Response to insulin treatment and survival in 104 cats with diabetes mellitus (1985-1995)

Association between Hyperglycemia and Canine Serum Pancreatic Lipase Immunoreactivity Concentration in Diabetic Dogs

It has been reported that hypertriglyceridemia can partially mediate between diabetes mellitus (DM) and pancreatitis in dogs, implying that another mediator, such as chronic hyperglycemia, might exist. Therefore, this study aimed to evaluate the relationship between hyperglycemia and serum canine pancreatic lipase immunoreactivity (cPLI) concentration in diabetic dogs. This retrospective cohort study included 26 client-owned diabetic dogs, divided according to their serum fructosamine levels (<500 μmol/L = well-controlled DM group; ≥500 μmol/L = untreated or poorly controlled DM group). Five of the 26 DM dogs (19.2%) had serum cPLI concentrations consistent with pancreatitis, among which two showed ultrasonographic evidence of pancreatitis without clinical signs. The serum cPLI concentrations (median [interquartile range]) were significantly higher in the untreated or poorly controlled group (520 μg/L [179.76-1000 μg/L]) than in the well-controlled group (77 μg/L [32.22-244.6 μg/L], P = 0.0147). The serum fructosamine concentration was positively correlated with the serum cPLI concentration (r = 0.4816; P = 0.0127). Multivariate analysis revealed serum triglyceride and fructosamine concentrations were associated with the serum cPLI concentration. In conclusion, this study suggests that chronic hyperglycemia may induce pancreatic inflammation in diabetic dogs; however, the clinical significance of increased cPLI concentration is unknown.

Survival, remission, and quality of life in diabetic cats

BACKGROUND

Remission is documented in a substantial proportion of cats with diabetes. The effects of diabetes mellitus (DM) on the lives of cats and their owners should be considered when evaluating treatment success.

OBJECTIVES

To study outcome in cats with DM and the impact DM has on the life situation of cat and owner.

ANIMALS

Domestic and pedigree cats with a diagnosis of DM (n = 477) insured by a Swedish insurance company during 2009 to 2013.

METHODS

Retrospective cross-sectional study. A questionnaire was sent to 1369 owners of cats diagnosed with DM. The questions concerned the cat, treatment, owner perceptions of the disease and treatment and disease outcome. Data were analyzed using multiple linear and logistic regression, with outcomes set as survival for more than 4 weeks after diagnosis, survival time, achieving remission, remission without relapse and quality of life (QoL) for the cat.

RESULTS

The response rate was 35%, leaving 477 questionnaires for analysis. The remission rate among treated cats was 29% (118/405). Feeding a commercially available wet diet was associated with both remission (OR 3.16, 95% confidence interval 1.27-8.12) and remission without relapse (OR 14.8, 95% confidence interval 2.25-153.8). Remission was associated with a better QoL for the cat.

CONCLUSIONS AND CLINICAL IMPORTANCE

The association between feeding a commercially available wet diet and remission is important and strengthens the role of diet in treatment of DM in cats. Linking remission and a better QoL for the cat emphasizes remission as a goal in disease management.

Feline Comorbidities: Clinical perspective on diabetes mellitus and pancreatitis

PRACTICAL RELEVANCE

Diabetes mellitus (DM) is one of the most common feline endocrine disorders. It has been shown by several studies that DM in cats frequently coexists with pancreatitis.

CLINICAL CHALLENGES

It has not been definitively established what the exact pathogenetic association between DM and pancreatitis is in the cat. However, the association between these two conditions is most likely bidirectional, with DM predisposing cats to pancreatitis and vice versa. Diagnosis of pancreatitis in cats with DM is crucial because concurrent pancreatitis commonly leads to difficulties in the management of DM. When pancreatitis is associated with diabetic ketoacidosis (DKA), therapeutic management is even more challenging.

AIMS

This review focuses on the concurrent presence of DM or DKA and pancreatitis in cats, mainly focusing on their clinical management.

EVIDENCE BASE

Information provided in this review is based on feline-specific clinical research when available. In addition, comparative and human research, as well as clinical experience, has been used to enrich knowledge in areas where feline-specific research is not yet available.

Feline Adipose Derived Multipotent Stromal Cell Transdifferentiation Into Functional Insulin Producing Cell Clusters

Diabetes mellitus (DM) is one of the most prevalent feline endocrinopathies, affecting up to 1% of pet cats. De novo generation of functional insulin producing cell (IPC) clusters via transdifferentiation of feline adipose-derived multipotent stromal cells (ASCs) may not only provide a viable, functional cell therapy for feline DM, but may also serve as a platform for developing a comparable human treatment given feline and human DM similarities. Cells were induced to form IPCs with a novel, three-stage culture process with stromal or differentiation medium under static and dynamic conditions. Clusters were evaluated for intracellular zinc, viability, intracellular insulin, glucagon, and somatostatin, ultrastructure, glucose stimulated insulin secretion in the presence or absence of theophylline, and protein and gene expression. Isolated cells were multipotent, and cell clusters cultured in both media had robust cell viability. Those cultured in differentiation medium contained zinc and mono- or polyhormonal α-, β-, and δ-like cells based on immunohistochemical labeling and Mallory-Heidenhan Azan-Gomori’s staining. Ultrastructurally, cell clusters cultured in differentiation medium contained insulin granules within vesicles, and clusters had a concentration-dependent insulin response to glucose in the presence and absence of theophylline which increased both insulin secretion and intracellular content. Expression of NK6.1, Pax6, Isl1, Glut2, RAB3A, glucagon, insulin, and somatostatin increased with differentiation stage for both sexes, and expression of nestin at stages 1 and 2 and Neurod1 at stage 2 was higher in cells from female donors. The cluster insulin secretion responses and endocrine and oncogene gene expression profiles were inconsistent with insulinoma characteristics. A total of 180 proteins were upregulated in differentiated clusters, and the majority were associated with biological regulation, metabolic processes, or stimulus response. Dynamic culture of IPC clusters resulted in clusters composed of cells primarily expressing insulin that released higher insulin with glucose stimulation than those in static culture. Collectively, the results of this study support generation of functional IPC clusters using feline ASCs isolated from tissues removed during routine sterilization. Further, cluster functionality is enhanced with dynamic, motion-driven shear stress. This work establishes a foundation for development of strategies for IPC therapy for short or long-term diabetes treatment and may represent an option to study prevention and treatment of diabetes across species.

