May 10, 2024

#120: Rethink Diabetes: Why Basal Insulin is a Game-Changer In Feline Diabetes Management. With Dr Linda Fleeman.

#120: Rethink Diabetes: Why Basal Insulin is a Game-Changer In Feline Diabetes Management. With Dr Linda Fleeman.

This episode features an enlightening discussion with Dr. Linda Fleeman, an internationally renowned expert on veterinary diabetes management, focusing primarily on cats. Listeners are introduced to groundbreaking approaches that challenge traditional paradigms, such as the use of basal insulin protocols, flexible dosing schedules, and the dissociation of insulin administration from feeding times. Dr. Fleeman simplifies the complexities of managing feline diabetes by advocating for practical dietary adjustments, including low-carbohydrate wet foods and portion control. The conversation also highlights innovative monitoring methods, from urine glucose testing to the Freestyle Libre continuous glucose monitor, offering flexible solutions for different client needs. Packed with actionable insights, this episode empowers veterinarians to improve outcomes for diabetic patients while addressing common misconceptions and practical challenges.

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Season 1

What if I told you that your clients never have to worry about when they inject their diabetic cats with insulin, and still maintain beautiful glucose control? And timing insulin with meal times: forget about it!

Those are just some of the things you’ll learn about in this episode about using basal insulin in veterinary diabetic patients. We also discuss:

  • Why you don't need fancy diets for good glucose control.
  • How traditional glucose curves not necessary for monitoring diabetic cats on basal insulin.
  • Great tips for using continuous glucose monitoring devices.

Dr Linda Fleeman is an internationally renowned veterinary expert on the treatment of diabetes, and is regularly invited to write textbook chapters and speak on this topic at international forums. Linda has worked in both university referral practice and general small animal practice, with her primary focus for more than 20 years being all aspects of diabetes in dogs and cats. She completed a Residency in Small Animal Medicine, followed by a PhD on the clinical management of diabetes mellitus in dogs.  She’s held positions as Lecturer in Small Animal Medicine at the University of Queensland and Senior Lecturer in Small Animal Medicine at the University of Sydney before deciding to return to private clinical practice back in 2010. She currently does her work through Animal Diabetes Australia, the only diabetes-specific veterinary clinical service in the world, where she and her team pioneer ground-breaking diabetes treatments and management strategies and help practitioners better manage their patients through her consulting service.

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Transforming Feline Diabetes Management with Basal Insulin

The management of feline diabetes is undergoing a paradigm shift with the introduction of basal insulin, specifically Toujeo, a new formulation of glargine insulin. This approach offers a simpler, more effective, and less stressful way to manage diabetes in cats, moving away from traditional methods that often relied on strict timing and meal-matching insulin protocols.
The foundation of this transformative approach lies in understanding the physiology of insulin secretion in cats and mimicking it with a long-acting insulin that provides a consistent background level of insulin throughout the day.
Here’s a closer look at how this approach is reshaping feline diabetes management:
  • Embracing Basal Insulin: Toujeo, a highly concentrated glargine insulin (300 units/ml), is designed to provide a flat and prolonged action profile, making it an ideal basal insulin for cats.
  • Simplified Insulin Delivery: The higher concentration necessitates the use of insulin dosing pens for accurate measurement, eliminating the inaccuracies associated with traditional syringes.
  • Flexible Dosing: While twice-daily injections are typically recommended, Toujeo's extended duration of action allows for flexibility in timing, making it less disruptive to owners' routines.
  • De-Coupling Insulin from Meals: Basal insulin eliminates the need to synchronise insulin injections with meal times, a significant departure from conventional methods. This is because the background level of insulin provided by Toujeo is sufficient to manage blood glucose fluctuations even after meals.
The success of basal insulin therapy is further enhanced by dietary modifications that focus on reducing carbohydrate intake and controlling portion size.
  • Wet Food is Key: Transitioning cats to a wet food diet is crucial as dry cat food is typically high in carbohydrates. Wet food, being naturally lower in carbohydrates and providing inherent portion control, helps minimise postprandial glucose spikes.
  • Portion Control Matters: Even with wet food, portion control is essential to prevent obesity, which can worsen insulin resistance. Zucchini, a low-calorie, low-carbohydrate vegetable, can be offered as a healthy way to satisfy hungry cats without adding significant calories.
Shifting the Focus of Monitoring: Traditional monitoring methods, such as in-hospital glucose curves, are being challenged in favour of more practical and insightful approaches.
  • Clinical Signs as Guides: Monitoring clinical signs like weight loss, excessive thirst, and urination provides valuable insights into the effectiveness of the treatment plan.
  • Urine Glucose as an Early Indicator: Regular urine glucose monitoring allows owners to track blood glucose control. Consistent absence of glucose in the urine can indicate remission or the need to adjust the insulin dose.
  • Embracing Continuous Glucose Monitoring: For more detailed insights and faster decision-making, continuous glucose monitoring devices like the Freestyle Libre can be extremely valuable.
  • Home Blood Glucose Monitoring: While home blood glucose monitoring can be helpful, it’s crucial to collect multiple measurements (7-10) over time to account for day-to-day variability, rather than relying on single spot checks.
The overarching principle is to move away from viewing monitoring results as rigid targets and instead use them as tools to inform adjustments to the treatment plan. The ultimate goal remains the same: control clinical signs, improve the cat's quality of life, and potentially achieve diabetic remission.
Implementing this new approach requires a collaborative effort between veterinarians and owners, with clear communication and ongoing support being essential for successful long-term management of feline diabetes.

