Pathogenesis of feline diabetes mellitus

Incretin therapy in feline diabetes mellitus - A review of the current state of research

Incretin hormones potentiate the glucose-induced insulin secretion following enteral nutrient intake. The best characterised incretin hormones are glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) which are produced in and secreted from the gut in response to nutrient ingestion. The property of incretins to enhance endogenous insulin secretion only at elevated blood glucose levels makes them interesting therapeutics for type 2 diabetes mellitus with a better safety profile than exogenous insulin. While incretin therapeutics (especially GLP-1 agonists, and more recently also GLP-1 / GIP dual agonists and other drugs that influence the incretin metabolism (e.g., dipeptidyl peptidase-4 (DPP-4) inhibitors)) are already widely used treatment options for human type 2 diabetes, these drugs are not yet approved for the therapy of feline diabetes mellitus. This review provides an introduction to incretins and feline diabetes mellitus in general and summarises the current study situation on incretins as therapeutics for feline diabetes mellitus to assess their possible future potential in feline medicine. Studies to date on the use of GLP-1 receptor agonists (GLP-1RA) in healthy cats largely confirm their insulinotropic effect known from other species. In diabetic cats, GLP-1RAs appear to significantly reduce glycaemic variability (GV, an indicator for the quality of glycaemic control), which is important for the management of the disease and prevention of long-term complications. However, for widespread use in feline diabetes mellitus, further studies are required that include larger numbers of diabetic cats, and that consider and test a possible need for dose adjustments to overweight and diabetic cats. Also evaluation of the outcome of GLP-1RA monotherapy will be neceessary.

The processing intermediate of human amylin, pro-amylin(1-48), has in vivo and in vitro bioactivity

Amylin is released by pancreatic beta-cells in response to a meal and its major soluble mature form (37 amino acid-peptide) produces its biological effects by activating amylin receptors. Amylin is derived from larger propeptides that are processed within the synthesizing beta-cell. There are suggestions that a partially processed form, pro-amylin(1-48) is also secreted. We tested the hypothesis that pro-amylin(1-48) has biological activity and that human pro-amylin(1-48) may also form toxic pre-amyloid species. Amyloid formation, the ability to cross-seed and in vitro toxicity were similar between human pro-amylin(1-48) and amylin. Human pro-amylin(1-48) was active at amylin-responsive receptors, though its potency was reduced at rat, but not human amylin receptors. Pro-amylin(1-48) was able to promote anorexia by activating neurons of the area postrema, amylin's primary site of action, indicating that amylin can tolerate significant additions at the N-terminus without losing bioactivity. Our studies help to shed light on the possible roles of pro-amylin(1-48) which may be relevant for the development of future amylin-based drugs.

Mammalian models of diabetes mellitus, with a focus on type 2 diabetes mellitus

Although no single animal model replicates all aspects of diabetes mellitus in humans, animal models are essential for the study of energy balance and metabolism control as well as to investigate the reasons for their imbalance that could eventually lead to overt metabolic diseases such as type 2 diabetes mellitus. The most frequently used animal models in diabetes mellitus research are small rodents that harbour spontaneous genetic mutations or that can be manipulated genetically or by other means to influence their nutrient metabolism and nutrient handling. Non-rodent species, including pigs, cats and dogs, are also useful models in diabetes mellitus research. This Review will outline the advantages and disadvantages of selected animal models of diabetes mellitus to build a basis for their most appropriate use in biomedical research.

The Decline and Fall of Materia Medica and the Rise of Pharmacology and Therapeutics in Veterinary Medicine

Materia Medica is a Latin term, relating to the history of pharmacy. It describes the sources (vegetable, animal and mineral), nature, preparation, and properties of substances or mixtures of substances, which were used as remedies for the treatment of diseases. Bourgelat authored the first veterinary Materia Medica book. This review describes the evolution and ultimate downfall of Materia Medica concepts and practices. Its survival for more than two millennia reflected the impact of religion and dogmas on therapy. The consignment of Materia Medica to history was signified by publication of the first modern book of veterinary pharmacology and therapeutics by Meyer Jones in 1953. Previously, the dominance of Materia Medica was linked to an hippiatry culture, which was shared with farriers and quacks. The Pasteurian and pharmacological revolutions of the second half of the nineteenth century led to its gradual abandonment. This review explains why the existence of authentically active substances, such as opioid analgesics, cardiotonics and general anesthetics either were not used for those actions or were badly prescribed, in part because of historical precedence and in part from lack of pathophysiological knowledge to justify rational use. The modern concept of dosage, in particular inter-species differences, was not understood. There were also major dogmas, supporting false indications, such as failure to recognize pain as a symptom to be treated, whereas inflammation was only a disease symptom involving excess of activity of the blood system, which had to be vigorously addressed by bleeding and purging. This review covers a well-defined period, ranging from Bourgelat, who wrote the first book of Materia Medica for veterinary studies to the first edition of Meyer Jones textbook in 1953, which marked the end of Materia Medica and the beginning of pharmacology in veterinary medicine.

Systemic and Central Amylin, Amylin Receptor Signaling, and Their Physiological and Pathophysiological Roles in Metabolism

This article in the Neural and Endocrine Section of Comprehensive Physiology discusses the physiology and pathophysiology of the pancreatic hormone amylin. Shortly after its discovery in 1986, amylin has been shown to reduce food intake as a satiation signal to limit meal size. Amylin also affects food reward, sensitizes the brain to the catabolic actions of leptin, and may also play a prominent role in the development of certain brain areas that are involved in metabolic control. Amylin may act at different sites in the brain in addition to the area postrema (AP) in the caudal hindbrain. In particular, the sensitizing effect of amylin on leptin action may depend on a direct interaction in the hypothalamus. The concept of central pathways mediating amylin action became more complex after the discovery that amylin is also synthesized in certain hypothalamic areas but the interaction between central and peripheral amylin signaling remains currently unexplored. Amylin may also play a dominant pathophysiological role that is associated with the aggregation of monomeric amylin into larger, cytotoxic molecular entities. This aggregation in certain species may contribute to the development of type 2 diabetes mellitus but also cardiovascular disease. Amylin receptor pharmacology is complex because several distinct amylin receptor subtypes have been described, because other neuropeptides [e.g., calcitonin gene-related peptide (CGRP)] can also bind to amylin receptors, and because some components of the functional amylin receptor are also used for other G-protein coupled receptor (GPCR) systems. © 2020 American Physiological Society. Compr Physiol 10:811-837, 2020.

