October 2007 Internal Medicine Louise Murray, DVM, DACVIM ASPCA, New York, NY Prevention and Management of Feline Diabetes Mellitus Feline Nutrition Cats are obligate carnivores Dogs, humans omnivores Many feline differences in nutritional biochemistry Natural diet of cat = high protein/low carb (prey) Feline differences: Lacking metabolic pathways for utilization of carbohydrates Reduced hexokinase activity, little glycogen synthetase activity Less able to convert carbs to hepatic glycogen, so glucose instead stored as fat Lack salivary amylase Decreased pancreatic and intestinal amylase Fewer disaccharidases & other brush border enzymes in SI for digesting/absorbing starches Lack fructokinase -> cannot digest simple sugars Results of dietary carbohydrates in cats: Glucose stored as fat -> obesity Glucose intolerance -> hyperglycemia-> hyperinsulinemia-> pancreatic beta cell down regulation and exhaustion -> eventual permanent beta cell loss Chronically high insulin demand -> beta cell exhaustion -> diabetes Vicious circle of carbohydrates in cats: Beta cell exhaustion -> hyperglycemia-> glucose toxicity ->suppression of insulin secretion by beta cells, downregulation of glucose transport systems, defect in posttransport insulin action (insulin resistance Administration of insulin reverses this The case for avoiding dry food: Dry food high in carbs -> obesity due to glucose stored as fat, diabetes IBD? Carbs may be less digested in cats ->increased microbial fermentation -> possible changes in flora Feline SI much shorter than omnivore; less able to handle complex carbs Water! Cat evolved to obtain fluid from prey -> water intake based on food intake Cats eating dry food ingest 50% less water -> Urinary issues, renal issues Feeding cats: Meals vs. Grazing: Farrow, Rand and Sunvold: Once daily feeding vs. ad lib Measurement of plasma insulin levels Ad lib feeding -> 40% higher mean plasma insulin concentration Greater demand on beta cells with ad lib Treatment of Feline Diabetes Diet: Low carb, high protein Dry foods higher in carbs Likely, ANY canned better than ANY dry food Purina DM, Hills m/d, Royal Canin diabetic Any canned/pouch kitten Any canned/pouch Farrow, Rand and Sunvold 2002: High protein/low carb diets reduced postprandial hyperglycemia and insulin concentration in normal cats Mazzaferro, Greco, and Turner 2003, Marshall and Rand 2004, Frank, Anderson, and Pazak et al 2002: All found that high protein, low carb diets in diabetic cats -> reduced insulin requirements, better clinical control, increased remission rates Prevention of Feline Diabetes Lederer et al, risk factors for feline diabetes: Indoor cat Chronic medical problems Dental disease Corticosteroid use Glargine (Lantus®) insulin: Long acting synthetic human insulin analogue Recombinant DNA technology Modification of human insulin molecule to produce stable compound that's soluble at ph 4, with decreased solubility at neutral pH Once in SQ tissue (pH 7) forms gradual release microprecipitates In humans: "peakless" In cats: longer duration of action than PZI or Lente Available at pharmacies (vs. PZI) U-100 syringes (PZI U-40) Insulin duration of action: Intermediate acting insulins (lente, isophane) have much shorter duration of action in cats than humans May be due to rapid lowering of blood glucose -> counterregulatory responses (secretion of glucagon, epi, cortisol, growth hormone) -> increased BG Marshall and Rand, 2003: Glargine duration of action in cats 23 hrs, 77% of cats still had decreased BG at 24 hrs Marshall and Rand, 2005: Comparison of lente, PZI, and glargine in diabetic cats: All fed high protein/low carb diets 100% of diabetic cats treated with glargine went into remission within 4 months Clinical hypoglycemia did not occur in glargine treated cats Glargine insulin in cats: Glargine given BID provides longer glucose lowering effect (vs. SID) Weaver et al 2006: Glargine SID -> only 1/6 cats went into remission -> Glargine should be given BID if at all possible, only SID if owner cannot do BID Treatment of Feline Diabetes: Non-dry food High protein/low carb BID glargine insulin For newly diagnosed diabetics, this regime will result in high remission rates Use of glargine in diabetic cats: Proposed regime = 0.25 - 0.5 U/kg BID, with 3 days of hospital or home BG curves, then serial curves at weeks 1, 2, and 4, then PRN Problems: cumbersome, expensive, invasive Due to prolonged duration of action, urine glucose can be used to monitor response to therapy or achievement of remission Intermediate insulins -> shorter duration of action -> uneven control -> urine sugar less reliable Glargine, alternative regime: Start with 1-2 U/cat BID based on size and initial BG Owner dips urine for glucose/ketones, daily if possible Ketodiastix® Urine collection litter box: www.felinediabetes.com Adjust dose based on urine dip results Ketodiastix measurement of urine; urine sugar range: negative, 1/10, ¼, ½, 1, 2 (neg., 100, 250, 500, 1000, 2000) Upwards adjustment by ½ unit BID q3 days until urine sugar 100-500 (1/10 to ½) Downwards adjustment daily if negative Remission - once urine dip negative for glucose, decrease dose by ½ unit BID daily If at ½ unit BID