dvm360: Before we dive in, what do you most want practitioners to take away from your session on SGLT2 inhibitors?
Behrend: I want people to leave believing that they can use SGLT2 inhibitors for diabetic cats, that they are a relatively safe option, they are an effective option, and that they can be used relatively easily
dvm360: The 2026 AAHA guidelines emphasize monitoring the patient and following beta-hydroxybutyrate rather than focusing primarily on blood glucose during stabilization. Why does that distinction matter, and what should practitioners know about euglycemic DKA?
Behrend: That’s a really hard question to answer. When the SGLT2 inhibitors were first approved for use in cats, the FDA made a huge deal out of the development of diabetic ketoacidosis, and I think they’ve done this drug class a disservice. Diabetic ketoacidosis is a serious complication. It’s an expensive complication. It can be a fatal complication. But it’s not all that common with SGLT2 inhibitors. A number of papers now have shown that it’s probably about 5% to 7% [of feline patients with diabetes who develop diabetic ketoacidosis], so we have to be aware of it, but it should not scare someone away from using this drug if the cat qualifies for it.
The point of monitoring ketones, whether you’re looking at urine or beta-hydroxybutyrate in blood, is to try to detect ketones early, before the cat becomes sick and goes into full-blown DKA
We are now learning that cats can develop ketones and never go into DKA. Unfortunately, we don’t have any way to predict which of the cats are going to go into DKA. Some people are actually emphasizing less monitoring now. The really important thing is to look at the clinical picture of the cat. If the cat is not feeling well at all, appetite has decreased, it begins having gastrointestinal signs, it has to be seen absolutely immediately and checked for the presence of DKA
dvm360: What are some misconception about SGTL2 inhibitors that you would like to correct?
Behrend: One big misconception is the fear of diabetic ketoacidosis, and [the idea] that blood ketones have to be monitored very carefully, multiple times, while the cat is on the drug. The licensing studies for Senvelgo in both Great Britain and the US were done with urine monitoring only, not blood monitoring. So you don’t have to do blood monitoring of ketones in order to use these drugs. And again, it’s the clinical picture that really matters. I think people need to focus less on DKA and be less afraid of using SGLT2 inhibitors.
Another misconception is, I think a lot of people don’t use these drugs because of the cost, and the cost of the drug itself, compared to insulin, is more expensive
However, there is so much less monitoring that you need to do with these drugs, and that is where the clients are going to save money. They’re going to save a lot of money. I don’t do all the monitoring that is recommended on the label. I think you don’t have to do that and can still use these drugs very safely. We don’t have to do glucose curves, unless it’s an unusual situation, and that just makes use of these drugs so much easier and so much cheaper for the owners
dvm360: Patient selection is one of the most important pieces of successful SGLT2 inhibitor therapy. Which cats should not receive one, and when should clinicians start insulin instead?
Behrend: Any cat that’s not feeling well, not eating well, is sick absolutely should not have an SGLT2 inhibitor and should be put on insulin instead. The contraindications for using SGLT2 inhibitors are not eating well, acute vomiting or diarrhea, and being of a low body weight. I think that’s everything, mainly
There’s a big question about whether cats that have ketones can receive an SGLT2 inhibitor. According to the label, they can’t. But I know we are rethinking that in veterinary medicine, and we’re giving more leeway to cats that may have some ketones already. Basically, we are looking for a happy diabetic cat that’s eating and drinking, urinating like you would expect for a diabetic cat, has no acute GI signs, and is of good body weight or overweight. There are a few other things you need to look at, like kidney function. But basically, a happy diabetic cat is probably going to be a good candidate.
dvm360: What about diet? What should practitioners recommend alongside an SGLT2 inhibitor, and when should they make a change?
Behrend: At this point, we don’t know what diets to recommend with use of an SGLT2 inhibitor. Actually, in people, use of a high-fat, high-protein diet with an SGLT2 inhibitor actually increases the chance of DKA. I still recommend—and I think a lot of people still recommend—use of what we consider the typical diabetic cat diet, high fat and high protein, in combination with an SGLT2 inhibitor. Cats are not small people. Cats handle carbohydrates totally differently than people do, and those diets are so beneficial for cats that are diabetic that I’m still recommending their use in combination with an SGLT2 inhibitor until someone tells me that it’s not a good idea or proves that it’s not a good idea.
I do recommend not changing the diet until about 2 weeks after starting the SGLT2 inhibitor, because SGLT2 inhibitors can cause vomiting and diarrhea without the cat going into DKA. Vomiting and diarrhea are [adverse] effects of the drug. Changing a diet can also cause vomiting and diarrhea, so I think that complicates the picture, and I don’t want to do the two together. So I recommend the SGLT2 inhibitor first, and then once the cat is stable on the drug after a couple of weeks or so, try a diet change.
dvm360: After years of researching and teaching in this area, what excites you most about where feline diabetes is headed?
Behrend: I’m most excited about these drugs. I think they are just a godsend for feline diabetes. When I first heard about this class of drug, I thought it was the stupidest idea I had ever heard, because the way they work is by putting glucose in the urine, so it should make the [polyuria and polydipsia] horrific. But it doesn’t, for any number of different reasons. I think there are a lot of owners who will now treat their diabetic cats with an oral hypoglycemic because it’s once a day. The cat still needs to be eating, but you don’t have to pair it with the food.
Using these drugs is so much easier for clients that I think we’re going to be able to treat a lot more diabetic cats than we used to. I think they’re going to be helpful in situations like cats that are on glucocorticoids and are diabetic — I think that’s a great use for SGLT2 inhibitors. I just presented research at the ACVIM Forum last month about use of these drugs in cats with acromegaly and diabetes. Those cats can be impossible to treat with insulin alone, and SGLT2 inhibitors are a godsend and can really help those cats a lot.
Ellen Behrend, VMD, MS, PhD, DACVIM (SAIM), is the Joezy Griffin Professor in the Department of Clinical Sciences at Auburn University and an internationally recognized expert in small animal endocrinology. She earned her VMD from the University of Pennsylvania in 1988, completed an internship at Michigan State University, practiced in private practice, then went on to earn a master’s degree and complete a residency in small animal internal medicine at Colorado State University before obtaining a fellowship in endocrinology and a PhD from Auburn University. A board-certified veterinary internal medicine specialist, Behrend has served as a consultant for Auburn’s Endocrine Diagnostic Service and the Veterinary Information Network (VIN) for decades. Her research focuses on canine and feline endocrine disorders, particularly adrenal disease and hyperadrenocorticism (Cushing’s disease), and she has authored or coauthored more than 130 scientific publications and book chapters while earning multiple awards for excellence in teaching and endocrinology.
