As a veterinarian, I am continually advocating for early disease detection, intervention and treatment. Many of the diseases that affect our pets are deteriorations, rather than sudden failures of the body. Signs and symptoms are often subtly progressive and once these disease states arise, they frequently progress to an irreversible state. It is critical to know your pet and observe changes that may be early indications of disease. Some changes should be addressed right away, including changes in:
Metabolic diseases such as kidney disease, liver disease and diabetes may all be similar in their initial signs (changes in appetite water intake). My own cat, Ritz, recently demonstrated that with an early diagnosis and immediate intervention, a better outcome is possible. For Ritz, an early diagnosis saved him from a lifetime of inconvenience—at the very least—and possibly even from an early death.
My cat, Ritz
Ritz is a 10-year-old orange tabby with a grouchy disposition. He lives completely indoors with his roommate, Mobier. For the last couple of years Ritz has struggled with a chronic itch, and my wife and I have struggled to help him. In spite of our best efforts, a diagnosis remained an enigma. The itch responded only to cortisone injections. We ruled out allergies, parasites and, to the best of our ability, stress induced problems. Finally we were forced to either treat him with cortico-steroids or let him itch.
Ritz was given periodic injections of steroids with mixed results. We tried to minimize his dose, along with the frequency of administration, and for a while things seemed pretty good. Then one day, about 2 weeks after an injection, things changed.
Signs that something was wrong with Ritz
We noticed that after Ritz used his litter pan, the litter was always wetter than it used to be. He also spent more time drinking water than usual. We thought it was probably the steroids, but we wanted to be sure. We submitted to blood and urine tests for Ritz. He had always been very healthy, but we were concerned.
Testing results for Ritz
For Ritz, urine was strongly positive for glucose, but his liver and kidney function were normal. His blood glucose was very high and his level of fructosamine confirmed that he was in fact diabetic. To make matters worse, we had probably caused it.
We started insulin right away and called our friend, Dr. Deb Greco, for her thoughts. Dr. Greco is one of the foremost authorities on feline diabetes and she offered us a straw to grasp: perhaps his diabetes was, in fact, due to the steroids. If so, there was a chance that it was only passing and Ritz would return to normal.
Treating Ritz for diabetes
At Dr. Greco’s suggestion we started feeding Ritz with a new diet. [Editor’s Note: Always check with your veterinarian before starting a new diet.] We did our best to eliminate carbohydrates and emphasize protein in his diet. All the while, we continued low dose insulin and monitored his blood and urine glucose. To our optimistic delight he required very little insulin and, in a few days, his glucose was normal and we began to reduce his insulin until we reached a point where he didn’t require it anymore. We have monitored his blood and urine glucose often and are now comfortable that he is no longer insulin dependent. We are able to keep Ritz regulated solely with diet control. He has been insulin free for 3 weeks. [Editor's Note: Learn more about detecting and monitoring diabetes in cats.]
So what did we all learn from this misadventure? Well, for starters Ritz is sensitive to steroids and so will not be receiving any future injections. This is relatively uncommon, however, if your veterinarian wants to give your cat cortisone bloodwork and urinalyses need to be regularly monitored to detect potential adverse effects early. Secondly, diabetes can be transient in cats, and the best way to catch it (and other diseases) early is to watch for signs and run regular blood testing. Most importantly, know your pet and ask for your veterinarian’s advice sooner than later. In this case, an early diagnosis made for a happy outcome.
Learn more about what to do if your cat, “just aint’ doin’ right.”
If your cat has diabetes, learn more about it here.
If you have any questions or concerns, you should always visit or call your veterinarian -- they are your best resource to ensure the health and well-being of your pets.
It was early July 2003, and we were headed to the mall for a gift for Carly, about to turn 15. We parked near a bus equipped as an animal shelter.
Inside, kitten-filled cages lined the walls, except for one, which had a large, orange and white cat stuffed into it. Carly made a beeline for him and the attendant hoisted him out and handed him over. I reminded Carly that we already had 5 felines, but we knew he’d be left behind as the kittens were adopted.
