984-1987. 
13. Engwerda EE, Abbink EJ, Tack CJ, et al. Improved pharmacokinetic and pharmacodynamic profile of rapid-acting insulin using needle-free jet injection technology. Diabetes Care 2011;34:1804-1808. 
14. Engwerda EE, Tack CJ, de Galan BE. Needle-free jet injection of rapid-acting insulin improves early postprandial glucose control in patients with diabetes. Diabetes Care 2013;36:3436-3441. 

What's the Best Diet to Fed Dogs with Diabetes?

I'm writing about my dog Minnie, a 7-year old female spayed miniature pinscher (Min Pin). In November of 2012, she was diagnosed with diabetes and started on insulin (Humulin N; NPH insulin). She was very overweight when I adopted her (body weight of 26 pounds) and looked more like a football with legs. After being diagnosed as diabetic, my vet changed her diet to Hills Science Diet w/d. It really helped her lose weight, and now she looks like a Min Pin should look (current weight, 14 pounds).

Despite her body condition normalizing, I am now very concerned about her current health. Her blood sugar levels generally range from 100-120 mg/dl on 7 units of NPH twice daily, but her thirst and urinations remain high. In addition to the polyuria, she now is showing signs of hair loss, muscle weakness, and thinning of the skin. Also, when I feed her, you would think it was her last meal. My thought was that it was from her diet but my vet insists that w/d has everything Minnie needs. 

The vet was concerned that she may have Cushing’s syndrome. We did a screening test for Cushing's syndrome (i.e. a low-dose dexamethasone suppression test), which came back today negative for Cushing’s disease. A test for thyroid function was also normal. I once again asked about the food, which my vet still believes isn’t the cause of her hunger and hair loss.

My question is – Could there be something in W/D that Minnie is allergic to that could be causing some of the same symptoms? Or could it be that she isn’t getting the appropriate nutrition? I’m also wondering what would be another good dog food for diabetic dogs that she might respond to better?

Anyway – thank you for taking the time to read this and I hope you could offer some good advice. 

My Response: 

It's very difficult to attribute all of your dog's clinical signs to the feeding of the Hill's w/d diet. That said, I would change Minnie's diet as the first step in her management.

What's the best diet for canine diabetes?
There is not one type of diet that is recommended for all dogs with diabetes. Diabetic dogs can do well when fed a number of diets as long as they are nutritionally complete and balanced, do not contain simple sugars, are fed at consistent times in consistent amounts, and are palatable to ensure a predictable and consistent appetite. As we all know, it's difficult enough to regulate a diabetic when they are eating consistently well— if they refuse to eat their diet, adequate glucose regulation can become next to impossible.

With any diabetic dog, the most important dietary factor in the diabetic is consistency, so that you can match your insulin dose to the degree of postprandial (after feeding) hyperglycemia. The key to feeding diabetic dogs is to feed the same amount of the same diet at the same time every day!

Feeding diabetic dogs to optimize body weight
In diabetic dogs that are overweight or obese, I always recommend feeding a reduced calorie diet designed to help the dog lose weight. The high fiber diets (such as Hills w/d) are good for this purpose (1-4). So feeding Minnie the w/d when she was grossly obese was a very good idea.

In underweight dogs with diabetes, however, the goal of dietary therapy is the complete opposite. In these thin dogs, our priority is to normalize body weight and restore and preserve muscle mass. These dogs may never regain the weight needed if a food with moderate to high amounts of fiber is fed — they may even continue to progressively lose even more weight. Therefore, these thin to emaciated dogs should be fed a high-quality, higher energy diet that can contain a slightly increased fat content to ensure that they regain their lost body weight (3-5).

Recent studies fail to show a clear-cut clinical benefit of feeding a high-fiber diet over a typical adult maintenance diet with moderate-fiber content to diabetic dogs. In one study, no significant differences in insulin requirements or glycemic control were found in dogs fed a high-fiber, moderate-carbohydrate, moderate-fat diet versus an adult maintenance diet with moderate fiber, lower carbohydrate, and higher fat (5). As expected, weight loss occurred when the dogs were fed the high-fiber diet, whereas body weights were maintained with the moderate-fiber diet. 