The diabetes pandemic and associated infections: suggestions for clinical microbiology

There are 425 million people with diabetes mellitus in the world. By 2045, this figure will grow to over 600 million. Diabetes mellitus is classified among noncommunicable diseases. Evidence points to a key role of microbes in diabetes mellitus, both as infectious agents associated with the diabetic status and as possible causative factors of diabetes mellitus. This review takes into account the different forms of diabetes mellitus, the genetic determinants that predispose to type 1 and type 2 diabetes mellitus (especially those with possible immunologic impact), the immune dysfunctions that have been documented in diabetes mellitus. Common infections occurring more frequently in diabetic vs. nondiabetic individuals are reviewed. Infectious agents that are suspected of playing an etiologic/triggering role in diabetes mellitus are presented, with emphasis on enteroviruses, the hygiene hypothesis, and the environment. Among biological agents possibly linked to diabetes mellitus, the gut microbiome, hepatitis C virus, and prion-like protein aggregates are discussed. Finally, preventive vaccines recommended in the management of diabetic patients are considered, including the bacillus calmette-Guerin vaccine that is being tested for type 1 diabetes mellitus. Evidence supports the notion that attenuation of immune defenses (both congenital and secondary to metabolic disturbances as well as to microangiopathy and neuropathy) makes diabetic people more prone to certain infections. Attentive microbiologic monitoring of diabetic patients is thus recommendable. As genetic predisposition cannot be changed, research needs to identify the biological agents that may have an etiologic role in diabetes mellitus, and to envisage curative and preventive ways to limit the diabetes pandemic.

Structural Modulation of Human Amylin Protofilaments by Naturally Occurring Mutations

Human islet amyloid polypeptide (hIAPP), also known as amylin, is a 37-amino-acid peptide, co-secreted with insulin, and widely found in fibril form in type-2 diabetes patients. By using all-atom molecular dynamics simulations, we study hIAPP fibril segments (i.e., fibrillar oligomers) formed with sequences of naturally occurring variants from cat, rat, and pig, presenting different aggregation propensities. We characterize the effect of mutations on the structural dynamics of solution-formed hIAPP fibril models built from solid-state NMR data. Results from this study are in agreement with experimental observations regarding their respective relative aggregation propensities. We analyze in detail the specific structural characteristics and infer mechanisms that modulate the conformational stability of amylin fibrils. Results provide a platform for further studies and the design of new drugs that could interfere with amylin aggregation and its cytotoxicity. One particular mutation, N31K, has fibril-destabilizing properties, and could potentially improve the solubility of therapeutic amylin analogs.

Histomorphology of the bottlenose dolphin (Tursiops truncatus) pancreas and association of increasing islet β-cell size with chronic hypercholesterolemia

Bottlenose dolphins (Tursiops truncatus) can develop metabolic states mimicking prediabetes, including hyperinsulinemia, hyperlipidemia, elevated glucose, and fatty liver disease. Little is known, however, about dolphin pancreatic histomorphology. Distribution and area of islets, α, β, and δ cells were evaluated in pancreatic tissue from 22 dolphins (mean age 25.7years, range 0-51). Associations of these measurements were evaluated by sex, age, percent high glucose and lipids during the last year of life, and presence or absence of fatty liver disease and islet cell vacuolation. The most common pancreatic lesions identified were exocrine pancreas fibrosis (63.6%) and mild islet cell vacuolation (47.4%); there was no evidence of insulitis or amyloid deposition, changes commonly associated with type 2 diabetes. Dolphin islet architecture appears to be most similar to the pig, where α and β cells are localized to the central or periphery of the islet, respectively, or are well dispersed throughout the islet. Unlike pigs, large islets (greater than 10,000μm(2)) were common in dolphins, similar to that found in humans. A positive linear association was identified between dolphin age and islet area average, supporting a compensatory response similar to other species. The strongest finding in this study was a positive linear association between islet size, specifically β-cells, and percent blood samples with high cholesterol (greater than 280mg/dl, R(2)=0.57). This study is the most comprehensive assessment of the dolphin pancreas to date and may help direct future studies, including associations between chronic hypercholesterolemia and β-cell size.

The effect of experimentally induced chronic hyperglycaemia on serum and pancreatic insulin, pancreatic islet IGF-I and plasma and urinary ketones in the domestic cat (Felis felis)

Like in humans, diabetes mellitus is on the rise in cats. Feline diabetes is a suitable model for human type-2 diabetes. We investigated magnitude and timing of insulin suppression with induced hyperglycaemia and its relationship to plasma and urinary ketones and to pancreatic islet insulin. IGF-I is under discussion as a protective mechanism but little is known about its role in diabetes in general and its distinct localisation in feline pancreatic islets in particular. Thirteen healthy, adult cats were allocated to 2 groups and infused with glucose to maintain their blood glucose at a high or moderate concentration for 42 days resulting in insulin secretion suppression. After initial increase, insulin levels declined to baseline but were still detectable in the blood at a very low level after 6 weeks of glucose infusion and then increased after a 3 week recovery period. While IGF-I in healthy cats was primarily located in glucagon cells, in hyperglycaemia-challenge IGF-I was pronounced in the β-cells 3 weeks after ceasation of infusion. Six/8 cats developing glucose toxicity became ketonuric after 3-4 weeks. Gross lipaemia occurred approx 1 week prior to ketonuria. Ketonuric cats required 1-2 weeks of insulin therapy after-infusion until β-cell recovery. In conclusion, ketosis and hyperlipidaemia are likely to occur in diabetic cats with glucose at 30 mmol/L, especially after ≥2 weeks. Three weeks after ceasation of infusions, clinical and morphological recovery occurred. We propose a local protective effect of IGF-I to support survival and insulin production in the hyperglycaemic state and recovery period.

