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Frequently Asked Questions List
for the Feline Diabetes Message Board (FDMB)

Compiled by Janet & Binky with major input from the FDMB Wise Ones
In Loving Memory of Robin, Tigger & Nikita
Last Updated: 10/20/2009

Welcome to the Feline Diabetes Message Board, the group you never wanted to join.  If your cat has just been diagnosed, you probably have lots of questions.  This is a support group of cat-loving amateurs; we're not experts, but among us we've accumulated much experience and information about feline diabetes.  This FAQ contains information on some of the commonly asked questions by newcomers (or questions which they should ask) but if you're unclear on anything, or just need some tender loving care right now, please post!  We've all been where you are now.



Table of Contents

1.  GENERAL

Q1.1.  Help!  My cat was just diagnosed!  What do I do?
Q1.2.  Many of the cats here seem to have problems.  Is my cat doomed to a poor quality of life?
Q1.3.  I don't understand all the terminology here.
Q1.4.  What is hypoglycemia, and how do I handle it?
Q1.5.  What treatment will my vet propose?
Q1.6.  What is the goal of treatment?
Q1.7.  Where can I find a vet who is knowledgeable about diabetes?
Q1.8.  How can I find other people with diabetic cats in my area?
Q1.9.  I can't afford to treat my cat.  What should I do?
2.  ADDITIONAL TREATMENT
Q2.1.  Can I give oral medication instead of insulin?
Q2.2.  Can I control this with herbs or something instead of insulin?
Q2.3.  What should I feed my cat?
Q2.4.  Can I free-feed my cat?
Q2.5.  My cat doesn't like / I can't afford the expensive prescription food. Is there any less expensive substitute?
Q2.6.  How much should I feed my cat?
3. INSULIN
Q3.1.  What kinds of insulin are there?
Q3.2.  Where can I get PZI insulin?
Q3.3.  What can I expect to pay for PZI insulin?
Q3.4.  What kind of syringe should I use?
Q3.5.  Do I need a prescription for insulin or syringes?
Q3.6.  Can I reuse syringes?
Q3.7.  How do I dispose of used needles?
Q3.8.  My cat hates getting his shot.  Now what?
Q3.9.  How long does a bottle of insulin last?
Q3.10.  Sometimes I can't be home to give one of my cat's shots; is it okay to give it late or early?
Q3.11. How much insulin should my cat be getting?
4.  MONITORING YOUR CAT -- GLUCOSE
Q4.1.  How can I monitor how well the insulin is working?
Q4.2.  What kind of glucometer should I get?
Q4.3.  How often should my cat's glucose levels be tested?
Q4.4.  My cat's pre-shot level was way below the usual value.  Should I give the injection?
Q4.5.  I'm not from the United States, and I don't understand your units of measurement.  My cat couldn't have a blood glucose of 300 even if you soaked her in honey for a week.
Q4.6.  I'm following the instructions faithfully, but I still can't get blood from my cat's ear.
Q4.7.  My cat has been off of insulin for several days, and I'm getting glucose readings in the 40s and 50s (2.2-3.3 mmol/L).  Should I treat him for hypoglycemia?
Q4.8.  Are there other signs besides blood glucose that I can monitor at home?
Q4.9.  I'm interested in home-testing, but my vet won't let me.  What should I do?
5.  MONITORING YOUR CAT -- KETONES
Q5.1.  What are ketones?
Q5.2.  How often should I test for ketones?
Q5.3.  How do I test for ketones?
Q5.4.  How are positive ketone readings usually treated?
Q5.5.  What is Diabetic Ketoacidosis?
6.  REGULATION
Q6.1. What is regulation?
Q6.2.  Which definition of regulation should be my goal?
Q6.3.  How do I achieve regulation?
Q6.4.  My cat has been on insulin for a while and her diabetes is still out of control. Why can’t I regulate her?
Q6.5.  What is tight regulation?
Q6.6.  Is remission possible?
Q6.7.  I just can't get my cat's glucose into regulation range -- is he doomed?
7.  OTHER PROBLEMS
Q7.1.  My cat is walking funny / weak in the hind legs / not jumping well.  Is this related?
Q7.2.  My cat has kidney failure.  How do I manage this as well?
Q7.3.  My cat has asthma; how can I avoid using steroids?
Q7.4.  I can't get my cat to eat!  What should I do?

1.  GENERAL

Q1.1.  Help!  My cat was just diagnosed!  What do I do?

A1.1. Steve & Jock recommend the following sites to help you get started learning about feline diabetes:
Cat Diabetes for Beginners (http://www.felinediabetes.com/diabetes-info.htm)
You Just Learned Your Pet Has Diabetes (http://www.indulgedfurries.com/petdiabetes/emot1a.html)
Feline Diabetes Basics (http://gorbzilla.com/fd_basics.htm)

Additional recommendations for more advanced reading include: 

FelineDiabetes.com Health Articles (www.felinediabetes.com/faq.htm)
Pets with Diabetes (www.indulgedfurries.com/petdiabetes)  -- recommended by Joni & Six.
Diabetes Education Index
(www.indulgedfurries.com/petdiabetes/education_index.htm) -- strongly recommended by Jud & Call
Boo's Valley Sugarcats (valleysugarcats.spaces.live.com) -- provided by Deanie & Boo
Sugar Cat Simon's Home Page
(sugarcat_simon.home.att.net) -- provided by Bob & Simon
FD Library (http://fdlibrary.yuku.com/) -- maintained by Anne & French Fry
Gorbzilla!
(www.gorbzilla.com) -- maintained by Lisa & Gorb.  If it's not in this document, it's there
Diana & TC's links page
(www.sugarcats.net/sites/dmstrickland/felinediabeteslinks.htm).
Max's house
(www.maxshouse.com)  -- lots of general health information, recommended by Joni & Six.
And Diana & TC have helpfully prepared a flyer for you to share all these good links with your vet. 
                 (www.sugarcats.net/sites/dmstrickland/printingoptions.htm).

