Pet diabetes: New meds and monitoring tools advancing care options

By Erica Tramuta-Drobnis, VMD, MPH, CPH

Diabetes mellitus (DM) is a commonly diagnosed problem in dogs and cats. While there is a lot we can do to prevent its onset through routine care and client education, it is still inevitable in many patients. To protect the human-animal bond, we must know what treatment options are available, how to monitor patients with those therapies, and how to select clients (and patients) for what modality. Additionally, we need to be aware of how to educate clients about the disease, treatment, and side effects of any medications, risks of disease complications due to treatment failure or disease progression, and costs of care.

By having the patients' best interests at heart, while not sending our clients into debt, and ensuring pet and pet parents know and understand the care needed, we can minimize harm and ensure a continued relationship for, hopefully, years to come.

With the advent of new noninsulin medications, the sodium-glucose transport protein 2 (SGLT2) inhibitors, we can address DM in a new way with our feline patients. We can potentially reach and treat more patients while preserving the pet-parent relationship, remaining within clients' budgets, and euthanizing fewer patients for cost and medication administration concerns.

According to the Centers for Disease Control and Prevention (CDC), the human prevalence of DM in the U.S. in 2021 was estimated at almost 12 percent of the population.¹ While we lack sufficient research data or reporting methodologies to determine the prevalence in domestic animals, we all recognize it is widespread. Novel drug treatments for DM can provide clients with options permitting treatment of patients that would otherwise be euthanized due to cost or other issues related to insulin therapy in pets.

Keys to effective patient care

Establishing treatment plans
Establishing a treatment plan is not a one-size-fits-all approach. Understanding your clients and what they want, need, and are capable of is crucial. This insight is key to devising a treatment path for your patient. Each client is unique, and their circumstances and capabilities must be considered when designing a treatment plan. Newly diagnosed diabetic patients require a lot of care, follow-up, client education, and TLC. However, we need to ensure we know what our clients want and can do at home.

It is of the utmost importance to know which clients are candidates for novel therapy and at-home monitoring and who need careful directions with explicit instructions not to deviate and to call you or an emergency clinic if a problem arises. Not all our patients and owners can be managed the same way.

Traditionally, treating diabetics has included insulin and diet management. Weight-loss strategies and prescription foods (or diet changes with over-the-counter foods) may be utilized. For diabetic dogs, this is still our mainstay of therapy, and it is lifelong. Researchers have yet to develop a medication that helps treat disease without using insulin in dogs. However, we do have several insulin choices for our pets. Thorough knowledge of the available medications, required insulin syringes for each product, the current insulin price, and the potential complexity of regulation when using generics are crucial for assisting your canine patients in achieving glycemic control.

Newer treatment options
For cats, DM management may no longer need to include insulin. This will depend on the patient, the owner, the severity of illness at diagnosis, and underlying conditions. However, we now have options other than insulin.

A new class of oral, once-daily DM medication has recently been utilized to manage feline DM. SGLT2 inhibitors may help transform how we manage newly diagnosed feline DM patients. Velagliflozin and bexagliflozin work by increasing the urinary excretion of glucose through the inhibition of proximal renal tubule sugar resorption. Early research is promising and suggests this drug class effectively helps create glycemic control.^2–6

Bexagliflozin comes as a tablet, while velagliflozin is a liquid. Selection should be tailored to each patient's needs.

An ideal candidate for starting the oral DM medication in a cat would be a newly diagnosed cat that:

1. Has never received insulin
2. Has an owner willing to monitor intensively and commit to frequent evaluations
3. At the time of diagnosis is not ketotic, eating, and otherwise acting normally
4. Has owners who fully understand and are educated about the possibility of developing euglycemic diabetic ketoacidosis (eDKA), the seriousness of the condition, and the potential need for hospitalization (generally) should it arise
5. Has owners who are aware that if they notice signs of complications, including lethargy, anorexia, or vomiting, the pet should be evaluated ASAP
6. Has owners who agree to commit to intense monitoring for the first up to eight weeks or more, then usually every 90 days thereafter
7. Has owners who (regardless of the reasons) cannot give injections (insulin is not an option), and euthanasia is the alternative

More research is available on the oral tablet than the liquid product, but they function similarly. The difference seems to be in formulation only, but research is ongoing. Additional studies are needed to evaluate the ability of this class of drug to induce remission in feline patients.^7,8

Monitoring diabetics

There are several ways to monitor our diabetic patients, from at-home glucose curves with a glucometer to at-home curves with interstitial glucose monitors, urine ketone strips, fructosamine levels, or A1C values.

However, to truly assess glycemic control, a combination of monitoring tools, physical exam findings, and clinical signs is often needed. We can definitively recommend that no animal's insulin dose should be increased based on a single spot blood glucose level, though a too-low reading may trigger a decrease in dose.⁷ Still, the other methods of monitoring all have pluses and minuses.