Effective Monitoring of Diabetic Cats: Moving Beyond Traditional Methods

Traditionally, monitoring diabetic cats often involved in-hospital glucose curves, which are now considered less useful and reliable. The focus has shifted to more practical and insightful methods that empower owners to track their cat's progress and inform treatment adjustments.
Here are some effective ways to monitor diabetic cats:
  • Observing Clinical Signs: Keep a close eye on your cat's weight, water intake, and urination frequency. Weight loss, excessive thirst (polydipsia), and frequent urination (polyuria) are classic signs of uncontrolled diabetes.
  • Urine Glucose Monitoring: This simple and inexpensive method involves checking the cat's urine for glucose daily. Consistent absence of glucose suggests good control, potentially indicating remission or a need to lower the insulin dose.
  • Home Blood Glucose Monitoring: While useful, it's crucial to collect 7-10 blood glucose readings over time, rather than relying on single spot checks, to account for day-to-day fluctuations.
  • Continuous Glucose Monitoring (CGM): CGM devices, such as the Freestyle Libre, offer detailed insights into blood glucose patterns, aiding in faster decision-making.
The key is to use these monitoring tools to identify patterns of change and make informed, long-term decisions, rather than reacting to isolated readings. Remember:
  • Monitoring results are not the goals themselves; they are tools to help you achieve the desired outcomes for your cat.
  • The ultimate goals are to control clinical signs, improve your cat's quality of life, and potentially achieve diabetic remission.
Regular communication with your vet is essential to discuss monitoring results, make necessary adjustments to the treatment plan, and ensure your cat receives the best possible care.

 

 

 

