Product information

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Veterinary technical brochure Prescription Animal Remedy (P.A.R) Class I. For use only under the authority or prescription of a veterinarian. Registered pursuant to the ACVM Act 1997, No. A7401. See www.nzfsa.govt.nz/acvm/ for registration conditions.

For further information see safety data sheet. www.intervet.co.nz ®Registered trademark. Schering-Plough Animal Health Ltd, 33 Whakatiki Street, Upper Hutt. Phone: 0800 800 543 CAN-350-2010.

Insulin for Dogs and Cats

DESCRIPTIONCaninsulin is an aqueous suspension of 40 IU per mL of highly purified porcine insulin, 30% as amorphous zinc insulin and 70% as crystalline zinc insulin.

MODE OF ACTIONCaninsulin is an insulin product with intermediate action. It contains porcine insulin, which is structurally identical to canine insulin. In cases of insulin deficiency and/or decreased insulin sensitivity, the required blood levels can be achieved by using an individually adjusted dose of Caninsulin.

The action of Caninsulin on blood glucose concentrations, following subcutaneous administration, peaks in diabetic dogs at about 6-8 hours post-injection and lasts for about 14 - 24 hours; in diabetic cats, it peaks at about 4 – 6 hours and lasts for about 8 -12 hours post-injection.

INDICATIONSTreatment of diabetes mellitus in dogs and cats.

CONTRAINDICATIONS

• Hypoglycaemia.• Caninsulin is not intended for the initial treatment of animals with severe acute diabetes

mellitus that are presented in a ketoacidotic state.• Must NOT be administered by intravenous route. • The use of progestogens (oestrus inhibitors) should be avoided in animals suffering from

diabetes mellitus. In entire bitches, ovariohysterectomy may have to be considered.• Care must be taken with the use of glucocorticosteroids.

• Stress and irregular exercise must be avoided.

DIRECTION FOR USECaninsulin should be administered by subcutaneous injection.

The dose depends on the degree of deficit in the animal’s own insulin production and is therefore different in each case. As a consequence, a dose-titration phase will always be necessary in order to tailor the treatment to each individual animal.

Once daily injection of Caninsulin may be sufficient to reduce the blood glucose in some diabetic dogs. Other dogs may require twice daily injections as the duration of action of the insulin may vary within an individual. In diabetic cats, it is necessary to administer Caninsulin twice daily.

DOSAGE AND ADMINISTRATIONThe use of a 40 IU per mL syringe is strongly recommended.

Caninsulin should be re-suspended by inverting a few times before each use until a homogenous suspension is obtained.

Stabilisation phase

DOG: The initial STARTING dose is 0.5 IU/ kg body weight once daily (rounded down to the nearest whole unit).

Example:

Dog Bodyweight Starting dose per dog

5kg 2 IU once daily

10kg 5 IU once daily

15kg 7 IU once daily

20kg 10 IU once daily

Subsequent adjustment to establish the maintenance dose should be made by increasing or decreasing the daily dose by approximately 10% according to clinical signs and the results of serial blood glucose measurement. Alterations in dose should not normally be made more frequently than every 3 to 7 days.

In some dogs, the duration of insulin action may require treatment to be administered twice daily. In such cases, the dose per injection must be decreased by 25% and this dose given twice daily. E.g. A 10kg dog receiving 5 IU once daily, the new dose (5 minus 25%, rounded down to the nearest whole unit) would be 3IU per injection initially. The two daily doses must be administered at 12 hour intervals. Further dose adjustments should be made progressively (in 10% increments) as previously explained.

To achieve a balance between the generation of glucose and the effect of the product, feeding must be synchronised with the treatment and the daily ration divide into two meals. The composition and quantity of the daily food intake should be constant.

In dogs treated once daily, the second meal is usually fed at the time of peak insulin effect. In dogs treated twice daily, feeding coincides with Caninsulin administration. Each meal should be fed at the same time each day.