Read, read, read!  Information is your best health-care tool in managing your cat's diabetes.  And ask here if you have any questions or anything is unclear.


Q1.2.  Many of the cats here seem to have problems.  Is my cat doomed to a poor quality of life?

A1.2. People tend to post here when they are having problems. Most diabetic cats are doing just fine, so their owners tend to stay quiet.  Diabetes is highly treatable. Diabetic cats who are well regulated can live normal lifespans with excellent quality of life, and tend to die of other ailments of old age, rather than from diabetes.  See Gorbzilla's Sugarcat Journal for some inspiring stories of our cats' post-diagnosis quality of life.


Q1.3.  I don't understand all the terminology here.

A1.3.  Never fear!  The FelineDiabetes.com glossary and Melissa & Popcorn's glossary will help you understand the language.


Q1.4. What is hypoglycemia, and how do I handle it?

A1.4.  Your vet should have warned you about hypoglycemia, which is dangerously low blood sugar brought on by too much insulin.  Hypoglycemia can kill your cat or cause blindness or other permanent damage, so you must always be on the alert for the symptoms.  Read the hypoglycemia page at Pets with Diabetes to familiarize yourself with the problem.  Then print out Melissa & Popcorn's hypoglycemia page and post it on your refrigerator, because hypoglycemia can come on suddenly, and you don't want to be running around trying to find this information.  You should always have a bottle of Karo or other sugar syrup handy in your cupboard.


Q1.5.  What treatment will my vet propose?

A1.5.  Options your vet may discuss include: If insulin treatment is elected, the type of insulin and the dose are important choices. Generally, the dose should be low (1-2 units once or twice a day) to begin with, increasing gradually if needed.  Your vet should explain the risks and benefits of each choice, and will recommend a protocol that he/she feels will work best for your individual cat. You should feel comfortable asking your vet to discuss with you the rationale for the recommended treatment.  A list of good questions to ask your vet can be found at Pets with Diabetes.

There is no consensus here on whether an otherwise healthy diabetic cat needs to be routinely hospitalized.  Hospitalization is necessary if the cat is suffering from ketoacidosis, and is probably a good idea if the cat is extremely dehydrated or has a very high blood glucose (for example, more than 600 mg/dl or 33 mmol/L).  Many vets prefer to keep the cat for a day or two to observe how he responds to the insulin, but some will teach you how to give the shot and ask you to bring your cat in the next day for another glucose reading.  Some of this may depend on your own comfort level and your vet's perception of your ability to manage at home in the early days.  If you already have some medical background or experience with diabetes, you may feel ready to jump right in to treating your cat.  On the other hand, if you find the whole experience completely overwhelming, you may prefer for your vet to get things started for you.  In general, however, your vet does not need to keep an otherwise healthy cat for more than a few days, and regulation of blood glucose levels is not likely to take place in the clinic.

The FDMB in general recommends a conservative approach to regulation and dosage adjustment which you can find at Susan & Shadow's Five Steps to Regulation page and the Frugal Feline Diabetes page. You may find your vet's treatment to be similar or more aggressive; however we do not recommend frequent increases each week or large dosage increases for any cat. All increases should be based on an analysis of blood glucose readings taken on the current dosage; this means that the pre-injection blood glucose, the lowest blood glucose, and the duration of insulin activity all need to be taken into account.


Q1.6.  What is the goal of treatment?

A1.6.  The overall goal is a happy and healthy cat with a normal lifespan.  Ideally, this is achieved by using diet and insulin (and possibly drugs and exercise) to get your cat's blood glucose as close as possible to normal glucose values (under 120 mg/dl or 6.7 mmol/L) without ever descending into unsafe hypoglycemic levels (under 40 mg/dl or 2.2 mmol/L).  For some cats, particularly that lucky minority that can be controlled with a low-carbohydrate diet alone, normal blood glucose values are attainable ("normalization").   Most other cats, particularly those who do not respond consistently to food and insulin, or those who have health problems which interfere with their ability to get to near-normal blood glucose values, may need to be kept at higher overall blood glucose values in order to avoid the risk of hypoglycemia.  For these cats, a more realistic goal is "regulation," see Section 6.


Q1.7.  Where can I find a vet who is knowledgeable about diabetes?

A1.7.  Your best bet is probably to get referrals from other people in your area who are happy with their vet's treatment of their diabetic cat.  See also Debra & Care Bear's page on what to look for when interviewing a vet.


Q1.8.  How can I find other people with diabetic cats in my area?

A1.8.   You can find a list of current members, carefully compiled by Carol & Charlie, at FelineDiabetes.com.  You may also post a message to the Feline Diabetes Message Board; be sure to include your approximate area in the title of the post, since not everyone reads every post.  And be sure check the registry at Gorbzilla's Sugarcat Member Directory.  


Q1.9.  I can't afford to treat my cat.  What should I do?

A1.9.  A diabetic cat must be treated; otherwise he will essentially starve to death, which is a cruel way to die.  But the good news is that home care can substantially reduce costs.  See Frugal Feline Diabetes for some tips on treating your cat on a budget.  If after reading our money-saving tips, you still believe you will not be able to afford the cost of caring for a diabetic cat, please do not hesitate to post your concerns to the Feline Diabetes Message Board. Someone may be able to help you. DON'T GIVE UP ON YOUR SUGARCAT.