One of my favorite things about working in emergency rather than GP practice is that I don't have to manage those complicated and sometimes frustrating diabetic cases, especially cats, right?That is, until I recorded this conversation with doctor Linda Fleeman.
It completely flipped some of the things that I thought I knew about diabetes and how we manage it.And now I feel like I'm missing out by not being involved with the long term management of those diabetes cases.Like what if you could tell your clients that they no longer have to worry about when they inject the insulin.
So if they forget in the morning or they can't find the cat or they need to work late, you know life.And that nobody has to stress about their pet having insulin and they're not eating because you completely dissociated.Mealtimes and insulin administration.Those are exactly some of the things that you learned in this episode and a lot more, including how to feed your diabetic cats without any fancy foods, why your fat feline patients should probably eat zucchini, which might be my favorite tip from this entire episode, and how to monitor your diabetic kits, including some great tips on using continuous glucose monitoring devices effectively.
So who is Doctor Linda Fleeman?Doctor Linda is an internationally renowned veterinary expert on the treatment of diabetes and is regularly invited to write textbook chapters and speak on this topic at international forums.Linda has worked in both university referral practices and general small animal practice, with her primary focus for more than 20 years being all aspects of diabetes in dogs and cats.
Doctor Linda completed a residency in Small Animal Medicine at the University of Melbourne, followed by a PhD at the University of Queensland on the clinical management of diabetes militias and dogs.She's held positions as lecturer in Small Animal Medicine at the University of QLD and senior lecturer in Small Animal Medicine at the University of Sydney before deciding to return to private clinical practice back in 2010.
She currently does her work through her company Animal Diabetes Australia, the only diabetes specific veterinary clinical service in the world, where she and her team pioneer ground breaking diabetes treatment and management strategies and helps veterinary teams implement these strategies in their practices through her consulting service.
I've put a link to this for you in the show description if you want more diabetes content on our Subscriber Clinical podcasts.We have another series with Doctor Linda on using basal insulin in dogs, which is a complete flip on how we think about managing diabetes that can be potentially life changing for those dogs and their owners.
We also have a Bank of Diabetes episodes with the legendary Professor David Church that totally changed my personal understanding of diabetes pathophys in management, including the most elegant treatment plan for treating the crashing DKA patient that you'll ever hear.So just to be clear, those episodes are on the subscriber only podcast, which you won't find on your podcast player until you subscribe at vvn.supercast.com.
That's VVN for vetvault.supercast.com.I've put the link for you in the share description right here on your podcast player.Go check it out to level up your diabetes knowledge with our race approved CBD podcasts so that you can actually start looking forward to the next case.But for now, diabetic cats?
Basal insulin doctor Linda Fleeman Enjoy.I feel like it's the topic.That the more we dig into it on the podcast, the more I learn and the more I want to dig into it.
It's like a bottomless pit of of really cool information and I'm hoping that we can get some new stuff out of this one today.OK.So previously on the podcast on our on our medicine series, we we did quite a lot of content worth of Doctor Dave Church talking about.
There's a few kind of paradigm shifting ideas just about things like food, diet, the role it does and does at play, the timing of feeding, the new things in monitoring.So the freestyle Libra and all those sort of things.But then when we talked about insulin, there were a few key takeaways for me that I've feel like maybe has changed since we recorded those.
That was about a year, year and a half ago with them and the the first of them was that for for dogs specifically.I think he said the majority of cases will categorically still do better on a twice a day insulin protocol.It did mention an insulin I think called determiner or something like that that you can use as a once a day.
But he still said probably not going to be great results.Let's let's stick with that one.Since then I've had conversations and I've spoken to other vets and I've actually spoken to a vet who works for you who said you have a different or a new protocol with a different insulin.
That's all, all brand new, is that is that correct?That I understand that correctly.Yes.And I guess to grapple with this idea, we need to sort of go back to our basic understanding of how insulin is secreted in the body.And so there are, there are two phases to insulin secretion.
There's what's called the basal phase.This is just background insulin secretion that's occurring all the time that allows the body to keep glucose under control and to keep energy metabolism going in between meals.And then there is bolus insulin secretion and this is something that happens within minutes of us taking our first bite.
Our beta cells suddenly release a lot of insulin and the reason for that is to deal with the nutrients that are absorbed from the meal.So if we are to have a diabetic animal that cannot produce its own insulin, the very best response that we're going to get is if we can mimic what happens in the normal animal physiologically.
So in other words, where there's basal insulin secretion all the time and then an appropriate bowl, less insulin secretion at the time of meals.So until now, we haven't had good evidence about there being a good basal insulin supplement for dogs and cats.
And now we've got some products that actually have been shown to work in that way.And in order to be a a good basal insulin, a key point is that it doesn't have a peak.And so when you inject a dog or a cat with a basal insulin, it tends to build up in the body after perhaps two or over two or three days.
And then it's just there.If you give the same dose every day, it's just there as a constant level all the time.And there is only one insulin.That kind of approaches that definition, if you like, in cats, and that is Toujeo insulin, which is a a new form of glargine insulin.
And in dogs, there's two insulins that can be classified as basal insulins.That's again Toujeo insulin, but also Degladec insulin, which is called Tresiba, the brand name.And now that we have those, we can start to think in terms of basal and bolus insulin treatment in dogs and cats.
And so we now have got basal insulin.And then if we're going to complete the picture, we have to then think about adding in a bolus instrument mealtimes.And for that bolus insulin to do what we want it to do, it has to mimic what would happen in the normal dog or the normal cat.
And the situation with cats is just super easy because they have minimal increase in insulin during the bolus phase.So they have a very, very long prolonged postprandial period and the insulin barely increases.
And so basically the way the cats work is that they operate almost all the time, especially if they eat very low diet that's very low in carbohydrates that what they function basically with basal insulin all the time and they don't require the bolus insulin.