FIV CAT #1
The shelter had named him Juice, and his owner had just gone to a nursing home. On the drive home, in the rearview mirror I saw Juice pop his head up from the box, swiveling like a periscope. We already knew he was one-of-a-kind.
Our house is on a dead end, with an acre of woods and several ways in and out. Juice, given sudden freedom, bolted. Our three daughters were home for the summer, and we plastered the neighborhood with signs and searched everywhere. After two weeks, we held a family meeting in the living room to discuss strategy – and Juice sauntered past.
While AWOL, Juice fell into the company of two feral cats, who bit or scratched him, transmitting FIV – feline immunodeficiency virus. After the winter, I discovered the remains of the feral cats, flattened bones bearing matted hair, like macerated mummies, at the back of our shed.
The following summer, during a visit to middle daughter Sarah in Savannah, Carly called.
“Juice may have AIDS!” she wailed.
Carly and our eldest, Heather, had taken Juice for a routine physical, and the vet had picked up on persistent ear mites and swollen, bleeding gums. These were usually the earliest signs, she said, while sampling his blood to test for FIV antibodies.
DISCOVERY IN A CALIFORNIA CATTERY
Finding FIV occurred against a backdrop of full-blown AIDS panic, especially in the Bay area of California. “The medical insights on AIDS ran the gamut from depressing to dismal,” wrote Randy Shilts of the situation in 1985, in And The Band Played On. With nearly a million people in the U.S. infected, researchers were beginning to realize that the incubation period exceeded five years. The numbers, they knew, would explode.
Also in 1985, Niels Pedersen, DVM, PhD and Janet Yamamoto, PhD, and colleagues from the University of California, Davis heard about “a peculiar outbreak of disease” at a cattery in Petaluma, an hour’s drive from San Francisco. The facility housed 43 strays, some feral, in five pens. None had feline leukemia virus (FeLV).
From 1968 until 1982, all residents of the cattery had been healthy. Then pen D welcomed a newcomer, a kitten named Cy, who developed diarrhea, a drippy nose, and conjunctivitis. At age two, she miscarried. By her third year, Cy was skeletal and compulsively moved her mouth and tongue. Her gums bled and her teeth fell out. “Several blood transfusions were of temporary benefit but ultimately the emaciation, chronic infections, and anemia worsened and the cat died,” wrote the researchers.
By 1986, 8 more cats died in much the same way, all from pen D. The syndrome started with gum and ear infections, which was why our vet was so alarmed at the otherwise robust Juice. A few cats were discovered dead, after seeming well the night before. One poor animal was “found depressed and hypothermic with terminal hysteria and rage.”
The apparent immune breakdown spread. Kittens intentionally exposed to blood from sick cats got sick. The researchers isolated a novel virus from two sick kittens, cultured the virus, gave it to other kittens, observed these kittens get sick and isolated the virus from them. Koch’s postulates fulfilled.
DIAGNOSIS: CAT AIDS
We didn’t really expect Juice to have FIV, but he did.
Carly participated in the annual HIV/AIDS walk in Albany the September after his diagnosis, taking her place among others honoring their loved ones, and contributed her chalk drawing of a cat with Juice’s information.
Meanwhile, we didn’t do what we were supposed to do.
We didn’t keep Juice or our other cats indoors.
We didn’t test our other cats. And if we had, and they had been positive, we wouldn’t have vaccinated them. Vaccinated pets who’d wandered into shelters had been euthanized because the antibody response to vaccine is indistinguishable from that to infection, even before symptoms arise. Our vet had mentioned the vaccine, halfheartedly.
What was the point of all this intervention? Our crew stayed among themselves, were too mellow to bite or scratch, and if we kept them indoors, where I write, I’d go insane. But this was a very anti-science situation for me, advising against a test that would identify disease before symptoms (like genetic tests) and refusing to vaccinate.
