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Research Study: Survival, remission, and quality of life in diabetic cats

Rothlin-Zachrisson N, Öhlund M, Röcklinsberg H, Ström Holst B. Survival, remission, and quality of life in diabetic cats. J Vet Intern Med. 2023 Jan;37(1):58-69.

Diabetes mellitus (DM) is a well-researched endocrinopathy in cats. A plethora of published literature exists detailing the risk factors, treatment options, and treatment outcomes. However, more attention is now being paid to both owners’ and cats’ lifestyles and quality of life (QoL) while managing this chronic disease process. This recently published Swedish study evaluated the outcome of cats with DM and the impact the disorder had on the lives of cat and owner via a 46-question online questionnaire. Owners were recruited through insurance records (Agria Pet Insurance) from 2009-2013 with the following diagnoses: DM, DM without complication, DM with complication, DM with ketoacidosis. Initial survival was defined as surviving more than 4 weeks after diagnosis. Cats did not have to be alive when the questionnaire was answered.

Inside the numbers of this study:
– 477 questionnaires were analyzed, with the majority of cats (333/477, 70%) not alive at the time the questions were answered.
– The mean age of diagnosis in all cases was 10.6 (+/- 3.1) years
– 405 out of 477 cats were alive 4 weeks after diagnosis. The remaining 15% (72/477) had been euthanized for the following reasons: Owners did not want cats to suffer (53%), Prognosis was poor (32%), Concurrent disease (21%), Treatment too difficult (13%), Poor veterinary support (4%).
– Treatment in cats with survival greater than 4 weeks included: 89% insulin therapy, 7% oral hypoglycemic, and 93% with dietary adjustments. The most common diet fed was a dry veterinary prescription diet specifically formulated for DM (62%: 253/405). 11% of cats were fed a predominantly commercially available wet food.
– 51% of owners performed at-home blood glucose monitoring, 12% measured urine glucose, and 6% performed both. 31% of owners did no monitoring.
– 118/405 (29%) cats underwent remission, with 45/118 (38%) of those relapsing, and 73/118 (62%) not experiencing relapse
– Factors that were significant for an increased chance of remission included breed (Norwegian Forest Cats) and being fed a predominant commercially available wet diet. QoL was better or the same in cats that underwent remission.
– Time needed for achievement of remission: 22% in 0-3 months, 29% in 4-6 months, 19% in 7-12 months, and 25% in greater than 12 months
– Survival time in all 477 cats included 63% more than 1 year, 25% more than 3 years, 10% more than 5 years, and 1.4% greater than 8 years
– Owner-perceived difficulties in cats that survived greater than 4 weeks included these top 5: Owner feeling limited (51%), Worrying about complications (45%), Worrying about cat’s medication (29%), Difficulty in measuring blood glucose (21%), and Worrying about costs (15%). 20% of owners had no perceived difficulties or worries.
– For cats surviving greater than 4 weeks, there was a positive association between owners experiencing lifestyle limitations, worrying about complications, and their cat’s QoL not being negatively affected by DM
– QofL perception was affected by whether that cat was alive or dead when the questionnaire was answered: 67% (96/144) owners believed their cat’s overall QofL to be the same or better than before diagnosis if their cat was still alive. On the other hand, if their cat was deceased, only 40% (134/333) believed their cat’s overall QofL to be the same or better than before diagnosis.

A review of some of the factors associated with the numbers:

1. Survival Time:
– In owners that were concerned about cost, the odds of survival greater than 4 weeks was lower in younger cats. However, in general, there was no association between owner costs and survival time
– Survival time was associated with age in cats treated with insulin
– There was no association between survival time and comorbidities or achieving remission

2. Remission:
– Cats were 3 times more likely to go into remission if they were fed a commercially available wet food (low carbohydrates) than if they were fed a veterinary prescription diet. There was also a strong association between the commercially available wet diet and remission without relapse.
– Norwegian Forest Cats had an increased odds of remission compared to DSH. Norwegian Forest Cats are a breed with an increased risk for DM, and this was likely the first study with an association between breed and disease outcome.
– There was no association between insulin treatment and remission
– There was a surprising number of cats who achieved remission (25% of the total) more than 1 year after diagnosis

3. Owners’ perceptions and concerns:
– About 50% of owners perceived limitations in their lives because of their cat’s DM, though this did not influence the odds of the cat surviving the first 4 weeks
– More than 58% of owners said their relationship with their cat strengthened after diagnosis, while 1% said their relationship worsened.

Limitations of this Study
The major limitations involved in this study were that all case information was obtained from owners and not all cats were alive at the time of completing the questionnaire. Recall bias as well as misinterpretation of a cat’s medical condition by their owner may have resulted. Information on how each cat’s DM diagnosis was confirmed by their veterinarian as well as scientific evidence of diabetic remission was also not available.

What Can Be Gained From This Study?
DM is a complicated medical condition that affects the lives of both cat and owner. More than 1 in 10 cats in this study were euthanized within the first 4 weeks of diagnosis. Understanding the disease process from the perspective of the owner is imperative as their ability to implement their veterinarian’s recommendations and manage their cat’s condition in a home environment are keys to success in their treatment. Hopefully, this success improves as the veterinary community starts to understand this endocrinopathy from the perspective of the owner. – BJP

For further reading:

Behrend E, Holford A, Lathan P, Rucinsky R, Schulman R. 2018 AAHA Diabetes Management Guidelines for Dogs and Cats. J Am Anim Hosp Assoc. 2018 Jan/Feb;54(1):1-21.

Fleeman L, Gostelow R. Updates in Feline Diabetes Mellitus and Hypersomatotropism. Vet Clin North Am Small Anim Pract. 2020 Sep;50(5):1085-1105.

Niessen SJ, Powney S, Guitian J, Niessen AP, Pion PD, Shaw JA, Church DB. Evaluation of a quality-of-life tool for cats with diabetes mellitus. J Vet Intern Med. 2010 Sep-Oct;24(5):1098-105.