Intramuscular glargine with or without concurrent subcutaneous administration for treatment of feline diabetic ketoacidosis

Frequency of diabetic remission, predictors of remission and survival in cats using a low-cost, moderate-intensity, home-monitoring protocol and twice-daily glargine

OBJECTIVES

The aim of the present study was to retrospectively assess remission rates and survival in diabetic cats managed using a moderate-intensity, low-cost protocol of home blood glucose measurements and insulin adjustment by clients of a cat-only practice, and to determine if predictors of remission, relapse or survival could be identified.

METHODS

The records of a cat-only practice were used to identify 174 cats with newly diagnosed diabetes managed using only pre-insulin home blood glucose measurements for insulin dose adjustments based on a protocol provided to clients aimed at maintaining pre-insulin blood glucose in the range of 6.5-11.9 mmol/l (117-214 mg/dl). Cats were excluded for the following reasons: insufficient follow-up in the records; a lack of owner compliance was recorded; they were receiving ongoing corticosteroids for the management of other conditions; they were euthanased at the time of diagnosis; or they were diagnosed with acromegaly or hyperadrenocorticism.

RESULTS

Using only pre-insulin blood glucose measurements at home to adjust the insulin dose to maintain glucose in the range of 6.5-11.9 mmol/l, 47% of cats achieved remission, but 40% of those cats relapsed. A minority (16%) of cats were hospitalised for hypoglycaemia. The survival time was significantly longer in cats in remission and Burmese cats.

CONCLUSIONS AND RELEVANCE

The cost and time burden of treating diabetic cats may cause some clients to choose euthanasia over treatment. While the highest rates of diabetic remission have been reported in studies of newly diagnosed cats treated with intensive long-acting insulin protocols and low carbohydrate diets, these protocols may not be suitable for all clients. Nearly 50% of cats with newly diagnosed diabetes achieved remission with this low-cost, moderate-intensity, insulin dosing protocol. As remission was significantly associated with survival time, discussing factors in treatment to optimise remission is important, but it is also important to offer clients a spectrum of options. No cats that started treatment in this study were euthanased because the owner did not wish to continue the diabetes treatment.

Diabetes Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome in Companion Animals

Diabetes mellitus is a common endocrinopathy in dogs and cats. Diabetes ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life-threatening complications of diabetes resulting from an imbalance between insulin and the glucose counter-regulatory hormones. The first part of this review focuses on the pathophysiology of DKA and HHS, and rarer complications such as euglycemic DKA and hyperosmolar DKA. The second part of this review focuses on the diagnosis and treatment of these complications.

Glargine versus regular insulin protocol in feline diabetic ketoacidosis

Objectives

To determine whether basal‐bolus administration of glargine insulin is a safe and effective alternative treatment compared to the standard continuous rate infusion (CRI) protocol.

Design

Prospective randomized clinical trial.

Setting

University teaching hospital.

Animals

Twenty cats diagnosed with diabetic ketoacidosis (DKA).

Interventions

The cats were block‐randomized to either a CRI protocol using regular insulin (CRI‐group; n = 10) or a basal‐bolus SC and IM glargine protocol (glargine‐group, n = 10). Baseline blood gases, electrolytes, glucose, and β‐hydroxybutyrate (β‐OHB) concentrations were measured at the time of admission and later at predefined intervals until reaching the primary endpoint of the study, defined as a β‐hydroxybutyrate concentration < 2.55 mmol/L.

Measurements and main results

The main outcome measure was time (h) to resolution of ketonemia. Secondary outcome measures were time until first improvement of hyperglycemia and ketonemia, decrease of glucose to ≤13.9 mmol/L (250 mg/dL), resolution of acidosis, consumption of first meal, and discharge from hospital. Additionally, occurrence of treatment‐associated adverse events and death were compared. Seventeen cats (85%) survived to discharge, with no difference in survival between groups (P = 1.0). Median times to β‐OHB < 2.55 mmol/L were 42 (CRI‐group) and 30 (glargine‐group) hours, respectively (P = 0.114). Median times to first improvement of hyperglycemia (glargine‐group: 2 h; CRI‐group: 6 h; P = 0.018) and until discharge from hospital (glargine‐group: 140 h; CRI‐group: 174 h; P = 0.033) were significantly shorter in the glargine‐group. No significant differences were observed in any other parameter under investigation (P > 0.05).

Conclusions

Basal‐bolus administration of glargine insulin appears to be an effective and safe alternative to the current standard CRI‐protocol for the management of DKA in cats. The positive outcomes and simplicity make it a viable option for the treatment of feline DKA.

Lispro insulin and electrolyte supplementation for treatment of diabetic ketoacidosis in cats

Background

Intravenous continuous rate infusion (IVCRI) of lispro at a starting dose of 0.09 U/kg/h and the use of 0.9% sodium chloride (NaCl) for fluid resuscitation in cats with diabetic ketoacidosis (DKA) have not been reported. Protocols for correction of electrolyte deficiencies in cats with DKA are lacking.