and dip still negative; discontinue Dips daily, then weekly, monthly Feline Transfusion Medicine and Blood Banking - Michelle Falcon Purpose & Benefits The purpose of an in-house blood bank is to maintain a "safe" and readily available source of feline blood products. While there are commercially available feline blood products, the advantages of maintaining an "in-house" blood donor program are realized the first time your commercial blood bank is on back-order. Key Benefits Always having blood products available when you need them Tested & screened; feel confident knowing that the blood you are giving is "safe" Time saver; puts an end the last minute, 10 p.m. hunt for blood Use of component therapy Being able to provide a higher standard of medicine to your patients Donor Sources The main source of feline blood for most small practices is a live-in hospital cat or employee-owned pets. Some will also purchase from a commercial bank. Busier and specialty hospitals will almost always use a blood bank with very few having a client-based bank. Commercial Banks When using commercial banks be sure to consider the following: Anticipate your needs! * Most banks are always on some type of back-order with "STAT" blood being available only if you have a patient, at a greater expense and not available till next day Be sure of when your blood expires. *Feline blood products should never have to be thrown out! There is such a need in this world for feline blood, we should sooner give it away to a fellow hospital a day or two before it expires than to discard it in the trash. Have good relationships with area hospitals. *As blood in your bank comes close to expiring, call fellow hospitals and check on their need. They may be able to use it and exchange a fresher unit to you. This also fosters good will and in a pinch you can also probably borrow blood. Hospital Cats In-house hospital cats are acquired from multiple sources, mainly from being "dumped" or stray. Many hospital cats live long happy lives and are rarely inconvenienced to give blood. We should afford to them the same courtesies that would be given to an owned animal, and follow the guidelines that we will discuss later on. When taking blood from a hospital cat we should not use them more often than every 8 to 12 weeks. Owned Donor Cats The biggest advantage to a hospital in having an owner-based bank is having the ability to call in owners on short notice, even same day, and never being in the position of having to run out of blood. Your donors' owners benefit from the program because of incentives that the hospital will offer to them. These incentives are cost effective to the hospital when you consider the cost of purchasing blood from a bank versus a donor coming in 3 to 4 times a year. Recruitment of Donors It will probably be necessary to offer incentives to owners. Some examples include: Free yearly physical while pet is in program Free vaccinations Free yearly blood work Free or discount flea / heartworm preventative Credit towards hospital bill If donor cat ever needed blood, free blood Excellent communication should be provided to owners, with only one or two people being in charge of coordinating your bank. Owners must be communicated with about all of the details involved before signing on, such as: Frequency of donation - prescheduled appointments 4 times a year or possible emergency donations same day. Small area on neck that must be shaved The need and risk associated with sedation. Donor Selection Despite the fact that feline blood donors will need to be sedated, only cats with good dispositions should be chosen. Should be healthy adults between 1 & 8 years old Should weigh more than 10 lbs Indoor only cat, not from rescue or foster homes (where infectious diseases are common) Should be fully vaccinated Should never have had a litter Should never have had a transfusion Should have a PCV of at least 35% CBC and chemistry panel should be checked yearly MUST be blood TYPED!!! Should be screened and negative for infectious diseases including: FeLV/FIV Toxoplasma gondii Heartworm Mycoplasma hemofelis (formerly Hemobartonella felis) Must be PCR Bartonella henselae (cat-scratch disease) Must be PCR Donor Disqualification Donors should be disqualified for the following reasons: Poor disposition, fractious, overly fearful Failing to meet any of the above listed requirements Poor veins Must be disqualified if positive results on blood test for an infectious disease Must be disqualified for poor recovery from sedation Be sure to keep good track of your donors! Blood Typing ALL cats MUST be blood typed!!! That means donor and recipient. In-house blood typing cards are available which are simple to use and cost effective. In fact many labs use these cards themselves. Feline Blood Types The AB system is the major blood group system in domestic cats, and consists of 3 blood types: type A, type B, and type AB. Type A is the most common blood type, followed by type B, with type AB being extremely rare. Cats with blood type A have naturally occurring, low-level, anti-B antibodies Cats with blood type B have naturally occurring, very strong, anti-A antibodies These antibodies are