CAT: Cats require twice daily Caninsulin administration. The initial STARTING dose depends on the weight and the fasting blood glucose of the diabetic cat (see table below for guidance). However, a maximum of 2 IU should only be given twice daily in the first 3 weeks e.g. an 8kg cat calculated to require 4 IU twice daily should initially receive 2 IU twice daily for the first 3 weeks.

Cat Blood Glucose Concentration Starting dose per cat twice daily

<20 mmol/L 0.25 IU/kg twice-daily

>20 mmol/L 0.5 IU/kg twice-daily

Subsequent adjustment to establish the maintenance dose should be made by increasing or decreasing the daily dose according to the results of serial blood glucose measurements. Alterations in dose should not normally be made more frequently than every week. Increments of 1 IU per injection are recommended. Due to the day-to-day variation in the blood glucose response, and the variation in insulin responsiveness that are seen with time, larger or more frequent increases in dose are not recommended.

The composition and quantity of the daily food intake should be constant.

Maintenance phase in dogs and cats

Once the maintenance dose has been reached and the animal is stabilised, a long term management programme needs to be established. The aim should be to manage the animal in such a way as to minimise the variations in its insulin requirement. This includes clinical monitoring to detect under or over dosage of insulin and adjustment of dose if required. Careful stabilisation and monitoring will help to limit the chronic problems associated with diabetes, including cataracts (dogs), fatty liver (dogs & cats), etc.

Follow up examinations should be performed every 2-4 months (or more often if there are problems) to monitor the animals health, the owner’s records and biochemical parameters like blood glucose and/or fructosamine concentrations. Adjustments to the insulin dose should be based on clinical signs supported by the laboratory results.

ADVICE ON CORRECT ADMINISTRATIONAdministration of Caninsulin must be carried out by an adult responsible for the welfare of the animal. The ability of owners to recognise the clinical signs of hypo- or hyper-glycaemia, and to respond appropriately, is important if control is achieved during maintenance therapy.

Polyuria (frequent urination), polydipsia (excessive water intake) and polyphagia (excessive food intake) in combination with weight loss, poor general condition, hair loss or abnormal coat, and lethargy (marked apathy) are the most common clinical signs of hyperglycaemia and requires the administration of insulin or a dose adjustment in insulin to restore blood glucose concentrations to within the normal range.

Insulin over-dosage results in signs of hypo-glycaemia. Signs of hunger, increasing anxiety, muscle twitching, stumbling or hind limb weakness or disorientation indicate progression of hypoglycaemia and requires immediate administration of glucose solution and/or food to restore blood glucose concentration.

Somogyi effect (rebound hyperglycaemia), is a response to an overdose of insulin sufficient to cause potentially fatal hypoglycaemia. As hypoglycaemia begins to develop, a hormonal counter-regulatory response is triggered which results in release of glucose from hepatic glycogen stores. This results in rebound hyperglycaemia which may also manifest as glycosuria for part of the 24-hr cycle. There is a danger that the Somogyi effect is interpreted as a requirement for increase in the insulin dose rather than a decrease. This can be avoided by basing decisions on serial blood glucose measurements rather than single point measurements.

ADVERSE EFFECTSHypoglycaemia may result from administration of excessive insulin. Oral glucose should be given immediately.

Very rare cases of local adverse reactions associated with administration of porcine insulin have been reported in dogs and cats. These reactions are usually mild and reversible. In extremely rare cases, allergic reactions to porcine insulin have been reported.

HANDLING PRECAUTIONSCare should be taken when administering. Accidental self-injection can provoke clinical signs of hypoglycaemia, which should be treated by oral administration of glucose. Seek medical advice immediately and show this leaflet or label to the doctor. In sensitised subjects, accidental administration can induce local or general allergic reactions.

See Safety Data Sheet for further information. www.intervet.co.nz

STORAGEStore unopened vials in upright position, between 2°C and 8°C (Refrigerate. DO NOT FREEZE). After first use, opened vials may be stored between 2°C and 25°C, for 6 weeks. Discard any unused portion after 6 weeks. Protect from light.