Not all diabetic dogs should be automatically fed a high-fiber diet, such as Hills w/d. In your dog, a change in diet to one higher in calories would now be indicated, at least in my opinion.

Cushing's syndrome and diabetes in dogs
I do agree with your veterinarian that the signs of increased hunger, continued polyuria and polyuria (despite good control of the blood glucose values), hair loss, and thin skin all point to hyperadrenocorticism (Cushing's syndrome) (8).  This is a common problem is middle-aged to older dogs, resulting from an excess production of cortisol from the adrenal glands. Secondary diabetes will develop in about 10% of dogs with Cushing's syndrome, and the diabetes is frequently difficult to control (8-10).

The fact that a single test for Cushing's has been negative cannot completely rule out Cushing's syndrome (8,11).  However, the fact that Minnie is showing signs of weight loss cannot be explained by Cushing's, a condition in which weight gain is more common (8-10).

In any case, additional testing of adrenal function should be considered, especially if a diet change hasn't caused a marked improvement within a month or two.

The Bottom Line 

Dogs should never be fed a high-fiber diet just because they have diabetes. Such high-fiber diets are contraindicated in thin or emaciated dogs with diabetes, as well as normal weight dogs that are undergoing unwanted weight loss (5).

Many diabetic dogs do better on maintenance diets containing lower amounts of fiber and carbohydrate and higher amounts of protein. A consistent diet —that is, the type, amount, and time of feeding —is generally much more important in diabetic regulation than any particular fiber content or specific type of diet. Other than that, we want to feed any diabetic dog a diet that will maintain normal body weight.

References: 

1. Nelson R, Duesberg C, Ford S, et al. Effect of dietary insoluble fiber on control of glycemia in dogs with naturally acquired diabetes mellitus. J Am Vet Med Assoc 1998;212:380–386.  
2. Graham PA, Maskell E, Rawlings L. Influence of a high fibre diet on glycaemic control and quality of life in dogs with diabetes mellitus. J Small Anim Pract 2002;43:67–73. 
3. Rucinsky R, Cook A, Haley S, et al. American Animal Hospital Association. AAHA diabetes management guidelines. J Am Anim Hosp Assoc 2010; 46:215-224. 
4. Zicker SC, Nelson RW, Kirk CA, et al. Endocrine Disorders. In: Hand MS, Thatcher CD, Remillard RL, Roudebush R, Novotny, BJ (eds), Small Animal Clinical Nutrition. Mark Morris Institute. 2010; 559-584. 
5. Fleeman LM, Rand JS, Markwell PJ. Lack of advantage of high-fibre, moderate-carbohydrate diets in dogs with stabilised diabetes. J Small Anim Pract 2009;50:604-614. 
6. Rand JS, Farrow HA, Fleeman LM, et al. Diet in the prevention of diabetes and obesity in companion animals. Asia Pac J Clin Nutr 2003;12 Suppl:S6.1 
7. Elliott KF, Rand JS, Fleeman LM, et al. A diet lower in digestible carbohydrate results in lower postprandial glucose concentrations compared with a traditional canine diabetes diet and an adult maintenance diet in healthy dogs. Res Vet Sci 2011;96; 288-95.
8. Melián CM, Pérez-Alenza D, Peterson ME. Hyperadrenocorticism in dogs In: Ettinger SJ, Feldman EC, eds. Textbook of Veterinary Internal Medicine: Diseases of the Dog and Cat. Seventh ed. Philadelphia: Saunders Elsevier, 2010;1816-1840.
9. Peterson ME, Nesbitt GH, Schaer M. Diagnosis and management of concurrent diabetes mellitus and hyperadrenocorticism in thirty dogs. J Am Vet Med Assoc 1981;178:66-69. 
10. Eigenmann JE, Peterson ME. Diabetes mellitus associated with other endocrine disorders. Vet Clin North Am Small Anim Pract 1984;14:837-858. 
11. Peterson ME. Diagnosis of hyperadrenocorticism in dogs. Clin Tech Small Anim Pract 2007;22:2-11. 