2.  ADDITIONAL TREATMENT

Q2.1.  Can I give oral medication instead of insulin?

A2.1.  Possibly.  You should discuss this with your vet. Oral medications such as glipizide or glyburide will allegedly work for about 30% of diabetic cats.   However, because these drugs can cause liver damage (and even further damage to the pancreas), and because giving an injection is often easier than giving a pill, most people on this board prefer insulin.  Several people who switched to insulin after using drugs have reported that they thought the oral medication only delayed regulation.  Others believe that starting with drugs rather than insulin made it impossible for their cats' diabetes to be controlled with changes in diet alone.  Another drug, acarbose, works by blocking or delaying the absorption of carbohydrates from food.  It probably is not necessary for a cat who is on a low-carbohydrate diet.

Oral medications are not a good idea for cats with elevated liver values (due to the possibility of liver damage), or ketoacidosis or neuropathy (due to the need to bring glucose levels down immediately). See the Pets with Diabetes site for a more detailed explanation.  If your cat shows uncharacteristic lack of appetite, vomiting, lethargy or jaundice, discontinue the medicine and call your vet.  You should also have liver enzymes monitored frequently during the early months.


Q2.2.  Can I control this with herbs or something instead of insulin?

A2.2.  If your cat needs insulin, then you must give it to her.  If you're interested in an alternative approach, your best bet is to find a holistic veterinarian who is familiar with treating diabetic cats.  A holistic vet will take a "whole animal" approach to see if there is any way to strengthen the entire system, using diet, vitamins & minerals, herbs, homeopathy, glandular supplements, Chinese medicine, or whatever approach the vet is personally familiar with.  A good vet will keep your cat on insulin until and unless it is no longer needed.  For more ideas, read the Holisticat page on diabetes, but keep in mind that there often is not a lot of research on these approaches.


Q2.3.  What should I feed my cat?

A2.3.  This is the topic of numerous debates and discussions here, partly because the scientific research is limited.  Here are some general principles: Most vets follow one of two basic approaches to diet for diabetic cats: 1.) moderate-protein, low-carbohydrate, or 2.) high-carbohydrate, low-fat, high fiber. Diabetic cats have been regulated on each type of diet, as well as regular cat food, and what works for one cat may be less than ideal for another. 

A diet moderate in protein and low in carbohydrates has been used with great success by many owners of diabetic cats, who have found that this approach can reduce their cat's insulin requirements, or, in a minority of cases, even eliminate the need for injected insulin for long periods of time.  This diet may be appropriate for a cat who is otherwise healthy and who will eat canned cat food.  Vets using this approach may prescribe Purina DM or Hill's M/D or may recommend canned kitten food.  You can also duplicate this diet using high-quality commercial foods with similar nutrient composition, see below.  The low-carbohydrate diet may not be appropriate for cats who are currently suffering from any of the health conditions listed above.  Discuss your cat's most recent bloodwork with your vet to be certain that the higher protein, fat, and/or phosphorus levels commonly found in this diet are appropriate for your cat's condition.  Purina DM dry is high in sodium, which may not be appropriate for cats with cardiovascular problems.  If your cat has a past history of any of these conditions, please consult your vet for specific recommendations.

An older approach, which is no longer popular at the FDMB, is to feed the cat a diet fairly high in carbohydrates and low in fat, with extra soluble fiber added to slow the conversion of starch to glucose.  Vets using this approach recommend Hill's W/D, a high-carbohydrate, high-fiber prescription cat food which is designed for weight maintenance.  (Other similar foods are Hill's R/D, Purina OM, and various hairball formulas sold by Hill's and Iams, see below.)  If your cat needs to gain weight, a high-fiber diet may not be the best approach.  If your vet recommends this diet for your cat, do not hesitate to ask him or her to explain the advantages and disadvantages of the two dietary approaches.

Some people prepare food at home; these diets can be high or low in carbohydrates depending on whether grains are included in the recipes.  Further sources of information can be found in Dr. Strombeck's Home-Prepared Dog and Cat Diets, the Holisticat raw food page, Feline Future, and Dr. Lisa's Feeding Your Cat page.  Additional sources for recipes are Dr. Pitcairn's Complete Guide to Natural Health for Dogs and Cats and The New Natural Cat: A Complete Guide for Finicky Owners by Anitra Frazier.  Some recipes may contain grain, which many people consider to be inappropriate for cats in general and diabetic cats in particular, so you may want to reduce or eliminate the grain content. If you wish to include grains, pearl barley  and rice are both considered good possibilities (barley has a low glycemic index; rice is thought to be digested more completely), but corn should be avoided because many cats are allergic or sensitive to it.  Don't simply feed meat, poultry or fish by themselves, though, because such a diet is nutritionally inadequate.

For details on the protein, fat, and carbohydrate content of various commercial foods, see Janet & Binky's canned food list and dry food list.


Q2.4.  Can I free-feed my cat?

A2.4.  Generally, you want your cat to eat around the time he receives his insulin injections.  Some people have set meal times, and others use free-feeding.  Still others put down food at meal times only, but let the cat eat at his leisure.  Insulin type is an important factor in this decision.  Short-acting insulins, such as N (NPH), can be dangerous if the cat has not had a solid meal about half an hour or so before the shot; on the other hand, a cat on a long-acting insulin such as Lantus (insulin glargine) or PZI can follow a "grazing" schedule much more safely.  Most people here would agree that feeding a cat between the time insulin peaks and the next shot is unwise, although a small high-protein, zero-carbohydrate snack such as chicken or tuna should not substantially affect blood glucose.  Whatever you decide, be consistent.