Cyclosporine Treatment in Cats with Presumed Chronic Pancreatitis-A Retrospective Study

Simple Summary

Chronic pancreatitis (CP) is a common disease in middle-aged to older cats. Cyclosporine, an immunosuppressive drug, has been suggested as an alternative treatment when other drugs that suppress inflammation are ineffective or unsuitable. However, no published studies have investigated its efficacy in cats with CP. The aim of this retrospective study was to evaluate the efficacy of cyclosporine as a treatment for pancreatitis in cats with presumed CP. All cats had a history and clinical signs suggestive of CP and blood samples showed abnormally high concentrations of feline pancreas-specific lipase (Spec fPL) on at least two occasions. This is common in CP. All cats were treated with cyclosporine for at least three weeks. Nineteen cats, aged 6.9–17.5 years, were included. Daily treatment with cyclosporine resulted in an improvement of serum Spec fPL concentrations which indicates that the pancreatic inflammation likely had improved. The study has several limitations, including different treatment durations and doses, lack of biopsies to confirm CP and the treatment effect was not compared with an untreated control group. Despite the limitations, our results suggest that cyclosporine treatment decreases serum Spec fPL concentrations and may be effective in the management of feline chronic pancreatitis.

Abstract

Chronic pancreatitis (CP) is a common disease in middle-aged to older cats. Cyclosporine has been suggested as an alternative treatment when other immunosuppressive treatments are insufficient or contraindicated. However, no published studies have investigated its efficacy on feline CP. The aim of this retrospective study was to evaluate the efficacy of cyclosporine on supranormal serum feline pancreas-specific lipase (Spec fPL) concentrations in cats with presumed CP. Inclusion criteria were history and clinical signs suggestive of CP, serum Spec fPL concentrations above 5.3 μg/L (reference range 0–3.5 μg/L, equivocal range 3.6–5.3 μg/L) on at least two occasions and treatment with cyclosporine for at least three weeks. Serum Spec fPL was analyzed at Idexx Laboratories, Kornwestheim, Germany. Nineteen cats, aged 6.9–17.5 years (median 11.6), were included. No pancreatic biopsies were available. Median (range) serum Spec fPL concentration was 14.2 μg/L (6.1–43.3) at baseline and 6.7 μg/L (0.9–23.6) at follow-up. Cyclosporine treatment (5.0–7.9 mg/kg orally SID) was associated with a significant reduction in serum Spec fPL concentrations (p < 0.001) at follow-up after 23–206 days (median 35). Body weight decreased significantly between inclusion and follow-up (p = 0.013). Significant improvement of clinical signs could not be measured (p = 0.781). This study has several limitations, including unstandardized treatment length and dose, no control group and lack of pancreatic biopsies. Despite the limitations, our results suggest that cyclosporine treatment reduces supranormal serum Spec fPL concentrations in cats with presumed CP.

Relationship between anti-insulin antibody production and severe insulin resistance in a diabetic cat

A 5-year-old castrated male domestic shorthair cat was diagnosed with diabetic ketoacidosis and severe insulin resistance. Although the conventional treatment for diabetic ketoacidosis was provided, the cat required frequent hospitalization because of severe dehydration and repeated diabetic ketoacidosis. We detected anti-insulin antibodies for human in this cat. Serum insulin-binding IgG levels were markedly elevated compared with those in healthy cats and other diabetic cats. We initiated prednisolone to suppress the effects of anti-insulin antibodies. After initiation of prednisolone, the cat was gradually recovered with increasing activity and appetite. Furthermore, satisfactory glycemic control was achieved with combined subcutaneous injection of insulin detemir and insulin degludec.

Feline comorbidities: Recognition, diagnosis and management of the cushingoid diabetic

PRACTICAL RELEVANCE

Diabetes mellitus (DM) is a common feline endocrinopathy, and is often driven by underlying insulin resistance with associated pancreatic beta (β)-cell dysfunction. Although spontaneous hyperadrenocorticism (HAC) with hypercortisolemia (hypercortisolism) is relatively uncommon in cats, it is a well-established cause of insulin resistance and is routinely associated with DM in this species.

CLINICAL CHALLENGES

Many of the clinical signs associated with feline HAC are subtle and may be attributed to concurrent DM or the aging process. Failure to recognize HAC in the diabetic cat can impact patient wellbeing and predispose the patient to progressive compromise. Unfortunately, it can be difficult to establish a diagnosis of HAC, as test results may be influenced by poor diabetic regulation, and protocols are different to those used in canine patients. Treatment options depend on the underlying cause, and often require careful, ongoing assessment and modulation of both adrenal function and insulin requirements. However, various approaches have been shown to either improve glycemic control in cats with sustained insulin dependence, or facilitate diabetic remission.

EVIDENCE BASE

This review summarizes the current literature on feline HAC, with a particular focus on cats with concurrent DM. The clinical findings that suggest HAC are discussed, along with an outline of diagnostic options and their limitations. Published outcomes for various medical options, surgical procedures and radiation therapy are provided. The authors also share their thoughts on the safe and effective management of cats with HAC and DM, with an emphasis on the anticipation and recognition of changing insulin requirements.

Is It Being Overdiagnosed? Feline Pancreatitis

In recent years, increased awareness of feline pancreatitis by the veterinary profession and improved diagnostic modalities have led to an increased frequency of diagnosis of pancreatitis in this species. Consequently, pancreatic diseases, especially chronic pancreatitis, are considered highly prevalent, even in populations of apparently healthy individuals. This prevalence has led to the suspicion that the condition may be overdiagnosed. This article summarizes the difficulties of diagnosis of acute and chronic pancreatitis, assesses the reasons why this is a challenging disease to recognize, and considers whether these difficulties could result in either overdiagnosis or underdiagnosis.