Invert vial several times to ensure consistent suspension of insulin before withdrawing dose.

Approval not required under the HSNO Act 1996.

Registered to: Schering-Plough Animal Health Limited, 33 Whakatiki St, Upper Hutt. Phone: 0800 800 543

Keep out of reach of childrenFOR ANIMAL TREATMENT ONLY

CANINSULIN®

successful for the Guidelines

management

of the

www.caninsulin.comwww.caninsulin.com

Diabetes incidence and ae tiologyIntroduction

Diabetes mellitus is a fairly common endocrine disorder

of dogs and cats that results from an absolute or relative

insulin deficiency. In general, the prognosis is very good,

provided that the diagnosis is made at an early stage

and treatment is adequate.

Insulin treatment is the cornerstone of successful

management, but dietary adjustment and a regular

lifestyle are also important. First rate communication

between you, the veterinary surgeon, and the pet

owner is of major importance. Your attitude to diabetes

mellitus will largely determine the owner's motivation

and compliance with treatment.

Incidence

Estimates of the incidence of diabetes mellitus in dogs

and cats range from 1:100 to 1:500.1 The disease occurs

most commonly in middle aged and older dogs and cats.

In dogs, there is preponderance among intact bitches

while in cats the disorder is most frequently seen in

neutered males.

Aetiology

Diabetes mellitus can originate from either pancreatic or

non-pancreatic disease.

Pancreatic disease

Endocrine

Destruction of endocrine pancreatic tissue can lead to

diabetes mellitus. In dogs, there is some evidence that

autoimmune destruction of the islets of Langerhans

plays a role in the pathogenesis of diabetes. In cats,

amyloid deposition may contribute to the destruction of

the islets of Langerhans.

Exocrine

Severe inflammation or neoplasia of the exocrine

pancreas can also lead to loss of islet function. In these

cases, diabetes is complicated by exocrine pancreatic

insufficiency.

Non pancreatic disease

Overproduction of counteracting hormones and insulin

resistance.

Growth hormone excess

Progesterone induced

Progesterone produced during the luteal phase induces

the production of growth hormone by the mammary

gland. This counteracts the action of insulin.

Pituitary origin

At present, pituitary tumours producing growth

hormone have only been described in cats.

Diabetes mellitus due to pancreatic disease

Vacuolar degeneration of islets of

Langerhans in a dog, Haematoxylin

and Eosin (HE) stain, 10x.

Amyloidosis of islets of Langerhans

in a cat, HE stain, 25x.

Amyloidosis of islets of Langerhans

in a cat, polarized light (left) and

Congo red stain (right).

Reference 1: Panciera DL et al. (1990) J Am Vet Med Assoc 197, 1504-1505.

Photographs courtesy of Pathology Department, Faculty of Veterinary Medicine, University of Utrecht, NL.

Cushing’s disease

Corticosteroids stimulate gluconeogenesis, leading to

an increase in the blood glucose concentration. This

stimulates insulin synthesis, which can eventually result in

exhaustion of the islets of Langerhans.

Glucose toxicity

Glucose toxicity occurs when insulin secretion is

reduced by prolonged hyperglycaemia. Prolonged

hyperglycaemia can be due to a number of causes

including the iatrogenic ones listed below.

Iatrogenic

Corticosteroids

The therapeutic use of corticosteroids can induce

diabetes mellitus.

Progestogens

The use of exogenous progestogens can lead to growth

hormone excess. Progestogens also have an affinity

for glucocorticoid receptors. This is responsible for the

diabetes mellitus that is sometimes seen following the

administration of progestogens to cats.

Obesity

In obesity, tissue receptors have decreased insulin

sensitivity. This leads to a greater demand for insulin,

which can result in exhaustion of the islets of Langerhans

Potential diabetes mellitus

Potential diabetes mellitus, defined as impaired insulin

synthesis and/or decreased sensitivity of tissue receptors

to the effects of insulin, results in an increased blood

glucose concentration that does not yet exceed the renal

threshold. This is seen in intact bitches during metoestrus.

