How to choose and monitor diabetes treatment for cats

In an interview at the Fetch dvm360 Conference in Long Beach, California, Catharine Scott-Moncrieff, DVM, PhD, walked through the practical decisions clinicians face when treating newly diagnosed diabetic cats.

Editor’s note: This dvm360 Q&A has been lightly edited and consolidated from a verbal interview to better fit a written format while retaining the substance of the original conversation.

dvm360: What is your background?

Scott-Moncrieff: I’m Catharine Scott-Moncrieff. I’m originally from England and I’ve been at Purdue University a long time…since 1986. I’m a full professor and I recently stepped down as department head. I’ve been on sabbatical for a year and I’m returning to the clinics, primarily to do endocrinology.

dvm360: When you start a newly diagnosed diabetic cat, what’s your practical plan for the owner and clinic?

Scott-Moncrieff: The most important first step is deciding which treatment is right for that individual cat, because monitoring differs depending on whether you choose insulin or an SGLT2 inhibitor.

For insulin-treated cats, much of the early work is owner education: how to store insulin, draw it up, administer injections, coordinate insulin with feeding, recognize and respond to hypoglycemia, and what to do if the cat doesn’t eat. Avoiding hypoglycemia is the main risk with insulin, so owners must understand warning signs and what actions to take.

For SGLT2 inhibitor–treated cats, the owners have an easier regimen—the drugs are oral and once daily, don’t have to be synchronized with feeding, and the available formulations (tablet or palatable liquid) are generally well accepted. That said, early monitoring for ketones is crucial with SGLT2 therapy; the first 14–30 days are when you’re most likely to catch cats developing ketosis or diabetic ketoacidosis (DKA). So, while administration is simpler, monitoring (especially for ketones) is still important early on.

Note: SGLT2 inhibitors commonly used/approved for cats are bexagliflozin (Bexacat; Elanco) and velagliflozin (Senvelgo; Elanco). Both are once-daily oral agents.

dvm360: How do you decide whether to start a cat on insulin or an SGLT2 inhibitor? What specific indicators do you look for?

Scott-Moncrieff: Ideally, we’d distinguish type 1 from type 2 diabetes, because type 1 cats (no endogenous insulin production) require insulin. We don’t have a simple in-clinic test that cleanly separates type 1 from type 2, but most newly diagnosed cats—roughly 80%—are type 2. So, we look for a newly diagnosed cat with classic diabetic signs (polyuria, polydipsia, polyphagia, weight loss) without other systemic illness or comorbidities. That means, not lethargic, not anorexic, and no obvious liver disease, kidney disease, pancreatitis, or other complicating conditions.

You should also screen to rule out ketosis (urine ketones or blood BHB) before starting an SGLT2 inhibitor. If the cat is systemically ill, ketotic, or has significant concurrent disease, insulin is the safer option. If the cat meets the “otherwise healthy, newly diagnosed” profile and is not ketotic, she’s a reasonable candidate for an SGLT2 inhibitor, but you must watch closely early on.

dvm360: Are owners more compliant with SGLT2 inhibitors compared with insulin?

Scott-Moncrieff: Yes, administration is simpler. The 2 available SGLT2 products are palatable (one is liquid, one is a tablet), can be mixed with food or given directly, and only require once-daily dosing. That generally leads to high owner compliance. For the first month the monitoring burden is similar to insulin. You’re just monitoring different parameters, ketones for SGLT2s vs glucose curves and hypoglycemia risk for insulin. After that initial period, the monitoring requirements for SGLT2-treated cats often decline.

dvm360: What influences diabetic remission in cats? What factors make remission more likely?

Scott-Moncrieff: Reported remission rates vary widely in the literature (15 to 70% in different studies), which reflects differences in patient populations and treatments. Factors that increase the chance of remission include resolving any underlying disease that causes insulin resistance, achieving an appropriate body weight (obesity reduction), a low-carbohydrate diet, and—above all—good glycemic control. In my view it’s not the specific insulin type that matters so much as achieving and maintaining effective glycemic control early in the course of disease.

dvm360: Any common misconceptions about SGLT2 inhibitors you want to clear up?

Scott-Moncrieff: The major concern clinicians have is euglycemic diabetic ketoacidosis (euDKA). Cats treated with SGLT2 inhibitors can become ketotic while appearing euglycemic because these drugs lower blood glucose by promoting glucosuria. That makes euDKA easy to miss if you only check blood glucose and not ketones. It’s correct to be concerned, but the incidence appears lower than some fear. In newly diagnosed, previously untreated cats, clinically significant DKA occurs in a minority (in my experience and the data I cited, around 5% of naïve cats), and appropriate early monitoring can reduce risk by catching ketone accumulation before cats become systemically ill. Nevertheless, vigilance for ketones is essential.

dvm360: Can a cat treated with an SGLT2 inhibitor go into diabetic remission? How would you detect it?

Scott-Moncrieff: Some cats on SGLT2 inhibitors do go into diabetic remission, but the studies that led to approval didn’t follow cats long enough after stopping therapy to answer what percentage remain in remission. The key difference compared with insulin is this: an insulin dose that becomes excessive will cause hypoglycemia and reveal that the cat is producing enough insulin (so you can detect remission indirectly when insulin needs fall). SGLT2 inhibitors don’t cause hypoglycemia the same way because renal glucose reabsorption mechanisms can buffer blood glucose—so excellent glycemic numbers on an SGLT2 do not reliably prove remission. The only way to know is to stop the drug and monitor for recurrence of clinical signs and hyperglycemia. That longitudinal, post-withdrawal data for SGLT2-treated cats is limited and an area we need more research on.

dvm360: What research are you and your team working on now? Anything clinicians should watch for?

Scott-Moncrieff: We’re validating ketone meters for cats. The Precision Xtra meter has been validated for β-hydroxybutyrate (βHB) in cats, but its strips are expensive and not always available. We’re comparing the Precision Xtra to other meters that measure both glucose and βHB so clinics could use a single meter for both. That would simplify monitoring. We’re also evaluating βHB urine dipsticks because urine ketone tests measure acetoacetate whereas blood tests measure βHB, and βHB is likely the more clinically relevant ketone. Practically, it’s often easier to get a drop of blood than a urine sample from a cat.

Separately, we’re analyzing long-term safety data from extended safety cohorts in the pivotal SGLT2 studies where some cats were followed for up to 3 years. That work should help clarify long-term renal outcomes, rates of ketoacidosis over time, and other potential complications. We’re actively recruiting for some of these studies, and we hope to have abstracts and manuscripts submitted in the coming months.

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