And so that just makes the whole concept of insulin treatment and diabetic cats really straightforward and simple for dogs.The dogs really do have a very prominent bolus insulin phase.And so if we treat them only with a basal insulin, what happens is that their their glucose is well controlled.
But every time they eat their, their blood glucose goes up a bit and comes down a bit.Because unless they're given a bolus insulin.And in order for us to choose an appropriate bowl ascension for dogs, we have to understand what happens in the normal dog.And in the normal dog, the postprandial period lasts for about 6 to 9 hours depending on the size of the meal and the amount of carbohydrate that they consume.
And it the insulin would increase five to seven fold.And so the postprandial period in dogs is really substantial and it is much longer than what happens in people.And So what that means is that the bowlers insulin formulations that are developed for that purpose in people don't, are not the best choice for dogs because they're too short acting.
And the most appropriate insulin for bowlers, insulin dogs is one that has maximum effect over 6 to 9 hours, which is a lot of the intermediate acting insulin that we have been using for years in dogs.Wow.So many questions immediately because there's already a few shifts there for me.
I've, I've never actually considered the, I don't think I was aware of the basal insulin that we have sort of as a background in my in my head, the way I I've always understood how we deal with food is food comes in, insulin goes up, and everything normalizes again once you've dealt with all that food.
So when when you're a diabetic, do you make no insulin, a good standard?That's to pick a breed, maybe canine first?Once that once those islets stop producing insulin, are they done so there's zero basal production?Or do they still produce enough, but it's not enough to deal with meal times?
That's an excellent question.It's a key to understanding what we're doing with when we're treating these patients.Basically, diabetes is an interplay between insulin resistance and and beta cell capacity or beta cell function.And if there's a lot of insulin resistance, for example, as might happen with obesity or cushings, then the animal needs to produce much more insulin to overcome that insulin resistance.
And so if they have beta cell function that is failing or deteriorating, they might have enough beta cell function to for it to work perfectly well if there wasn't that insulin resistance.But that insulin resistance has just increased the workload of the beta cells, and so they can't keep up anymore.
And that's the classic idea of what happens with type 2 diabetes.And what we understand is what usually happens in cats.So the answer to your question is, it depends.An animal might have sufficient beta cell function to live without insulin if they didn't have complicating factors.
Or they might have half as much insulin as they need and just need a little bit of a supplement just to help them out.Or they might have no insulin function left at all.And we presume that what happens is that in an uncomplicated diabetic that the point at which they're diagnosed with diabetes as we recognize it, they've probably lost 70% of their beta cell function at that point.
OK.And that's canine and and cats or is that just dogs?Because I I know we talk about dogs traditionally are are type 1 where there's islet cell destruction and the resistance plays less of a role than it does in cats.Well, I guess it depends, you know, So I think that rather than thinking in terms of type one type 2 which is the classic way that diabetes is described in human medicine.
If we just think about our species and understand that they each one of them might have some residual beta cell function.And we don't know how much, but we know that every single one of the diabetic animals that we treat has got has had lost and reduction of beta cell function.
Every single one of them.And yet each one of them has a variable amount of inch and resistance, which might be 0 to extreme.Quick interruption to remind you about the Vet Vault Specialist support service, and then I'll let you get back to the conversation.
So as you'll figure out in this episode, it's great to learn about new and better ways of doing things with this podcast, or a cool article or a textbook, or whatever your choice of entity in education is, and then you're itching to go and try out your new knowledge on your next case.But then invariably you'll hit a snag because your patients don't read textbooks and they don't even listen to podcasts, and you will want to ask for advice.
Which is why we started the Vetwelt Specialist support space, where you have access to a team of specialists who can help you get over the hump in those tricky cases where you don't need to or you can't refer, but you just need a little bit of expert knowledge.In fact, Doctor Linda is one of the specialists available to help you on the space.
She is there to help you institute all of this new diabetes knowledge for any diabetes specific questions.We also have two more medicine specialists, an emergency and critical care specialist, a dermatologist and an oncologist.How it works is through a set subscription fee of around $15 per month.
That's 15, not 50, which gives you unlimited access to the team through a dedicated app where you can share files and photos and videos, and even have a live chat if you need to.I've put a link for the space in the show description wherever you're listening.We would love you to come and live with us.
OK, back to Doctor Linda.So how do we make this practical in terms of our patient management and and protocols?So I guess what we now can do is we can use basal insulin treatment for both dogs and cats.
And essentially the way cats have been treated for well over 10 years has been using the principles of basal insulin treatment.So in other words using a long acting insulin that has a minimal peak and using that as a way of controlling the diabetes.
And what we have now is we have Toujeo insulin which which in at least theory works a bit better than the other products.So the new improved version of glargine if you like works better than the than the traditional one and that kind of makes sense.
You know as new products are made we need to embrace them and we have to accept that the new versions are probably work better than the previous ones.And so I guess with cats, I would suggest that Toujeo glargine insulin is a is a really sensible first choice for cats.
It works really well if it's given twice daily.For some cats, it can work as a once daily injection, but it certainly doesn't work in all cats as a once daily injection.So it's not a perfect basal insulin, It's just the best we've got.And because and I guess if we have already embraced this idea that cats do better if they're fed a diet that's low in carbohydrate.
But it just makes so much more sense if we recognize that what we're doing is we're treating them with a basal insulin.And so we want to minimize any postprandial effects at all.And the best way of doing that is to feed them a low carbohydrate diet and because they're carnivores that's that's usually very easy to do.
And so I guess my approach to managing diabetes in cats is that if we want to make things better than they are for an individual, I consider changing to a basal insulin, which is Toujeo insulin and reducing the carbohydrate content and controlling the way that the food is fed.
