Q&A: Beyond the numbers—what success looks like in feline diabetes management

The American Animal Hospital Association (AAHA) updated its diabetes guidelines this year, bringing changes to how veterinary teams treat, monitor, and define success for diabetic cats. For Feline Diabetes Awareness Month, Kelly Cairns, DVM, MS, DACVIM (SAIM), spoke with dvm360 about how feline diabetes care has evolved during her time in practice. Below, she details what the updates mean for treatment selection, nutrition, client communication, and the realistic odds of remission.

Below is a transcript of the conversation, lightly edited for length and clarity.

dvm360: The American Animal Hospital Association (AAHA) updated its diabetes guidelines for cats this year. In your time in practice, how has treating diabetic cats changed?

Kelly Cairns, DVM, MS, DACVIM (SAIM): I think the biggest change is that we have a lot more tools now, and we're becoming more thoughtful about how we use them. Insulin has been the cornerstone or central treatment for feline diabetes for a really long time, and while insulin is still super important, we now have other medications, including the sodium-glucose cotransporter-2 (SGLT2) inhibitors, which can be super helpful for very carefully selected newly diagnosed cats that have never received insulin.

At the same time, the way that we monitor these cats has changed the information we can get from insulin-treated cats. Instead of trying to make decisions after a stressful day in the hospital, we’re turning more to using continuous glucose monitors to look at trends while the cat is in its normal home environment.

One of the things that I think is super striking about the AAHA guidelines is that routine in-hospital glucose curves are no longer recommended. That’s not saying that glucose curves are unimportant. It’s saying we should do it in a way that’s going to produce more useful information in a less disruptive environment for the patient. And the last thing that I think has changed with the new guidelines is an increased emphasis on clinical outcomes, really looking at if the cat is feeling better. Is their thirst and urination normal? Is their weight stable? These are very meaningful measures of success, not just looking at the glucose numbers.

dvm360: For cats that have been on insulin for a while, do these new guidelines change insulin management?

Cairns: Absolutely. I think the biggest thing in the new guidelines is how we monitor and define success for cats receiving insulin. Now, what type of insulin? It’s insulins that I think we’ve been using for a while. So, glargine U-100, as well as protamine zinc insulin—or ProZinc—are very commonly used options. The guide has introduced some newer basal options, including a U-300 glargine, also known as Toujeo, as well as Tresiba, for which the generic is degludec. These are newer insulins that may be very useful in selective cases. It is important to know that both are extralabel use in cats, and we can’t use them as interchangeable with the more classic insulins that I’ve described.

Another thing that the guidelines have brought up with the use of insulin is, again, what does great look like? Our goal with insulin is not a completely normal blood glucose level within reference range for every minute of every hour of every day. Our primary goal with insulin therapy is resolving those clinical signs and preventing significant hypoglycemia.

The last thing that is super important is how we’re measuring cats receiving insulin therapy. Continuous glucose monitors are incredibly useful, especially really early in regulation or when we’re partnering with the client about whether a dose adjustment of insulin might be needed. We know they show us patterns that single glucose measurements cannot. We also know that taking those measurements at home continuously is going to minimize that stress hyperglycemia that is so common in cats when they come to the hospital.

The last thing with insulin therapy that’s very important: If the clinical signs aren’t where we want them to be, and glucose levels are high on measurement, we really need to back up and check the product and how we’re giving it. There are syringes; there are pens. Look at the technique, diet, medications, and all those comorbidities that can cause insulin resistance before we go to simply increasing the insulin dose.

dvm360: When you first see a newly diabetic cat, how do you decide between insulin or SGLT2 drugs?

Cairns: For me, the decision is really based upon safety and patient selection, not at all about whether an oral medication might be easier for that client to give that cat, so there [are] really clear lines in my mind.

We have 2 great drugs in Bexacat [bexagliflozin] and Senvelgo [velagliflozin oral solution]. There’s a liquid, there is a tablet. They are contraindicated in cats that have ever received insulin, who are receiving insulin now, or have insulin-dependent diabetes. We shouldn’t take a cat off insulin to just put them on an SGLT2 inhibitor.

I also do not use the oral drug if a cat is sick at the moment—clinically anorectic, dehydrated, lethargic, or ketotic. If the cat is vomiting, if the cat has comorbidities, we do need to do an assessment including checking for ketones, including beta-hydroxybutyrate. We also need to make sure that the kidney function and the liver function are OK, because both drugs have warnings or overt contraindications in the setting of those diseases, as well as other comorbidities. We want to use these drugs on label.

One of these 2 drugs could be a great potential starting point in an otherwise healthy, newly diagnosed diabetic cat that has never received insulin, that is eating, well hydrated, and not in ketosis.