The Burmese cat as a genetic model of type 2 diabetes in humans

The recent extension of genetic tools to the domestic cat, together with the serendipitous consequences of selective breeding, have been essential to the study of the genetic diseases that affect them. Cats are increasingly presented for veterinary surveillance and share many of human's heritable diseases, allowing them to serve as natural models of these conditions. Feline diabetes mellitus is a common condition in domestic cats that bears close pathological and clinical resemblance to type 2 diabetes in humans, including pancreatic β-cell dysfunction and peripheral insulin resistance. In Australia, New Zealand and Europe, diabetes mellitus is almost four times more common in cats of the Burmese breed than in other breeds. This geographically based breed predisposition parallels familial and population clustering of type 2 diabetes in humans. As a genetically isolated population, the Australian Burmese breed provides a spontaneous, naturally occurring genetic model of type 2 diabetes. Genetically isolated populations typically exhibit extended linkage disequilibrium and increased opportunity for deleterious variants to reach high frequencies over many generations due to genetic drift. Studying complex diseases in such populations allows for tighter control of confounding factors including environmental heterogeneity, allelic frequencies and population stratification. The homogeneous genetic background of Australian Burmese cats may provide a unique opportunity to either refine genetic signals previously associated with type 2 diabetes or identify new risk factors for this disease.

A retrospective study of 157 hospitalized cats with pancreatitis in a tertiary care center: Clinical, imaging and laboratory findings, potential prognostic markers and outcome

BACKGROUND

Pancreatitis in cats (FP) has been increasingly diagnosed in recent years, but clinical studies of large numbers of affected cats are scarce.

OBJECTIVES

To describe a large cohort of cats with FP requiring hospitalization.

ANIMALS

One hundred and fifty-seven client-owned cats.

METHODS

Retrospective study, including cats diagnosed with pancreatitis based on sonographic evidence, positive SNAP feline pancreatic lipase immunoreactivity test results, increased 1,2-o-dilauryl-rac-glycerol-glutaric Acid-(6'-methylresorufin ester)-lipase activity, histopathology, or some combination of these.

RESULTS

One-hundred and twenty-two cats (77.7%) survived to discharge. Median time from onset of clinical signs to presentation was longer (P = .003) in nonsurvivors. Causes of FP included recent general anesthesia, trauma, hemodynamic compromise, and organophosphate intoxication, but most cases (86.6%) were idiopathic. Ultrasonographic findings consistent with pancreatitis were documented in 134 cats, including pancreatomegaly (81.3%), decreased (31.3%), or increased (14.9%) pancreatic echogenicity, extra-hepatic biliary tract dilatation (24%), and increased peri-pancreatic echogenicity (13%). Lethargy (P = .003), pleural effusion (P = .003), hypoglycemia (P = .007), ionized hypocalcemia (P = .016), azotemia (P = .014), parenteral nutrition administration (P = .013), and persistent anorexia during hospitalization (P = .001) were more frequent in nonsurvivors, whereas antibiotics were more frequently administered to survivors (P = .023). Nevertheless, when Bonferroni's correction for multiple comparisons was applied, none of the variables was statistically significant.

CONCLUSIONS AND CLINICAL IMPORTANCE

Previously unreported, clinically relevant, potential prognostic factors, including hypoglycemia, azotemia, parenteral nutrition, and withholding antibacterial treatment were identified in this exploratory study. These preliminary results should be examined further in confirmatory studies.

Managing feline diabetes: current perspectives

Diabetes mellitus is a common endocrine disease in cats. While type 2 diabetes is the most common form seen in cats, other underlying causes may contribute to insulin resistance. Guidelines for diagnosis vary and often do not take into account prediabetic cats. The goals of treatment are to maximize the chance of remission, while minimizing the risks of hypoglycemia. This article presents a further overview of current treatment and monitoring recommendations for diabetic cats.

Hypoglycemic episodes in cats with diabetes mellitus: 30 cases (2013-2015)

Objectives The purpose of this study was to review the characteristics of diabetic cats presenting to a specialty and emergency center for signs attributed to hypoglycemia and to identify the factors that may have contributed to the hypoglycemic episode, the patient's clinical signs and laboratory findings, and the response of hypoglycemic cats to therapy. Methods Twenty-eight cats were presented a total of 30 times for symptomatic hypoglycemia. Data were collected from cat owners at the time of presentation and from subsequent patient records. Results The majority of cats presented for neurologic signs attributed to the reduced ingestion or subsequent vomiting of a meal after insulin had been administered or the accidental double-dosing of insulin. Concurrent illnesses that may have affected insulin requirements were also common. Conclusions and relevance Cats that demonstrated clinical improvement within 12 h of treatment were more likely to recover despite their mental status and glucose level on presentation.

Computed Tomographic Angiography of the Pancreas in Cats with Chronic Diabetes Mellitus Compared to Normal Cats

Background

Diabetes mellitus (DM) is a common endocrinopathy in cats. No known diagnostic test or patient characteristic at the time of diagnosis can predict likely disease course, unlike in people in whom computed tomographic angiography (CTA) is used. No published data exist regarding the CTA appearance of the pancreas in cats with DM, and thus, it is unknown what if any CTA variables should be further assessed for associations with pancreatic endocrine function.

Hypothesis/Objectives

A significant difference in pancreatic attenuation, volume, and size will be identified between normal cats and those with chronic DM on CTA.

Animals

Ten healthy control cats and 15 cats with naturally occurring DM present for >12 months.

Methods

Prospective cross‐sectional study comparing pancreatic attenuation, enhancement pattern, size, volume, pancreatic volume‐to‐body weight ratio (V:BW), pancreatic arterial: portal phase ratio (A:P), time‐to‐arterial enhancement, and time‐to‐peak portal enhancement on CTA between sedated healthy control cats and those with chronic DM.

Results

The pancreas in cats with chronic DM was significantly larger, had higher volume, higher V:BW, and shorter time‐to‐peak portal enhancement on CTA when compared to normal cats.

Conclusions and Clinical Importance

Peak portal enhancement time, pancreatic size, pancreatic volume, and V:BW can be used to differentiate normal sedated cats from those with chronic DM by CTA. These variables warrant further investigation to identify possible associations with endocrine function.