Q2.5  My cat doesn't like / I can't afford the expensive prescription food. Is there any less expensive substitute?

A2.5  Yes. The idea that a diabetic cat must have prescription food is misguided (to say the least), and many people prefer to feed commercial or home-made foods because they are cheaper, or have higher-quality ingredients, or are preferred by their cats.  However, diet can affect insulin requirements, so changes to an existing dietary regimen have to be done carefully for a cat who is already on insulin or pills.  As mentioned above, you should ask your vet if your cat has other medical conditions that need to be addressed with diet.

If you're feeding canned Purina DM, you can substitute any canned cat food which has a similar level of carbohydrate (no more than 10-12% of calories -- see the canned food table), mixed with:  1.) a low-fat source of high-quality protein (chicken, turkey, lean beef, egg, the occasional bit of cooked seafood) equal to no more than 20% of the total calories, and 2.) (optionally) 50-100 IU of vitamin E per day.  Keep in mind that this diet may not be appropriate for cats with kidney disease.

If you're feeding dry Purina DM or dry Hills M/D, check out Innova EVO Cat & Kitten, which has about 6% of calories from carbohydrate (warning for guardians of cats with kidney disease: it is somewhat high in phosphorus).

If you're feeding dry Science Diet W/D, any dry food with a similar fiber level will do the trick.  If you're feeding canned Science Diet W/D, Science Diet Feline Light is similar, or you can feed any good quality canned cat food and add extra fiber in the form of psyllium (1/4 teaspoon mixed with 1 tablespoon water) or canned unsweetened pumpkin (1 tablespoon). Check the  food tables to make sure the levels of other nutrients, particularly carbohydrate are similar; otherwise, you must make the switch slowly, over a period of several weeks, and monitor your cat's glucose levels carefully.   Changing the diet without changing the insulin dose can result in brain damage or death from hypoglycemia -- be cautious!

In all cases, home-cooking is always an option, so don't feel that you're doomed to feed commercial foods.

The easiest way to give vitamin E is to buy it in liquid form in a bottle or in powder (water-soluble) form in a gelatin capsule (which can be opened and closed).  Another option is to buy the regular 400 IU capsules for humans, and mix the contents of one with the food once or twice a week.   Experiment to find out what's palatable to your cat.   The d-alpha (natural) form is more potent than the dl-alpha (synthetic) form, and if it contains extra selenium, or mixed tocopherols and tocotrienols, so much the better.


Q2.6.  How much should I feed my cat?

A2.6.  As many calories as your cat needs to maintain a healthy weight; typically 15-25 calories per pound of ideal weight, depending on your cat's activity level.   Cats who require fewer calories may benefit from more nutrient-dense foods so that they do not develop nutritional deficiencies.  Unregulated cats may require more food at first because they are not able to properly metabolize what they are eating.  


3. INSULIN

Q3.1.  What kinds of insulin are there?

A3.1.  Insulin comes in all sorts of varieties.  Some are human insulins, and some are animal insulins, usually beef or pork. Some have fairly short durations (N, NPH, Novolin Insulatard), some medium (Lente (now discontinued), Caninsulin, Novolin Monotard (now discontinued)), and some animal-based NPH), and some long (Ultralente (now discontinued), Novolin Ultratard (now discontinued), PZI, Lantus (insulin glargine), and Levemir (insulin detemir)).  For more information, see the Pets with Diabetes pageWe strongly recommend that you avoid using a short duration insulin as your first insulin, because of the significant risk of hypoglycemia.  If your cat does not respond well to the human insulins, many cats here have obtained excellent results from beef insulin (which is closer biochemically to feline insulin), most notably the PZI duration.  For cats who do better with beef insulin but have problems with the PZI lasting too long, Beef Lente (also known as UK Lente) is available from the Wellington Pharmacy in London.


Q3.2.  Where can I get PZI insulin?

A3.2.  For lots of good details on where to find PZI, see the PZI page at the Feline Diabetes website. Be aware that not all PZI formulas are  beef- or pork-based; most people who switch to PZI do so because human insulin is not working for their cat, so be sure to ask!  The Professional Arts Pharmacy in Baltimore only compounds human insulin, for example.


Q3.3.  What can I expect to pay for PZI insulin?

A3.3.  UK PZI is currently $63 per bottle (U-100) plus $50 shipping for up to 25 bottles; Blue Ridge is around $60  (U-40, which is much more dilute; minimum order 3 bottles), but your vet may mark up the price.  BCP is $58 per bottle (U-100) plus $10 shipping (Fed-Ex overnight).  Summit is CDN$25 per 5 ml bottle (U-100) plus $5 shipping, next-day delivery.


Q3.4.  What kind of syringe should I use?

A3.4.  Most people here have been satisfied with BD Ultra-fine U100 3/10 cc, Monoject  Ultra Comfort (available from diabeticpromotions.com), or Walmart ReliOn Ultra Comfort.  The latter two measure half-units, are manufactured by the same company with different branding, and are less expensive than B-Ds, with ReliOns being less expensive than the Monojects.  Get the finest needle possible, which is 31 gauge.  Some people have difficulty with the longer (1/2 inch) needles and recommend the 3/8 inch needles to avoid shooting "through the tent"; others experience the opposite problem with shorter needles not delivering the insulin properly, so experiment to find out what's right for your cat.  If you're giving a U-40 insulin, either use the appropriate syringe, or use a conversion factor for giving U-40 insulin in a U-100 syringe.


Q3.5.  Do I need a prescription for insulin or syringes?

