Striving for Success

Tips to Start New Diabetic Pets and Owners Off Right

by Kate Boatright, VMD

Receiving a diagnosis of diabetes mellitus can be overwhelming for a pet owner. Extensive client education is needed once the diagnosis is made. Discussion points should include the feasibility of treatment, finances, prognosis, the treatment plan itself, and monitoring. Having a clear communication plan is essential to ensure that clients feel prepared for treatment and that it is as minimally stressful for both client and patient as possible.

Barriers to Treatment

Owners must consider many factors before committing to the lifelong treatment of a diabetic pet. It is the veterinarian’s responsibility to have candid, comprehensive conversations with their clients to determine if treatment is the right choice for each individual pet and family.

These conversations can be especially important for owners of pets presenting in diabetic ketoacidosis. In the moment of an emergency, it can be tempting to focus on getting the pet through the initial crisis, but owners must be aware that hospitalization is only the beginning. Including information about long-term management of the disease is essential in these cases to properly guide owners in their decision whether or not to treat.

From a financial perspective, both initial and long-term costs should be considered. In patients diagnosed with uncomplicated diabetes mellitus, the initial financial investment can be hundreds of dollars depending on the type of insulin, diet changes, initial diagnostics, and frequency of monitoring. For patients requiring treatment of concurrent disease, such as pancreatitis, or who present in diabetic ketoacidosis, pet owners may invest thousands of dollars in diagnostics and treatment in a matter of days.

Long-term costs include treatment of the primary disease, monitoring, and diagnosis and treatment of potential complications that can arise for diabetic patients. “Diabetes is a lifelong diagnosis which can hardly be made cheap,” said Heather Kvitko-White, DVM, DACVIM. “It is important that practitioners do not overextend clients’ initial funds on diagnostics that may not change treatment and to be aware that continued cost and unanticipated expenses are inevitable over the course of the pet’s lifetime.”

“Beyond the financial investment, managing a diabetic pet requires a lifestyle commitment as a chronic caretaker,” continued Kvitko-White. This commitment includes administering insulin injections twice daily, controlling diet, close monitoring, and attending many follow-up appointments. While this commitment has the potential to strengthen the human-animal bond between owner and pet, difficulties in treatment due to both owner and pet factors also have the potential to be detrimental to this bond.

Insulin injections can cause fear in both owner and pet. According to Apketmann et al. (2014), over half of owners reported being fearful of administering injections at the beginning of treatment, but most were able to overcome this fear. Teaching owners that most pets tolerate insulin injections well and that they are relatively easy to administer is an important part of preparing owners for treatment.

Despite our best efforts though, some pets are simply not amenable to injections. A pet that begins hiding from their owner or biting when medicated will have a detrimental effect on the quality of life of both the pet and the owner, and patient temperament should be considered when electing to pursue treatment.

For some clients, work or travel schedules make regular insulin injections challenging, especially for a pet owner who lives alone. Many studies have reported that the need to find appropriate boarding or pet sitting services for diabetic pets when traveling is considered a major stressor for diabetic pet owners. For owners who travel frequently, this may be the factor that makes treatment impossible.

All of these factors should be discussed with the client before treatment is pursued. Diabetic treatment is not for everyone, and clients should hear this from their veterinarian. “Pet owners should never be made to feel bad for euthanizing a diabetic pet,” said Kvitko-White. In fact, beginning treatment that is not sustainable may be more detrimental for the physical, mental, and financial health of both pet and owner than to elect humane euthanasia without treatment.

Insulin Considerations

One of the first decisions the veterinarian needs to make once treatment is elected is which insulin product to prescribe. “Diabetes [requires] insulin forever, especially in dogs. Even though it might go into a non–insulin-dependent state, insulin therapy is required in addition to diet, even in cats with type 2 diabetes,” said Kvitko-White. Insulin selection will impact diabetic control and the overall finances of treatment.

Considerations for insulin selection should include the duration of action, anticipated efficacy, and cost. The 2018 AAHA Diabetes Management Guidelines for Dogs and Cats offer a summary of available insulin products, both the FDA-approved veterinary products and human products. “In general, I prefer to start with Vetsulin for small and medium dogs, glargine for cats, and detemir for large- and giant-breed dogs,” said Kvitko-White. “This is based both on the anticipated length and efficacy of insulin effect but also cost-conscientiously based on a cost-per-unit basis.” Veterinarians should evaluate insulin costs based on the price per unit of insulin instead of price per vial to determine the best value for the client. However, choosing a less efficacious insulin because of the price may, in the long run, cost the owner more owing to poor diabetic control.

Once an insulin is selected, owners must be carefully educated on insulin storage, handling, and administration. Kvitko-White reminds veterinarians that insulin vials often need to be disposed of before the vial is empty, which is an important detail to stress to pet owners. In cases of tight finances, owners may be tempted to stretch their insulin vials longer, which can result in decreased efficacy and, ultimately, higher potential for complications due to poor glycemic control.

Owners should also be advised that there are different types of insulin syringes and shown how to identify the correct syringe for use with their pet’s insulin product. If an owner is sent to a community pharmacy to purchase a human insulin product, be very clear with the owner about cost expectations. Owners who are shocked by the cost of insulin glargine or insulin detemir upon arriving at the pharmacy may be told about NPH insulin that is available over the counter by a well-meaning pharmacist who lacks the species-specific veterinary knowledge to know the reasoning behind the veterinarian’s insulin choice. If the owner purchases a different insulin than what was prescribed, diabetic control and dosing can be affected.

