2002 Diabetes UK.

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77

Introduction

Dogs and cats have played a crucial role in the understanding
of diabetes and during the development of its therapies:
pancreatectomized dogs along with serependity [1] helped
von Minkowski and Mehring to understand that the pancreas
was essential to maintain blood glucose levels normal [2];
in 1913, the partially pancreatectomized female bullterrier
B2-31 led Allan to the erroneous belief that the avoidance
of sugar consumption might represent a therapy for diabetes
[3]as the

sugar-Verbot

it has terrorized the life of millions
of people with diabetes during the past century [4]; in 1921,
the pancreatectomized beagle Majorie helped Banting to
prove for the first time that survival was possible by injections
of pancreatic extracts (later called insulin) [5] and Dr Lukens
cats demonstrated that overexposure to glucose could exhaust
the endocrine pancreas and thus bring about permanent
diabetes [6]. However, when dogs or cats became spon-
taneously diabetic, other than euthanasia very little medical
help was available to them up to quite recently. Around the
diabetes publicity generated during the Annual Meeting of the
European Diabetes Association held in Dsseldorf in 1994,
we were contacted by a practising veterinarian as to whether
it would indeed be evidence-based to switch insulin treatment
in his canine diabetic patients from porcine to human insulin,
as had been suggested to him by some of their owners. This
request heralded a seminal change in the citys veterinary
practice, since during the 1960s diabetes treatment in dogs had
been practically unheard of. It led us to conduct a systematic
study of the frequency and nature of diabetes care in cats and
dogs in veterinarian practices in the city of Dsseldorf.

Methods

Dsseldorf is a city with a population of approximately
550 000 people and 16 000 dogs registered at the city council (as
an absolutely minimal estimate of the citys canine inhabitants).
In the summer of 1995 we contacted all 25 veterinarians
registered as practitioners in the city of Dsseldorf. Two of
them had already discontinued their practice at the time of
the survey, two were not willing to co-operate in the study. The
remaining 21 veterinarians were visited by one of us (T.P.N.)
during office hours in their practices. Information on the
quality and quantity of diabetes care currently provided for
cats and dogs in these practices was obtained by standardized
interviews comprising 24 questions and by extracting data
from respective patients files. Since in veterinary practices,
in general, no third-party payment system is operative, case
documentation is not necessarily as complete as in German
general practitioners offices.

Results and discussion

During the survey 52 dogs and 38 cats were identified as
diagnosed and subsequently treated diabetics; in 46 animals a
complete set of data comprising demographic characteristics,
details about therapy and achieved degree of metabolic control
as well as concerning the acute and late complications of the
disease was obtainable from the practice files.
In accordance with veterinary textbook information [7], of
the diabetic dogs, 57% were thoroughbred dogs, and 68%
female; of the diabetic cats, 3/4 of which belonged to the
ordinary European domestic cat type, 60% were male (about
half of which had been castrated before diabetes was diagnosed).
On average, the animals were quite old by the time diabetes
had been diagnosed: dogs (

n

= 52) mean 9

3 (

SD

) years (range
121 years); cats (

n

= 32) 12

4 years (624 years). At the time
of diagnosis, around 70% of the animals had been classified as
overweight by the veterinarians. In some cases, the veterinarians
had noted apparent precipitating causes for the manifestation
of the disease, such as corticoid therapy, infections, oestrogen/
progesterone treatment, or psychological stress, such as
jealousy or changes of location and/or owners.
The veterinarians diagnosed diabetes in the presence of
typical symptoms (polyuria, polydipsia, polyphagia, weight loss)
by measuring fasting venous glucose levels (20 veterinarians);
for one veterinarian clinical symptoms plus glucosuria was
sufficient to make the diagnosis. One difficulty in diagnosing
diabetes was the frequent occurrence of transient stress-
induced hyperglycaemia in cats; thus, reproducibility of
hyperglycaemia over time and values >15 mmol/l were taken