For the next year, Juice was healthy. Then sores appeared, everywhere, and wouldn’t heal. He oozed blood and pus to the point that his coat bore pink patches he flung phlegm. His hair fell out in clumps and he scratched constantly. If he could have read the Science paper, he’d have recognized his “chronic severe pustular dermatitis” and “extremely thin, rough hair coat.” He apparently missed the part about weight loss.
Years passed. Gradually Juice’s skin cleared up and his glossy coat regrew. But then he began drooling and his mouth swelled hideously, deforming his face. He started sneezing and dripping, fortunately only from his front end.
Yet Juice never became depressed like the original cattery cats – quite the opposite. He’s charmingly sociable. And so “juice” as a verb entered the family lexicon.
“You haven’t truly been welcomed into the Lewis home until you’ve been juiced,” explains Heather, referring to the phenomenon of Juice detonating at close range, hurling multicolored mucus. He’d famously do this at parties, where he’d plop himself on any available human and settle in until the next eruption.
In the fall of 2011, Juice became gravely ill with a systemic infection that rendered him unresponsive. Antibiotics saved him. Last spring the vet removed many rotting teeth. In days Juice perked up, his face deflating to normal proportions as he happily gummed the hard food, refusing the wet goop the vet had suggested.
Today Juice is enjoying his fifth or so life. He’s slowed down. Capturing him for a vet visit used to require a three-person battle plan, but now he doesn’t even awaken as I drop him into the once-dreaded cat box. He still drips. A shot of antibiotics in the tush every 2 months keeps the serious infections away. At his last check-up, he’d gained weight – he’s a very solid 20 pounds.
AN IMMUNODEFICIENCY VIRUS BY ANY OTHER NAME
Naming viruses is tricky, both for scientific reasons and because human egos can get in the way. The name must have meaning, to distinguish the types of viruses that live within any particular species.
Cats get lots of retroviruses, which have RNA as their genetic material: the very common FeLV, feline sarcoma virus, endogenous type C onconavirus, feline syncytium-forming virus. HIV and FIV belong to a subtype called lentivirus, which means “slow virus” – incubation time is typically years. In contrast, distemper can start just two days after exposure.
The UC Davis researchers first named the new virus “feline T-lymphotropic lentivirus” (FTLV), because dubbing it FIV without further experiments would be “presumptuous.” Given the timing of the mid 1980s, I suspect they wished to avoid the embarrassing turf war over who discovered HIV : was it Robert Gallo or Luc Montagnier?
HIV’s first name was HTLV, for human T lymphotropic virus, due to initial misclassification. AIDS, too, had another name: GRID, for “gay-related immune deficiency,” circa 1981. That vanished with the discovery of the disease in other groups.
FIV resembles HIV, shares some of its genes, but has a small, cone-like protrusion. Cats can’t transmit FIV to humans, nor can humans give HIV to cats. But FIV is more similar to HIV than are lentiviruses from goats, sheep, and horses to each other. Conquering AIDS may come from untangling the pathways of lentivirus evolution.
Just as HIV likely evolved from simian immunodeficiency virus (SIV), FIV originated from a lentivirus seen today in lions, with variants in pumas (aka mountain lions or cougars), cheetahs, and panthers. Chimps and lions live with their lentiviruses, in health.
FIV CAT #2
With Juice constantly sneezing, snuffling, and snoring, it was clear that we couldn’t increase our cat population. I was sad.
Then one day last March, I wandered into a pet store hosting an adoption clinic. I gazed at the homeless felines, especially a beautiful fellow who looked like he was wearing a Tuxed
“Are you interested in adopting a cat?” asked a cat lady.
“No. But I have a cat with FIV. So I can’t get a healthy cat.”
The lady launched into a lecture in defense of FIV cats, but remembering Juice’s recent brush with death by infection, I wasn’t convinced. Then she said something I hadn’t thought of.