naturally occurring and unlike other species, no previous transfusion or pregnancy is necessary for antibody development. Neonatal isoerythrolysis occurs when a type B queen is breed to a type A tom, and the type A kittens (type A is a dominant to B) absorb the anti-A antibodies from the queens colostrum. Hemolytic disease that follows can be lethal. Type B frequency Breeds None Siamese and related breeds, Burmese, Tonkinese, Russian blue 1-10% Maine Coone, Norwegian Forest, DSH, DLH 11-20% Abyssinian, Birman, Himalayan, Persian, Somali, Sphinx, Scottish fold 20-45% Exotic and British Shorthair cats, Cornish and Devon Rex Type AB DSH, Scottish fold, Birman, British shorthair, Somali, Bengal, Abyssinian Equipment Needed for Feline Collection & Storage Immediate-Use Open System Small Volume Draw. 60ml syringes with luer lock (Terumo brand is much easier on the hands) 19ga butterfly catheter needles Anticoagulant Closed system for Storage and/or Cell Separation Specialized collection and storage bags listed in Appendix 1. (Human collection and storage bags should NOT be used with cats.) Tube Stripper & plastic hemostats or hemostats with rubber tubing slipped over teeth Hand Sealer for use with metal clips (heat sealers are available but are expensive) Terumo brand has a stripper and clip sealer in one tool Plasma extractor, frozen plasma cartons & Blood type stickers Anticoagulant Gram Scale Dedicated/separate "blood" refrigerator and "frozen plasma freezer" (Be careful not to purchase a freezer with a self-defrost cycle) Anticoagulant & Preservative The anticoagulant of choice is CPDA (citrate phosphate dextrose adenine). Whole blood and PRBCs collected in a closed system with CPDA have a shelf-life of 30 days when refrigerated. Whole Blood vs. Packed Red Blood Cells Whole Blood Whole blood is used primarily for volume expansion & increased oxygen carrying capacity. It is also a source of proteins and certain coagulation factors. Should be used when the anemic feline patient's protein level (albumin) is low, or the patient has a need for clotting factors. Freshly drawn whole blood also contains platelets for cats who have low platelet levels. Packed Red Blood Cells PRBCs increase the oxygen carrying capacity of the patient. Packed red blood cells are preferable to whole blood for most anemic cats. The smaller volume decreases the likelihood of volume overload, and most anemic cats only need red blood cells, not plasma. Plasma Fresh frozen plasma is a source of clotting factors and albumin. When using an open system, acceptable for immediate use, whole blood will be the end result product. A closed system, which allows for long term storage and cells separation, is the method of choice. We are able to inexpensively separate the RBCs from the plasma, providing us with two blood products from one donation. Preparation of Whole Blood Blood collected in an open system must be transfused as soon as possible. Its shelf-life when at room temperature is only four hours. If refrigerated immediately, its shelf-life increases to twenty-four hours. If using a closed system, refrigerate the product immediately for later separation and/or storage. Phlebotomy Technique Items Needed Scrub & Alcohol Clippers 60cc Syringe 19ga Butterfly Needle CDPA Solution Propofol and/or Isoflurane or Sevaflurane O2 Hookup Pulse OX & BP Doppler Donor Gloves - surgical is preferred If you will be storing blood, a closed syringe & bag kit is needed Sedation Using a butterfly inside the hind leg, give propofol SLOWLY to effect; use the minimal amount necessary to immobilize the donor. If you are unfamiliar with propofol or do not have access to it, the next best thing is Isoflurane or Sevaflurane. We do not recommend Ketamine/Valium or Telazol due to the higher incidents of fatal anesthesia reactions! Do not remove hind leg butterfly! Carefully keep in place during the procedure. O2 mask MUST be used at all times! ALL proper sedation monitoring techniques must be used!!!! i.e., BP, Pulse Oximeter Procedure Clip a conservative (small) area over venipuncture site. Scrub with Chlorhexidine and alcohol Draw into a 60ml syringe 8mls of CDPA solution. (CDPA dose is 7-8mls per 50ml whole blood) If drawing less blood - Do The Math using the formula above Attach a 19ga butterfly to the 60ml syringe & flush the butterfly line with the CDPA from the syringe. Using the 19ga Butterfly needle attached to the 60ml syringe, make venipuncture downward, toward the heart. (Like when placing a jugular catheter.) There should be a very small blood "flashback". It won't be very obvious with syringe attached, so if you think you are in, have someone else draw back on the syringe DO NOT let go of the butterfly or release pressure on jugular occlusion. While blood is flowing in to syringe, syringe should be gently rocked every 10-15 mls to mix CDPA. DO NOT accidentally pull out butterfly till done. Collect a total of 50-52mls of whole blood. It should reach to the "60" mark (52 blood + 8 CDPA=60) Remove needle from donor and apply pressure to venipuncture site for at least five minutes. If all goes smoothly (procedure lasts no more than ½ hour) and cat recovers well, no SQ LRS needed. When