Updated Vetsulin Insulin Approved For Release in USA

Merck Animal Health announced last week that Vetsulin (porcine insulin zinc suspension) will again be available for distribution in the USA (1). This is welcome news, especially for dogs with diabetes mellitus that are not be well regulated with other available insulin preparations, such as human recombinant NPH. Most authorities consider Vetsulin, known as Caninsulin outside the USA (2), to be the initial insulin of choice for treatment of dogs with diabetes mellitus (3-6). It can also be used to successfully cats with diabetes (7,8), but we have many other good options for treatment of feline diabetes.

As you may know, Vetsulin has had its share of problems of the last few years, which lead to the FDA having it withdrawn from the US market. All of these manufacturing issues have been resolved and the FDA has re-approved the drug for release.

How is the "new" Vetsulin different than the original insulin product?

According to the company, the updated Vetsulin product has the same characteristics as the original insulin preparation, and the action in diabetic patients is expected to be the same as before. There have been no changes in the safety profile of Vetsulin for use in either dogs or cats.

The only difference in the Vetsulin itself is a slight change in the listed proportion of the short-acting amorphous fraction and long-acting crystalline fraction. The short-acting amorphous fraction is now listed as 35% (it was 30%), whereas the long-acting crystalline fraction is now listed as 65% (it was 70%).  See my discussion below, where I discuss why this listed proportion in the short-and long-acting insulin fractions has been changed.

Vetsulin will now be available only in 10-ml vials. The 2-5 ml vial formulation of Vetsulin has been discontinued.

Two important differences in the updated in Vetsulin Package Insert: (9)

1. Prior to use, vials of Vetsulin should be shaken thoroughly (manually) until a homogeneous, uniformly, milky suspension is obtained. Foam on the surface of the suspension formed during shaking should be allowed to disperse before the product is used.
2. Vetsulin contents should be used within 42 days after the vial is first punctured.  

For the first new vials of Vetsulin that are released, the initial product dating will be only 12 months from the manufactured date. The company expects that Vetsulin will eventually have a 24-month shelf-life.

Additional information can be found on the Veterinary Home Page under Product Update section (10). Also, see the package insert for full information regarding contraindications, warnings, and precautions (9).

Bottom line:

It's great to have Vetsulin, an FDA-approved insulin for use in both dogs and cats, back on the market. The company has done a great deal of work showing that Vetsulin is stable and effective, and they have made a few minor but good improvements in this insulin preparation.

Vigorous manual shaking of the Vetsulin? How will that impact accurate dosing?
We have all been taught that vigorous shaking will interfere with accurate dosing because of air bubbles that form when the insulin bottle is shaken (5,11). When the dose is drawn up, the insulin suspension may come out into the syringe together with lots of air bubbles.  In addition, we tend to worry that too vigorous shaking may damage the insulin protein structure itself. For these reasons, we generally instruct owners to gently roll the insulin vial than that vigorously shake it!

According to the company, the instructions are now are to give the Vetsulin bottle a a vigorous shake on initial use; then let it settle for a few minutes to let the bubbles rise before drawing up the dose. Upon subsequent insulin dosing, the bottle should only need a quick shake (less vigorous) to resuspend the insulin prior to drawing up the insulin dose.

Why this difference in vigorous shaking vs. rolling? I don't know, but I suspect it has sometime to do with the way the study was designed and input from the FDA. In any case, Merck Animal Health actually has done the studies to prove that this vigorous manual shaking does not interfere with the measured insulin concentration in the product (10).

Why was the proportion in the short-and long-acting insulin fractions changed? 
According to the company, the proportions of the short-acting amorphous fraction and long-acting crystalline fraction have not actually changed, as compared to the original Vetsulin product. Instead, the new stated ratio (65% long-acting and 35% short-acting insulin) represents a more accurate reflection of the actual composition of both the original and updated Vetsulin product (10).