“That cat there. The Tuxedo. He’s FIV positive. Take him!” And she handed me a piece of paper.
“In a million years, I never expected to see my face on an adoption flyer!” read the announcement, beneath a photo of Artie. His owner was dying of cancer, and could no longer care for him, so the Animal Support Project brought him to a cat adoption clinic in the pet store in Albany sponsored by Orange Street Cats. No one knew how he’d become infected.
But we couldn’t just waltz in and take Artie. We had to go home and download an extensive contract more detailed than the college application Common Form. And then ensued a several-week investigation that would put the FBI to shame. Finally, when we passed the cat police qualifications, a cat social worker conducted a home visit.
We’d recently lost a brother-sister pair to very old age, which was in our favor. When the cat social worker sat at our dining room table and started shuffling papers, the remaining 3 Lewis cats jumped up to investigate. Juice rubbed his perpetually runny nose on the visitor, as we recited the genealogy of all our cats, tortoises, assorted rodents and lagomorphs, and hedgehog.
The social worker then asked a series of questions.
“If the new cat peed on the floor, what would you do?”
“If the cat vomited on your bed, what would you do?”
“If the cat seemed upset, what would you do?”
Two weeks later, the nice cat lady delivered Artie, and a huge contraption that unfolded into a cage. We set it up in my office.
We’d gotten our other cats in varied places: a sorority house at Indiana University (cat #1, Angie, white Persian). A poison-ivy-infested cornfield that landed Larry in the ER (cat #2, Sydney, American shorthair). A petrified forest in Saratoga (cat #4, Bullwinkle, long-haired grey). We’d never put a cat in a cage.
Yet according to the detailed instructions, Artie was to stay in prison, with his blankie, for a week. Then we were to let him out for short periods, and gradually work up to freedom.
The first morning in my office, Artie stared at me from behind bars. I sprung him. He spent the first week biting my feet as he followed me everywhere, then began to explore. Jelly taught him how to drink from faucets, and with astonishing speed, Artie was absorbed into the continuum of Lewis catdom.
Artie remains healthy. A few days ago we walked into the pet store to a chorus of “Artie’s parents!” I signed up for more FIV cats.
Artie, now 3, is FIV positive, but healthy. How and why may provide clues to HIV/AIDS. (Credit: Dr. Wendy Josephs)
So is this blog just an excuse to post cat photos? No, I could’ve done that on Facebook. But the fact that Juice and Artie will likely live normal lifespans, with manageable symptoms, makes me wonder why this isn’t true for many people with HIV/AIDS. I’m also intrigued by what we can learn from the problems that the FIV vaccine has encountered. I’ll address these in another post.
Although nearly all antidiabetes drug classes may be used in combination, there are particular combinations that have been extensively studied, particularly for those available as single pill combinations, thereby enhancing patient compliance. Combination pills comprised 6.7% of the prescriptions fills in the U.S. retail pharmacies in 2012 (53). The most commonly used combinations were those of DPP-4 inhibitors and metformin however, combination therapy of metformin-sulfonylureas and metformin-pioglitazone were commonly used as well (53).
Metformin is now the most widely accepted first-line therapy for type 2 diabetes (16,17) therefore, most initial combination therapies proposed include metformin. A recent meta-analysis assessed the benefit of early combination therapies that included metformin versus metformin alone and demonstrated superior results of the combination therapy with better HbA1c reduction (weighted mean difference −0.43% [95% CI −0.56, −0.30]) and increased odds of attaining the goal of HbA1c View this table:
Selected trials comparing initial combination therapy with initial monotherapy
Combination of metformin with thiazolidinediones has been studied in multiple trials. Though the results of these trials are positive, demonstrating better HbA1c reduction with these fixed-dose combinations (61,62), safety issues surrounding the drug class (48) have significantly restricted its use. On the other hand, pioglitazone has recently become generically available, thus reducing its cost and possibly increasing its use in the near future.