standing, offer donor something very yummy to eat. If your intention is to store the blood, you would just replace the use of your own syringe and needle with the closed system kit. Storage & Separation Bags There are generally two kinds of bags used in cats. They both have a needle, syringe & three-way stopcock attached to collection bags. In a single bag system there is only one collection bag attached. This bag only allows for the collection & storage of one unit of whole blood. The double bag system has two bags attached, which when used with a plasma separator, allows for the separation of whole blood into a red cell suspension & plasma for freezing. Special Notes The amount of blood to anticoagulant ratio is critical!!! Too little blood in too much citrate is contraindicated in cats. Citrate not used in anticoagulation is a chelator of patient calcium. Severe and often delayed hypocalcemia can occur. Animal Blood Bank has an excellent video available on the above-mentioned procedures. Appendix: Collection Bag Source Animal Blood Bank PO Box 118 Dixon, CA 65620 (800) 243-5759 www.animalbloodbank.com Commercial Feline Blood Banks Animal Blood Bank PO Box 118 Dixon, CA 65620 (800) 243-5759 www.animalbloodbank.com North West Veterinary Blood Bank (360) 752-5554 The Veterinarians' Blood Bank (877) 838- 8533 Suggested Reading Feldman BF, Sink CA: Practical Transfusion Medicine for the Small Animal Practitioner Teton NewMedia, Innovative Publishing, Jackson, WY, 2006 Update on Feline Infectious Disease Mycoplasma hemofelis The infection previously known as hemobartonella felis Prior classification as rickettsia Rickettsiae have cell walls and multiply within host cells Mycoplasma hemofelis has no cell walls and multiplies on host cells Classified into 2 strains: Mycoplasma hemofelis Severe hemolytic anemia Mycoplasma hemominutum Minor clinical signs and hematological changes When infected with both -> more severe disease Mechanism of anemia: Organism attachment -> membrane damage -> increased osmotic fragility -> shortened RBC lifespan Membrane damage -> exposure or alteration in RBC antigens -> antiRBC antibodies Antibodies against organism -> RBC destruction Carrier status: Infection may result in chronic carrier state post recovery Cat clinically normal Reactivation can occur Implications for other cats in household? Diagnosis: Examination of blood smears: false positives and negatives PCR: more sensitive, may be negative during antibiotic treatment PCR + does not equate with clinical dz "Normal" cats may carry Hackett et al 2003: Tested 133 Colorado cats for M hemofelis and M hemominutum 9.8% positive (7.5% M hemominutum, 2.3% M hemofelis) When excluded SPF free colony cats, 12.4 % positive Of cats allowed outside, 19.6% positive Treatment: Doxycycline: can cause esophageal strictures; administer H20 after pilling Enrofloxacin? 5-10 mg/kg/day Dowers et al 2002: enrofloxacin 10/mg/kg/day effective Imidocarb for resistant/recurrent infections? Transfusion prn +/- Corticosteroids? Canine Parvovirus in Cats Parvoviruses: Replicate best in rapidly dividing cells Germfree cats w/ FPLV have none to mild intestinal lesions, implying GI lesions caused by secondary bacterial infections Csiza et al 1971: FPLV persists over 50 weeks in lungs & kidneys of recovered cats Canine Parvovirus in Cats: In vitro, CPV-type viruses replicate well in feline and canine cell lines In vitro, FPLV-type viruses only replicate well in feline cell lines Abs against CPV detected in large felids, wildcats, civets, otters, bears Ikeda 2002: "Interspecies transmissions probably result in accelerated emergence of other new antigenic types of CPVs…" Ikeda et al 2002: In vivo: FPLV replication in cats: e.g., LNs, thymus, spleen, GI epithelium, shed in feces FPLV replication in dogs: Only thymus and bone marrow (not gut -> no fecal shedding) Viral evolution: ancestor of CPV-2 had only to develop ability to replicate in gut to cause fecal shedding and be spread dog -> dog Canine Parvovirus: CPV-2 emerged in the 1970s First positive titers in dogs: Europe 1975, USA/Japan/Australia 1978 Spread rapidly around the world; killed thousands of dogs Theory: Emerged from variant of FPLV or a closely related virus of another carnivore (mink, fox) CPV-2 more likely arose from virus of fox or another carnivore Virus isolated from Finnish Arctic fox intermediate between CPV-2 and FPLV Mink, foxes susceptible to FPLV-like viruses; may be reservoir for CPV-2 ancestor German red foxes may harbor CPV-2 ancestor New types of CPV-2 have now emerged and largely replaced CPV-2: -> CPV-2a, CPV-2b Canine parvovirus in cats: First isolation of CPV-2a in a cat: 1987 CPV-2a and CPV-2b then isolated from cats in USA and Germany (Truyen et al 1996) Ikeda et al 2000: 15 of 18 isolates from unvaccinated cats = CPV-2a or CPV-2b CPV-2a/2b have advantages over conventional FPLV (spread thru cats and dogs) -> CPV-2a/2b may replace FPLV as dominant virus in cats -> Could an outbreak result? Evolution of feline parvoviruses: CPV-2a and 2b found in felids worldwide (cheetahs, tigers, others) CPV-2c: Isolated from leopard cats; not domestic cats in the area Will likely spread to domestic dogs and cats