Objectives

To characterize the use of IVCRI lispro at an initial dose of 0.09 U/kg/h and the use of NaCl for resuscitation. Explore protocols for electrolyte supplementation in cats with DKA.

Animals

Twelve cats with DKA enrolled from the cat population of a university hospital.

Methods

Randomized, controlled, blinded study. Six cats were randomized into each group, the lispro insulin treatment group (LITG) and regular insulin treatment group (RITG). All cats received IVCRI fluid resuscitation with NaCl. Solutions with higher than previously published electrolyte concentrations were used to treat electrolyte deficiencies.

Results

The median time to blood glucose (BG) concentration <250 mg/dL was significantly shorter in the LITG (median 7 hours, 2‐10 hours) than the RITG (median 12.5 hours, 8‐20 hours; P = .02). Two cats had nonclinical hypoglycemia (BG = 40 mg/dL). The most rapid change in 157 measurements of corrected sodium concentrations was 0.7 mmol/L/h. Low concentrations of serum sodium, potassium, phosphate, and magnesium were over 3 times more common than above normal electrolyte concentrations, despite supplementation with fluids of high electrolyte concentrations.

Conclusions and Clinical Importance

Lispro at a starting dose of 0.09 U/kg/h and NaCl administered for fluid resuscitation are safe and effective for treatment of DKA in cats.

Use of lispro insulin for treatment of diabetic ketoacidosis in cats

OBJECTIVES

The aim of this study was to evaluate the efficacy and safety of lispro insulin for the treatment of feline diabetic ketoacidosis (DKA). Times to resolution of hyperglycaemia, ketosis and acidosis were compared between cats treated with continuous rate infusion (CRI) of lispro insulin and cats treated with CRI of regular insulin.

METHODS

Client-owned cats with naturally occurring DKA, newly diagnosed with diabetes mellitus (DM) or already receiving treatment for DM, were included. Diagnosis of DKA involved the presence of at least two clinical signs consistent with DKA (eg, polyuria/polydipsia, anorexia, severe lethargy, vomiting and dehydration), blood glucose (BG) concentration >13.9 mmol/l (>250 mg/dl), blood beta hydroxybutyrate (BHB) concentration >2.5 mmol/l and venous pH <7.3 or bicarbonate <15 mEq/l. Cats were treated with a standard protocol of an intravenous (IV) CRI of regular insulin (group R) or lispro insulin (group L). The time to resolution of DKA was defined as the time interval from when the IV CRI of insulin began until marked hyperglycaemia (BG >13.9 mmol/l [>250 mg/dl]), ketosis (BHB concentration >1 mmol/l) and acidosis (venous pH <7.3 and/or bicarbonate <15 mEq/l) resolved.

RESULTS

Eighteen DKA cases (nine per group) were enrolled into the study. There were no significant differences in the median time to resolution of three variables (hyperglycaemia, ketosis and acidosis) between the two groups. Two cats in group R developed hypoglycaemia during the CRI of insulin. One cat in group L and three cats in group R developed hypophosphataemia, which required phosphate supplementation.

CONCLUSIONS AND RELEVANCE

IV CRI of lispro insulin has few side effects and appears to be as effective as IV CRI of regular insulin in the treatment of cats with DKA.

Basal insulin for the management of diabetic ketoacidosis

Due to its pharmacokinetic properties, it has been suggested that long-acting insulin analogues may have a role in facilitating the transition from continuous intravenous insulin infusion to subcutaneous maintenance therapy in patients with DKA for prevention of rebound hyperglycemia, particularly if there are high insulin requirements. Concomitant administration of basal insulin analogues with regular insulin infusion accelerates ketoacidosis resolution and prevents rebound hyperglycemia. Several studies have investigated the use of basal insulin in the management of DKA. Studies have been instituted on pediatric patients and adult patients. These studies reveal that co-administration of basal insulin in combination with an insulin infusion in the acute management of DKA is feasible. Basal insulin co-administration with regular insulin infusion was well tolerated, associated with faster resolution of acidosis without any adverse effects; patients required a shorter duration of intravenous insulin infusion and had a lower total dose of intravenous insulin and significantly decreased hyperglycemia after discontinuation of the intravenous insulin. This could potentially lead to a shorter ICU length of stay and reduced costs in the treatment of DKA. However, this approach may be associated with an increased risk of hypokalemia. The current literature on this management approach is incomplete, due to its many limitations (retrospective nature, small sample size, nonrandomized design). Additional prospective randomized studies are needed on this new therapeutic approach in the management patients with DKA.

Diabetic ketoacidosis in the cat: Recognition and essential treatment

Practical relevance: Diabetic ketoacidosis (DKA) is a not uncommon emergency in both newly diagnosed and poorly regulated diabetic cats. When there is a heightened metabolic rate and energy requirement due to concurrent illness, an increase in the release of glucose counter-regulatory hormones causes insulin receptor resistance, lipolysis, free fatty acid release and ketogenesis. This necessitates not only treatment to eliminate the ketosis and control blood glucose, but also investigation of concurrent illnesses. Clinical challenges: A number of metabolic derangements can occur with DKA, requiring a comprehensive diagnostic evaluation, elimination of ketones, careful correction of glucose, electrolyte and acid base abnormalities, and close monitoring.