2018 AAHA Diabetes Management Guidelines for Dogs and Cats*

Diabetes mellitus (DM) is a common disease encountered in canine and feline medicine. The 2018 AAHA Diabetes Management Guidelines for Dogs and Cats revise and update earlier guidelines published in 2010. The 2018 guidelines retain much of the information in the earlier guidelines that continues to be applicable in clinical practice, along with new information that represents current expert opinion on controlling DM. An essential aspect of successful DM management is to ensure that the owner of a diabetic dog or cat is capable of administering insulin, recognizing the clinical signs of inadequately managed DM, and monitoring blood glucose levels at home, although this is ideal but not mandatory; all topics that are reviewed in the guidelines. Insulin therapy is the mainstay of treatment for clinical DM. The guidelines provide recommendations for using each insulin formulation currently available for use in dogs and cats, the choice of which is generally based on efficacy and duration of effect in the respective species. Also discussed are non-insulin therapeutic medications and dietary management. These treatment modalities, along with insulin therapy, give the practitioner an assortment of options for decreasing the clinical signs of DM while avoiding hypoglycemia, the two conditions that represent the definition of a controlled diabetic. The guidelines review identifying and monitoring patients at risk for developing DM, which are important for avoiding unnecessary insulin therapy in patients with transient hyperglycemia or mildly elevated blood glucose.

Evaluation of insulin-like growth factor-1, total thyroxine, feline pancreas-specific lipase and urinary corticoid-to-creatinine ratio in cats with diabetes mellitus in Switzerland and the Netherlands

Objectives The aim of the study was to evaluate circulating insulin-like growth factor-1 (IGF-1), feline pancreas-specific lipase (fPLI) and total thyroxine (TT4) concentrations and urinary corticoid-to-creatinine ratio (UCCR) as indicators for the prevalence of acromegaly, pancreatitis, hyperthyroidism and hypercortisolism in cats with diabetes mellitus. Methods Blood and urine samples were collected from diabetic cats treated in primary care clinics in Switzerland and the Netherlands. Standardised questionnaires and physical examination forms provided clinical information from owners and veterinarians. Laboratory testing included serum biochemistry profile analysis and measurement of circulating fructosamine, IGF-1, fPLI, and TT4 concentrations and UCCR. CT of the pituitary gland was performed using a multidetector computed tomography scanner. Results Blood samples were available from 215 cats and urine samples were collected at home from 117 cats. Age ranged from 2-18 years (median 12 years) and body weight from 2.7-12.3 kg (median 5.5 kg). Sixty-five percent of the cats were castrated male and 35% were female (33% spayed); 82% were domestic shorthair cats. Eighty percent of cats received a porcine insulin zinc suspension, 19.5% insulin glargine and 0.5% a human neutral protamine hagedorn insulin. Thirty-six of 202 (17.8%) cats had IGF-1 concentrations >1000 ng/ml. Serum fPLI, and TT4 concentrations and UCCR were increased in 86/196 (43.9%), 9/201 (4.5%) and 18/117 cats (15.3%), respectively. Prevalence did not differ between countries. Conclusions Hyperthyroidism is rare, whereas increased fPLI concentration, possibly reflecting pancreatitis, is common in diabetic cats. The high UCCR may reflect activation of the hypothalamus-pituitary-adrenal axis, which also occurs in diabetic humans. The percentage of cats with increased IGF-1 was high but lower than reported in recent studies.

The Big Pet Diabetes Survey: Perceived Frequency and Triggers for Euthanasia

Current pet diabetes mellitus (DM) treatment necessitates the active daily involvement of owners and can be costly. The current study aimed to investigate the owner population which opts for euthanasia instead of DM treatment. A survey was designed using multiple feedback steps and made available online to veterinarians world-wide. A total of 1192 veterinarians completed the survey and suggested a median one in 10 diabetic pets are euthanased at diagnosis; a further median one in 10 within one year because of lack of success or compliance. Perceived most important motivating factors included "presence concurrent disease" (45% respondents); "costs" (44%); "animal age" (37%); "problems obtaining adequate control" (35%); "pet welfare" (35%); and "impact owner's lifestyle" (32%). Cats in Canadian (odds ratio (OR) 2.7), Australian (OR 2.3), rural (OR 1.6) and mixed (OR 1.7) practices were more likely to be euthanased because of DM diagnosis, while cats presented to referral/university were less likely to be euthanased (OR 0.6). Dogs were more likely to be euthanased because of DM in Canadian (OR 1.8), rural (OR 1.8) and mixed (OR 1.6) practices. The survey results suggest that benefit exists in improved DM education with emphasis on offering a choice of treatment styles ranging from intense and expensive to hands-off and cheap.

What's in a Name? Classification of Diabetes Mellitus in Veterinary Medicine and Why It Matters

Diabetes Mellitus (DM) is a syndrome caused by various etiologies. The clinical manifestations of DM are not indicative of the cause of the disease, but might be indicative of the stage and severity of the disease process. Accurately diagnosing and classifying diabetic dogs and cats by the underlying disease process is essential for current and future studies on early detection, prevention, and treatment of underlying disease. Here, we review the current etiology-based classification of DM and definitions of DM types in human medicine and discuss key points on the pathogenesis of each DM type and prediabetes. We then review current evidence for application of this etiology-based classification scheme in dogs and cats. In dogs, we emphasize the lack of consistent evidence for autoimmune DM (Type 1) and the possible importance of other DM types such as DM associated with exocrine pancreatic disease. While most dogs are first examined because of DM in an insulin-dependent state, early and accurate diagnosis of the underlying disease process could change the long-term outcome and allow some degree of insulin independence. In cats, we review the appropriateness of using the umbrella term of Type 2 DM and differentiating it from DM secondary to other endocrine disease like hypersomatotropism. This differentiation could have crucial implications on treatment and prognosis. We also discuss the challenges in defining and diagnosing prediabetes in cats.