Pathogenicity of CPV-2a/b/c in cats: Mochizuki et al 1996: Isolation of CPV-2a from cat w/ panleukopenia Steinel et al 2000: CPV-2a/2b from cheetahs w/ chronic diarrhea/enteritis, tiger w/ anorexia/diarrhea Goto et al 1984: Experimental infection of cats w/ CPV-2a. Depression, vomiting, diarrhea, leukopenia, death Nakamura et al 2001: Compared virulence of FPLV, CPV-2a, and CPV-2c in SPF cats CPV-2a: diverse pathogenicity; none to typical panleukopenia CPV-2c: all cats developed disease, but milder than FPLV -> 2c more infectious/higher frequency of disease than 2a? Persistent infection: FPLV: will be completely eliminated from infected cats CPV: found in feces of healthy cats Isolated from peripheral blood mononuclear cells (PBMCs) of cats w/ high Ab titers CPV may persistently infect cats, even w/ Ab titers PBMC may be reservoir Sporadic shedding of virus?? Effectiveness of FPLV vaccines against CPV in cats: Chalmers et al 1999: modified live FPLV vaccine protected against CPV-2b (SPF cats) Nakamura et al 2001: Cats vaccinated w/ inactivated FPLV developed neutralizing Abs against CPV-2a/b/c Titers lower against CPV than FPLV Steinel 2000: Cheetahs vaccinated w/ killed FPLV vaccine developed CPV infection Proposed need for CPV-2a/b vaccines for cats FPLV vaccines may not protect cats against CPV long-term Nakamura et al 2001: Cats infected w/ CPV-2a developed high titers against 2a and 2b but low levels against FPLV CPV-2c infected cats developed equal Ab titers against 2a, b, & c as well as FPLV -> CPV-2c vaccine might be promising Feline Bordetella Infection Bordetella bronchiseptica Aerobic, gram-negative coccobacillus Respiratory pathogen of multiple species Previously thought to be secondary respiratory pathogen in cats Now known to be primary pathogen in cats Willoughby et al 1991: Isolated from cattery kittens w/ bronchopneumonia Binns et al 1999: Sampled 740 cats Bordetella isolated from 11% of cats Rescue catteries: 19.5 % Breeding catteries: 9% Research colonies: 13.5% 0% in household pets Significant predictors: Living in rescue cattery Larger numbers of animals Households containing a dog w/ recent respiratory infection Clinical signs: sneezing, coughing, ocular and nasal discharge Seemed to cause disease independently Williams et al 2002: Testing intranasal Bordetella vaccine (Intervet) in cats Control kittens: rhinitis, ocular and nasal discharge, fever, sneezing, coughing Vaccination effective AAFP guidelines: vaccine optional (noncore) Helps et al 2005: Upper respiratory tract disease in cats Tested 1748 cats Prevalence by PCR on swabs Cats w/ URI: FHV 16%, FCV 47%, C. felis 10%, Bordetella 5% Without URI: FHV 8%, FCV 29%, C. felis 3%, Bordetella 1.3% Seroprevalence Bordetella: 61%/41% Contact w/ dogs w/ URI a risk factor Welsh 1996: 11 cats from 10 households diagnosed w/ B. bronchiseptica TTW or lung tissue cultures grew Bordetella in all cases 7 cases fatal (pneumonia) Most cases in kittens < 8 weeks Coughing in all cases Feline Bordetella Infection: May be shed for 19 weeks post infection Carrier state exists: up to 9% of healthy cats may carry Can be transmitted from dogs to cats Can infect humans, especially immunocompromised Virulent Feline Calicivirus Caliciviridae: highly diverse group of RNA pathogens causing wide range of human and animal disease Feline calicivirus: High level of antigenic and pathogenic variability High evolution rate Coyne et al 2006: Studied 5 multicat households Studied endemic infection within households to elucidate mechanisms and rates of evolution, mechanisms of persistent infection of individuals "Opportunity to study their evolution, diversification, and mechanisms of persistence in their natural host population…" "Feline calicivirus infection within stable household groups of cats provides a useful model system to characterize evolutionary strategies employed by caliciviruses to ensure long-survival in their host population." Mean overall prevalence of FCV = 35% 10 distinct viral strains across 5 households 31 individual cats who shed virus over prolonged periods How/why? Coyne et al 2006; 2 mechanisms of viral persistence/evolution: Progressive evolution: mutation accumulation in given variant of a strain within an individual (4 cats) Sequential reinfection: Cats periodically reinfected from within the household (27 cats) At least one cat infected with 2 distinct strains simultaneously Study illustrates the high level of diversity that can occur over time within a viral strain circulating in a population New strains of FCV emerging Grouped endemically infected cats (e.g. rescue, cattery, foster) "provide ideal conditions for the generation of viral biodiversity and possible increased virulence". Multiple outbreaks of virulent systemic feline calicivirus have been recently reported: Hurley et al 2004: CA Pedersen et al 2000: CA Schorr-Evans et al 2003: New England Coyne et al 2006: UK France ? Clinical signs of feline calici: URI Oral ulcerations, acute/chronic stomatitis Arthritis Skin ulcerations/dermatitis Pneumonia Cystitis Hepatitis Neurological dz Virulent systemic feline calicivirus: Widespread vasculitis Multi-organ failure Edema of limbs & face Alopecia/ulceration/crusting