Impact of commercially available diabetic prescription diets on short-term postprandial serum glucose, insulin, triglyceride and free fatty acid concentrations of obese cats

Diet therapy is an important treatment component available for obese cats. In this study, the impact of four commercially available prescription diet regimens (1 for general use and 3 aimed at treating obesity and diabetes mellitus (DM)) on short-term postprandial serum glucose, insulin, triglyceride and nonesterified fatty acid (NEFA) concentrations was investigated with five obese cats. The diet regimens used were as follows: C/D dry (general use: moderate protein, moderate fat, high carbohydrate and low fiber), M/D dry (DM: high protein, high fat, low carbohydrate and high fiber), W/D dry (DM: high protein, low fat, high carbohydrate and high fiber) and Diabetic dry (DM: high protein, low fat, low carbohydrate and high fiber). A significant reduction (10-13%) in postprandial glucose (area under the curve; AUC) was observed with the M/D and Diabetic diets, which both contained lower concentrations of carbohydrates than the C/D diet. An accompanying significant reduction (30-36%) in postprandial insulin AUC was also observed with the three DM diets, which all had higher amounts of fiber, as compared with the C/D diet. Lastly, a significant increase (32-65%) in postprandial NEFA AUC was observed with the M/D and Diabetic diets as compared with the C/D diet. Therefore, dietary amounts of carbohydrates and fiber, as opposed to protein content or dietary fat, appear to have a very significant impact on postprandial glycemia and subsequent insulin requirement levels in obese cats. In addition, dietary amounts of carbohydrates may also impact lipid metabolism in obese cats.

Diabetes from humans to cats

Diabetes mellitus is a common endocrinopathy in humans and in cats. The general prevalence of diabetes mellitus, and in particular of type 2 diabetes, has risen dramatically in recent years. This increase has often been linked to the rise in the obesity pandemic because obesity and the ensuing metabolic consequences constitute major risk factors for human type 2 and for feline diabetes. Feline diabetes shares many features of human type 2 diabetes in respect to its pathophysiology, underlying risk factors and treatment strategies. This review will briefly summarize major characteristics in the human and the feline disease and where available, point out the current knowledge on similarities and differences.

Extent of linkage disequilibrium in the domestic cat, Felis silvestris catus, and its breeds

Domestic cats have a unique breeding history and can be used as models for human hereditary and infectious diseases. In the current era of genome-wide association studies, insights regarding linkage disequilibrium (LD) are essential for efficient association studies. The objective of this study is to investigate the extent of LD in the domestic cat, Felis silvestris catus, particularly within its breeds. A custom illumina GoldenGate Assay consisting of 1536 single nucleotide polymorphisms (SNPs) equally divided over ten 1 Mb chromosomal regions was developed, and genotyped across 18 globally recognized cat breeds and two distinct random bred populations. The pair-wise LD descriptive measure (r²) was calculated between the SNPs in each region and within each population independently. LD decay was estimated by determining the non-linear least-squares of all pair-wise estimates as a function of distance using established models. The point of 50% decay of r² was used to compare the extent of LD between breeds. The longest extent of LD was observed in the Burmese breed, where the distance at which r² ≈ 0.25 was ∼380 kb, comparable to several horse and dog breeds. The shortest extent of LD was found in the Siberian breed, with an r² ≈ 0.25 at approximately 17 kb, comparable to random bred cats and human populations. A comprehensive haplotype analysis was also conducted. The haplotype structure of each region within each breed mirrored the LD estimates. The LD of cat breeds largely reflects the breeds’ population history and breeding strategies. Understanding LD in diverse populations will contribute to an efficient use of the newly developed SNP array for the cat in the design of genome-wide association studies, as well as to the interpretation of results for the fine mapping of disease and phenotypic traits.

First WNK4-hypokalemia animal model identified by genome-wide association in Burmese cats

Burmese is an old and popular cat breed, however, several health concerns, such as hypokalemia and a craniofacial defect, are prevalent, endangering the general health of the breed. Hypokalemia, a subnormal serum potassium ion concentration ([K⁺]), most often occurs as a secondary problem but can occur as a primary problem, such as hypokalaemic periodic paralysis in humans, and as feline hypokalaemic periodic polymyopathy primarily in Burmese. The most characteristic clinical sign of hypokalemia in Burmese is a skeletal muscle weakness that is frequently episodic in nature, either generalized, or sometimes localized to the cervical and thoracic limb girdle muscles. Burmese hypokalemia is suspected to be a single locus autosomal recessive trait. A genome wide case-control study using the illumina Infinium Feline 63K iSelect DNA array was performed using 35 cases and 25 controls from the Burmese breed that identified a locus on chromosome E1 associated with hypokalemia. Within approximately 1.2 Mb of the highest associated SNP, two candidate genes were identified, KCNH4 and WNK4. Direct sequencing of the genes revealed a nonsense mutation, producing a premature stop codon within WNK4 (c.2899C>T), leading to a truncated protein that lacks the C-terminal coiled-coil domain and the highly conserved Akt1/SGK phosphorylation site. All cases were homozygous for the mutation. Although the exact mechanism causing hypokalemia has not been determined, extrapolation from the homologous human and mouse genes suggests the mechanism may involve a potassium-losing nephropathy. A genetic test to screen for the genetic defect within the active breeding population has been developed, which should lead to eradication of the mutation and improved general health within the breed. Moreover, the identified mutation may help clarify the role of the protein in K⁺ regulation and the cat represents the first animal model for WNK4-associated hypokalemia.

Exendin-4 improves resistance to Listeria monocytogenes infection in diabetic db/db mice

The incidence of diabetes mellitus is increasing among companion animals. This disease has similar characteristics in both humans and animals. Diabetes is frequently identified as an independent risk factor for infections associated with increased mortality. In the present study, homozygous diabetic (db/db) mice were infected with Listeria (L.) monocytogenes and then treated with the anti-diabetic drug exendin-4, a glucagon-like peptide 1 analogue. In aged db/db mice, decreased CD11b(+) macrophage populations with higher lipid content and lower phagocytic activity were observed. Exendin-4 lowered high lipid levels and enhanced phagocytosis in macrophages from db/db mice infected with L. monocytogenes. Exendin-4 also ameliorated obesity and hyperglycemia, and improved ex vivo bacteria clearance by macrophages in the animals. Liver histology examined during L. monocytogenes infection indicated that abscess formation was much milder in exendin-4-treated db/db mice than in the control animals. Moreover, mechanistic studies demonstrated that expression of ATP binding cassette transporter 1, a sterol transporter, was higher in macrophages isolated from the exendin-4-treated db/db mice. Overall, our results suggest that exendin-4 decreases the risk of infection in diabetic animals by modifying the interaction between intracellular lipids and phagocytic macrophages.