A3.5.  Probably not.  Check the chart at the Children with Diabetes site for more information on your state or country.  But even if your state requires a prescription, you may still be able to get supplies via mail order.


Q3.6.  Can I reuse syringes?

A3.6.  Although some people do reuse (generally not more than once), most people here recommend against it.  After the first injection, the needle is no longer sterile, (which can contaminate the insulin and promote infection in the cat), and the coating is degraded.  Take a look at the picture of a reused needle and decide for yourself.  If cost is an issue, try a generic brand.


Q3.7.  How do I dispose of used needles?

A3.7.  Laws vary from one location to the next, and your vet or local waste removal facility should be able to give you appropriate advice.  Some vets will dispose of the needles for you.  The safest way to keep them until disposal is to get a strong plastic "sharps" container which you can purchase at your pharmacy.  You may also want to buy a clipper so that you can dispose of the needle separately from the syringe.


Q3.8.  My cat hates getting his shot.  Now what?

A3.8.  Make sure you're using the thinnest possible needle -- 31 gauge is the thinnest, and 30 gauge is usually acceptable, but many people report success with 29 gauge.  You also need to make sure you aren't hitting a muscle; the insulin is supposed to be deposited under the skin.  To brush up on your injection techniques, and learn new techniques, check out Feline Diabetes, Pet Diabetes, and Jamie's explanation.


Q3.9.  How long does a bottle of insulin last?

A3.9.  Unopened insulin is good until the expiration date when handled gently, stored at the manufacturer's recommended temperature range (36º to 46º F for Humulin vials), and kept covered from light. However, an insulin bottle which has been used, will need to be replaced before the expiration date. There are several reasons for this, including exposure to possible contaminants when the rubber seal is punctured, exposure to oxygen, and imperfect mixing (which may change the concentration of the insulin, even when care is taken to mix well).  Because of this, it's always a good idea to inspect your insulin.  Material settled on the bottom after mixing, or clumps, indicate potential problems.

Eli Lilly, the manufacturer of Humulin insulin, has recommended replacing Humulin vials within 28 days after opening.  Many people on the FDMB view this recommendation as overly conservative for single-user vials, and have found that Humulin is often good for somewhat longer. Some people on this board do replace Humulin vials every 4 weeks. Others replace every 6 weeks, every 8 weeks, or when they notice reduced glucose control.

Lantus has mixed reviews, with some people observing that it doesn't last more than a month, and others getting greater usage from it.  A pack of 5 3-ml cartridges may be more cost-effective than the 10 ml vial, even though the up-front expense is higher.

The consensus on the board is that animal-source PZI (protamine zinc insulin) lasts longer than Humulin insulin. Many people here use PZI until the bottle is empty. PZI which has been diluted with sterile saline solution by a vet, pharmacist, or consumer should be replaced every 30 days.


Q3.10. Sometimes I can't be home to give one of my cat's shots; is it okay to give it late or early?

A3.10.  In general, you should keep on a schedule for giving injections. If you give the shot once a day, do it at the same time every day. If you give shots twice a day, do it at the same time twelve hours apart. However, occasionally giving insulin an hour earlier or later isn't likely to cause any trouble. If you need to vary the timing by more than this, it may be prudent to give a reduced dose (at the previous shot if you need to shoot early, and at the current shot if you need to shoot late). If your schedule never permits you to shoot 12 hours apart, you may need to experiment with different morning and evening doses, or even use different types of insulin for the morning and evening shots; however, you'll need to hometest your cat's blood glucose to determine a safe approach.


Q3.11. How much insulin should my cat be getting?

A3.11.  As much as he needs to keep him regulated.  This could be anywhere from 1/4 unit to 10 units twice a day (or even more for cats with rare health conditions such as Cushing's disease or acromegaly.)  A survey once carried out on the FDMB suggested that most cats will not need more than 4 units twice a day if on a low-carbohydrate diet or 8 units twice a day if on a high-carbohydrate diet.  The Cornell Feline Center recommends that "Cats requiring excessively high insulin doses (greater than one to two units of insulin per pound per day) should be evaluated further."


 4.  MONITORING YOUR CAT -- GLUCOSE

Q4.1.  How can I monitor how well the insulin is working?

A4.1.  Many people on this board recommend home-testing for blood glucose.  You will find excellent details, with pictures, at Harry's page (http://www.sugarcats.net/sites/harry/bgtest.html); more tips are available at Bob & Simon's page; a short video can be found at the Veterinary Information Network; and a longer video has been created by Mark & Buddy.

Secondarily, you can monitor your cat's urine, which will tell you if glucose is high at some point during the day, but will not tell you if your cat is getting too much insulin and the blood glucose level is dropping dangerously low.  One very good method for monitoring a cat who is not being hometested besides urine strips is to keep track of the amount of water being consumed; increased consumption usually means that blood glucose is too high.  Finally, you should watch your cat for unusual attributes, such as excessive urination,  rough coat, or dilated pupils, and learn what this tells you about your individual cat's glucose levels.


Q4.2.  What kind of glucometer should I get?

A4.2.  Most of the regulars here use either the Bayer/Ascensia Elite or Elite XL (but see the caution below), LifeScan OneTouch Ultra, or AccuChek Advantage with only the Comfort Curve strips.  A newer model requiring even less blood, the TheraSense Freestyle, appeared promising at first, but our experience is that it can substantially underestimate blood glucose values (if you already own one, don't panic, but be aware of this problem). You want a model that only requires a small amount of blood (2-3 microliters) and which has "sipping" action; it may cost a little more, but it will make your life tremendously easier.  One online source of glucometers which has good prices is diabeticpromotions.com, and another is hocks.com.  You can also get the glucometer at pharmacies, Walmart, Costco, or any similar store.  There's often a rebate coupon included.  Occasionally, you can even get a meter free if you buy 100 test strips.