Nevertheless, on a clinical basis, such a small change in the short- vs. the long-acting insulin fractions would not be expected to make any difference in the animal's glycemic control, even if the composition of the product did change slightly.

Must Vetsulin really be discarded after only 42 days? 
The Vetsulin product insert (9) clearly states that the product should be used within "42 days of first vial puncture."

Has the has efficacy really been determined to decrease after 42 days?  The answer to that is no — it's almost certain that the potency of this preparation will extend many days (or even weeks) longer than this 42 days.  However, because Merck Animal Health only did the FDA studies for a period of 42 days, that's what they have been required to put on the package insert. But remember, in addition to efficacy, we must also worry about bacterial contamination secondary to repeated puncture of the insulin vial (11).

Why such a short expiration date? 
Again, for the first new vials of Vetsulin that are released, the initial product dating will be only 12 months from the manufactured date. This is not because the updated Vetsulin is unstable, but the FDA requires ongoing studies of the insulin's duration. The company expects that Vetsulin will eventually have a 24-month shelf-life (10).

Since we do not have to worry about Vetsulin disappearing again, at least anytime soon, I wouldn't recommend purchasing too many insulin vials now, since the initial "expiration" date will be only a few months.

References:

1. Vetsulin website. www.vetsulin.com
2. Caninsulin website. www.caninsulin.com
3. Monroe WE, Laxton D, Fallin EA, et al. Efficacy and safety of a purified porcine insulin zinc suspension for managing diabetes mellitus in dogs. J Vet Intern Med 2005;19:675-682. 
4. Fleeman LM, Rand JS, Morton JM. Pharmacokinetics and pharmacodynamics of porcine insulin zinc suspension in eight diabetic dogs. Vet Rec 2009;164:232-237. 
5. Nelson RW. Canine diabetes mellitus In: Ettinger SJ,Feldman EC, eds. Textbook of Veterinary Internal Medicine: Diseases of the Dog and Cat. Seventh Edition ed. St. Louis: Saunders Elsevier, 2010;1449-1474.
6. Davison LJ. Canine diabetes mellitus In: Mooney CT, Peterson ME, eds. BSAVA Manual of Canine and Feline Endocrinology. Fourth ed. Quedgeley, Gloucester: British Small Animal Veterinary Association, 2012;116-132.
7. Michiels L, Reusch CE, Boari A, et al. Treatment of 46 cats with porcine lente insulin—a prospective, multicentre study. J Feline Med Surg 2008;10:439-451. 
8. Martin GJ, Rand JS. Control of diabetes mellitus in cats with porcine insulin zinc suspension. Vet Rec 2007;161:88-94. 
9. Vetsulin Package Insert. www.vetsulin.com/PDF/Vetsulin-Package-Insert.pdf
10. Vetsulin website: Veterinary Product Updates. www.vetsulin.com/vet/Product_Update.aspx
11. American Diabetes Association. Insulin administration. Diabetes Care 2001;24:1984-1987. 

Changing Brand of NPH Insulin May Disrupt Diabetic Control

Treating dogs and cats with diabetes can be challenging but this article— Changing insulin brands may disrupt diabetics— published on the Veterinary Information News Service points out another issue to complicate treatment of this common disease (1).

In dogs, we commonly use human NPH insulin, which is an intermediate-acting insulin preparation (2,3). This insulin does not work well in cats, and I do not recommend using it for initial treatment of feline diabetes.

Two brands of NPH insulin are on the market: Humulin N, made by Eli Lilly and Co. and Novolin N, made by Novo Nordisk Inc. (2-4). Although both contain NPH insulin, Humulin and Novolin are made using different ingredients and manufacturing techniques, so they are not exactly the same. A number of owners and veterinarians around the country have reported in recent months cases of dogs whose insulin brands were switched developing out-of-control blood glucose levels, a potentially life-threatening condition that can be expensive to remedy.