Nutritional modulation of insulin resistance in the true carnivorous cat: a review

Cats are strict carnivores that rely on nutrients in animal tissues to meet their specific and unique nutritional requirements. In their natural habitat, cats consume prey high in protein with moderate amounts of fat and minimal carbohydrates in contrast to commercial diets, which are sometimes moderate to high in carbohydrates. This change in diet has been accompanied by a shift from an outdoor environment to an indoor lifestyle and decreased physical activity, because cats no longer need to hunt to obtain food. This transformation of the lifestyle of cats is thought to be responsible for the recent increase in incidence of obesity, insulin resistance, and diabetes mellitus in domestic cats. At first, an overview of the evolutionary physiological adaptations of carbohydrate digestion in the feline digestive tract and of the hepatic carbohydrate and protein metabolism reflecting the true carnivorous nature of cats is given. Secondly, this literature review deals with nutritional modulation of insulin sensitivity, focusing on dietary macronutrients, carbohydrate sources, and dietary fiber for prevention and treatment of insulin resistance.

Subacute endotoxemia induces adipose inflammation and changes in lipid and lipoprotein metabolism in cats

Acute inflammation in humans is associated with transient insulin resistance (IR) and dyslipidemia. Chronic low-grade inflammation is a pathogenic component of IR and adipose tissue dysfunction in obesity-induced type 2 diabetes. Because feline diabetes closely resembles human type 2 diabetes, we studied whether lipopolysaccharide (LPS)-induced subacute inflammation, in the absence of obesity, is the potential primary cause of IR and metabolic disorders. Cats received increasing iv doses (10-1000 ng/kg(-1) · h(-1)) of LPS (n = 5) or saline (n = 5) for 10 d. Body temperature, proinflammatory and metabolic markers, and insulin sensitivity were measured daily. Tissue mRNA and protein expression were quantified on d 10. LPS infusion increased circulating and tissue markers of inflammation. Based on the homeostasis model assessment, endotoxemia induced transient IR and β-cell dysfunction. At the whole-body level, IR reverted after the 10-d treatment; however, tissue-specific indications of IR were observed, such as down-regulation of adipose glucose transporter 4, hepatic peroxisome proliferative activated receptor-γ1 and -2, and muscle insulin receptor substrate-1. In adipose tissue, increased hormone-sensitive lipase activity led to reduced adipocyte size, concomitant with increased plasma and hepatic triglyceride content and decreased total and high-density lipoprotein cholesterol levels. Prolonged LPS-induced inflammation caused acute IR, followed by long-lasting tissue-specific dysfunctions of lipid-, glucose-, and insulin metabolism-related targets; this ultimately resulted in dyslipidemia but not whole-body IR. Endotoxemia in cats may provide a promising model to study the cross talk between metabolic and inflammatory responses in the development of adipose tissue dysfunction and IR.

Effect of hyperlipidemia on 11β-hydroxysteroid-dehydrogenase, glucocorticoid receptor, and leptin expression in insulin-sensitive tissues of cats

Glucocorticoid (GC) action depends on GC plasma concentration, cellular GC receptor expression, and the pre-receptor hormone metabolism catalyzed by 11β-hydroxysteroid dehydrogenase (11β-HSD). 11β-Hydroxysteroid dehydrogenase exists in 2 isoforms; 11β-HSD1 converts inactive cortisone to cortisol, and 11β-HSD2 converts cortisol to cortisone. Increasing evidence in humans and experimental animals suggests that altered tissue cortisol metabolism may predispose to diabetes mellitus (DM). Once DM is established, hyperglycemia and hyperlipidemia may further maintain the abnormal metabolism of cortisol. To gain further insight in this regard, healthy cats were infused for 10 d with lipids (n = 6) or saline (n = 5). At the end of the infusion period, tissue samples from adipose tissue (visceral, subcutaneous), liver, and muscle were collected to determine mRNA expression of 11β-HSD1, 11β-HSD2, and GC receptor by real-time reverse-transcriptase polymerase chain reaction; blood samples were collected to determine plasma cortisol and leptin concentrations. Lipid infusion resulted in greater 11β-HSD1 expression and lower GC receptor expression in visceral and subcutaneous adipose tissue, and lower 11β-HSD2 expression in visceral adipose tissue and liver. Plasma cortisol did not differ. Leptin and body weight increased in lipid-infused cats. In spite of comparable circulating cortisol levels, up-regulation of 11β-HSD1 and down-regulation of 11β-HSD2 expression may result in increased tissue cortisol concentrations in fat depots of hyperlipidemic cats. Down-regulation of GC receptor may represent a self-protective mechanism against increased tissue cortisol levels. In conclusion, hyperlipidemia has a profound effect on 11β-HSD expression and supports the connection between high lipid concentrations and tissue cortisol metabolism.

Endocrinology of obesity

Obesity is a growing health concern in humans and companion animals. Obesity is highly associated with various endocrine abnormalities that are characterized by hormonal imbalance and/or resistance. Weight reduction generally normalizes these endocrine alterations, implicating obesity as a direct cause. Most data in this area have been derived from obese humans, with little data pertaining to hormonal changes in obese dogs and cats. Because the literature contains inconsistent results and because considerable hormone-hormone interactions occur, we have a limited understanding of the obesity-induced changes on the endocrine system in dogs and cats.

Effect of glimepiride and nateglinide on serum insulin and glucose concentration in healthy cats

Glimepiride and nateglinide are two common oral hypoglycemic agents currently being used with humans suffering from Type 2 diabetes mellitus. Neither drug has been tested with cats thus far and it is currently unknown whether either of these drugs exert any effect in cats or not. The objective of this study was to determine the effect of glimepiride and nateglinide on glucose and insulin responses in healthy control cats, in order to determine their potential use in diabetic cats. The intravenous glucose tolerance tests was carried out since it is an excellent test for evaluating pancreatic beta-cell function for insulin secretion. Alterations in the insulin secretion pattern can be perceived as the earliest sign of beta-cell dysfunction in many species, including cats. Nateglinide demonstrated a quick action/short duration type effect with serum glucose nadiring and insulin response peaking at 60 and 20 minutes, respectively. Alternatively, glimepiride is medium-to-long acting with serum glucose nadiring and insulin response peaking at 180 minutes and 60 minutes, respectively. Nateglinide's potency was evident allowing it to induce a 1.5-2 higher preliminary insulin peak (3.7 +/- 1.1 pg/ml) than glimepiride's (2.5 +/- 0.1 pg/ml), albeit only for a short period of time. Because glimepiride and nateglinide have a shared mode of action, no significant differences in overall glucose AUC(0-360 min) (24,435 +/- 2,940 versus 24,782 +/- 2,354 mg min/dl) and insulin AUC(0-360 min) (410 +/- 192 versus 460 +/- 159) in healthy control cats were observed. These findings may provide useful information when choosing a hypoglycemic drug suited for the treatment of diabetic cats depending on the degree of diabetes mellitus the cat is suffering from.