of skin, esp. muzzle, pinnae, footpads Icterus Pancreatitis (+/- More typical symptoms) Death 32-50% Patterns of outbreaks: Private vet practice, 6 cases, 3 deaths Shelter kitten hospitalized w/ URI in practice -> employee and client cats All cats had been vaccinated prior Small animal hospital, 24 cases: shelter cats w/ URI -> spread rapidly among patients, employee -> housecat Prior vaccination not protective 32% mortality Mother cat and 3 kittens from rescue group spayed/neutered at vet practice -> outbreak at the vet clinic Mother cat and kittens treated at another vet clinic -> outbreak Cat who had GI surgery at 1st vet -clinic -> owner vectors -> feline housemates (no direct contact) -> another vet clinic -> outbreak Healthy boarding cat, no symptoms, carried home to housemate -> died UK: Outbreak in 4-cat household, adult cat from neighboring household 3 of 4 cats in household died Different strains in each outbreak Resistant to vaccination Adult cats more affected, increased mortality Index cases tend to be shelter or rescue cats Viral strain disappears in 1-2 months Control: Strict sanitation in facility, between patients, when employees go home Isolation of URI patients, gowns/gloves/shoe covers/caps Separate area for rescue/shelter cats? Early recognition and quarantine Nursing by staff who don't own cats? Tracing index case(s) Inform neighboring practices, shelters, rescue Survives in environment 14-28 days Transmitted by aerosol, contact, fomites, feces, urine Bleach best disinfectant? Consider all exposed cats contagious 50% of feline calici strains now resistant to commonly used vaccine Feline Infectious Disease: General Information and Hospital Protocols Feline Panleukopenia: Feline "distemper" A parvovirus, closely related to canine parvovirus From Greek: 'all' (pan), 'white' (leuko) 'decrease in' (penia) Severe disease, sudden death Attacks the bone marrow -> Very low WBC count, +/- low platelets, anemia Attacks the intestines -> Severe vomiting/diarrhea +/- bloody Pregnant cat/young kitten -> damage to kittens' developing brains (cerebellar hypoplasia: wobbly gait, mild to severe) Highly contagious Virus survives years in the environment Cages, bowls, litter boxes What about virus on: Clipboards Pill and injection bottles Doors Glucometer, refractometer Equipment, records What about virus on: Jewelry Shoes Clothes (cuffs, sweatshirts, sweaters, etc.) Panleukopenia/Parvovirus - did you know that: Dogs and cats shed for weeks after infection Seem healthy and normal, but infectious to other dogs and cats Canine parvovirus can now infect cats! Closely related viruses Previous canine parvo strain which did not infect cats has evolved into at least 3 new strains that do Panleukopenia - did you know that: 1/3 of kittens vaccinated 2-3 times before 12 weeks of age not protected Maternal antibody in colostrum interferes with vaccine Maternal antibody lasts from one to four months -> Last vaccine should be given at 4 months Feline Herpesvirus: Fever Sneezing Nasal discharge Corneal ulcers, blindness Tracheitis Pneumonia Skin conditions Feline Herpesvirus: Highly contagious Spread by hands, objects After initial infection, shed by cat for weeks Shed by "normal" cats Lifelong infection Reactivation after: stress, illness, steroids Feline Herpesvirus - did you know that: Vaccination does not prevent infection Lessens symptoms in infected cats Feline Calicivirus: "URI" - fever, sneezing, nasal discharge Feline Calicivirus also causes: Pneumonia Oral ulcerations Swollen, painful joints Feline Calicivirus - new strains: "Virulent Feline Calicivirus": Severe, systemic disease Multi-organ failure Severe skin lesions Outbreaks Up to 50% mortality Worse in adults Feline Calicivirus: Shed for 2-3 weeks after infection Infected cats may have no symptoms "Healthy" cats may be shedding & infectious Feline Calicivirus - did you know that: Many "carrier" cats Carriers may shed for months, years Multiple viral strains exist Vaccines don't protect against all Vaccine strains are 40 years old Poor protection against new & virulent strains Vaccination does not prevent infection, and does not prevent carrier state, it just lessens symptoms in infected cats (sometimes) Bordetella: Bacteria causing respiratory disease in various species One cause of canine kennel cough Can cause fatal pneumonia Bordetella - did you know that: Vaccine does not protect well Dogs can be infected for months Carriers Cats can be infected as well as dogs Sneezing, coughing, Discharge from nose, eyes Pneumonia, death Can be shed by cats for 19 weeks after infection Carrier cats exist 9% or more of healthy cats may carry Transmitted between dogs and cats Studies show that cat exposed to or living with dog with URI more likely to get URI Can infect humans, especially immunocompromised people Feline Coronavirus: Virus which can cause mild GI upset (diarrhea) or fatal FIP No accurate test currently which distinguishes between exposure to corona and current illness with FIP Outbreaks can occur Must be treated as infectious What can we do to help prevent infectious diseases in our patients and in our own pets? Wash hands between EVERY animal, thoroughly Disinfect