Caution on Bayer Ascencia Elite meter: The Bayer Elite is generally a good meter, but it has the bad habit of beeping before the strip is filled with blood, leading people to withdraw the strip prematurely and obtain a false low value.  See Terry's graphic of how full the strip should be for a reliable reading.


Q4.3.  How often should my cat's glucose levels be tested?

A4.3.  As often as is convenient for both of you. Many people test before every single shot, usually because past experience with hypoglycemia has made them cautious. Some people do sporadic testing, but run a curve every couple of weeks (or less often if the cat is regulated).  If you choose to do this, the best times to check are right before the shot and around the time that glucose reaches its low point, typically from 4 to 6 hours post-shot. Some people only test if something is clearly wrong (for example, strange behavior, lethargy, or increased urination) and they need to know what the problem is.


Q4.4.  My cat's pre-shot level was way below the usual value.  Should I give the injection?

A4.4.  There's no hard and fast rule, but if you don't have data on how your cat responds to insulin, here are some general guidelines.  Below 150 mg/dl (8.3 mmol/L), don't give insulin.  Between 150 and 200 (8.3-11.1 mmol/L), you have three options: a.) give nothing; b.) give a token dose (10-25% of the usual dose); c.) feed as usual, test in a couple of hours, and make a decision based on that value.  Above 200 (11.1 mmol/L) but below the cat's normal pre-shot value, a reduced dose might be wise.  In all cases, if you are reducing or eliminating insulin, it's wise to check for ketones in the urine.  Above the normal pre-shot value, give the usual dose, but if the pre-shot value is consistently elevated, it's a good idea to schedule a full glucose curve to see whether a change in dose or insulin is appropriate. In most cases, the target "peak" value should not be below 100 mg/dl (5.6 mmol/L), and for some cats it might be higher.

Keep in mind that these are general guidelines, and they should be personalized to your own cat's reactions to insulin.  If your experience is that your cat does not became hypoglycemic with a dose which is close to her usual, then your experience should be your guide.
  
Lantus and Levemir users: Because Lantus and Levemir are gentler insulins, you may find that these guidelines are stricter than you need.  If you have some data on how your cat responds to insulin, please read Jojo and Jill (Team J)'s guidelines at FDMB (http://www.felinediabetes.com/phorum5/read.php?22,1017956).


Q4.5.  I'm not from the United States, and I don't understand your units of measurement.  My cat couldn't have a blood glucose of 300 even if you soaked her in honey for a week.

A4.5.  Americans have only recently switched from the traditional scruples/quart to the metric mg/dl.  While we were busy patting ourselves on the back for being sophisticated, the remainder of the world moved on to the international system (SI) and now measures blood glucose in mmol/L. Just divide the American values by 18 to see what's really going on.


Q4.6.  I'm following the instructions faithfully, but I still can't get blood from my cat's ear.

A4.6.  In addition to the excellent tips in the above links, here are some extra suggestions: Be sure to give your cat a hug and/or a treat afterward to reinforce the idea that this can be a pleasant experience!


Q4.7.  My cat has been off of insulin for several days, and I'm getting glucose readings in the 40s and 50s (2.2-3.3 mmol/L).  Should I treat him for hypoglycemia?

A4.7.  Congratulations!  As long as you're sure your meter readings are based on full test strips, then it looks like your cat is on a  honeymoon.  Although lab printouts indicate that 70-120 mg/dL (4-7 mmol/L) is normal, we have observed that non-diabetic cats can typically have lower values on our meters.  As long as your cat is not showing any symptoms of hypoglycemia or signs of distress, all is well.  You might want to monitor his blood glucose values for the next week or so; after that, occasionally monitor his blood and urine for glucose. Also, you need to keep a close eye on his drinking habits and general health, because it's always possible that this is temporary.  In the meantime, enjoy!


Q4.8.  Are there other signs besides blood glucose that I can monitor at home?

A4.8.  There's no substitute for knowing your cat's blood glucose.  But it's always a good idea to keep the "whole cat" in mind.  Signs that your cat may not be getting enough insulin include excessive urination, high glucose in urine (although for some cats it's always high), weight loss, lethargy, depression, dull or dry fur, dandruff, lameness (may indicate neuropathy), and change in pupil size (for some cats).  Signs that your cat may be getting too much insulin include all the symptoms of hypoglycemia, sleepiness or lethargy an hour or two after receiving insulin, all the symptoms just mentioned for hyperglycemia (if he is suffering from chronic rebound), and little or no glucose in the urine.  Signs that your cat is doing well include the 5 P's [purring, playing, peeing (normally), pooping (ditto), and preening], as well as normal appetite and thirst.


Q4.9.  I'm interested in home-testing, but my vet won't let me.  What should I do?

A4.9.  You don't need your vet's permission to home-test.  Ideally, of course, you and your vet should have a partnership in the care of your diabetic cat.  But many vets aren't familiar with home-testing, or they're worried that the client will arbitrarily change the dose of insulin.  Your vet may be persuaded to change his or her mind by the following articles by veterinarians:  Blood glucose monitoring; Home Testing of Blood Glucose for Diabetic Cats;  or Home Blood Glucose Testing for Diabetic Cats.  If not, and you still want to home-test, you have that right.  After all, human diabetics wouldn't dream of injecting insulin without monitoring their blood glucose, and no reputable physician would recommend against it.


5.  MONITORING YOUR CAT -- KETONES

Q5.1.  What are ketones?