In-house 12- or 24-hour glucose curves^7,9
Previously considered the gold standard, we recognize the challenges in performing and interpreting them due to the patient's stress. The American Animal Hospital Association (AAHA) Guidelines recommend curves under several conditions, including when one suspects hypoglycemia. Clinical signs previously controlled recur every three months in well-regulated patients after starting new insulin (usually within seven days) and then within seven to 14 days of any dose change.

Interstitial glucose monitors (IGMs) and at-home glucose curves^10–16
This option permits owners to perform testing and monitoring at home, lessening the influence of stress on curves and allowing more frequent evaluations and monitoring. However, research shows the precision of IGM measurements decreases significantly when glucose concentrations reach very high levels.

Generally considered safe, IGMs may help improve owner and pet quality of life while permitting veterinarians to gauge general trends in glycemic control. Taken together with physical exam findings and clinical signs, insulin adjustments may be made reasonably.

Fructosamine levels^7,17
These levels reflect what the body's sugar levels have been doing for about two weeks. Research suggests they shouldn't be the only means to gauge glycemic control, yet they often are. However, they are thought to be much less reliable at evaluating glycemic control in dogs and cats than previously thought. Therefore, additional research is necessary.

Glycated hemoglobin A1C^17,18
Cats show an average of blood sugars over approximately 70 days, and in dogs, 120 days. Research suggests A1C may be more accurate than fructosamine and possibly a more usable standalone test for evaluating glycemic control. Additional research is ongoing.¹⁸

Urine glucose/ketone monitoring
Using this method, results may lag clinical levels, can be difficult for owners to acquire samples, and the presence of glucosuria does not equate to actual blood glucose values at the time of collection. Urine sugar levels reflect the mean blood glucose levels at the time the bladder was being filled. Utility is valuable when ketones are present and should trigger a call to the veterinarian, but insulin doses should not be adjusted based on urine evaluation alone.⁷

Regardless of what monitoring you use, please do not use spot blood glucose checks or urine dipsticks alone to adjust insulin levels. This can lead to dysregulation and increase the risk of complications, potentially costly trips to the ER, and more.

Paramount to provide complete client education

As responsible professionals, we must have open and honest discussions with our clients about the long-term commitment and costs of managing a diabetic pet. This includes the cost of life-long monitoring and bloodwork needs, the cost of medications, and many other facets of caring for a diabetic pet. By being proactive in these discussions, we can help ensure our clients are fully informed and prepared for the journey ahead.

Educating our clients about the disease, treatment, and potential complications empowers them to make informed decisions and improve patient outcomes. If you diagnose a pet with a DKA or even a stable diabetic who is still eating and drinking at home, please do your due diligence and educate the client (See: "They need to know").

Non-insulin therapy

DM is a manageable disease, though costly and not without the possibility of complications. Owners need transparency and honesty. DM is not like a skin infection you treat for a week or two and are done; it is often a life-long condition with bumps and roadblocks that may make it costly and challenging.

Owners need complete education at the time of diagnosis and support throughout the treatment process. They need to be prepared to have a rainy-day fund for not if but when the pet takes a turn for the worse due to any situation that triggers a decrease in glycemic control.

Knowing and understanding the now increasing available options for managing (cats) and monitoring response to treatment (dogs/cats) remains crucial for veterinarians to provide the most up-to-date information to their clients and help them manage their diabetic population best.

While these new oral medications provide hope and alternatives for our feline patients, is there something on the horizon for our canine friends, or will they always be stuck with needles and need insulin? Hopefully, novel therapy options for canines are on the horizon; in the meantime, we have more opportunities to help a larger feline population with these oral options, the right client, and the right patient.

Erica Tramuta-Drobnis, VMD, MPH, CPH, is the CEO and founder of ELTD One Health Consulting, LLC. Dr. Tramuta-Drobnis works as a public health professional, emergency veterinarian, freelance writer, consultant, and researcher. She is passionate about One Health issues and believes pet health, food safety, agricultural health, and more can address the interconnection of human, animal, and environmental health.

References

1. Centers for Disease Control and Prevention. National Diabetes Statistics Report. CDC's Diabetes. May 15, 2025. Accessed September 2, 2024. https://www.cdc.gov/diabetes/php/data-research/index.html
2. Buishand F. Diabetes Mellitus in Dogs and Cats. Merck Veterinary Manual. May 2024. Accessed September 2, 2024. https://www.merckvetmanual.com/endocrine-system/the-pancreas/diabetes-mellitus-in-dogs-and-cats
3. Behrend EN, Ward CR, Chukwu V, et al. Velagliflozin, a once-daily, liquid, oral SGLT2 inhibitor, is effective as a stand-alone therapy for feline diabetes mellitus: the SENSATION study. Published online August 14, 2024.
4. Hadd MJ, Bienhoff SE, Little SE, et al. Safety and effectiveness of the sodium-glucose cotransporter inhibitor bexagliflozin in cats newly diagnosed with diabetes mellitus. J Vet Intern Med. 2023;37(3):915-924.
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