Comparison of three commercially available prescription diet regimens on short-term post-prandial serum glucose and insulin concentrations in healthy cats

Dietary therapy is an important treatment component for diabetes mellitus (DM). In this study, the impact of three different commercially available diet regiments (1 general use and 2 aimed for treating obesity and DM) on short-term post-prandial serum glucose and insulin concentrations of five healthy cats to better understand what impact each of these diets may have for diabetic cats. The diet regiments used in this study were as follows: C/D dry (General Use- Low protein, High fat, High carbohydrate, and Low fiber), M/D dry (DM- High protein, High fat, Low carbohydrate, and High Fiber), and W/D dry (DM- Low Protein, Low Fat, High Carbohydrate, and High Fiber). No significant difference in post-prandial serum glucose levels were observed with the C/D (84.6 +/- 1.5 mg/dl) and W/D (83.8 +/- 1.4 mg/dl) dry diets when compared to pre-prandial fasting levels (83.9 +/- 1.4 mg/dl). However, a significant reduction was observed with the M/D diet (78.9 +/- 0.8 mg/dl) which had 50-60% less carbohydrates than either C/D or W/D diet. Unlike what was observed with post-prandial glucose levels, an interesting pattern emerged with post-prandial insulin levels, which were increasing with W/D, C/D, and M/D diets in that order (1.1 +/- 0.2, 1.7 +/- 0.2, and 2.3 +/- 0.2 ng/ml respectively). Most surprising, though, was the fact that the W/D diet did not seem to stimulate insulin secretion as compared to pre-prandial levels (1.1 +/- 0.1 ng/ml) in healthy cats. Interestingly, the W/D diet had high levels of carbohydrate and low levels of protein. Coincidentally, the only diet (M/D) which had a significant reduction in post-prandial glucose also showed the highest increase in post-prandial insulin in healthy cats. Therefore, dietary amounts of carbohydrate, fat, protein and fiber can all have an individual impact on post-prandial glycemia and subsequent insulin requirement levels. Just as concepts regarding dietary management of people with DM are evolving, investigators are reassessing what constitutes the ideal diet for the diabetic feline. As such, having a better understanding for each dietary component, may lead us to better understand how we can synergize certain dietary components to aid in DM management.

Amylin reduces plasma glucagon concentration in cats

Pancreatic amylin plays an important role in the control of nutrient fluxes and is an established therapy in human diabetes as it reduces post-prandial glucagon secretion and slows gastric emptying. Given the similar pathophysiology of human type-2 and feline diabetes mellitus, we investigated whether amylin reduces plasma glucagon levels in cats. Healthy cats were tested using an intravenous arginine stimulation test (IVAST), a meal response test with the test meal comprising 50% of average daily food intake, and an IV glucose tolerance test (IVGTT). Non-amyloidogenic rat amylin injected 5 min before the respective stimulus significantly reduced plasma glucagon levels under all test situations. In the IVAST and IVGTT, cats treated with amylin also had lower plasma insulin concentrations. It was concluded that amylin does reduce plasma glucagon levels in cats, a feature that has treatment potential in diabetic animals as co-administration of amylin would reduce the insulin requirement to control glycaemia.

Hyperglycaemia but not hyperlipidaemia causes beta cell dysfunction and beta cell loss in the domestic cat

AIMS/HYPOTHESIS

In vitro studies point to a toxic effect of high glucose and non-esterified fatty acids on beta cells. Whether elevated levels of glucose and lipids induce beta cell loss in vivo is less clear. The domestic cat has recently been proposed as a valuable animal model for human type 2 diabetes because feline diabetes shows several similarities with diabetes in humans, including obesity-induced insulin resistance, impaired beta cell function, decreased number of beta cells and pancreatic amyloid deposition.

METHODS

We infused healthy cats with glucose or lipids for 10 days to clamp their blood concentrations at the approximate level found in untreated feline diabetes (glucose: 25-30 mmol/l; triacylglycerols: 3-7 mmol/l).

RESULTS

Glucose and lipid levels were adequately targeted. Plasma non-esterified fatty acids were increased by lipid infusion 1.7-fold. A dramatic and progressive decline of plasma insulin levels was observed in glucose-infused cats beginning after 2 days of hyperglycaemic clamp. In contrast, plasma insulin concentration and glucose tolerance test were not affected by hyperlipidaemia. Compared with controls, glucose-infused cats had a 50% decrease in beta cells per pancreatic area. Apoptotic islet cells and cleaved caspase-3-positive beta cells were observed in glucose-infused cats only.

CONCLUSIONS/INTERPRETATION

Sustained hyperglycaemia but not hyperlipidaemia induces early and severe beta cell dysfunction in cats, and excess glucose causes beta cell loss via apoptosis in vivo. Hyperglycaemic clamps in cats may provide a good model to study the pathogenesis of glucose toxicity in beta cells.

Endoneurial microvascular pathology in feline diabetic neuropathy

Endoneurial capillaries in nerve biopsies from 12 adult diabetic cats with varying degrees of neurological dysfunction were examined for evidence of microvascular pathology and compared to nerves obtained at necropsy from 7 adult non-diabetic cats without clinical evidence of neurological dysfunction. As reported previously [Mizisin, A.P., Nelson, R.W., Sturges, B.K., Vernau, K.M., LeCouteur, R.A., Williams, D.C., Burgers, M.L., Shelton, G.D., 2007. Comparable myelinated nerve pathology in feline and human diabetes mellitus. Acta Neuropathol. 113, 431-442.], the diabetic cats had elevated glycosylated hemoglobin and serum fructosamine levels, decreased motor nerve conduction velocity and compound muscle action potential (CMAP) amplitude, and markedly decreased myelinated nerve fiber densities. Compared to non-diabetic cats, there was a non-significant 26% increase in capillary density and a significant (P<0.009) 45% increase in capillary size in diabetic cats. Capillary luminal size was also significantly (P<0.001) increased, while an index of vasoconstriction was significantly decreased (P<0.001) in diabetic cats compared to non-diabetic controls. No differences in endothelial cell size, endothelial cell number or pericyte size were detected between non-diabetic and diabetic cats. In diabetic cats, basement membrane thickening, seen as a reduplication of the basal lamina, was significantly (P<0.0002) increased by 73% compared to non-diabetic controls. Regression analysis of either myelinated nerve fiber density or CMAP amplitude against basement membrane size demonstrated a negative correlation with significant slopes (P<0.03 and P<0.04, respectively). These data demonstrate that myelinated nerve fiber injury in feline diabetic neuropathy is associated with microvascular pathology and that some of these changes parallel those documented in experimental rodent and human diabetic neuropathy.