A Placebo-Controlled Study on the Effects of the Glucagon-Like Peptide-1 Mimetic, Exenatide, on Insulin Secretion, Body Composition and Adipokines in Obese, Client-Owned Cats

Glucagon-like Peptide-1 mimetics increase insulin secretion and reduces body weight in humans. In lean, healthy cats, short-term treatment has produced similar results, whereas the effect in obese cats or with extended duration of treatment is unknown. Here, prolonged (12 weeks) treatment with the Glucagon-like Peptide-1 mimetic, exenatide, was evaluated in 12 obese, but otherwise healthy, client-owned cats. Cats were randomized to exenatide (1.0 μg/kg) or placebo treatment twice daily for 12 weeks. The primary endpoint was changes in insulin concentration; the secondary endpoints were glucose homeostasis, body weight, body composition as measured by dual-energy x-ray absorptiometry and overall safety. An intravenous glucose tolerance test (1 g/kg body weight) was conducted at week 0 and week 12. Exenatide did not change the insulin concentration, plasma glucose concentration or glucose tolerance (P>0.05 for all). Exenatide tended to reduce body weight on continued normal feeding. Median relative weight loss after 12 weeks was 5.1% (range 1.7 to 8.4%) in the exenatide group versus 3.2% (range -5.3 to 5.7%) in the placebo group (P = 0.10). Body composition and adipokine levels were unaffected by exenatide (P>0.05). Twelve weeks of exenatide was well-tolerated, with only two cases of mild, self-limiting gastrointestinal signs and a single case of mild hypoglycemia. The long-term insulinotropic effect of exenatide appeared less pronounced in obese cats compared to previous short-term studies in lean cats. Further investigations are required to fully elucidate the effect on insulin secretion, glucose tolerance and body weight in obese cats.

Longitudinal evaluation of serum pancreatic enzymes and ultrasonographic findings in diabetic cats without clinically relevant pancreatitis at diagnosis

Background

Cats with diabetes mellitus can have subclinical pancreatitis but prospective studies to confirm this are lacking. Metabolic control of diabetic cats with pancreatitis is difficult.

Hypothesis

Subclinical pancreatitis occurs in diabetic cats at the time diabetes is diagnosed or might develop during the follow‐up period, hampering diabetic remission.

Animals

Thirty cats with newly diagnosed diabetes without clinical signs of pancreatitis on admission.

Methods

Prospective study. On admission and 2 and 6 months later, serum Spec fPL and DGGR‐lipase were measured and the pancreas underwent ultrasonographic examination. Pancreatitis was suspected if serum markers were increased or ≥2 ultrasonographic abnormalities were detected. Cats were treated with insulin glargine and diabetic remission was defined as euglycemia ≥4 weeks after discontinuation of insulin. Nonparametric statistical tests were used for analysis.

Results

Subclinical pancreatitis at the time of diagnosis was suspected in 33, 50, and 31% of cats based on Spec fPL, DGGR‐lipase and ultrasonography, respectively; and in 60% when diagnostic criteria were combined. During the follow‐up period, suspected pancreatitis developed in additional 17–30% cats. Only 1 cat had transient clinical signs compatible with pancreatitis. Seventeen of the 30 cats (57%) achieved remission. Frequency of abnormal Spec fPL and DGGR‐lipase and abnormal ultrasonographic findings did not differ in cats achieving remission and those who did not. Cats achieving remission had significantly lower Spec fPL at 2 months (P < .001).

Conclusions and Clinical Importance

Based on laboratory and ultrasonographic measurements, many cats with diabetes might have pancreatitis, although without clinical signs. Cats with high Spec fPL might have a reduced chance of diabetic remission; however, this topic needs further studies in large cohorts of diabetic cats.

Exocrine Pancreas in Cats With Diabetes Mellitus

Pancreatitis has been described in cats with diabetes mellitus, although the number of studies currently available is very limited. In addition, ketoacidosis has been hypothesized to be associated with pancreatitis in diabetic cats. The aims of the present study were to investigate whether diabetic cats have pancreatitis and to determine if pancreatitis is more frequent with ketoacidosis. Samples of pancreas were collected postmortem from 37 diabetic cats, including 15 with ketoacidosis, and 20 control cats matched for age, sex, breed, and body weight. Sections were stained with hematoxylin and eosin, double-labeled for insulin/CD3, insulin/CD20, insulin/myeloperoxidase, insulin/PCNA, and glucagon/Ki67, and single-labeled for Iba1. A previously proposed semiquantitative score was used to characterize pancreatitis, along with counts of inflammatory cells. Scores of pancreatitis and the number of neutrophils, macrophages, and lymphocytes in the exocrine pancreas did not differ between diabetic and control cats or between diabetic cats with and without ketoacidosis. Of note, PCNA-positive acinar cells were increased ( P = .002) in diabetic cats, particularly near islets ( P < .001). Ki67-positive acinar cells were increased only near islets ( P = .038). Ketoacidosis was not linked to proliferation. The results suggest that histopathologic evidence of pancreatitis may not be more frequent in diabetic cats and that ketoacidosis may not be associated with it at the time of death. Augmented PCNA-positive acinar cells might indicate increased proliferation due to chronic pancreatitis. The reason behind the prevalent proliferation of acinar cells surrounding pancreatic islets deserves further investigation.

Endocrine Pancreas in Cats With Diabetes Mellitus

Pancreatic amyloidosis and loss of α and β cells have been shown to occur in cats with diabetes mellitus, although the number of studies currently available is very limited. Furthermore, it is not known whether pancreatic islet inflammation is a common feature. The aims of the present study were to characterize islet lesions and to investigate whether diabetic cats have inflammation of the pancreatic islets. Samples of pancreas were collected postmortem from 37 diabetic and 20 control cats matched for age, sex, breed, and body weight. Histologic sections were stained with hematoxylin and eosin and Congo red; double labeled for insulin/CD3, insulin/CD20, insulin/myeloperoxidase, insulin/proliferating cell nuclear antigen, and glucagon/Ki67; and single labeled for amylin and Iba1. Mean insulin-positive cross-sectional area was approximately 65% lower in diabetic than control cats ( P = .009), while that of amylin and glucagon was similar. Surprisingly, amyloid deposition was similar between groups ( P = .408). Proliferation of insulin- and glucagon-positive cells and the number of neutrophils, macrophages, and T (CD3) and B (CD20) lymphocytes in the islets did not differ. The presence of T and B lymphocytes combined tended to be more frequent in diabetic cats ( n = 8 of 37; 21.6%) than control cats ( n = 1 of 20; 5.0%). The results confirm previous observations that loss of β cells but not α cells occurs in diabetic cats. Islet amyloidosis was present in diabetic cats but was not greater than in controls. A subset of diabetic cats had lymphocytic infiltration of the islets, which might be associated with β-cell loss.