So rather than letting the cat feed ad Lib, I think that it works better to give them portions of food.OK, so let's let's dig into a couple of things.The first thing is how do you spell Tojeo?I'll put it in the show notes, but just if somebody listens to this or they want to go and look for it.
It's spelled TOUJEO.OK, cool.Thank you.And I don't know if that's the right way to say it.Say it.That's just the way I say it.OK, great.Some people say 2GO. 2GO TJO OK great.And you said it isn't glargine, but did you say it's longer acting or or how is it different from the glargine we have available we have had available so far?
It's it's exactly the same as the glargine that we know and love.The only difference is, is that the formulation is 3 times as concentrated, so it's 300 units per mil as opposed to 100 units per mil.
And the idea behind that is it's stunningly simple, which makes it so brilliant, really.When the dose is injected into the subcutaneous space, the surface area of the droplet of insulin in the subcutaneous depot is much smaller.
Because the droplet is smaller, because the insulin is more concentrated, and because the surface area is smaller, the absorption from the subcutaneous depot occurs much more gradually and slowly.And so it's just a stunningly simple idea.And the thing that is that, the thing that's clever about it is that they have made a insulin dosing pen that can accurately give doses of such a concentrated insulin.
That's the bit that's technologically clever.OK, is it a a an automated pen or still a normal?Like is it an injection pen or or still a syringe?So you cannot use Toujeo inchin with a syringe.There's no syringe in the world that can accurately measure out 300 units per mil solution of Inchulin, and it's written in capital letters and bold on the side of each pen that says must not be drawn out of the pen with a syringe.
And so the only way to use it is with an inchin dosing pen.But that, of course is the easiest and most accurate way of giving insulin anyway.So I mean, diabetic people have not been routinely delivering insulin to themselves with syringes since I think probably the 70s or the 80s.
And we have, is that purely A costing, is that the reason why it hasn't becomes the the norm in in veterinary science because it's cheaper to use a syringe or?It's not cheaper, no.So what?Why the hell are we still making people draw up insulin and syringes?I I don't.
I have been using insulin dosing pens for more than 10 years and I I actually don't understand the hesitation with using it.I suppose it's just the fact that people are unfamiliar with it and they go along with what has been done for years and but there's just no advantage to to recommending syringes for insulin administration for diabetic dogs or cats.
I've never actually thought of it.Why don't we use it?It's just that the way we were taught was using a syringe, and that's what I'm comfortable with.And suppose that's why it stays that way.But whoever actually, seriously looked at at the pens at all?I don't know why.And so the, the, the, I mean it's worth talking about that because there's plenty of data that show that it is impossible to accurately deliver a dose less than 8 units using a syringe and that's even.
And so it's just to cling to this old fashioned way of doing things because it's always been done that way.It's not, it's just not valid at all.And sure, it means that we all have to learn how to use a pen and how to show people how to use the, but that's what being a vet is.
We have to learn new stuff and go with it.Protocols for cats using the Toujeo, well, get to dosing and things like that, but I just wanted to to clarify.So you said it's an ideal first choice.You're gonna go probably twice a day.Maybe you get lucky and you get away with once a day.
And then you said control the feeding.And with that approach you should have should be able to avoid having to give bolus insulin to deal with postprandial insulin spikes.How do you control the feeding?What is a A what food?What was interesting with the conversation with Rough Church was him saying that exactly the low carb food, which he said is pretty much any cat food, so even the cheap.
Thin food supermarket.If it's a cat food it will be low carb anyway.Is that correct?Is that generally an acceptable way to go or or do we still need to look at diap specific diabetic diets for our cats?What do you advise people?So just to take one step back, I will answer that question.
But the twice daily injection approach, it doesn't have to be done at strict 12 hour intervals with a basil insulin.So remember that and I will get back to the diet 'cause it is super important.But the the the pros and cons if you like, of twice daily versus once daily is that once daily is is more convenient.
But if if the twice daily dosing protocol is flexible, suddenly becomes massively less inconvenient.To put it that way, if people can actually go out to dinner with their friends and give the cat an insulin dose either before or after that they leave the house, that makes a massive difference.
So with a basal insulin, there's it's AI would describe it as a flexible, twice daily dosing protocol as opposed to, which is I think an important point to make.But to get to the food.So there's a massive difference between whether the food is wet cat food or dry cat food.
Dry cat food has a lot of carbohydrate in it.It's it's basically really, really difficult to make a biscuit without flour.It's it's that simple.The other thing about dry food is that because the water has been removed from the food, that the food contains three or four times as many calories as wet food.
So basically there are lots and lots and lots of low carbohydrate wet cat foods, lots of whiskers, dine, many of the fancy feast flavours, lots of food that is low carbohydrate.The only foods that might be classified as low carbohydrate in the dry cat food range are the prescription diets for diabetic cats.
But even they, especially if they are fed in a reasonably large quantity, can end up containing a lot of carbohydrate.So you've got to think about that kibble as if it is has been rehydrated with water when you're trying to imagine the effect it's having on the diabetes.
So a bowl of wet food and then this is the same size bowl of dry food.There's three or four times as many calories in the dry food.And if the cat eats all that food, it's getting three or four times as much carbohydrate if if presuming that the products have the same amount carbohydrate.And the other thing is that if cats will eat dry food presumably most of the time until their stomach is full, they will eat wet food until their stomach is full.
And so in their stomach after a meal of dry food, they have three or four times as many calories and nutrients.And then we know that cats do not drink enough water to reconstitute that that dry food that's in their stomach.
And so the water that reconstitutes that dry food in the cat's stomach comes from the cat.So in a cat that has problems with water metabolism because of polyuria, polydipsia associated with diabetes, that presents a little bit of a problem.
And then that huge amount of food is gradually digested and moves into the small intestine and absorbed.So basically there are lots and lots of ways where how dry food can have a much bigger impact on diabetic management of a cat and wet food.It's the total carbohydrate content, It's the amount that they can take in a single time.