At this stage, the problem may still be reversible by

spaying (elimination of the progesterone source).

Mild hyperglycaemia may also be encountered in

Cushing’s disease and reversal of the cortisol excess may

prevent the development of diabetes mellitus.

Complications, due to protein glycosylation, include

•cataract (mainly in dogs)

•peripheral neuropathy (mainly in cats)

Fructosamine and glycated haemoglobin concentrations

also increase due to protein glycosylation.

Complicated by ketoacidosis

Animals may become comatose if the ketoacidosis is

severe.

Hyperosmolar hyperglycaemic non-ketotic syndrome

When resistance of target tissues to insulin plays a role in

the disease, insulin levels can be elevated. In these cases,

ketosis is suppressed and blood glucose concentrations

can become very high. These animals are usually

comatose.

Pathogenesis

Diabetes mellitus is a paradox: simultaneous extracellular

hyperglycaemia and intracellular glucose deficiency.

The consequences of this paradox are shown in Figs 1

and 2.2a

Clinical signs

There are three distinct clinical pictures in diabetes

mellitus

•uncomplicated

• complicated by ketoacidosis

• hyperosmolar hyperglycaemic non-ketotic syndrome

Uncomplicated diabetes mellitus

The classical signs are

• polyuria/polydipsia

• polyphagia

• cachexia

• increased susceptibility to infections (e.g. urinary

tract infections)

Diabetes pathogenesis and clinical signsExtracellular hyperglycaemia

hyperosmotic plasma blood glucose >renal threshold

high urine specific gravity

osmotic diuresis

polyuria hypokalaemia

hyponatraemia

polydipsiahyperglycaemic coma

dehydration of cells glucosuria

Figure 1

Extracellular hyperglycaemia

Figure 2

Intracellular energy shortage

Intracellular energy shortage

fat metabolism

increase of fatty acid

concentrations in plasma

ketosis

ketoacidosis; ketonuria

protein synthesis decreases

cachexia/lethargy

polyphagia

decreased gamma globulin concentrations

increased susceptibility to infections impaired wound healing

acidotic coma

gluconeogenesis increases

Reference 2a: Rijnberk A. (1996) Clinical Endocinology of Dogs and Cats, Kluwer Academic Publishers, NL. pp 95-117.

Diagnosis

Diabetes mellitus is not the only cause of polyuria,

polydipsia and weight loss. Cases should be investigated

fully to rule out other causes before starting insulin

treatment.2b A preliminary diagnosis of diabetes mellitus

based on clinical signs must be confirmed by urine and

blood tests.

A diagnosis is based on persistent fasting

hyperglycaemia and glycosuria. Reference values for

blood glucose are approximately 3.5-6.1 mmol/L in

normal dogs and 2.6-8.4 mmol/L in normal cats. The

renal threshold is around 10 mmol/L in dogs and around

14 mmol/L in cats. If the blood glucose concentration

exceeds this threshold, glucose is excreted in the urine.

Transient hyperglycaemia can occur in cats in stress

situations, usually where struggling is involved.

Fructosamine concentrations are correlated with the

average blood glucose concentration over the previous

1-2 weeks. Blood fructosamine measurement is a valuable

tool in confirming a diagnosis of diabetes mellitus

particularly in cats.

www.caninsulin.com

www.caninsulin.com

Reference 2b: Rijnberk A. (1996) Clinical Endocinology of Dogs and Cats, Kluwer Academic Publishers, NL. pp 221-222.

Successful diabetes management

Diabetes management

General considerations

Treatment of diabetes mellitus is likely to succeed

only if the pet owner understands all aspects of its

management, including dietary regulation and a regular

exercise schedule. Investment of time in a careful

explanation of all aspects of diabetes management is

strongly recommended.

