Brand Name: Bexacat

Available in 15 mg tablets 

Background

Diabetes mellitus in cats is traditionally treated with insulin injections, glucose monitoring either at home or in the hospital, and special diets that the cat may or may not be inclined to eat. The process is expensive, labor intensive, and intimidating for many cat owners. Many cats are euthanized at the time of diagnosis because this disease represents a substantial project in pet care that an owner may not be willing or able to undertake. Human diabetics have many choices of oral medications, so why can't cats?

It turns out that perhaps they can, but only in the right circumstances.

Bexagliflozin is what is called an SGLT2 inhibitor. SGLT stands for Sodium Glucose Transporter. Under normal circumstances, we want to keep our glucose as it is a valuable resource. Glucose is a small molecule circulating through the bloodstream, and if we are not careful, we can lose it accidentally in intestinal contents and in our urine. Fortunately, we have SGLT2's in our kidneys reabsorbing 97% of glucose that would have been lost in the urine and SGLT1's reabsorbing the rest that would have been lost in our GI tract. When we inhibit SGLT2, we lose a lot of glucose in urine. Since diabetics have huge amounts of circulating glucose to manage, dumping the extra in urine turns out to be very helpful.

SGLT2 inhibitors have been very popular for human diabetics. In addition to dumping extra glucose in urine, they also reduce high blood pressure and assist with weight loss. Unfortunately, all that glucose in urine increases the risk of urogenital infections and increases the risk of an extreme diabetic complication called Diabetic Ketoacidosis.

For cats, this medication is very new and much is unknown about how the potential for serious problems will pan out. For now, this medication is a good choice for an owner willing to accept some element of the unknown in exchange for an oral diabetic treatment. It is very important to understand the monitoring test schedule as well as what to watch for.

• Bexagliflozin cannot be used in:

  • Cats with a history of pancreatitis (FPL test >5.3 mg/dl)
  • Cats with a history of ketoacidosis
  • Cats under 6.6 lbs of body weight
  • Cats with evidence of liver disease
  • Cats with evidence of kidney disease
  • Cats with elevated beta-hydroxybutyrate (ketone) levels

The cat in question must be in apparent health other than being diabetic. 

How This Medication Is Used

Bexagliflozin is given once daily, with or without food. 

Monitoring rechecks in the veterinarian hospital with testing after two weeks, four weeks, and eight weeks. If all goes well, testing can be extended to every 90 days. Testing includes a glucose curve at least eight hours in duration, liver enzyme levels, fructosamine levels, and levels of a special ketone called beta-hydroxybutyrate. The instability of any of these parameters can indicate a switch to insulin.

• Bexagliflozin must be discontinued, and the cat must be switched to insulin if:

  • there is poor glucose regulation based on the curve and fructosamine levels
  • there is weight loss
  • there are rising beta-hydroxybutyrate levels
  • diarrhea results and cannot be controlled with traditional therapy

Side Effects

The extra glucose going through the urinary tract can lead to an increase in thirst and urination, but this is usually temporary as glucoses should readily become controlled. It can be bad enough to create dehydration. If this occurs, bexagliflozin should be discontinued.

• The following side effects were seen in the test cats:

  • 44% had vomiting (mild and temporary)
  • 33% had diarrhea (mild and temporary)
  • 31% had appetite loss (mild and/or temporary)
  • 43% had an increase in their FPL test (a test for pancreatitis)

The risk of developing ketoacidosis goes up two to sevenfold with the use of SGLT2 inhibitors, so it is crucial to watch for this complication. Ketoacidosis is typically associated with very high blood sugar levels, but patients on SGLT2 inhibitors can get a form of ketoacidosis called euglycemic ketoacidosis, where blood sugars are deceptively normal. Both forms are equally life-threatening and require hospitalization. Obviously, if a cat develops this complication, the cat must switch to insulin when recovered.

Extra sugar going through the urinary tract can result in urinary tract infections. Periodic screening is needed.

Hepatic lipidosis (fatty liver) is a potentially serious side effect. Any cat with appetite loss or lethargy should be seen by the veterinarian as soon as possible.

Interactions With Other Drugs

Medications that lower blood pressure/treat hypertension may lower blood pressure too much if bexagliflozin causes dehydration.

Concerns and Cautions

• Bexagliflozin is for non-insulin diabetic cats. There is no way to know if a cat is insulin-dependent or not. Cats that have been diabetic for over six months have likely become insulin-dependent. Cats freshly diagnosed with diabetes mellitus have a good chance of being non-insulin-dependent.  Giving bexagliflozin to an insulin-dependent cat will create ketoacidosis.
• Bexagliflozin should not be given to cats previously on insulin.

Any cat that becomes lethargic, loses appetite, or experiences weight loss should be evaluated for ketoacidosis.