It's the effect that has on their water metabolism.You know, all of these things together mean that it just has a bigger impact potentially and one of the biggest problems that we see when we're managing diabetes and cancer is what's called glycemic variability.
So that's where there is a lot of day-to-day variability in the glucose results, but also within day variability.And and one of the best ways of managing that is to control the amount of carbohydrate that's going into the cat's stomach and so portion control.
So the absolute worst way of managing diabetes in the cat is for them to have ad Lib access to dry cat food, whether it's a prescription diet or not.OK.So the wet food as a sort of a built in portion control to some just as you say because of the the automatic filling you're filling them up with more water than just food.
So they're invariably will take in fewer calories.So then specifically carbohydrates per per meal?Exactly.And then also it's just logical to open a sachet or a can and feed all of that, you know or and then when the bowl is empty, give another portion.
It's just a.The dynamic is a little bit different as well with how the portions are given to the cat.Yeah, OK.In terms of food choices, it sounds like wet cat food is the answer for your diabetic cats.It's as simple as that.Almost to say Yep, Wet, Wet cat food.That'll do the job for us.
And basically what we don't want to do is take a cat that is unwell, that's in hospital, that has never seen wet food food before and forced them to eat wet food in that scenario.So any diet change has to be introduced when the cat's happy, healthy at home, relaxed, and preferably they should be fed wet food that they like that they have eaten before.
And there are some cats that are very reluctant to try eating wet food, but it's but most of them actually do like it.And once that never empty bowl is removed, it's much easier for people to see when their cats eat and what they like and so on as well.
And yeah, they they eat a lot more wet food once that great big bowl of dry food's been removed.Right.So how what does it look like in terms of feeding times for let's say your standard cat that's on a twice a day to Jo injection?I'll come back to that flexible, I want to ask about that.
But when do you feed them in relation to their injections?How many times a day?What's the ideal scenario look like?Well, I think a very basic thing that makes sense for both cats and dogs is that they need to be given some sort of reward for having an insulin injection.
And so for for both dogs and cats.If very early on the animal understands that after the injection that immediately something really good happens, such as getting some food, then that just makes sense.
So I think it's logical to feed a cat after that had an insulin injection, more or less to give them a reward.Other than that, it doesn't really matter when you feed them, it's a basal insulin that we're using for a start.So there's no requirement, no sense even to matching the insulin injections with meals.
But that's not what happens with a basal insulin.A basal insulin is just something that that has the same amount of insulin effective every hour of the day over 24 hours, and so trying to match that up with food doesn't make any sense at all.The idea is to it's enough usually to cut out the dry food and feed wet food.
That just spreads things out enough that it has a negligible effect on the diabetic control if a cat's.So.So the owner feeds it a wet food at a convenient schedule for the owner at an amount at a daily amount that meets the cats killer it needs and that's that's the rest kind of take takes care of itself because you're using the basal insulin.
And the hardest thing is to prevent relapse of obesity if or or having the cat become overweight because that's that always causes internal resistance in cats.And it I would go so far as to say that a cat that is more than 20% overweight it's almost impossible to get them into remission.
They need to have an ideal body condition for the rest of their life.And if you get a cat into remission and then that cat just gradually gains weight almost always at that point where they're about 20% overweight or a body condition that score of seven out of nine, the diabetes relapses at that point.
And so a calorie control is very important.And as everybody knows that if a cat is hungry, you can't live with that cat.The cat will always win when they're hungry and they're trying to get food.And so an important concept is to be able to give them food that doesn't contain calories that will fill their stomach and and make them stop begging for food.
And the only one that's really appropriate is zucchini.And and everyone laughs at that idea.But so zucchini is a unique vegetable in that it has almost no oxalates.So one of the biggest problems that we see when it comes to urolathiasis and cats is calcium oxalate urolathiasis.
So and almost all vegetables have loads of oxalates in them.So it's not safe to feed lots of vegetables to a cat unless that vegetable has no oxalates in it.So that's why we choose zucchini.And zucchini basically has no calories and no carbohydrate.
It's fiber and water, and cats will eat it if they're hungry.Sorry, but how hungry does your cat have to be to eat zucchini?Well, there are cats that eat two or three zucchinis a day.No way.And if they didn't, they would be attacking people's legs as they walk past, or scratching their face at night when they're asleep or something.
You know, like.Wow.Just because they they're so hungry, they're so food driven that they'll actually.Well, The thing is that these are carnivals, and so appetite makes them hunt.So appetite.Appetite is followed by hunting behavior in cats, and so it's often a hungry cat.
It's often interpreted as being aggressive, when in fact they're just getting hungrier and hungrier and displaying more and more hunting activity.So they'll lie in ambush as you walk down the corridor and leap out of people's legs.Or they'll jump on pounce on people when they're in bed.
If they're hunters, what else could you expect them to do if they want food?I've worked with people who are like that, Linda.I feel like them will hang anyway.I might be a bit like that myself.Can I quickly just circle back?
It's going to bother me if I don't ask.So the Toujeo being flexible, that doesn't have to be strictly 12 hourly.I understand or I think I can figure out why that works in terms of if you late with giving it.So let's say as you said only gives it at 7:00 in the morning and then they have a long day and they come back at 11:00 at night and there's still going to be a baseline but what about bringing it earlier?
I why does it not?Why don't you get a double up effect if you injected say it?8 hours versus 12 hours is another risk of going too high with the insulin.It's a very small effect because the insulin so long acting and and so and that it So what to to qualify as a basal insulin, it's got to have a flat time action profile.
And so if you give dose X, you might find that the insulin increases and then it goes down again after 8 hours and there's a duration of action of eight hours.If you give dose 2X, then it starts to to produce a a flatter effect.
And eventually what will happen is that there'll be overlap.And so as you go higher and higher and higher with a basal insulin formulation, if it is truly a basal insulin formulation, what will end up happening over days is that the concentration of insulin in the body remains as a flat line, but it gets higher and higher and higher as the doses increased, But it doesn't ever have a peak.