AUDIENCE

Any veterinarian that cares for cats in urgent and emergency situations should understand the pathophysiology of DKA in order to address an individual's clinical signs and metabolic derangements. Evidence base: This review draws evidence from the peer-reviewed literature as well as the author's personal clinical experience.

Effectiveness of Insulin Glargine on Recovery of Patients with Diabetic Ketoacidosis: A Randomized Controlled Trial

BACKGROUND

Diabetic Ketoacidosis (DKA) is a major hyperglycemic emergency in diabetes mellitus (DM). The basic treatment is injection of Regular insulin (RI). This study was aimed to investigate the effects of insulin Glargine (GI) on recovery of patients with DKA.

MATERIALS AND METHODS

A randomized clinical trial conducted on 40 patients (twenty patients in each group) with DKA. Both groups received standard treatment for DKA. Experimental group was given 0.4U/kg of GI within three hours of initiation of IV insulin infusion.

RESULTS

The mean duration of acidosis correction time and recovery from DKA was 13.77±6.10 and 16.91±6.49 h in the intervention and control groups respectively (p=0.123). The mean dosage of RI until recovery from DKA was 84.8±45.6 in the intervention and 116.5±91.6 units in control groups (p=0.17). Hypokalemia occurred in three patients in intervention and four patients in control groups. In 35% of samples in intervention group and 51% in controls blood sugar was more than 10 mmol/l for 24 h after discontinuation of the insulin infusion (p=0.046). The mean duration of hospitalization was 5.1±1.88 in intervention and 5.9±2.19 d in control group (p=0.225).

CONCLUSION

Adding GI to the standard treatment of DKA reduced average time of recovery from DKA, without incurring episodes of hypoglycemia and hypokalemia. This also reduced in the time of recovery from DKA, amount of required insulin and the duration of hospitalization. It seems that the non-significant difference in the time of recovery from DKA be related to the small sample size and study design. Further studies are recommended.

Update on insulin treatment for dogs and cats: insulin dosing pens and more

Insulin therapy is still the primary therapy for all diabetic dogs and cats. Several insulin options are available for each species, including veterinary registered products and human insulin preparations. The insulin chosen depends on the individual patient’s requirements. Intermediate-acting insulin is usually the first choice for dogs, and longer-acting insulin is the first choice for cats. Once the insulin type is chosen, the best method of insulin administration should be considered. Traditionally, insulin vials and syringes have been used, but insulin pen devices have recently entered the veterinary market. Pens have different handling requirements when compared with standard insulin vials including: storage out of the refrigerator for some insulin preparations once pen cartridges are in use; priming of the pen to ensure a full dose of insulin is administered; and holding the pen device in place for several seconds during the injection. Many different types of pen devices are available, with features such as half-unit dosing, large dials for visually impaired people, and memory that can display the last time and dose of insulin administered. Insulin pens come in both reusable and disposable options. Pens have several benefits over syringes, including improved dose accuracy, especially for low insulin doses.

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.

A pilot study comparing a protocol using intermittent administration of glargine and regular insulin to a continuous rate infusion of regular insulin in cats with naturally occurring diabetic ketoacidosis

OBJECTIVE

The goal of this pilot study was to compare regular insulin administered by continuous rate infusion (CRI) to an approach using insulin glargine and regular insulin administered intermittently.

DESIGN

Prospective randomized clinical trial.

SETTING

University teaching hospital.

ANIMALS

Sixteen cats with diabetic ketoacidosis (DKA).

INTERVENTIONS

Cats with DKA were randomized to either low-dose regular insulin CRI (CRI group; n = 8) or intermittent short- and long-acting insulin injections (subcutaneous [SC] glargine plus intramuscular [IM] regular insulin; SC/IM group; n = 8).

MEASUREMENTS AND MAIN RESULTS

Time of normalization of pH, bicarbonate, hyperglycemia, ketonemia, and appetite, as well as duration of hospitalization were recorded. Eleven of 16 cats (59%) survived to discharge, with no difference in survival between groups (P = 0.99). Times of resolution of hyperglycemia (P = 0.02) and ketonemia (P = 0.04), and normalization of pH (P = 0.04), and bicarbonate (P = 0.03) were significantly shorter in the SC/IM group. Cats in the SC/IM group also had a significantly shorter duration of hospitalization (SC/IM: median = 54 hr [range, 19-118 hr]; CRI: median = 111 hr [range, 58-271 hr]; P = 0.04). Time of first meal was not significantly different between groups.

CONCLUSIONS

Although further research is required, an approach using intermittent short- and long-acting insulin injections appeared to be an effective option for treatment of DKA in cats.