Correspondence to

: Professor Michael Berger MD, Klinik fr
Stoffwechselkrankheiten und Ernhrung (WHO Collaborating Centre for
Diabetes), Heinrich-Heine Universitt Dsseldorf, Moorenstrasse 5, 40225
Dsseldorf, Germany. E-mail: bergermi@uni-duesseldorf.de

Blackwell Science, Ltd Oxford, UK DME Diabetic Medicine 0742-3071 Blackwell Science Ltd, 2002 January 2002 19 113Occasional Report Occasional report Diabetes care in cats and dogs T. P. Neuvians & M. Berger

Diabetes care in cats and dogs

T. P. Neuvians and M. Berger

Department of Metabolic Diseases and Nutrition (WHO Collaborating Centre for Diabetes), Heinrich-Heine University Dsseldorf, Dsseldorf, Germany

Accepted 4 June 2001

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2002 Diabetes UK.

Diabetic Medicine

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Diabetes care in cats and dogs

T. P. Neuvians & M. Berger

as indicators of diabetes. One veterinarian relied also on
fructosamine determination, and in four practices oral glucose
tolerance tests were performed in doubtful cases. Opportunis-
tic screening for asymptomatic venous hyperglycaemia has
become routine in some practices.
In the cases in this study, at diagnosis fasting venous
glycaemia was 21.5

6.4 mmol / l (

n

= 44; range 11.0
44.2 mmol / l) in dogs and 24.3

4.2 mmol / l (

n

= 34, range
12.333.1 mmol / l) in cats. The veterinarians were well aware
of the particular pathogenic heterogeneity of diabetes in these
animals and the outstanding relevance of secondary diabetes
[7]; nevertheless, they argued that any effort to obtain a
differential diagnosis was not warranted as it had no conse-
quences for any therapeutic strategy.
In female dogs, with two exceptions, the veterinarians
favoured an ovario-hysterectomy as the first-line antidiabetic
treatment, especially in cases of menstrual cycle-associated
insulin resistance. This strategy is in line with veterinary
textbook recommendations for the therapy of diabetic dogs
and, although somewhat less straightforward, for female
diabetic cats [7]. In practice, however, this treatment was
carried out in only two of 27 (previously non-castrated) female
dogs, mainly because the animal owners did not consent or
because surgery was contraindicated due to the patients
advanced age and/or poor general condition. None of the
veterinarians used oral antidiabetic agents; in all practices,
diabetic dogs and cats with blood sugar values > 11.0 mmol / l
were immediately put on subcutaneous insulin therapy.
One veterinarian reported the successful additional use of a
homeopathic substance, Syzygium jambolanum (Myrtaceae).
In general, the initiation of insulin therapy was performed
on an ambulatory basis with repeated blood glucose measure-
ments during the day, the frequency depending on the owners
co-operation; only two veterinarians admitted animals for this
purpose. On the whole, hospitalization was seen as too stress-
ful for both pet and owner. Adjustment of insulin dose to opti-
mize control was usually performed on the basis of blood
glucose measurements (e.g. fasting and post-prandial, or 4 h
and 8 h post-insulin injection, respectively) and occasionally
urine tests, carried out in the practices: one veterinarian regu-
larly measures serum fructosamine. All veterinarians asked
the owner to check the animals drinking behaviour and/or
body weight. Five practices recommend recording the animals
water consumption; 14 veterinarians handed out dry-chemistry
strips for regular or for occasional glucosuria monitoring to
the owners. Two veterinarians found it sufficient to adjust
insulin dosages based upon their patients clinical symptoms.
During therapy, office blood glucose levels for dogs (

n

= 41)
were 13.5

8.5 (range 3.338.9) mmol/l, and for cats (

n

= 31)
12.3

5.0 (range 4.627.6) mmol / l.
All diabetic animals were treated with (medium-) long-
acting insulin preparations, once or twice daily. In most
cases bovine (Depot-CR in 13 practices) or porcine (Depot
CS in four practices) surfen insulin preparations and in
four practices a mixture of bovine and porcine insulin (Novo
lente) were used. Four veterinarians preferred human
insulin. The fact that amino acid sequences of porcine and dog
insulins are identical and of bovine and cat insulins almost
identical (except for a rare substitution in the A chain, i.e. the
substitution of His for Asn at position 18) did not appear to
play a role in the selection of insulin preparations. During
treatment, mean insulin dosages were for dogs (