Most diabetic cats are treated with either insulin glargine (Lantus) or PZI insulin (ProZinc), both long-acting insulin preparations (5-7). Only one brand of these insulin preparations exists, so this will not ever be a problem.

References:

1. Lau E. Changing insulin brands may disrupt diabetes. The VIN News Service, February 5, 2013.
2. Peterson ME. Blog Post, Insights to Veterinary Endocrinology. Insulin Choice for the Diabetic Dog and Cat: Which is Best? h 
3. Palm CA, Boston RC, Refsal KR, et al. An investigation of the action of Neutral Protamine Hagedorn human analogue insulin in dogs with naturally occurring diabetes mellitus. Journal of Veterinary Internal Medicine 2009;23:50-55. 
4. American Diabetes Association. Insulin administration. Diabetes Care. 2004;27 (Suppl 1):S106-9. 
5. Gilor C, Graves TK. Synthetic insulin analogs and their use in dogs and cats. Veterinary Clinics of North America: Small Animal Practice 2010; 40:297-307. 
6. Nelson RW, Henley K, Cole C, et al. Field safety and efficacy of protamine zinc recombinant human insulin for treatment of diabetes mellitus in cats. Journal of Veterinary Internal Medicine 2009;23:787–793. 
7. Norsworthy GD, Lynn R, Cole C. Preliminary study of protamine zinc recombinant insulin for treatment of diabetes mellitus in cats. Veterinary Therapeutics 2009;10:24–28. 

State of Pet Health Report Shows Chronic Diseases, Overweight, and Obesity Up Dramatically in Past 5 Years

Banfield Pet Hospital Releases State of Pet Health 2012 Report

The Banfield Pet Hospital released its State of Pet Health 2012 Report, revealing that certain chronic diseases in dogs and cats have risen drastically since 2007. The report, compiled by Banfield's internal research team, captured and analyzed medical data from the 2 million dogs and nearly 430,000 cats cared for in Banfield's 800 hospitals in 2011. The largest report of its kind, the State of Pet Health 2012 Report breaks down the data by these chronic diseases: overweight and obesity, diabetes, thyroid disease, arthritis, kidney disease, and heart disease.

This report shows that the prevalence of many chronic diseases of dogs and cats has increased dramatically, just over the last 5 years.

• Overweight and obesity up 37% in dogs and 90% in cats
• Arthritis by increased 38% in dogs and 67% in cats
• Nearly half of arthritic dogs and more than 1 in 3 arthritic cats are also overweight
• Almost half of diabetic dogs and diabetic cats  are overweight
• About 60% of dogs with hypothyroidism are also overweight
• Feline chronic kidney disease, a common cause of death in cats, increased by 15% 

The rise in pet overweight and obesity mimics the increase in humans. According to the Centers for Disease Control and Prevention (CDC), overweight and obesity in humans is also on the rise. The CDC reports that overweight/obesity in humans has increased to 1 in 3 of U.S. adults.

To view and download the full State of Pet Health 2012 Report, visit www.stateofpethealth.com.

American Diabetes Alert Day: March 27, 2012

24th ANNUAL AMERICAN DIABETES ALERT DAY   

AMERICAN DIABETES ASSOCIATION

What is American Diabetes Association Alert Day?
Today is the American Diabetes Association Alert Day, which is held every year on the fourth Tuesday in March (1). The purpose of this Diabetes Alert Day is to call special attention to diabetes and to encourage everyone to find out if they are at risk.

While diabetes is often a hereditary condition, it is still possible to develop diabetes even if you have no known history of it in your family. In addition, type 2 diabetes is often preventable through regular medical checkups and a healthy lifestyle.

Why is Alert Day important? 
Diabetes is a serious disease that strikes nearly 26 million children and adults in the United States, and a  quarter of them—7 million—do not even know they have it. An additional 79 million, or one in three American adults, have prediabetes, which puts them at high risk for developing type 2 diabetes.