A5.1.  Ketones are a source of fuel manufactured from fatty acids by the liver and utilized by the body when glucose is unavailable due to a lack of insulin or glucose supply.


Q5.2.  How often should I test for ketones?

A5.2.  If your cat is well-regulated and behaving normally, test for ketones on an occasional basis.  However, if your cat has been refusing to eat or seems ill,  you should test for ketones as soon as possible.  Ketone testing should be part of standard diabetic care.


Q5.3.  How do I test for ketones?

A5.3.  Ketones are tested in the urine using Keto-stix (R) or Keto-diastix (R), which you should be able to buy in the diabetic supplies section of your local pharmacy.  If you can catch your cat on the litter box, you can either hold the end of the stick in the urine stream, or collect the urine in a small paper cup and dip the stick in (for a female cat, a deep plastic ladle kept by the litter box may be helpful for urine collection).  If you see any signs of ketones, contact your vet right away.


Q5.4.  How are positive ketone readings usually treated?

A5.4.  The remedy depends on the reason ketones appear but it will either involve feeding more food to anorexic kitties, a switch to a 2 injection schedule, a longer duration insulin or a higher insulin dosage or a combination of any of the above.


Q5.5.  What is Diabetic Ketoacidosis?

A5.5.  Diabetic ketoacidosis is a life threatening condition caused by an accrual of too many ketones in the bloodstream altering the pH and blood chemistry.  As the condition worsens, dehydration, anorexia and vomiting usually appear.  If untreated, seizures and then death occur. Crisis treatment includes restoration of the blood chemistry through hydration and electolyte replacement and returning the main fuel source back from ketones to glucose by using small doses of fast acting insulin and a glucose drip.


6.  REGULATION

Q6.1. What is regulation?

A6.1.  There are different definitions of regulation.  As hometesting becomes more common, we've been getting a better understanding of what cats and their humans might be capable of.  Janet & Fitzgerald propose the following "regulation continuum":
There may also be an extra category of "mostly above 300 (16.7) but with good clinical signs" which occurs with some cats who are getting insulin.  We don't know why it happens, but such a cat probably should not be considered to be regulated.  On the other end of the spectrum, it is possible for a cat who is not getting insulin to have blood glucose as low as 40 mg/dl (2.2 mmol/L) on a home glucometer.  If you have a non-diabetic cat, try testing her with the same meter to get a safe comparison figure.


Q6.2.  Which definition of regulation should be my goal?

A6.2.  That depends on your individual situation.  Generally, it's thought that a cat will suffer less long-term organ and nerve damage if his average blood glucose is lower rather than higher.  However, because preventing hypoglycemia is a top priority, it may not be practical to try for normal numbers.  The ability of your cat to respond to food and insulin in a consistent manner and your own ability to monitor your cat are both important factors in setting your goal.  For most cats who are receiving insulin, "regulated" is a reasonable first goal, after which you can try for "well-regulated".  For the lucky minority who can be diet-controlled, normalization is often achievable.  It’s important to realize that some cats never consistently stay in regulation range in spite of all efforts, and yet they can be happy and healthy anyway.  Ultimately, you should tailor your goals to your cat's individual situation, and you should always consider your cat's quality of life as well as the numbers as you evaluate how well your treatment protocol is working.


Q6.3.  How do I achieve regulation?

A6.3.  We recommend following a systematic protocol, the “Start Low & Go Slow Approach”. This method has been tested and improved by hundreds of members of the Feline Diabetes Message Board over the years, and it typically produces improved blood glucose control, without risking rebound or hypoglycemia.  


Q6.4.  My cat has been on insulin for a while and her diabetes is still out of control. Why can’t I regulate her?

A6.4.  The most common causes for poor control of blood sugar are: Other medical issues (such as insulin resistance, acromegaly, and Cushing’s disease / hyperadrenocorticism) may also cause obstacles to regulation. These problems are relatively uncommon, and should not be prime suspects until the more common causes have been ruled out. More details can be found at The Hard-to-Regulate Pet.

If a previously regulated cat suddenly starts showing poor response to insulin, two likely reasons are infection and loss of potency of insulin.

Q6.5.  What is tight regulation?
A6.5.  Tight regulation refers to using insulin to keep a diabetic cat's blood glucose levels within normal or near-normal ranges as much of the time as possible.  This approach to regulation is very controversial because of the high perceived risk of hypoglycemia.  However, it is not merely an exercise in vanity; keeping blood glucose in this range is thought to reduce long-term damage to the organs and nerves.  Additionally, some people believe that diabetic cats kept in or near a normal glucose range have a higher chance of achieving diabetic remission, especially if so controlled during their first year after diagnosis.  (An alternative explanation, though, is that the cats who achieved remission might have done so under almost any insulin regimen as long as they were fed a low-carbohydrate diet.)  The downsides are that heavy monitoring is often required, and that some cats simply cannot be tightly regulated no matter how hard the human tries.  If you are interested in this technique, the Feline Diabetes Message Board has a special forum for discussing it.


Q6.6.  Is remission possible?

A6.6.  It is possible for some diabetic cats to be controlled without insulin.  There is increasing anecdotal evidence that a low-carbohydrate diet (5-10% of calories from carbohydrates) and perhaps a short course of insulin can result in a cat whose diabetes can be controlled by diet.  However, this can't be guaranteed for any specific cat.  Our historical estimate is that about 1/3 to 1/2 of newly-diagnosed cats may respond this way, and whether your cat belongs to this group is a matter of luck.  There is also preliminary evidence which suggests that this rate may be higher in cats who are given Lantus (insulin glargine). Remission is also possible for steroid-induced diabetics; in some of these cats, pancreatic function resumes over time.  