n

= 27) 1.2
(range 0.32.3) U/kg body weight and for cats (

n

= 21) 1.0
(range 0.31.7) U/kg body weight.
Along with insulin therapy, various special diet regimens
were recommended, except for three veterinarians who
maintained the animals on their preferred nutritionin
order to avoid additional behavioural disturbances and
stress, especially in cats that are considered particularly
stress-susceptible. As in human diabetology [4], almost any
diet theoretically possible is advocated, mainly calorie-
reduced manufactured nutrition, e.g. enriched with fibre
and protein, or with reduced protein and carbohydrate
contents. It appears common to these diet food products
that they are expensive and that their advocates call for their
regular and exclusive use.
The success of diabetes care in the animals was reported
by the veterinarians as variable, dependent on the overall
status of the animal, the ease of combining insulin therapy
with predictable nutrition (with particular difficulties in the
stress-susceptible and often erratically behaving cats) and the
understanding and co-operation of the owners. Insulin therapy
was initiated in the vast majority of cases, only seldom did
owners ask for primary euthanasia. During the course of
treatment, discontinuation of therapy and/or euthanasia is
frequently opted for by the owners, mostly in cases in which
insulin treatment does not lead to an improvement of the
animals general condition (due to advanced age or concom-
itant diseases), if the animal appears to reject treatment
(mostly cats), and when owners feel overburdened by having
to carry out the treatment. Nevertheless, 13 veterinarians
reported diabetes treatment lasting for 24 years, three for
57 years and one had treated a diabetic cat for 10 years
with insulin.
During treatment, the most frequent acute complication
was hypoglycaemia (which was lethal in two cases); there was
no case of diabetic ketoacidosis. The veterinarians reported
frequent concomitant diseases and or complications such as
skin and urinary tract infections, fatty infiltration of the
liver and hyperlipoproteinaemia. By far the most frequent
diabetes-related complication in dogs was cataracts; four of 52
diabetic dogs were blind. In contrast, cataracts were only
rarely seen in diabetic cats. Clinically and on necropsy (two
cases) there were no apparent signs of vascular diabetic late
complications.

Conclusions

This report of a cross-sectional study on diabetes care reflects
the substantial importance of diabetes in a small-animal urban

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79

2002 Diabetes UK.

Diabetic Medicine

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veterinary practice. With an estimated prevalence of 0.31.0%
in dogs and 0.10.3% in cats [8,9] diabetes represents a
relevant proportion of chronic diseases in household animals,
predominantly at a geriatric age. The growing number of dogs
and cats in big cities, their living conditions (resulting in
increasing body weight, decreasing physical activity and
increasing psychological stress) along with augmenting life
expectancy will lead to a dramatic increase in incidence
rates of diabetes in the future. On the other hand, it appears
that an increasing number of owners are prepared to accept
the burden in effort and expense associated with treating
their animals. As in human diabetology [4,10], much of the
current practice observed in this study is neither directed to
patient-orientated goals nor based on adequate evidence with
regard to efficacy and safety of diagnostic and therapeutic
interventions. Veterinarians, responsible animal owners and
animal protectionists should work together to formulate
evidence-based guidelines to be used in day-to-day veterinary
practice for education of animal owners and the exercise of
sensible diabetes care in cats and dogs.

Acknowledgements

We thank Professor Lotte Herberg DVM, MD (Dsseldorf)
and Professor Eleazar Shafrir MD, PhD ( Jerusalem) for their
help. M.B. had the original idea for the study and has written
the paper. T.P.N. is a DVM and carried out the study as part
of her MD thesis.

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