counter between EVERY animal; the whole counter! (not just one spot) Wear scrubs (no hoodies, sweaters, etc.). Nothing that can't be bleached Minimize jewelry Disinfect cages after each animal, even when we're in a rush Including recovery cages, holding cages ENTIRE cages: door, ceiling, latch Disinfect clipboard or other items hanging on cages Put all infectious animals in isolation wards Treat ALL animals as potentially infectious ANY animal may be incubating ANY animal may be shedding ANY animal may be carrier No muzzles, toys, etc. in hand-washing sinks (don't wash our hands onto objects) Keep wards and treatment areas neat No fabric, etc in wards; nothing that can't be disinfected Minimize hospital clutter Ask clients about vaccination status of pets - in detail, not just whether the pet was vaccinated, but how often and when. Educate clients about vaccinations Avoid petting cute kittens and puppies in hospital 9 Step into bleach pans on way INTO and OUT of wards Wash hands BEFORE leaving wards What else can we do? Give each other a hard time! : Vets listen to techs! Your ideas??? Client Handout: Glargine Insulin Treatment of the Diabetic Cat General information regarding diabetes Diabetes mellitus is a condition of insulin deficiency. Insulin allows glucose (sugar) that the body absorbs and manufactures to get into the body cells for utilization. Without insulin, the glucose cannot enter cells, and the body experiences a state of starvation. Because the glucose cannot get into the cells, it builds up in the blood and overflows into the urine. The symptoms that your pet may have been exhibiting (excessive drinking and urination, increased appetite, weight loss) are due to high glucose in the blood and urine, and starvation of the body cells. A diabetic may develop ketones. Ketones are the result of the body's abnormal metabolism of fat during severe diabetes. Ketones are toxic acids. A life threatening condition called ketoacidosis may develop (diabetic ketoacidosis or DKA). Uncontrolled diabetes can also result in a decreased immune system or poor wound healing. To treat diabetes mellitus, we administer insulin by injection, usually twice a day. If insufficient amounts are given, diabetes remains uncontrolled. Conditions that can contribute to uncontrolled diabetes include: incorrect handling, storage, or administration of insulin; infections; other diseases such as hormonal problems or too much variation in diet or exercise. If too much insulin is given, the blood sugar may drop too low (hypoglycemia), which can be dangerous or even life threatening. Our aim is to establish the correct insulin protocol for your pet without significantly affecting your pet's lifestyle, or your own. This involves close communication with your veterinarian, and may involve periodic trips to the veterinarian's office. It is very important to follow instructions closely, and to keep in touch with your veterinarian. Diabetic pets can live long healthy lives. Many cats if treated and fed appropriately will stop being diabetic and no longer need insulin. You can greatly increase the chance of this occurring by following these instructions carefully. Treatment Diabetes mellitus is treated by injecting insulin under the skin twice a day, using an insulin syringe. Pick the times (twelve hours apart) you are most likely to be home, e.g., 7am and 7pm. It's okay for the insulin dose to be given one hour early or late. It is okay to skip a dose once in a while if unavoidable. Log Book It is helpful to keep a logbook during treatment so we can keep track of your pet's therapy and symptoms. The log should include the date, the urine dipstick glucose and ketone results that day (if obtained), the insulin doses and times, and any other notes you feel are important, such as vomiting or appetite. You should bring your log whenever you bring your cat to the vet. Feeding We often recommend Hill's M/D canned, Purina DM canned or Science Diet Feline Growth canned kitten food, since high protein canned food has been shown to be very helpful for many diabetic cats, and can even cure diabetes in some cases. Please ask your veterinarian which food is recommended for your cat. It is very important that your cat eats consistently, so we will feed a less ideal diet if we have to. Any canned food, particularly kitten food, is good if your cat won't eat the above. Diabetic cats should be fed twice a day, 5 or 10 minutes BEFORE getting insulin (to prevent hypoglycemia from an empty stomach). If your cat won't eat canned food, please ask your vet for recommendations, as it is very important that cats eat every day. Insulin Insulin should be kept in the refrigerator. Insulin bottles should be replaced every three months even if not expired. Be careful to monitor the expiration date as well. Avoid exposure to heat or sunlight. The insulin must be gently but thoroughly mixed just before administration. It can be rolled between your hands or tilted back and forth. It should NEVER be shaken. Give the injection as shown, under the skin, after your pet has eaten. If you ever feel some of the insulin did not go under the skin, DO NOT give it again. Urine Dipsticks Urine dipsticks