Spaying

If diabetes mellitus has been diagnosed in an intact bitch,

immediate spaying (ovariohysterectomy) is imperative, to

prevent further exposure to endogenous progesterone.

In animals fit for surgery, this can be carried out prior

to insulin treatment and intravenous fluid therapy is

administered.

If the animal’s condition is critical (dehydration, anorexia,

uraemia, severe hyperglycaemia and glucosuria) and

surgery is contraindicated, intravenous fluid therapy

and insulin administration should be started. Spaying

can then be carried out as soon as the bitch’s condition

has improved sufficiently. On the day of surgery, pre-

operative fasting will necessitate reducing the insulin

dose, e.g. to around 30%.

Following surgery, regular monitoring of the blood

glucose concentration is necessary until the bitch’s

condition is stable. The response to insulin will

often improve and the insulin demand will decrease

accordingly.

Diet and feeding schedule

The volume and composition of meals should be identical

from day to day to avoid changes in insulin requirements.

As this is difficult to accomplish with home-prepared

meals, commercial pet food is preferred.

Commercial diets with a high quality, highly digestible

protein source and a low fat content provide a more

gradual intestinal uptake of glucose. In animals that

are over- or under-weight the ideal body weight

should be reached by gradual weight loss or gain. Very

calorie dense diets, especially those high in soluble

carbohydrates, should be avoided.

For dogs the daily food intake is usually divided into

two meals. The first meal is given around the time

of the morning insulin injection and the second meal

approximately 8 hours later, for dogs on once daily

Caninsulin treatment.

For dogs receiving twice daily treatment, feeding occurs

at the time of Caninsulin administration i.e. 12 hours

apart.

Feed for Diabetic Dogs Feed for Diabetic Cats

Palatable

Nutritionally Balanced

Provide Sufficient Calories

Consistent Carbohydrate Content

Address Individual Needs

Consistent Amount, Content & Timing

High Quality

High Protein

Palatable

Low Carbohydrate

Carbohydrate with Lowest Glycaemic Index

(Corn & Sorghum better than Rice)

Cats are often very fussy eaters and usually prefer to eat

when they choose. Free access to a measured amount of

the food is often the best option. Diabetic cats can be

stabilized on their usual diet if need be.

Clean drinking water should be available at all times.

A reduction in excessive water consumption indicates

successful management of the diabetes mellitus.

www.caninsulin.com

Figure 3

Schematic representation of Caninsulin

concentration in dogs showing

biphasic activity

0 2 4 6 8 10 12 14 16 18 20 22 24

amorphous(30%)

crystalline(70%)

acti

vity

of

Can

insu

lin

time in hours

Pharmacokinetics of Caninsulin

Caninsulin is an aqueous suspension of 40 IU of highly

purified porcine insulin per mL, consisting of 30%

amorphous and 70% crystalline zinc insulin.

In dogs the amorphous fraction has peak activity

approximately 3 hours after subcutaneous

administration and its effects last for about 8 hours.

Thereafter, the effect is maintained by the crystalline

fraction, which has a slower onset of action and peak

effects from 7 to 12 hours following injection.3,4

Afterwards, the effect gradually declines to zero

(Fig.  3).

In cats, the maximum effect is seen around 4 hours after

administration and the total duration of action is around

12 hours.5

Diabetes management with Caninsulin®

Dogs

The duration of activity of Caninsulin may be sufficient

to treat dogs once daily. In some cases, injections have

to be given twice daily, particularly if blood glucose

concentrations are monitored closely.

Cats

The duration of action of Caninsulin is shorter in cats

than in dogs. As a result, all cats require twice daily

injections. Twice daily injection of Caninsulin provides

excellent glycaemic control that can result in remission of

the clinical signs in around 25% or more of cases.

Due to differences in metabolism, the duration of activity

of a particular insulin will vary from animal to animal.

The source of the insulin can be also different. Caninsulin

contains porcine insulin. Porcine insulin is identical to

canine insulin, but differs from feline insulin by three

amino acids.