Pancreatic Abscess in a Cat with Diabetes Mellitus

An 11 yr old spayed female Maine coon cat was referred with uncontrolled diabetes mellitus. The cat had a 2 mo history of weight loss and intermittent vomiting. An abdominal ultrasound identified the presence of a large cavity measuring a maximum of 4.6 cm in the pancreas that was filled with a homogeneous echogenic fluid. Cytological analysis and culture of the fluid obtained from the pancreatic mass indicated the presence of a bacterial abscess. The application of nonsurgical drainage and the administration of glargine insulin and antibiotics resolved the clinical signs. The size of the pancreatic abscess was reduced after 5 mo, and the cat achieved diabetic remission and remained healthy at the time this report was prepared. This case report describes the successful treatment of a pancreatic bacterial abscess concurrent with diabetes mellitus in a Maine coon cat.

ISFM consensus guidelines on the practical management of diabetes mellitus in cats

PRACTICAL RELEVANCE

Diabetes mellitus (DM) is a common endocrinopathy in cats that appears to be increasing in prevalence. The prognosis for affected cats can be good when the disease is well managed, but clinical management presents challenges, both for the veterinary team and for the owner. These ISFM Guidelines have been developed by an independent, international expert panel of clinicians and academics to provide practical advice on the management of routine (uncomplicated) diabetic cats.

CLINICAL CHALLENGES

Although the diagnosis of diabetes is usually straightforward, optimal management can be challenging. Clinical goals should be to limit or eliminate clinical signs of the disease using a treatment regimen suitable for the owner, and to avoid insulin-induced hypoglycaemia or other complications. Optimising bodyweight, feeding an appropriate diet and using a longer acting insulin preparation (eg, protamine zinc insulin, insulin glargine or insulin detemir) are all factors that are likely to result in improved glycaemic control in the majority of cats. There is also some evidence that improved glycaemic control and reversal of glucose toxicity may promote the chances of diabetic remission. Owner considerations and owner involvement are an important aspect of management. Provided adequate support is given, and owners are able to take an active role in monitoring blood glucose concentrations in the home environment, glycaemic control may be improved. Monitoring of other parameters is also vitally important in assessing the response to insulin. Insulin adjustments should always be made cautiously and not too frequently--unless hypoglycaemia is encountered.

EVIDENCE BASE

The Panel has produced these Guidelines after careful review of the existing literature and of the quality of the published studies. They represent a consensus view on practical management of cats with DM based on available clinical data and experience. However, in many areas, substantial data are lacking and there is a need for better studies in the future to help inform and refine recommendations for the clinical management of this common disease.

Insulin detemir treatment in diabetic cats in a practice setting

Insulin detemir is a long-acting insulin analogue and may represent a valuable treatment option for diabetic cats. So far, only one study addressing detemir treatment of diabetic cats has been published, and this was based on an intensive blood glucose monitoring protocol. The aim of the current, retrospective study was to evaluate the effect of detemir therapy in diabetic cats in a general clinical setting. Fourteen diabetic cats with a follow-up period of at least 3 months were included. Data were collected from medical records at the University Hospital for Companion Animals, University of Copenhagen, Denmark. Thirteen of 14 cats achieved moderate or excellent control of clinical symptoms within the initial 3 months of detemir therapy, including five cats previously treated unsuccessfully with other types of insulin. Clinical improvements were noted after 1 month of therapy and continued over time. Three cats achieved remission within the initial 3 months and none experienced a diabetic relapse during the study period. One cat achieved remission after 13 months of therapy. Improvements in clinical symptoms were markedly better than indicated by blood glucose and serum fructosamine concentrations. The safety of detemir was very high, with only two reported episodes of clinical hypoglycaemia, neither of which required veterinary attention. Based on these results detemir can be recommended for the treatment of diabetic cats, including cats previously treated unsuccessfully with other types of insulin.

Animal models of disease: classification and etiology of diabetes in dogs and cats

Diabetes mellitus is a common disease in dogs and cats. The most common form of diabetes in dogs resembles type 1 diabetes in humans. Studies suggest that genetics, an immune-mediated component, and environmental factors are involved in the development of diabetes in dogs. A variant of gestational diabetes also occurs in dogs. The most common form of diabetes in cats resembles type 2 diabetes in humans. A major risk factor in cats is obesity. Obese cats have altered expression of several insulin signaling genes and glucose transporters and are leptin resistant. Cats also form amyloid deposits within the islets of the pancreas and develop glucotoxicity when exposed to prolonged hyperglycemia. This review will briefly summarize our current knowledge about the etiology of diabetes in dogs and cats and illustrate the similarities among dogs, cats, and humans.

Systematic review of feline diabetic remission: separating fact from opinion

It is increasingly recognised that diabetic remission is possible in the cat. This systematic review, following Cochrane Collaboration (CC) guidelines, critically appraises the level of evidence on factors influencing remission rate and factors predicting remission. A systematic online, bibliographic search and reference list examination was conducted. A level of evidence was assigned to each identified article by five internists using the Newcastle-Ottawa Scale for follow-up, cohort, case-series and case-control studies, the CC's risk of bias tool for trials and the Cochrane Effective Practice and Organisation of Care Group risk of bias criteria for before and after trials. Twenty-two studies were included in the review, assessing influence of pharmaceutical intervention (n = 14) and diet (n = 4), as well as diagnostic tests (n = 9) and feline patient characteristics (n = 5) as predictors of remission. The current level of evidence was found to be moderate to poor. Common sources of bias included lack of randomisation and blinding among trials, and many studies were affected by small sample size. Failure to provide criteria for the diagnosis of diabetes, or diabetic remission, and poor control of confounding factors were frequent causes of poor study design. Addressing these factors would significantly strengthen future research and ultimately allow meta-analyses to provide an excellent level of evidence. No single factor predicts remission and successful remission has been documented with a variety of insulin types and protocols. Dietary carbohydrate reduction might be beneficial, but requires further study. A lack of well-designed trials prevents reliable remission rate comparison. Factors associated with remission resemble those in human medicine and support the hypothesis that reversal of glucotoxicity is a major underlying mechanism for feline diabetic remission.

Pancreatitis in cats: is it acute, is it chronic, is it significant?