are extremely useful to help monitor your cat's diabetes at home. They give us a rough estimate of the blood sugar, and also monitor for ketones. We recommend Ketodiastix (available over the counter) which measure urine glucose and ketones. Some suggestions for obtaining a drop of urine to sample: place saran wrap lightly over litter; use non-absorbable litter material such as aquarium gravel, regular gravel, or NoSorb; use a torn paper towel as litter. Even very wet clay litter will not work. The web site www.felinediabetes.com has a special litter box that allows urine to drip through onto a tray for easy collection. Adjusting the insulin dose The dose of insulin can be adjusted at home, based on the urine dipsticks, as follows: If the glucose is 1%, 2%, or more for 2-3 days: Increase by ½ unit over previous dose If the glucose is 1/10%, ¼%, or ½%: Stay at the same dose If the glucose is negative: Decrease by ½ unit from previous dose Do not adjust the dose daily. Wait to see a trend over 2-3 days. The exception is a negative reading. If this occurs, decrease the dose immediately. Do not increase the dose above 3 units without calling. At first, call us every other day with a progress report so we can help you adjust the dose. TROUBLE SHOOTING Hypoglycemia The most important problem that can occur is hypoglycemia (too low blood glucose). This can occur in the following situations: Incorrect calculation or measurement of dosage. Insufficient mixing of insulin solution. Insulin given in spite of the cat's failure to eat, or if he/she vomits his/her food. A change in the cat's insulin requirements. If the cat's diabetes resolves, he may not need insulin. The signs of hypoglycemia are: weakness, loss of balance, incoordination, blindness, collapse, muscle twitches or seizures. If you see any of these signs: If your cat is alert and conscious, offer food. If he/she eats, watch closely and, if all appears well, decrease the insulin dose by 1 unit the next time you give it. You should also call your veterinarian. If your cat is unable or unwilling to eat, give 1 tsp of Karo syrup orally. If no improvement is seen, take him/her to the veterinarian IMMEDIATELY. Once pet is recovered, do not give any more insulin with out speaking to a veterinarian. The best way to avoid a hypoglycemic crisis is to abstain from giving insulin when you are not sure whether to give it or not. Definitely, do not give insulin in the following situations: You are not sure whether he/she received the insulin. You think you gave the wrong amount of insulin. The cat moved when you gave the injection and some of the insulin may not have been injected. Not Eating If the cat does not eat, or vomits after eating, give only half the usual amount of insulin. If this occurs again, call. Ketones If the ketones on the urine dipstick are positive, call right away. This is a sign that we need to check him/her and readjust our dosages. Fluctuating Readings If you notice that the dipstick results fluctuate a lot, and you have had to frequently increase and decrease the insulin dosage, please give us a call. MONITORING Assessment of how well we are doing will be determined by: (1) your cat's attitude, urination and drinking, (2) urine dipsticks, and (3) periodic blood glucose curves or fructosamine levels. While urine glucose measurements are a useful tool for at-home monitoring, they are not completely reliable. They give a rough idea of the blood glucose level over the past several hours. They do not indicate the peak or trough blood levels, nor the duration of the action of the insulin. This can only be done by determination of a glucose curve, i.e., by measuring the blood glucose every 2-4 hours over a 12-hour period after insulin administration. These can be done by your veterinarian, or by you at home using ear-sticks. A curve may be done initially to be confident that we have the diabetes as well controlled as possible. Thereafter, some veterinarians recommend a curve every 3-6 months, or when you think you are having problems. SUPPLIES Glargine (Lantus®) Insulin *Remember - Keep the insulin refrigerated, and discard opened bottle after 3 months. Syringes: Requires a prescription from your veterinarian. Ketodiastix for urine testing: Over-the-counter pharmacy item. *It is important to leave the cap on the bottle when not in use. Read label on when to discard. **Please try to anticipate your needs, and refill supplies in advance. REMEMBER: Call your doctor if: Signs of hypoglycemia, as described above. Ketones seen on dipstick Persistently high glucose readings, despite increased insulin dose, necessitating an increase in insulin dose above 5 units. (Some cats need more than 5 units, but give us a call.) Persistently negative glucose readings, despite decreasing the insulin dose. Fluctuating glucose readings. Not eating well (2 consecutive meals). Vomiting, diarrhea, or any other unexpected problems. Daily Routine Summary Try to dip urine once a day if possible and record. Feed twice a daily, 12 hours apart. Give insulin injections twice daily, after meals (12 hours apart) according to urine dipstick results.

© 2007 - Louise Murray, DVM, DACVIM - All rights reserved