It’s also important to understand that they have a novel mechanism of action, so they’re lowering glucose by increasing the amount of glucose that is excreted in the urine. They’re not replacing insulin; they’re acting differently than insulin. I also need to [be certain] that the family is going to be able to complete the required monitoring.

dvm360: How is the required monitoring different with SGLT2 drugs?

Cairns: Monitoring a cat that’s receiving an oral SGLT2 inhibitor looks different than monitoring a cat on insulin. And this is probably one of the most important distinctions for primary care teams to understand. With insulin treatment, we’re really relying on the glucose data—a curve or continuous glucose monitoring—to help assess the response, see if the blood sugar is too low, and adjust the dose if necessary.

It’s very different with the SGLT2 inhibitors. The glucose can improve in these cats because they’re urinating out more glucose, even when the cat does not have enough insulin to prevent ketosis. What we use for these cats, largely, is the measurement of beta-hydroxybutyrate, or serum ketone, which is the major circulating ketone in the blood in DK or DKA. So the 2026 AAHA guidance emphasized early clinical checks and early checks of ketone, including defined measurement on days 2, 3, 7, and 14 after starting an SGLT2 inhibitor.

That’s not to say that we never assess glucose control in these SGLT2-treated cats, and it’s not to say that we never check ketones in an insulin-treated cat that’s sick. It’s just that our safety priorities are different. So if we do have a cat that’s on an SGLT2 inhibitor and that cat stops eating, vomits, becomes lethargic, and seems unwell, that would earn a visit to the vet, just like it would earn a visit to the vet in a cat that is receiving insulin. When the cat gets there, regardless of what their blood sugar is, we want to assess them for the presence of ketosis and ketoacidosis.

And lastly, when we’re using these drugs, either one of them, we want to follow the specific monitoring requirements for the specific product that is being prescribed and stay on label with that drug.

dvm360: How does nutrition play a role in feline diabetes management?

Cairns: Nutrition is absolutely a critical part of diabetes management. It’s key to understand that it has to be individualized. For many cats that have diabetes, a higher-protein, low-carb diet, often a canned diet, is a reasonable goal. If the cat is obese, it’s also really important to use nutrition to achieve a gradual weight loss, which can improve their peripheral insulin sensitivity.

The one thing that I think is key to understand with nutrition is that the best diet on paper may not be the most practical because, at the end of the day, the cat has to want to eat that diet. We have to make sure we’re protecting enough calories getting in, muscle mass, and what diet the cat is going to find really palatable.

The other thing that is really important is not just what we’re feeding, but paying attention to when we’re making changes, especially for a cat that’s being started newly on insulin or on an oral SGLT2 inhibitor. We want to make sure that we keep the current diet unchanged for a couple of weeks, then consider a gradual change if the cat is doing well, because it’s important to avoid multiple abrupt changes that can make it harder to recognize a problem.

dvm360: What are some clinical signs that immediately steer you in the direction of a diabetes diagnosis or at least suspecting diabetes?

Cairns: Most commonly, I think we’ll hear a history of an owner saying that the litter box is much wetter. The cat is peeing a lot more, larger clumps. They may notice that the cat is drinking more, although in my experience, that’s a less sensitive indicator because you may have multiple sources of water in the home or multiple cats. So looking at that litter box for larger clumps can be helpful.

The client might also report that the cat is ravenously hungry, but despite wanting to eat a ton or objectively eating a lot, that cat is still losing weight. And it’s really important for us as providers to remember that the client might not recognize how much weight the cat has lost until we put that number on the scale. We also might see a decrease in muscle mass, which we might need to identify on examination.

Cats can also get what’s called diabetic neuropathy, where they will have a decrease in functioning in the peripheral nerves. The classic posture would be a cat that has a plantigrade stance where they’re kind of sitting like a bunny would sit, dropped down on their hocks vs up on the tips of their toes. That is something that we as providers will frequently recognize as diabetes, but it can initially throw you off kilter.

dvm360: Clients can feel intimidated when they get a diagnosis of diabetes for their cat. What do you discuss with them about managing it?

Cairns: The first thing to recognize is that it’s really normal for this to feel overwhelming to a family. Any chronic disease can be overwhelming. They need to understand what they’re in for, whether it’s injections or oral medication, the diet change, the requirement for glucose monitoring, and repeat visits. Our job is not to make things sound easy. Our job is to be honest and to help make it manageable. So I like a transparent approach, and I like a stepwise approach. The first thing is for them to have a clear understanding upstream so they can make a decision that is comfortable for them, that they think is achievable within their means, within their lifestyle, within the support structure they have in the household.

I also think that it’s key to really explain the treatment we’re recommending and the “why” behind that treatment and make sure we are really supporting them to give that treatment—whether it’s giving a liquid medication, an oral pill, or how to give insulin. All of that really involves an education session where the owner is actually showing us how they would do it. For insulin, we would even use mock saline injections.