PRACTICAL RELEVANCE

Pancreatitis is a frequent finding in cats, the chronic form being more common than the acute form. Despite the large number of diseases or conditions that may be associated with feline pancreatitis, in most cases no cause is diagnosed and the pancreatitis is said to be idiopathic. The chronic form can be mild and asymptomatic, and has a high prevalence in apparently healthy cats. This has generated debate concerning the clinical significance of chronic feline pancreatitis. However, several reports have demonstrated the severity of clinical signs in certain forms of acute feline pancreatitis, while other studies have reported a strong association between chronic pancreatitis and the development of comorbidities such as hepatic lipidosis, diabetes mellitus, inflammatory bowel disease or exocrine pancreatic insufficiency. This suggests that feline pancreatitis should not be overlooked.

CLINICAL CHALLENGES

Diagnosis of feline pancreatitis is complicated by the non-specific clinical signs and poor diagnostic value of basic biochemistry and haematology or imaging techniques. Development of a feline-specific pancreatic lipase immunoassay has improved our diagnostic ability in the past decade, but may have more limited application for mild and chronic forms of pancreatitis. Moreover, histopathology (the 'gold standard' diagnostic test) can be associated with false-negative results due to multifocal distribution of lesions or mild forms of the disease. With respect to treatment, it is important to take into account the idiosyncrasies of the feline species when considering medical therapies.

EVIDENCE BASE

This article reviews the literature on feline pancreatitis, focusing on the different forms and their relative clinical significance, while explaining difficulties inherent in the diagnosis of this disease. An overview of current recommendations for the management of cats with pancreatitis is also provided.

Survival time and prognostic factors in cats with newly diagnosed diabetes mellitus: 114 cases (2000-2009)

OBJECTIVE

To determine overall survival time and identify prognostic factors associated with survival time in cats with newly diagnosed diabetes mellitus.

DESIGN

Retrospective case series.

ANIMALS

114 cats with newly diagnosed diabetes mellitus.

PROCEDURES

Data for analysis included history, signalment, physical examination findings, hematologic and serum biochemical data, presence of ketoacidosis, and diagnosis of concurrent diseases at initial evaluation. The effects of possible predictors on survival time were determined by calculating hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Median survival time of diabetic cats was 516 days (range, 1 to 3,468 days); 70%, 64%, and 46% lived longer than 3, 6, and 24 months, respectively. Survival time was significantly shorter for cats with higher creatinine concentrations, with a hazard of dying approximately 5% greater for each increase of 10 μg/dL in serum creatinine concentration (adjusted HR, 1.005; 95% CI, 1.003 to 1.007). Ketoacidosis was not significantly associated with survival time (HR, 1.02; 95% CI, 0.590 to 1.78).

CONCLUSIONS AND CLINICAL RELEVANCE

Cats with newly diagnosed diabetes mellitus had a fair to good prognosis. High serum creatinine concentration at diagnosis was associated with a poor outcome, likely because of the adverse effects of renal dysfunction. Ketoacidosis apparently was not associated with decreased survival time, suggesting that this complication should not necessarily be regarded as unfavorable.

Feline CKD: Current therapies - what is achievable?

PRACTICAL RELEVANCE

Treatment of feline chronic kidney disease (CKD) tends to focus on minimising the adverse effects of reduced renal function, rather than addressing an underlying cause. Despite this, and the progressive nature of CKD, treatment can improve quality of life and enable many cats to have long survival times.

EVIDENCE BASE

Strong evidence supports the provision of renal diets, which are protein and phosphorus restricted; compliance is improved by gradual dietary transition. Additional phosphorus restriction is achieved by the use of phosphate binding agents, although it is unknown if these yield similar survival benefits to those provided by renal diets. Interventions to control hypokalaemia and hypertension in affected cats are important to prevent serious complications. Administration of benazepril to cats with proteinuric kidney disease has been shown to significantly improve their appetite but not their survival. As CKD progresses, many cats will benefit from treatment to control clinical signs of uraemic gastroenteritis and anaemia.

Factors associated with clinical remission in cats with diabetes mellitus

Type 2 diabetes mellitus is a common endocrine disease in cats. The aim of this study was to investigate factors that are associated with clinical remission in diabetic cats, and those that might influence survival time. Medical records of 29 cats with diabetes mellitus were evaluated retrospectively. Data collected from each record included breed, age, and sex, types of diet before and after admission, degree of weight loss, duration of clinical signs before admission, elevation of alanine aminotransferase activity and ketonuria at the time of admission, concurrent pancreatitis or renal failure, glipizide administration, insulin supplement, and survival time. The diet after establishing diagnosis (restriction to non-carbohydrate canned food) was the only factor that was significantly associated with achieving clinical remission (P < 0.001). Survival time of cats was positively associated (P = 0.004) with clinical remission status and the type of diet after admission (P = 0.04) and negatively associated with the presence of chronic renal failure (P = 0.04). This was the first report of feline diabetes mellitus from Taiwan.

A survey of Southeastern United States veterinarians' preferences for managing cats with diabetes mellitus

This study evaluated primary practitioners' perceptions of managing feline diabetics. Surveys distributed during local continuing education events achieved a response rate of 46% (90/195). A mean of 74% feline diabetics required chronic insulin; 26% were transient diabetics. Choice of insulin was most influenced by duration of action: human recombinant protamine zinc insulin was ranked first (42%) and glargine second (27%). Dietary management was always/usually recommended by 97% respondents, with prescription or proprietary low-carbohydrate, high-protein diets recommended in 93% responses. More recent graduates (P=0.0419), those who worked in larger practices (P=0.0315), and those who saw more transient diabetics (P=0.0288) were more likely to recommend dietary change. In-house blood glucose curves (BGCs) were the most popular method of assessing glycemic control, while at-home BGCs were least popular, although their use correlated positively with annual diabetic caseload (r=0.43, P=0.0239). Owners mishandling insulin was cited as the most common cause of poor glycemic control, while clinical signs of acromegaly were rarely recognized.

Long-Term Survival in a Cat with Pancreatic Carcinoma and Splenic Involvement after Surgical Excision

A thirteen-year-old female spayed with a history of hydronephrosis was presented for a routine abdominal ultrasonographic exam. The imaging exam showed a mass involving the pancreas and a large mass affecting the spleen. Exploratory laparotomy evidenced a mass in the pancreas and another involving one-third of the spleen. The patient had partial pancreatectomy and splenectomy. The histopathology report came back with a diagnosis of pancreatic carcinoma. Adjuvant chemotherapy was declined. The cat is still free of gross tumor recurrence and metastatic disease after twenty-six months. Early diagnosed and aggressively treated feline pancreatic carcinoma might yield a favorable prognosis.