Comparable myelinated nerve pathology in feline and human diabetes mellitus

The occurrence of diabetic neuropathy in cats provides an opportunity to study the development and treatment of neurological complications not present in diabetic rodent models, where few pathological alterations are evident. The present study further defines pathological alterations in nerve biopsies from 12 cats with spontaneously occurring diabetes mellitus. Peroneal nerve biopsies displayed concurrent injury to both Schwann cells and axons of myelinated fibers that was remarkably similar to that present in human diabetic neuropathy. In addition to demyelination, remyelination (constituting 20-84% of the total myelinated fiber population) was indicated by fibers with inappropriately thin myelin sheaths. Unlike our previous investigations, striking axonal injury was apparent, and consisted of dystrophic accumulations of membranous debris or neurofilaments, as well as degenerative fiber loss resulting in a 50% decrease in myelinated fiber density. In spite of extensive fiber loss, regenerative clusters were apparent, suggesting that axonal regeneration was not completely frustrated. These data highlight the potential utility of feline diabetic neuropathy as a model that faithfully replicates the nerve injury in human diabetes mellitus.

Amylinergic control of food intake

Amylin is a pancreatic B-cell hormone that plays an important role in the regulation of nutrient fluxes. As such, amylin reduces food intake in laboratory animals and man, slows gastric emptying and it reduces postprandial glucagon secretion. Amylin deficiency which occurs concomitantly to insulin deficiency in diabetes mellitus, may therefore contribute to some of the major derangements associated with this disorder (hyperphagia, excessive glucagon secretion, accelerated rate of gastric emptying). The described actions of amylin all seem to depend on a direct effect of amylin on the area postrema (AP). As to amylin's satiating effect, the physiological relevance of this action is underlined by studies involving specific amylin antagonists and amylin-deficient mice. In the AP, amylin seems to modulate the anorectic signal elicited by CCK. Subsequent to AP activation, the amylin signal is conveyed to the forebrain via distinct relay stations. Within the lateral hypothalamic area, amylin diminishes the expression of orexigenic neuropeptides such as orexin and MCH. Whether these effects contribute to amylin's short term satiating action remains to be determined. Recent studies suggest that amylin may also play a role as a long-term, lipostatic signal, especially when other feedback systems to the brain are deficient. Obese, leptin-resistant Zucker rats which are hyperinsulinemic and hyperamylinemic, were chronically infused with the amylin antagonist AC 187. AC 187 significantly elevated food intake in obese Zucker rats while having no effect in lean controls. This indicates that at least under certain conditions, chronic blockade of endogenous amylin action may lead to an increase in food intake and/or body weight. As mentioned, the site and mechanism of action for peripheral amylin to reduce food intake seems to be well established. It is less clear how centrally administered amylin reduces food intake although it is well known that 3rd ventricular administration of amylin produces a very strong and long-lasting anorectic action. Amylin receptors have been described in various hypothalamic nuclei but the endogenous ligand of these receptors remains to be investigated. The same holds true as to the physiological relevance of the anorectic effect seen after central amylin administration.

Comparison of a low carbohydrate-low fiber diet and a moderate carbohydrate-high fiber diet in the management of feline diabetes mellitus

This study compared the effects of a moderate carbohydrate-high fiber (MC-HF) food and a low carbohydrate-low fiber (LC-LF) food on glycemic control in cats with diabetes mellitus. Sixty-three diabetic cats (48 male castrated, 15 female spayed) were randomly assigned to be fed either a canned MC-HF (n = 32) food or a canned LC-LF (n = 31) food for 16 weeks. Owners were blinded to the type of diet fed. CBC, urinalysis, serum chemistry panel, fructosamine concentration and thyroxine concentration were determined on initial examination, and a complete blood count, serum chemistry panel, urinalysis and serum fructosamine concentration were repeated every 4 weeks for 16 weeks. Insulin doses were adjusted as needed to resolve clinical signs and lower serum fructosamine concentrations. Serum glucose (P = 0.0001) and fructosamine (P = 0.0001) concentrations significantly decreased from week 0 to week 16 in both dietary groups. By week 16, significantly more of the cats fed the LC-LF food (68%, 22/31), compared to the cats fed the MC-HF food (41%, 13/32), had reverted to a non-insulin-dependent state (P = 0.03). Cats in both groups were successfully taken off of insulin regardless of age, sex, type of insulin administered or duration of clinical disease before entering the study. There was no significant difference in the initial or final mean body weights or in the mean change in body weight from week 0 to week 16 between dietary groups. Diabetic cats in this study were significantly more likely to revert to a non-insulin-dependent state when fed the canned LC-LF food versus the MC-HF food.

Evaluation of transdermal application of glipizide in a pluronic lecithin gel to healthy cats

OBJECTIVE

To evaluate plasma glipizide concentration and its relationship to plasma glucose and serum insulin concentrations in healthy cats administered glipizide orally or transdermally. ANIMALS-15 healthy adult laboratory-raised cats.

PROCEDURE

Cats were randomly assigned to 2 treatment groups (5 mg of glipizide, PO or transdermally) and a control group. Blood samples were collected 0, 10, 20, 30, 45, 60, 90, and 120 minutes and 4, 6, 10, 14, 18, and 24 hours after administration to determine concentrations of insulin, glucose, and glipizide.

RESULTS

Glipizide was detected in all treated cats. Mean +/- SD transdermal absorption was 20 +/- 14% of oral absorption. Mean maximum glipizide concentration was reached 5.0 +/- 3.5 hours after oral and 16.0 +/- 4.5 hours after transdermal administration. Elimination half-life was variable (16.8 +/- 12 hours orally and 15.5 +/- 15.3 hours transdermally). Plasma glucose concentrations decreased in all treated cats, compared with concentrations in control cats. Plasma glucose concentrations were significantly lower 2 to 6 hours after oral administration, compared with after transdermal application; concentrations were similar between treatment groups and significantly lower than for control cats 10 to 24 hours after treatment.