Teaching owners how to properly care for a diabetic pet can be a time-consuming conversation. It should include both demonstration of insulin administration and supervised practice for the owner on drawing up and administering insulin. These conversations and demonstrations are excellent opportunities for veterinary technicians to use their skills and knowledge. Utilizing veterinary team members to introduce owners to insulin administration ensures that these crucial conversations are not rushed because of pressure on the veterinarian to see other patients.

Owing to the large amount of information that owners are presented with in a short period of time, it can be helpful to provide them with trusted resources on insulin handling, administration, and storage. Even with detailed verbal instructions and a thorough demonstration of insulin administration, owners are unlikely to retain the large volume of information. The AAHA Diabetic Resource Center (aaha.org/aaha-guidelines/diabetes-management/resource-center) includes a customizable discharge template for new diabetic pets as well as handouts and videos for pet owners on insulin administration and home monitoring.

Dietary Management

Another crucial factor in achieving diabetic control and minimizing complications is appropriate diet. Clients may be hesitant to change their pet’s diet, but educating them on the role of diet in achieving glycemic control may help to improve compliance. Compliance with dietary changes can be very high, as 80% of dog owners and 93% of cat owners changed their pet’s diet after diagnosis, according to Aptekmann et al. (2014).

Dietary changes are a necessity in feline diabetic patients. High-protein diets are used to limit carbohydrates, improve satiety, and aid in weight loss without lean muscle mass loss. Combining this diet with twice-daily insulin injections improves the chances of remission. Canned diets can be especially beneficial for diabetic cats owing to the lower caloric density and higher water content.

“In dogs, the most important diet change is to immediately stop feeding any table snacks and treats, most especially those high in fat or salt, which may predispose these dogs to pancreatitis and the potentially significant complications associated with that,” said Kvitko-White. High-fiber diets help control glycemic control; however, many high-fiber diets are too low in protein to support weight loss in overweight cats. High-fiber diets may aid in weight loss and glycemic control in dogs.

For both species, meal feeding is preferred. This allows owners to more easily control caloric intake and ensure the pet is eating prior to receiving insulin treatments. For pets that have been free-fed for their entire lives, a transition to meal feeding may be difficult. In these cases, feeding several small meals throughout the day, as long as they are consistent in amount and time provided, may be a suitable alternative. This same feeding strategy is preferred for cats with type 2 diabetes on synthetic long-acting insulin, as they do not need to eat at the time insulin is administered.

“While prescription diabetic diets are available, they may not be the best choice for an individual pet, regardless of species,” shared Kvitko-White. Instead, the individual goals of treatment, patient preferences, cost of diet, and comorbidities should be considered.

Monitoring Plan

When diagnosing a new diabetic, giving clients an overview of the monitoring plan can help to prepare them for the future. Successful monitoring of diabetic patients requires partnership between the owner and the veterinary team. Owners should be advised of the importance of two-way communication with the veterinary team. Monitoring food and water intake as well as urine output at home are essential because control of clinical signs is one important goal of treatment. However, blood glucose levels must also be monitored, making compliance with follow-up visits critical to achieving diabetic control.

Many strategies for diabetic monitoring exist, and plans can be individualized for specific pets and owners. However, Kvitko-White cautioned, “Diabetes cannot be monitored on the basis of spot blood glucose checks and/or urine checks alone. Blood glucose curves are an essential component to monitoring insulin efficacy and duration.”

In-clinic glucose curves have been critiqued by some for being costly, time-consuming, inaccurate if normal feeding and exercise routines are not followed, and, in cats, easily affected by the stress level in the veterinary hospital. At-home glucose curves may actually be more ideal. Kvitko-White feels that “one of the most cost-conscientious approaches to managing diabetic pets is to teach clients to perform blood glucose monitoring at home.” Newer techniques for monitoring blood glucose levels using continuous glucose monitoring systems have shown promising results for both dogs and cats.

Preparation for Complications and Sequelae of Treatment

Potential complications of treatment should be discussed with owners, including risks and clinical signs of hypoglycemia. Clients should be given instructions for how to dose insulin when their pet is not eating well or vomiting. Information on when and where to seek emergency attention is also important.

Finally, pet owners should be advised of diabetic sequelae and concurrent diseases that may be observed in diabetic pets, including pancreatitis, urinary tract infections, peripheral neuropathy, and ocular changes. For dog owners, one of the most important changes to prepare owners for are ocular changes, as this can have a large impact on quality of life. “Greater than 90% of dogs develop cataracts within the first year,” said Kvitko-White. “Without management, [they] are at risk for lifelong painful uveitis, ulcers, and glaucoma.”

Setting Up for Success

While diabetes can be a frustrating and expensive disease to treat, most clients report good outcomes with treatment according to a 2014 JAAHA study. Additionally, the majority of owners treating a diabetic pet felt that diabetes treatments did not interfere significantly with their daily life, and they were more attached to their pet after beginning treatment, showing that treatment can be rewarding. Taking the time to have comprehensive conversations with owners of newly diagnosed diabetic pets can help to maximize success of treatment and minimize stresses for pet, owner, and veterinary team.

Kate Boatright, VMD, has been in small animal practice since graduating from the University of Pennsylvania in 2013. After nearly eight years of full-time practice in both general practice and emergency clinics, she moved to part-time clinical work to pursue her passion for educating veterinary professionals as a freelance speaker and author. She believes deeply in the role of organized veterinary medicine and holds leadership positions in the AVMA and PVMA. In her remaining time, she stays busy chasing her toddler, running, reading, and watching movies with her husband and cats.

Photo credits: ktaylorg/iStock via Getty Images Plus; ©AAHA; ©AAHA/Robin Taylor; tdub303/E+ via Getty Images; ©AAHA/Kimberly Lamb