The combination of pioglitazone and DPP-4 inhibitors has been studied as well (63–66). Better HbA1c reduction was perceived with the combination, yet weight gain was greater with the combination versus with pioglitazone alone in some of the trials. The utility of this combination as first-line therapy is limited and restricted to those who cannot tolerate metformin or have a contraindication to its use.
SGLT2 inhibitors are a novel class of antidiabetes medications exerting their effect by inhibiting renal glucose reabsorption and producing glucosuria. Initial combination therapy of dapagliflozin and metformin has been shown to be more effective in HbA1c reduction versus dapagliflozin monotherapy or metformin monotherapy (67).
The SGLT2 inhibitors are becoming available as single pill combination therapies with metformin, competing with the metformin–DPP-4 inhibitor combination pills as possible first-line initial combination therapy. Both options have minimal side effects, beyond those of metformin alone, and do not cause hypoglycemia. Whereas significant weight loss is observed with the combination of SGLT2 inhibitors and metformin (67), weight neutrality or minimal weight gain is observed with the combination of DPP-4 inhibitors and metformin (60). The glucosuric effect of SGLT2 inhibitors is accompanied by an increased rate of endogenous glucose production, a mechanism that offsets the drugs' glucose-lowering effect by ∼50%. DPP-4 inhibitors inhibit glucagon secretion, thus reducing endogenous glucose production, and the combination of the two drug classes appears to be a promising therapeutic modality (68).
Initial combination therapy of empagliflozin/linagliptin has demonstrated superior HbA1c reduction versus linagliptin alone, yet the efficacy of high-dose empagliflozin was similar to its combination with linagliptin, the cause for that being unclear. It has been hypothesized that the increased glucosuria observed with high-dose SGLT2 inhibitors, particularly when prescribed to individuals with high baseline HbA1c, may cause a reciprocal elevation in endogenous glucose production that is beyond the capacity of DPP-4 inhibitors to overcome (68). Contrary to the partially negative results of the initial combination therapy, use of a combination of empagliflozin and linagliptin as a second-line therapy, after metformin, yielded positive results, demonstrating superiority of the combination over empagliflozin alone (69).
Cats experience many of the above symptoms throughout each progressive stage of kidney failure.
As cats get closer to death the symptoms become much more severe.
Kidney disease escalates through four stages, and symptoms escalate as well.
Watching your beloved pet suffer more and more may become intolerable.
However, symptoms alone are not a direct indication your cat needs euthanasia.
A cat can appear to be moments from death, and with the right treatment, able to regain most of its health.
If you are able, exhaust all options, such as extended IVs and sub-Q’s.
Your veterinarian can assess the effectiveness of the prescribed treatments by doing additional blood work.
When treatment fails to improve the blood work of your cat, it is time to start preparing for the end.
Now, do you give the insulin injection before or after the meal? I typically wait to see if a pet will eat before giving the insulin injection. Again, diabetic humans usually give themselves the insulin a few minutes before they eat. The reason we wait until the diabetic pet is eating before we give insulin is actually pretty obvious: we wish to see if the pet will eat. If we give a pet an insulin injection and then the pet doesn’t eat, hypoglycemia may ensue. For good eaters who are well controlled, I will give the injection as the pet dives into the food bowl. For finicky pets, I’ll check the blood glucose and then decide how much insulin to give, taking into account how much the pet eats.
Life sometimes get is the way of our plans, but do your best to give the injections every 12 hours. Occasionally I hear of clients giving insulin injections 10 and 14 hours apart or 11 and 13 hours apart due to their family’s work and sleep schedule. Strive for 12 hours apart. Consistency is key to diabetes regulation. I encourage consistency of timing of injections and consistency of portions fed. Every family has individual quirks and schedules, but we all do our best for the love of Fluffy.
Have a question or comment? Then post below! I always enjoy hearing from my readers!
NOTE: Consult your veterinarian first to make sure my recommendations fit your pets special health needs.