And so the concept is that you get constant insulin activity because there's overlap anyway.OK, OK, gotcha.It's a really difficult concept to guess.You have to sort of kind of draw a graph of it and you just in some ways you just have to believe that if it's got a flat time action profile then that is what happens.
It's a it's a faith thing.It's a matter of faith.Just believe it.Yes, I like that.Is that us done with cats?Obviously the simple cat and I I want to say we can start this and we might have to dig into cats more.Or if people start these protocols and have issues, I will put the links to your service and how to get a hold of you to ask specific case based questions.
Are we done with cats or is there more specific things we need to talk about in cats?Well, we've what we've done is we've talked about insulin and food.We haven't talked about monitoring.Well, do you use Freestyle Libra?So I'll tell you what we discussed previously and if it's if it's the same sort of content, then we don't have to repeat it again.
But when we talked to Prof Church, he was a big fan of Freestyle.Do you like them?Yes.But I don't think that there's one size that fits all, OK.As clinicians, what we need to be is flexible and offer options.So the first thing is that there is no evidence at all that one way of doing things is the best way.
There's lots and lots and lots.What I tell my clients is that there's dozens of ways to treat diabetes and I'm going to discuss a few options with them and they need to let me know which one of those options feels best for them And and so for some people using Freestyle Libre is too expensive or they find it stressful because they just and they it just takes their focus away from the cat and they're staring at numbers all the time.
Other people love it.It gives them good feedback.There are cats that really easy to treat and you can use really simple ways of monitoring them and they go really well and it doesn't make any sense to to go through the to the fast and the expense of a continuous glucose monitor.
Yeah, OK.OK.So let's say the person who doesn't want to do or can't do Fristol Libra of cost to whatever reason.What are you using to monitor when, let's say you've started a protocol?
Are you using curves in hospital curves?What are the different options that you offer for monitoring?So I don't use in hospital curves at all.For cats and dogs or just cats, Linda?I haven't used one for years.I mean, I will look at the results in the histories that are sent to me.
It's not like I completely discount them, but I don't find them useful or reliable and they're quite expensive.If people are going to pay for a glucose curve to be done in the clinic, well, then that it you might as well use a continuous glucose monitor, you know, and get much more information.
And so I think that monitoring has to tie into our goals for the patient and mostly our goals always to control clinical signs.So we need to control the clinical signs of of diabetes in both cats and dogs to the satisfaction of the owner we have to that's that otherwise the animal might be euthanized And so just getting some handle on the clinical signs.
So one of the clinical signs of diabetes is weight loss.So just getting the cat weighed once a week tells us a huge amount about how well the diabetes is controlled and then getting an idea of of excessive thirst and urination.So that can be done very precisely by measuring how much water the cat drinks or it can be more of a of a scale, you know saying is the cat drinking excessively or not.
You know, and the I guess one thing is that if the diet is changed to wet food only diet, a normal cat would not need to drink water at all And then it's their overall demeanor.But then in addition to monitoring the clinical science, what we need to do is we need to track their glucose somehow.
And.And the most basic way of doing that is setting up a system of checking the urine glucose every day.And what that means is that people can determine every single day whether the cat's glucose was consistently below the renal threshold or not.
And that can be done.Or if if the cat uses a litter tray by basically people just need a cup and a spoon and and a dipstick so they can take a spoonful of litter that the cat's peed on, put in the cup, add some tap water, stir it and put the dipstick in.And that's a super simple and cheap way of telling if the cat's blood glucose was was above the renal threshold or not on that particular day.
And if the blood glucose is consistently below the renal threshold, then after one or two weeks, then I would always recommend a decrease of the insulin dose in both dogs and cats.And so that's the simplest way.So, so just to clarify what we're aiming for with that.
So he's sort of expecting that in the in the managed but non remission get that we're going to get what are we going to get most days still pick up glucose in the urine and if we start seeing as you say, if we start seeing there's never any glucose in the urine, there we go, all right.
We either over treating or you've gone into remission and you might not need insulin.Is is the expectation that most days will have some glucose in the urine.I think a very important concept is that the results of our monitoring are not goals.So our goal for the cat might be to control the clinical signs and to achieve remission if we can.
We do not have a goal of a certain blood glucose curve or a certain pattern on the continuous glucose monitor or a certain pattern to the urine glucose test.Those are not goals.The glucose monitoring is just a tool to reach our goals and it helps us to understand what's going on with the patient.
So if the cat is drinking buckets of water, then it's hardly surprising if the urine glucose is positive every day.But The thing is that when there is PUPD, it's really easy for owners to set up a system of testing the way every day because there's plenty of way basically.
And so by the time that the PUPD resolves, they're still able to keep monitoring it because they've got their system established, you know, and what we don't want to do is we don't want to overdose the cat.And we know that cats go into remission.
And if we, if we don't stop the insulin when a cat goes into remission, we'll overdose them.It's that's just the way it is.And so if a cat has got no clinical signs and also has no glucose in the urine, then there's a very good chance that that cat needs a lower insulin dose.
Then if the if the insulin dose is decreased and within three days there's glucose in the urine again, we might then decide, oh, it really wasn't ready for a decrease of the insulin dose, let's go back to the previous dose.So it just helps us to understand what's going on with the cat.
If there's no right or wrong, it's just it's all it is is the crudest way of getting in a handle on blood glucose, which is to say, is it above or below the renal threshold?Yeah, yeah.I'm still just trying to clarify of of what as a clinician client comes in and tells me that the OR what am I going to tell my clients to look out for on urine glucose.
So first and foremost, it'll be a quick way or an early way of picking up, catching a cat going into remission or that I'm overdosing.I feel like that's probably the most important part of it to go as well.If you see that, then we definitely need to act.Whereas if you see lots of positive glucose, if you're doing your dipsticks and 80% of them are glucose positive, but the cats really clinically, well kind of don't do anything about it.