References:

3. Graham PA, Nash AS & McKellar QA. (1997) J Small Anim Pract 38, 434-438.

4. Horn B & Mitten RW (2000) Aus Vet J 78, 831-834.

5. Martin GJ & Rand JS (2001) J Feline Med Surg 3, 23-30.

Dogs – Maintenance Phase

Subsequent adjustment to establish the maintenance dose should be made by increasing or decreasing the daily dose by

approximately 10% according to the clinical signs and the results of serial glucose (glucose curve) measurement. Alterations in

dose should not normally be made more frequently than every 3 to 7 days.

Table 1: Starting once daily Caninsulin treatment in dogs.

Dog Bodyweight Starting Dose Per Dog5kg 2 IU once daily

10kg 5 IU once daily

15kg 7 IU once daily

20kg 10 IU once daily

Initial Regulation

Dogs - Stabilisation Phase

Caninsulin administration in dogs can be once or twice daily

depending on their individual response and requirement.

The initial dose for dogs is 0.5 IU per kg body weight once daily

(rounded down to the nearest whole unit). Some examples are given

in Table 1. Feeding should coincide with Caninsulin treatment, and

then again 6-8 hours later to coincide with the peak activity of the

insulin.

In some dogs, the duration of insulin action may require treatment

to be administered twice daily. In such cases, the dose per injection

must be decreased by 25% and administered at 12 hour intervals.

Some examples are given in Table 2. Feeding should coincide with

Caninsulin treatment.

Table 2: Starting twice daily Caninsulin treatment in dogs.

Dog Bodyweight Starting Dose Per Dog

5kg 1 IU twice daily

10kg 3 IU twice daily

15kg 5 IU twice daily

20kg 7 IU twice daily

Cats – Stabilisation Phase

Cats require Caninsulin administration twice daily.

The initial dose for cats is 0.25 – 0.5 IU/kg twice daily,

with a maximum dose of 2 IU per injection depending

on the initial blood glucose concentration (Table 3).

Baseline blood glucose concentration

<20mmol/L>20 mmol/L

Initial Caninsulin dose (round down to nearest whole unit)

0.25 IU/kg body weight 0.50 IU/kg body weight

Table 3: Guide to starting twice daily Caninsulin treatment in cats.

Cats – Maintenance Phase

Subsequent adjustment to establish the maintenance dose should be made by increasing or decreasing the daily dose according to

the clinical signs and the results of serial blood glucose (glucose curve) measurements. Alterations in dose should not normally be

made more frequently than every week. Increments of 1 IU per injection are recommended. Ideally no more than 2 IU per injection

should be administered in the first three weeks of treatment. Due to the day-to-day variation in the blood glucose response, and

the variation in insulin responsiveness that are seen with time, larger or more frequent increases in dose are not recommended. The

composition and quantity of the daily food intake should be constant.

A maximum of 2 IU per dose in the first 3 weeks.

Dose adjustment and monitoringDose adjustment

In dogs, dose adjustment should be managed in steps

of 10%. In cats, the dose should be adjusted in steps of

1 IU. Following adjustment, full evaluation should not

take place before the new dose has been given a period

of at least 3 days, particularly in cats.

Maintaining a normal blood glucose concentration

throughout the entire day in a diabetic is impossible.

The aim is to try to maintain blood glucose

concentrations between around 5 and 15 mmol/L for

a substantial part of the day. This will result in the

disappearance of most of the clinical signs - the goal

of therapy.

Urine monitoring

Urine monitoring is a quick and easy method of detecting

ketones (ketonuria). Urine only tests positive for glucose

if the blood glucose concentration remains above the

renal threshold for a substantial period. Monitoring of

urine for glucose can be useful in diabetic animals that

are not yet stable or in those that have problems with

recurrent hypoglycaemia. Here it is used to identify the

absence of glucose.