Unfortunately, diagnosis often comes 7 to 10 years after the onset of the disease, after disabling and even deadly complications have had time to develop. Therefore, early diagnosis is critical to successful treatment and delaying or preventing some of its complications.

The Diabetes Risk Assessment Quiz
To find out if you are at risk for diabetes, you can do so by taking the Diabetes Risk Assessment and then read more below about what you can do to prevent or manage type 2 diabetes. Click here to take the diabetes risk test.

This test asks users to answer simple questions about weight, age, family history, and other potential risk factors for prediabetes or type 2 diabetes. Preventative tips are provided for everyone who takes the test, including encouraging those at high risk to talk with their health care provider.

I took the test and it was quick and painless. The results of my test? I'm at medium risk for type 2 diabetes. Although I'm not overweight, I'm almost 60 years old (remember that type 2 diabetes increases with age), and my mother has had type 2 diabetes (she's lost weight so she's not on insulin now and is doing well).

Why is the Diabetes Alert Day important for diabetic cats and dogs? 
Diabetes is a serious disease that strikes more than 1 in every 200 cats. Like the situation in human diabetic patients, Type 2 diabetes is the most common form of diabetes in cats. Although dogs commonly develop diabetes, the form of diabetes they develop is not type 2 and more closely resembles type 1 diabetes (2).

Many of the risk factors for development of Type 2 diabetes in domestic cats are similar to man and include advancing age, obesity, and physical inactivity (3-7). Cats are obligate carnivores and have no need for dietary carbohydrates (2).  Feeding cats diets high in carbohydrate can increase blood glucose and insulin levels and may predispose cats to obesity and diabetes. Feeding low-carbohydrate, high-protein diets may help prevent diabetes for cats at risk.

The incidence of feline diabetes has progressively increased over the past few decades (6,7). In one study looking at records of cats with diabetes mellitus from 1970 through 1999 (7), prevalence increased significantly from only 8 cases per 10,000 in 1970 to 124 per 10,000 in 1999!

The exact cause of this increase in feline diabetes in not known but may relate to higher obesity rates and more cats being fed high-carbohydrate diets (6,7). Male cats appear to be at greater risk, representing approximately 60-70% of all diabetics (2-7). Increasing age also correlates with increasing risk of diabetes, with two-thirds of cats diagnosed when older than 10 years (3,5-7).

Feline diabetes is definitely treatable and need not shorten the cat's life span or life quality. Management of the diabetic cat should be a multipronged approach incorporating insulin, dietary therapy (to reduce carbohydrate load and induce weight loss if the cat is overweight), and management of any infection or concurrent condition.  With early intervention and good glycemic control, diabetic remission was achieved in over 75% of cats (2).

References:

1. American Diabetes Association Website: American Diabetes Alert Day, 2012.    
2. Rand JS, Fleeman LM, Farrow HA, et al. Canine and feline diabetes mellitus: nature or nurture? Journal of Nutrition 2004;134(8 Suppl):2072S-2080S. 
3. Baral RM, Rand JS, Catt MJ, et al. Prevalence of feline diabetes mellitus in a feline private practice. Journal of Veterinary Internal Medicine 2003;17:433.
4. Lederer R, Rand JS, Jonsson NN, et al. Frequency of feline diabetes mellitus and breed predisposition in domestic cats in Australia. Veterinary Journal 2009;179:254-258. 
5.  Panciera D, Thomas C, Eicker S, et al: Epizootiologic patterns of diabetes mellitus in cats: 333 cases (1980-1986). Journal of the American Veterinary Medical Association 1990;197:1504-1508. 
6. McCann TM, Simpson KE, Shaw DJ, et al. Feline diabetes mellitus in the UK: the prevalence within an insured cat population and a questionnaire-based putative risk factor analysis. Journal of Feline Medicine and Surgery 2007;9:289-99. 
7. Prahl A, Guptill L, Glickman NW, et al. Time trends and risk factors for diabetes mellitus in cats presented to veterinary teaching hospitals. Journal of Feline Medicine and Surgery  2007;9:351-358.