Hyperglycaemia but not hyperlipidaemia decreases serum amylase and increases neutrophils in the exocrine pancreas of cats

The goal of the study was to determine whether hyperglycaemia or hyperlipidaemia causes pancreatitis in cats and to assess the effect of excess serum glucose and lipids on amylase and lipase activity. Ten-day hyperglycaemic and hyperlipidaemic clamps were carried out in five and six healthy cats, respectively. Ten healthy cats received saline and served as controls. The activity of amylase was below the normal range in 4 of 5 hyperglycaemic cats by day 10. The activity of lipase did not vary in any of the cats. Samples of exocrine pancreas were normal on histological examination, but the number of tissue neutrophils was increased in hyperglycaemic cats (P<0.05). In a retrospective study 14 of 40 (35%) cats with naturally occurring diabetes mellitus had amylase activities below the reference range at the time of admission. Amylase activities normalised within 1 week of insulin therapy and subsequent glycaemic control. Lipase activity was increased in 26 of 40 (65%) diabetic cats and remained elevated despite glycaemic control. In conclusion, hyperglycaemia, but not hyperlipidaemia, increases pancreatic neutrophils in cats. However, because the histological morphology of the exocrine pancreas was normal, hyperglycaemia may play only a minor role in the pathogenesis of pancreatitis. Low amylase activities in diabetic cats may reflect an imbalance in glucose metabolism rather than pancreatitis.

Determination of serum fPLI concentrations in cats with diabetes mellitus

Diabetes mellitus (DM) is one of the most common feline endocrinopathies. Pancreatitis is a reported cause for poor control of DM in cats; however, its prevalence in diabetic cats is unknown. Measurement of serum feline pancreatic lipase immunoreactivity (fPLI) has been proposed as a sensitive and specific test for the detection of pancreatitis in cats. The aim of this study was to assess fPLI concentrations in diabetic cats and compare these with non-diabetic cats of similar age. Samples from 29 cats with DM and 23 non-diabetic cats were analysed. Serum fPLI concentrations were significantly higher in samples from diabetic cats (P<0.01). A weak association was found between serum fructosamine and fPLI concentrations (R(2)=0.355, P=0.015), but there was no association between fPLI concentrations and the degree of diabetic control. There were no significant differences in reported clinical signs between cats with or without DM regardless of serum fPLI concentration. This is the first study to demonstrate elevated serum fPLI concentrations in cats with DM, suggesting that pancreatitis could be a significant comorbidity in these cats.

Treatment of 46 cats with porcine lente insulin--a prospective, multicentre study

This prospective, multicentre, non-blinded, open study followed 46 cats with diabetes mellitus during treatment with porcine lente insulin (also known as porcine insulin zinc suspension, Caninsulin, Intervet) for 16+/-1 weeks (stabilization phase), with additional monitoring of some cats (n=23) for a variable period. At least three of the following were present at initial presentation: appropriate history of clinical signs consistent with diabetes mellitus, glucosuria, blood glucose greater than 15 mmol/l and fructosamine greater than 380 micromol/l. Insulin treatment was started at a dose rate of 0.25-0.5 IU/kg body weight twice daily, with a maximum starting dose of 2 IU/injection. Twenty-eight of the cats were classed as reaching clinical stability during the study, in 23 of these cats this was during the stabilization phase. Seven cats went into remission during the stabilization phase and one of the cats in week 56. Clinical signs of hypoglycaemia, significantly associated with a dose of 3 units or 0.5 IU/kg or more per cat (twice daily), were observed in nine of the 46 cats during the stabilization phase and concomitant biochemical hypoglycaemia was recorded in most cases. Biochemical hypoglycaemia, recorded in 6% of the blood glucose curves performed during the stabilization phase, was significantly associated with a dose rate of 0.75 IU/kg or more twice daily. This further highlights the need for cautious stepwise changes in insulin dose. The protocol used in the present study is suitable for and easy to use in practice. This study confirmed the efficacy and safety of porcine lente insulin (Caninsulin) in diabetic cats under field conditions.

Time trends and risk factors for diabetes mellitus in cats presented to veterinary teaching hospitals

Veterinary Medical Data Base records of cats with diabetes mellitus (DM) from 1970 through 1999 were reviewed to identify trends in hospital prevalence of DM and potential host risk factors. Hospital prevalence increased from eight cases per 10,000 in 1970 to 124 per 10,000 in 1999 (P < 0.001). Case fatality percent at first visit decreased from 40% to 10% (P < 0.001). Hospital prevalence increased in all age groups (P < 0.002). There was no apparent seasonal pattern in hospital prevalence. Significant risk factors included male gender, increasing age for both genders (P < 0.001), increasing weight for males (P < 0.001), and mixed vs pure breed for females (P = 0.006).

Incidence of and risk factors for diabetes mellitus in cats that have undergone renal transplantation: 187 cases (1986–2005)

OBJECTIVE

To compare incidence of diabetes mellitus in cats that had undergone renal transplantation with incidence in cats with chronic renal failure, compare mortality rates in cats that underwent renal transplantation and did or did not develop diabetes mellitus, and identify potential risk factors for development of posttransplantation diabetes mellitus (PTDM) in cats.

DESIGN

Retrospective case series.

ANIMALS

187 cats that underwent renal transplantation.

PROCEDURES

Medical records were reviewed.

RESULTS

26 of the 187 (13.9%) cats developed PTDM, with the incidence of PTDM being 66 cases/1,000 cat years at risk. By contrast, the incidence of diabetes mellitus among a comparison population of 178 cats with chronic renal failure that did not undergo renal transplantation was 17.9 cases/1,000 cat years at risk, and cats that underwent renal trans-plantation were 5.45 times as likely to develop diabetes mellitus as were control cats with chronic renal failure. The mortality rate among cats with PTDM was 2.38 times the rate among cats that underwent renal transplantation but did not develop PTDM. Age, sex, body weight, and percentage change in body weight were not found to be significantly associated with development of PTDM.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that cats that undergo renal transplantation have an increased risk of developing diabetes mellitus, compared with cats with chronic renal failure, and that mortality rate is higher for cats that develop PTDM than for cats that do not.