Q6.7.  I just can't get my cat's glucose into regulation range -- is he doomed?

A6.7.  Not necessarily.  Your cat may benefit from a different approach besides the standard twice-a-day fixed dosing.  Check out Beyond Twice-a-Day Fixed Dosing for extra techniques that people use to help keep their cats glucose in desirable ranges.


7.  OTHER PROBLEMS

Q7.1.  My cat is walking funny / weak in the hind legs / not jumping well.  Is this related?

A7.1.  There is a condition common in diabetic cats called peripheral neuropathy, which causes weakness in the hind legs.  Symptoms include: weak hind legs; feet slipping out from under him/her on the floor; walking down on the hocks in back and/or on the wrists in front; lying down more frequently, especially after short walks   If your cat has this condition, it is a sign the cat's blood glucose is still too high, which is causing nerve damage. Improved regulation is the best way to reduce neuropathy, but check out Laurie & Jasper's page for additional treatment options using oral methylcobalamin (a form of vitamin B-12), and Jason & Mr. Kitts' research on using injectable methylcobalamin.   Avoid pills which contain xylitol.  Methyl-B12 can be useful as an adjunct to good regulation, but should not be considered a substitute. (The Life Extension Foundation also has some interesting supplement ideas.)  In the meantime, Vesla & Blondie suggest using Shaw's Paw Wax to help your cat get traction on slippery floors. Throw rugs will also give your cat places to stop and rest while trying to get around.

If you suspect your cat has neuropathy, please get a formal diagnosis; a cat can show some of these symptoms but have other problems such as arthritis or potassium depletion.  If your cat is wobbly and walking in circles or erratically, you may be dealing with a hypoglycemic episode, in which case go immediately to question 1.4.  If your cat can't walk at all, or has his head tilted, get him to the vet immediately.


Q7.2.  My cat has kidney failure.  How do I manage this as well?

A7.2.  Read Melissa & Popcorn's page on Chronic Renal Failure and Diabetes for an excellent summary of these issues.


Q7.3.  My cat has asthma; how can I avoid using steroids?

A7.3.  See Nancy's document on giving inhaler medicines to a cat.


Q7.4.  I can't get my cat to eat!  What should I do?

A7.4.  It depends on how long this situation has been going on.  If it's just one or two meals, it's probably not a serious situation.  Your cat may have a hairball or a minor infection.  Try to tempt him to eat something tasty (see next paragraph), reduce his insulin to compensate for the reduction in intake, and check for ketones as soon as you have the opportunity (see Q6.3 above).

If a diabetic cat persistently refuses to eat, this is a very serious situation and should not be ignored.  First, you need to verify whether your cat will eat absolutely nothing, or just won't eat the food that you've offered.  Try a variety of tempting dishes.  Your cat may be suffering from a poor sense of smell, so dishes which are very fragrant (such as tuna or liver), or heated up, may excite some interest.  Alternatively, your cat may prefer something bland like Hill's A/D (a prescription food) or baby food (meat flavors are best; make sure there are no onions or garlic added).  Sometimes, a cat will not eat from a dish but will eat from your hand.  Although eventually you need to feed your cat the most healthful diet, getting food into your cat is the most important thing in this situation, so feed whatever he'll eat.

If your cat won't eat anything at all, contact your vet.  Persistent lack of appetite can result from a variety of causes, including respiratory or urinary tract infection, pancreatitis, hepatic lipidosis, or even more serious conditions (including intestinal blockage).  Be alert for vomiting or signs of nausea (such as excessive salivating or lip-licking).  You should also test for ketones (see Q5.3) as soon as you have the opportunity, because ketones can cause lack of appetite.  Get your cat to the vet immediately if you detect ketones in his urine, or if his urine or breath smell fruity or like acetone.

Your vet may recommend syringe-feeding. Sometimes, if you put some food in the cat's mouth by hand (behind the teeth is fine), this will be enough to jump-start his appetite a little. If this doesn't work, buy an oral syringe (usually in the baby supplies at the grocery or pharmacy).  Dilute a smooth food such as baby food with a little water and put it into the syringe (it may help to pack it from the top and shake it down).  Put the syringe in his mouth, sideways, behind her back teeth, and slowly deliver the food (give him time to swallow!).  Give the cat as much as he will eat, but don't force too much, because he may not be able to tolerate more than a tablespoon or so of food at a time.  Many small feedings may be necessary.  If all else fails, your vet may need to prescribe appetite stimulants or even install a feeding tube (in the case of hepatic lipidosis).  For more ideas, see Louise & Chorniy's syringe-feeding FAQ.

You may need to give a reduced insulin dose or even skip a shot, because blood glucose is related to food intake.  However, it is dangerous to skip many shots, because ketones may develop.  Monitoring your cat's blood glucose at home can be very valuable in helping you and your vet make this decision.


Note to readers: This is an HTML document, and most of the useful information is contained in the links.  If you are reading a printed copy of this, you are not obtaining the full value of the document.  This document is copyright (C) 2000-2009.  You may freely copy and distribute the document, but you may not charge money for it (not even handling costs), and altering the content is prohibited, not to mention really rude to the people who have put so much effort into this.  The copyright includes the questions and not just the answers.   If you have corrections or suggestions, please post them to the Feline Diabetes Message Board (www.felinediabetes.com/terms.htm), and if the consensus is that you have offered an improvement, the FAQ will be updated.

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Version 3.15; last updated October 20, 2009.
The most recent version can be found at  http://binkyspage.tripod.com/faq.html.