That teach-back step is incredibly valuable at every step of the journey, and this is where I think we need to lean into our technical support staff. They are the key to the castle in any successful veterinary practice. I really suggest having a diabetes champion—or several—in your practice. The veterinarian should be leaning in on the techs; they should be the ones who are reinforcing the plan, teaching the clients, troubleshooting the practical problems, and really making sure that the family feels empowered to know what to watch for, when to call, and giving psychological safety to the family. We want them to call; we’d much rather clients say, “I can’t do this” or “I’m worried,” than for them to go home and not speak up.

So, at the end of the day, our number 1 job as a team is helping the owners succeed. Leverage every member on the team that plays a critical role. I’m team “tech first” as the single most important seat on the bus to help that family succeed. And number 2 is continuing to keep an open dialogue, normalizing that psychological safety, and being realistic about follow-up and a long-term open line of communication.

dvm360: How can veterinary teams help owners of diabetic cats succeed?

Cairns: It’s really important that we are good partners to the humans attached to that cat. And so, when talking to clients, I think it’s key for us to set the expectation early, making sure that they understand what diabetes is and what great looks like, what success through our lens looks like, and then stop and listen to the client and find out what success or great for them looks like, and really focus on the partnership that we’re going to have in the long-term management of that cat.

Also important is what we believe the reasonable expectation should be for the client to make sure they think it is something they’re able to achieve and, if not, that we’re working with them on the best plan we think is achievable and manageable for both of us.

dvm360: What do you look for when you see a newly diagnosed cat 6 months later?

Cairns: For me as a vet, great in 6 months would look like a cat that is clinically doing well and regulated with their diabetes. Again, that may not be a number that is exactly in the middle of normal reference range 24 hours a day, but is close enough to that range that the clinical symptoms are gone.

I want to see a cat that has a normal, good quality of life without any clinical symptoms of diabetes, and a case in which we have managed and/or prevented the complications of diabetes. We want clients who are feeling really good about what is needed at home chronically to keep the cat feeling well and clinically regulated.

We’re probably going to see that cat back a minimum of twice a year, but more realistically, 4 times a year; that is a very individualized schedule that the veterinarian and the family will come up with. But for me, no less frequently than twice a year for a physical exam, a touch base, and some routine wellness testing to look at the overall organ health and blood cell counts of that cat.

dvm360: Is remission possible? Is it realistic for cat owners to hope for it?

Cairns: I think remission is one of the most certainly hopeful, but potentially most easily misunderstood parts of feline diabetes. The data we have in the 2026 AAHA guidelines suggest that about 30% of cats will achieve remission. So that’s a pretty reasonable data point that we can discuss with clients. But we also recognize that individual studies and individual cat remission tendencies can vary a lot.

So first, talking about what remission is, it would be a normal blood sugar for more than 4 weeks without the need for any oral medication or insulin. What we know is that most cats that are going to achieve remission will do so within about 6 months after diagnosis. The things that we know will improve the odds are getting a diagnosis early so that the cat has been diabetic for a shorter period of time, getting good glycemic control early, and getting their numbers and their clinical symptoms where we want them to be early.

Also, seeing if there’s something that cat has that is reversible, that is driving insulin resistance, and we can address that comorbidity, that is helpful to achieve remission. For example, in the case of obesity, if we can get the cat to a more optimal body weight, maybe recent steroid or glucocorticoid exposure. Also, if we can treat these cats with the appropriate high-protein, low-carb diet, that may help. On the other side of the coin, if we’ve got a comorbidity or another unrelated condition, for example, hypersomatotropism or acromegaly, as it was once called, those comorbidities can make remission much less likely.

The other thing I think we need to remember with remission is that it’s not a cure, and…cats can have a relapse after remission. We don’t yet have a reliable remission estimate…for cats that are receiving those new oral SGLT2 inhibitors.

At the end of the day, when I’m talking to a client, I’m discussing remission as an opportunity that we hope for, that we strive for; we watch for it, but it can’t be the only definition of successful care. There are a lot of cats that don’t achieve remission but can do very well with chronic medication, whether it’s insulin or oral therapy.

dvm360: Are there any misconceptions about feline diabetes that you want pet owners or veterinary professionals to understand the truth about?

Cairns: I think one of the big misconceptions—and something I’d really love for people to keep in mind—is that not every diabetic cat can be treated the same way. It truly is an example of there not being a one-size-fits-all approach. That shows up in how they present, and it shows up in how they’re going to be best treated: whether that cat needs insulin or might be a candidate for oral medication, which does have specific rules and regulations associated with it, and whether that cat is going to go into remission or not.

So we need to think about what that cat needs. We also need to think about what that family or the people attached to that cat can realistically manage, so that we’re making a targeted, individualized recommendation about initial treatment and monitoring for that cat.