CONCLUSIONS AND CLINICAL RELEVANCE

Transdermal absorption of glipizide was low and inconsistent, but analysis of our results indicated that it did affect plasma glucose concentrations. Transdermal administration of glipizide is not equivalent to oral administration. Formulation, absorption, and stability studies are required before clinical analysis can be performed. Transdermal administration of glipizide cannot be recommended for clinical use at this time.

Treatment of feline diabetes mellitus using an alpha-glucosidase inhibitor and a low-carbohydrate diet

The purpose of this study was to determine the effect of an alpha-glucosidase inhibitor (acarbose), combined with a low-carbohydrate diet on the treatment of naturally occurring diabetes mellitus in cats. Eighteen client-owned cats with naturally occurring diabetes mellitus were entered into the study. Dual-energy X-ray absorptiometry (DEXA) was performed prior to and 4 months after feeding the diet to determine total body composition, including lean body mass (LBM) and percent body fat. Each cat was fed a commercially available low-carbohydrate canned feline diet and received 12.5mg/cat acarbose orally every 12h with meals. All cats received subcutaneous insulin therapy except one cat in the study group that received glipizide (5mg BID PO). Monthly serum glucose and fructosamine concentrations were obtained, and were used to adjust insulin doses based on individual cat's requirements. Patients were later classified as responders (insulin was discontinued, n=11) and non-responders (continued to require insulin or glipizide, n=7). Responders were initially obese (>28% body fat) and non-responders had significantly less body fat than responders (<28% body fat). Serum fructosamine and glucose concentrations decreased significantly in both responder and non-responder groups over the course of 4 months of therapy. Better results were observed in responder cats, for which exogenous insulin therapy was discontinued, glycemic parameters improved, and body fat decreased. In non-responders, median insulin requirements decreased and glycemic parameters improved significantly, despite continued insulin dependence. The use of a low-carbohydrate diet with acarbose was an effective means of decreasing exogenous insulin dependence and improving glycemic control in a series of client-owned cats with naturally occurring diabetes mellitus.

Neurological complications associated with spontaneously occurring feline diabetes mellitus

In this study, neurological complications associated with spontaneously occurring feline diabetes were comprehensively evaluated. Physical and neurological examinations, electrophysiological assessment, and biochemical and histological analysis of nerve and muscle biopsy specimens were performed in 19 diabetic cats and referenced to similar data from 28 nondiabetic cats without evidence of neuropathy. Compared to nondiabetic cats, diabetic cats exhibited a range of functional, structural, and biochemical defects that, depending on severity, manifested as striking neurological dysfunction. A broad spectrum of clinical signs was apparent with the most notable and severe impairment being a plantigrade posture when standing or walking. A sensorimotor neuropathy, characterized by conduction deficits and increased F wave and cord dorsum potential latencies, was present in both pelvic and thoracic limbs and, except in the most severely affected animals, occurred with little or no electromyographic abnormality. As for nerve structural abnormalities, Schwann cell injury was prevalent and included myelin defects, such as splitting and ballooning, and demyelination, although axonal degeneration was noted in biopsies from severely affected cats. Evidence of polyol pathway activity consisted of marked increases in nerve fructose without appreciable sorbitol accumulation. The occurrence of diabetic neuropathy in the cat, a relatively large animal with a long life span and long nerves, provides unique opportunities to study the development and treatment of this debilitating complication.

Diagnosis of diabetes mellitus in cats and dogs

This article describes the clinical presentation of diabetes mellitus in cats and dogs, including the types of diabetes, signalment, history, physical examination findings, and laboratory diagnosis. Newer diagnostic tests such as serum fructosamine concentrations and arginine response rate are also briefly discussed.

Determination of reference values for glucose tolerance, insulin tolerance, and insulin sensitivity tests in clinically normal cats

OBJECTIVE

To determine reference values and test variability for glucose tolerance tests (GTT), insulin tolerance tests (ITT), and insulin sensitivity tests (IST) in cats.

ANIMALS

32 clinically normal cats.

PROCEDURE

GTT, ITT, and IST were performed on consecutive days. Tolerance intervals (ie, reference values) were calculated as means +/- 2.397 SD for plasma glucose and insulin concentrations, half-life of glucose (T1/2 glucose), rate constants for glucose disappearance (Kglucose and Kitt), and insulin sensitivity index (Si). Tests were repeated after 6 weeks in 8 cats to determine test variability.

RESULTS

Reference values for T1/2glucose, Kglucose, and fasting plasma glucose and insulin concentrations during GTT were 45 to 74 minutes, 0.93 to 1.54 %/min, 37 to 104 mg/dl, and 2.8 to 20.6 microU/ml, respectively. Mean values did not differ between the 2 tests. Coefficients of variation for T1/2glucose, Kglucose, and fasting plasma glucose and insulin concentrations were 20, 20, 11, and 23%, respectively. Reference values for Kitt were 1.14 to 7.3%/min, and for SI were 0.57 to 10.99 x 10(4) min/microU/ml. Mean values did not differ between the 2 tests performed 6 weeks apart. Coefficients of variation for Kitt and SI were 60 and 47%, respectively.

CONCLUSIONS AND CLINICAL RELEVANCE

GTT, ITT, and IST can be performed in cats, using standard protocols. Knowledge of reference values and test variability will enable researchers to better interpret test results for assessment of glucose tolerance, pancreatic beta-cell function, and insulin sensitivity in cats.

Insulin sensitivity in normal and diabetic cats

Estimates of in vivo insulin sensitivity (S(I)) can be derived from minimal model analysis of a frequently sampled intravenous glucose tolerance test (FSIVGTT). Modification of the FSIVGTT by the injection of insulin allows insulin sensitivity to be measured in diabetics. To establish and compare reference values for insulin sensitivity in clinically normal and diabetic cats, we subjected 10 clinically normal cats and five diabetic cats to the insulin-modified FSIVGTT with minimal model analysis. Diabetic cats had a significantly lower insulin sensitivity than clinically normal cats (P<0.05). Mean insulin sensitivity in clinically normal cats was 3.22x10(-4)/min/microU/ml (range 1.71-5.23x10(-4)/min/microU/ml). In contrast, the mean insulin sensitivity in diabetic cats was 0.58x10(-4)/min/microU/ml (range 0.136-0.88x10(-4)/min/microU/ml), or approximately six times less insulin sensitive than clinically normal cats. Mean glucose effectiveness in clinically normal cats was 0.030/min (range 0.021-0.045/min). Mean glucose effectiveness in diabetic cats was 0.014/min (range 0.008-0.021/min). Our data demonstrate that insulin resistance is a feature of feline diabetes mellitus and that diabetic cats have a similar relative decrease in insulin sensitivity to humans with type 2 diabetes.