That's sort of expected because we do have a diabetic cat.Does that make sense?No, because the the question you're asking is from the point of view of a clinician who is only looking at a diabetic cat in a moment in time without appreciating, perhaps even being aware of what's happened beforehand or what the goals are at the moment.
So if I was to start treating a diabetic cat, my first thing that I would get people to focus on is to give the insulin injections comfortably.So that's all, Like I would say it doesn't matter if you muck it up the first time, just try again the second time you might get it.
I would be that would be one of the things I'd do.And then I'd get them to start using some sort of monitoring method so that we can see how the cat's going.And then I would give them feedback on the information that they're gathering.So if they're weighing the cat, for example, example, such a simple thing to do.
So this might be in a general practice setting.You might send someone home with an insulin dosing pen after showing them how to use it and get them back a week later and go, so how are those injections going?And then you put the cat on the scale and go, cat stopped losing weight.
We're making progress here.You know, it's it's it's about step by step going through things with people and then saying how have you gone with the urine test?Have you managed to do that?Oh, that's good.You've got that system working.Or why don't you try this to make it work and then talk about perhaps at that point reducing the dry food and introducing the wet food.
So each step along the way you're walking along through this with through this with people.And obviously when the cat's got clinical signs of diabetes and there's glucose in the urine, there's not much to say about that.That's just complete expected, you know.But then once you've got control of the clinical signs and the cat starts to gain weight and then you have to cut the food back to stop it gaining too much weight.
All of this is, is stuff that has to be done if we're going to look after a cat well and then we get to a point where everything's going really well.The clinical signs have resolved and there might be the first negative urine glucose test and then you say actually this is when the urine glucose testing is becoming really more useful to us.
We are really interested in now looking out for if this cat, there's five days in a row with no glucose in the urine, you've got to let us know because we might make some changes then gotcha.So this very basic way of monitoring is like all monitoring where you make a decision, you introduce, you monitor it, you see how the cat responds, you then modify your decision and so on.
And that is a challenge in in practices where there's lots of vets, the vets would if there if there's seven or eight vets following this cat, they all have to be really aware of what protocol is being used.It's extremely confusing for owners if every single vet changes the monitoring protocol every time.
What happens is people will often try and be really compliant and do everything that every vet has ever told them to do and it just it just doesn't work and it's stressful for people.Yeah.All right.That's really good.So we're looking for long term monitoring so we can identify patterns of change and and use it all together or use all the information we have to give it to make long term decisions.
They're not necessarily snap decisions.And if we really want to make rapid changes or to understand a confusing situation, then the continuous glucose monitor is by far the best way of using it.But when it's just one other point, which is blood glucose monitoring at home, one thing that has never ever been useful for not managing diabetes is spot blood glucose.
And So what I tell clients is that they need to collect 7 to 10 blood glucose measurements over a period of time before we can assess them.And I don't really care if they're all done on the one day or whether they're done over a week or over 2 weeks.
Like there's no reason for it had to be a traditional curve, it we just need to get a bunch of measurements.And the reason we don't need it in a in a defined time period is that because we're using the the different approach of a basal because there's we don't expect.
No.So the problem with blood glucose curves is that there's a lot of day-to-day variability in blood glucose in diabetics.So every single time you look at what's happening on for blood glucose on a single day, it's not necessarily representative of what's happening on any other day.
And so all we're ever trying to do, ever, is trying to get an idea of the spread of blood glucose.You know, is it between 25 and 35?Is it between 5 and 15?Is it between 2:00 and 4:00?
We're just trying to get, where are we?What's the range that this cat's operating in at the moment?You are messing with a lot of long standing beliefs that I have around diabetes and I think a lot of us will be listening to this guy.No, no, no, no.
It has to be at a 12 hour period it doesn't make and this will take some mulling over.It's really good good to shake the paradigms A.Little these paradigms were shaken decades ago.We have known about the day-to-day variability since the beginning of the century.
Not all of us.Some of us maybe should we talk about dogs?Have you got time to talk about how it's different for dogs, or is that a separate recording?Like is that an extra 40 minutes of of content?I suggest that if we're gonna talk about basal insulin treatment in dogs or basal bolus, it's even more complicated than talking about it in cats.
OK, so maybe we do that as a separate session.Yes, OK, I I think it's it's it's if if you're talking about paradigm shifts, this is massive, massive.Okay, Maybe we're not ready for it yet.Maybe we have to Mull this one over first before we start doing that.
One, I mean it it doesn't it.It works well, it works super well and and it's the way of the future.But it is very different from all the traditional ways of treating diabetes and dogs and just getting a little one or two facts about it and then thinking you can go back to your practice and and make that small change.
It won't work.Okay, right.Let's wrap this one up then for for now with with cats that was really cool.What I might do even is is get people to ask questions based on this and if I do have the the privilege of having you back on at some point start with questions because I I I think I'll think of more may maybe should we wrap up with with Linda maybe from your perspective when you introduce these ideas into a practice that you're supporting what are some of the most common concerns or or struggling points or misconceptions or anything that that us as vets have around this whole thing that you'd love to you must get 100 questions a day but what are the what's the top question that jumps out.
I think it's about feeding cats.OK.And we've addressed that we've talked about.That I think that your your questions are really insightful.I always say that's my my superpower is my vast level of ignorance.Yeah, be to expose to the world.Before you disappear, I wanted to tell you about our new weekly newsletter.
I speak to so many interesting people and learn so many new things while making the podcast, so I thought I'd go ahead a little summary each week of the stuff that stood out for me.We call it the Red Vault 321 and it consists of firstly 3 clinical Pearls.These are three things that I've taken away from the clinical podcast episode, my light bulb moments, the penny dropping, any new facts and the stuff that we need to know to make all the other pieces fit.
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Dr Linda Fleeman