Urine monitoring can be used once an animal is known

to have a blood glucose concentration in an acceptable

range. In this case it is a quick easy method of detecting

hyperglycaemia. This should then be investigated further

by measuring blood glucose concentrations.

Blood glucose curvesThe most accurate way to assess the response to

treatment is by making a blood glucose curve (Figs. 4-7).

The procedure is as follows: the first blood sample should

ideally be taken just prior to the insulin administration.

The animal should be given its first meal followed by its

morning Caninsulin injection. Blood samples should then

be taken approximately every 2 hours throughout the

day (at least 12 hours).

Check the following from the plotted graph:

―The baseline blood glucose

→ resting blood glucose level just before insulin

administration

―The Nadir → Lowest blood glucose reading obtained.

―The pre-insulin blood glucose

→ the last reading just before the next dose of

insulin is due to be given.

→ Refer to Table 4 for interpretation of blood

glucose curve results.

0 2 4 8 12 16 20 24

5

10

15

20

Blo

od

glu

cose

(m

mo

l/L)

Time (hours)

Figure 6 Short duration of action:

change to twice daily

Figure 5 Insulin resistance

(hyperglycaemia) (see Fig. 7):

If hyperglycaemia persists with dosage

reduction try increasing the dose.

0 2 4 8 12 16 20 24

5

10

15

20

Blo

od

glu

cose

(m

mo

l/L)

Time (hours)

Blo

od

glu

cose

(m

mo

l/L)

Time (hours)

Figure 4 Blood glucose curve from a

stable diabetic dog

0 2 4 8 12 16 20 24

5

10

15

20

Blood Glucose Curve Results Recommended Action

Nadir < 3 mmol/L Decrease dose by 50%

Clinical Signs of Hypoglycaemia Decrease dose by 50%

Nadir between 3 – 5 mmol/LDecrease dose by 10% (Dogs)

Decrease by 1 unit (Cats)

Pre-insulin blood glucose < 10 mmol/L (Dogs)Pre-insulin blood glucose < 15 mmol/L (Cats)

Decrease dose by 10% (Dogs)Decrease by 1 unit (Cats)

Nadir between 5 – 9 mmol/L andPre-insulin blood glucose for dogs > 10 mmol/LPre-insulin blood glucose for cats > 15 mmol/L

No Change

Nadir > 9 mmol/L andPre-insulin glucose values > 15 mmol/L

If clinical signs present, increase dose by 10% (Dogs) Increase by 1 unit (Cats)

Return to baseline glucose level too soonindicating duration of effect of insulin too short

Increase frequency of insulin administration

When to Re-evaluate for Insulin Dosage Adjustments

Signs of Good Glycaemic Control

Every 2 – 4 weeks During Initial Stabilisation PeriodWater Intake > 60 mL/kg/day

Signs of LethargyWeight Loss

Change in AppetitePersistent Negative Glucosuria

Anytime Hypoglycaemia is Suspected

Water Consumption < 60 mL/kg/dayNormal Appetite

Stable BodyweightAlert and Active Pet

Glucosuria, No Ketonuria

Table 4: Interpreting blood glucose curve results

Duration of action

Baseline blood

glucose

Pre-insulin blood glucose

Glucose Nadir

Time of peak effect

Injection

Challenges in diabetes management

Somogyi effect

An insulin dose that is slightly too high may bring

about the Somogyi effect (rebound hyperglycaemia)

(Fig. 7). This is a chain of reactions through which the

body attempts to counteract a decline in blood glucose

concentration. If the blood glucose concentration falls

rapidly or approaches hypoglycaemia (less than 5 mmol/L

or 90 mg/dL) following injection of insulin, the animal

will become hungry and restless or lethargic.

In response to a declining glucose concentration in the

CNS, adrenaline and subsequently cortisol, glucagon and

growth hormone are released. These hormones bring

about an increase in the blood glucose concentration

(through gluconeogenesis, release of glucose from

hepatic glycogen and increased peripheral resistance to

insulin). Polyuria and polydipsia are seen and this can

easily be misinterpreted.