Quantitative immunohistochemical analysis of islet amyloid polypeptide (IAPP) in normal, impaired glucose tolerant, and diabetic cats

Islet amyloid polypeptide (IAPP, "amylin") has been proposed as having important roles in the pathogenesis of type 2 diabetes mellitus via its biological activity and by forming islet amyloid. The domestic cat develops a type of diabetes that closely resembles type 2 diabetes in humans, including the frequent formation of islet amyloid deposits in the impaired glucose tolerant (IGT) and diabetic state. With the aid of computerized image analysis and immunohistochemistry, we examined the IAPP and insulin content in pancreatic islets of normal, IGT and diabetic cats. IAPP immunoreactivity in beta cells from IGT cats was significantly stronger (p < 0.01) as compared with cells from normal cats, while the insulin labelling strength was unchanged. Overtly diabetic cats were usually almost devoid of beta cells. As in humans, cellular IAPP but not IAPP in islet amyloid deposits was labelled by the newly developed monoclonal antibody to IAPP 4A5, thus providing further evidence that IAPP is modified by a yet unknown mechanism during the amyloidogenic process. The study provides evidence that an increased beta cell storage of IAPP independent of insulin may be an important factor in the early phase of the development of islet amyloid in this form of diabetes.

Diabetes mellitus in a koala (Phascolarctos cinereus)

OBJECTIVE

To describe a case of diabetes mellitus in a koala (Phascolarctos cinereus).

DESIGN

A case report with controls.

PROCEDURES

We describe clinical and laboratory findings in a 6-year-old, free-living, female koala presented with traumatic injury and subsequently found to have polydipsia, hyperglycaemia and glucosuria. Over a 5 week period, serum biochemical analyses, haematological examinations, urinalyses, measurement of serum insulin and fructosamine concentrations, necropsy, histopathological examination of a range of tissues and immunohistochemical examination of the pancreas for insulin-containing cells were done. For reference purposes, serum insulin and fructosamine concentrations were determined in four and two healthy koalas, respectively, and three healthy koalas' pancreases were examined histologically and immunohistochemically.

RESULTS

The koala had persistent hyperglycaemia, hyperlipidaemia, hyponatraemia, hypochloraemia and glucosuria. Serum insulin concentration of the diabetic koala was only marginally smaller than that of healthy koalas, but all concentrations were smaller than reference concentrations in dogs and people. Fructosamine concentration did not allow the diabetic koala to be distinguished from healthy koalas and concentrations of all koala analytes were greater than expected for healthy dogs and people. Histopathological examination revealed extensive degeneration of pancreatic islet cells and fatty infiltration of hepatocytes. Immunoperoxidase staining revealed decreased or absent insulin in the beta calls of the affected koala.

CONCLUSION

Clinical signs, clinicopathological results and histopathological changes were consistent with diabetes mellitus. The pathogenesis of the condition could not be determined but may have been related to the administration of a parenteral corticosteroid preparation, the stress of capture or tissue damage and inflammation.

Physiology of the endocrine pancreas

The endocrine pancreas is composed of nests of cells called the islets of Langerhans, which comprise only about 20% of pancreatic cell mass and secrete insulin, glucagon, somatostatin, and pancreatic polypeptide. Insulin is anabolic, increasing storage of glucose, fatty acids and amino acids, while glucagon namely stimulates hepatic glycogenolysis, gluconeogenesis, and ketogenesis. Somatostatin acts as a paracrine agent to inhibit both insulin and glucagon release, and, therefore, to modulate their output. This article explores factors controlling release of these hormones, as well as the way in which they affect fuel metabolism in the whole animal.

Over representation of Burmese cats with diabetes mellitus

OBJECTIVE

To determine if Burmese cats in Queensland have an increased risk of diabetes mellitus.

DESIGN

A retrospective study of diabetic and nondiabetic cats that had blood submitted to a veterinary clinical laboratory over a 22 month study period.

SAMPLE POPULATION

4402 cats

PROCEDURE

Cats were considered diabetic if blood glucose concentration was > 11 mmol/L and fructosamine was > 406 mumol/L or hydroxybutyrate was > 1 mmol/L. Cats were grouped into Burmese and non-Burmese. Adjusted odds ratios of diabetes were calculated for breed, gender and age group amongst cats with blood glucose > 11 mmol/L.

RESULTS

Burmese cats comprised 20% of 45 diabetic cats of known breed, which was higher (P < 0.001) than among the normoglycemic reference population of 2203 cats (7% Burmese). There were more females among the diabetic Burmese (62%), but this did not differ (P > 0.05) from the Burmese reference population (45% females). In contrast, males seemed to predominate among diabetic non-Burmese (63%), although this also did not differ (P > 0.05) from the reference population (55%) of from diabetic Burmese (38% males). The majority (90%) of diabetic cats were older than 6 years, irrespective of breed (median age 12 years, interquartile range 10 to 13 years). This was higher (chi(2) = 8.13, P < 0.005) than among the normoglycaemic reference population, where 69% were older than 6 years.

CONCLUSIONS

Burmese cats were significantly over represented among cats with diabetes mellitus. Irrespective of breed, the risk of diabetes in the study population increased with age.

Evaluation of a simplified intravenous glucose tolerance test and a reflectance glucose meter for use in cats

A simplified intravenous glucose tolerance test has been developed for use in domestic cats and the results compared with those obtained using the standard test. The simplified test used two cephalic catheters, implanted in unsedated, unanaesthetised cats three hours before the test. Blood samples were collected before and after intravenous administration of glucose (0.5 g/kg bodyweight). Blood glucose concentration was measured with a reflectance glucose meter and an automated chemistry analyser. There were no significant differences between the results derived from the two tests. Because the simplified glucose tolerance test is easier to perform, requires no anaesthesia, uses only cephalic catheters and can be done on an outpatient basis, it is more cost effective and more clinically applicable. There were no significant differences between the results of glucose measurements with the two machines and the simplified glucose tolerance test can therefore be carried out with the reflectance glucose meter.