Hyperglycaemia can sometimes persist for days after a

single hypoglycaemic episode. If the Somogyi effect is

suspected, an alternative approach involves decreasing

the dose by 20% and closely observing the clinical

picture. If the polyuria or polydipsia worsen following

dose reduction, it is unlikely that the Somogyi effect was

the cause of the regulation problems.

HypoglycaemiaIf the insulin dose is too high, clinical signs of

hypoglycaemia may be observed. The clinical signs

include hunger, restlessness, shivering, ataxia,

disorientation, convulsions and coma. However, some

animals just become very quiet and inappetent. This

serious and potentially fatal condition (which can also

be triggered by loss of appetite, vomiting or excessive

exercise) may occur at any stage, even after stabilisation

has been achieved.

Blo

od

glu

cose

(m

mo

l/L)

Time (hours)

Figure 7 Rebound hyperglycaemia:

reduce the dose

0 2 4 8 12 16 20 24

5

10

15

20

25

Immediate oral administration of a glucose solution (1 g

glucose per kg body weight, approximately one heaped

teaspoonful per 5 kg body weight) by the owner can

alleviate these signs. Owners need to keep a glucose

source readily available.

Following emergency administration of glucose, food

must be given repeatedly at intervals of 1-2 hours until all

the effects of the "extra" insulin have been counteracted.

Problems with regulationIf the response to insulin therapy is poor, a blood glucose

curve should be made and every effort made to rule out

other concurrent or underlying disorders.

Problems with administrationProblems related to dilution of insulin can be avoided

by injecting fresh, undiluted insulin. Caninsulin has

been specially developed for use in animals and has a

concentration of 40 IU/mL, making dilution unnecessary.

Problems with resorption from the injection siteThis has been reported in cats, especially with ultralente

insulin.

AntibodiesAntibodies may be directed either against the insulin or

against other foreign proteins in a preparation. Antibody

production is less likely if homologous insulin is given

- the porcine insulin in Caninsulin has exactly the same

structure as canine insulin.

Other hormones, either endogenous or exogenousWhen treating an animal for diabetes mellitus,

medication with progestogens should be discontinued.

Intact bitches should be spayed.

If animals are being treated with corticosteroids,

alternative treatment should be sought. If this is not

feasible, efforts should be made to minimise the

corticosteroid dose.

Stress, infections and obesityStress or infections (particularly infections of the oral

cavity or urinary tract) can lead to a decrease in the

sensitivity of target tissues to insulin. Obese animals have

reduced insulin sensitivity.

Diabetic pets can enjoy healthy, normal lives

Owner participationMost owners quickly learn to give daily insulin injections.

It is best to confirm that the animal is eating normally,

before giving the insulin injection.

During therapy the pet owner needs to actively

participate in monitoring their pet’s progress. Initially,

monitoring must be carried out on a daily basis but

once the animal is stable this frequency can often be

decreased.

Many owners can be successfully instructed to take

capillary blood samples and use a handheld blood

glucose meter. If this is not feasible, an alternative is to

have the owner test the urine for the presence of glucose

and ketones. Before dose changes are made, blood

glucose concentrations should be confirmed.

Prognosis in diabetes mellitusThe prognosis for a diabetic animal depends to a large

extent on the level of confidence, knowledge and

dedication of its owner. These factors can be favourably

influenced by your attitude and the quality of the

information you, the veterinary surgeon, provide.

It should be made clear that treating a diabetic animal

is rewarding and certainly not as complicated as is

sometimes thought.

Support material available

Starter kits

→ Fridge magnets

→ Collar tags

→ Syringe samples

→ Owner Education Booklets

Waiting Room Posters

General Information Brochures

Get more information

about Caninsulin online

More information to help you manage diabetes in dogs

and cats is available at www.caninsulin.com.

You can also visit the website that provides more

information for owners of diabetic pets at

www.cat-dog-diabetes.com.

www.caninsulin.com