scott@vtx-cpd.com

Replying to Katherine Howie 23/04/2025 - 11:43

Thanks so much for sharing, Kath. Really appreciate the tip about monitoring caudal vena cava compressibility, that’s such a handy one to keep in mind! Great point too about adjusting fluid balance reassessments depending on the patient’s losses.

Scott 🙂

Hi Emma,

I’ve spoken to Laura, and she very kindly replied with the following information. This is certainly contrary to what I had understood about the drug, so I’ve definitely learned something here. Thank you so much for the brilliant question. I’d very much go with what Laura is recommending in this case — she’s without doubt one of the most experienced clinicians in the UK using Senvelgo at the moment, and there’s clearly lots to take away from her guidance. Here’s what she shared:

Should Senvelgo be given on the morning of sedation, or withheld?

Senvelgo should be given as normal on the morning of sedation. There’s no increased risk of hypoglycaemia during sedation or anaesthesia, and the patient will benefit from avoiding hyperglycaemia during the procedure. Although there’s a minor difference in peak plasma concentration when given with or without food, this isn’t considered clinically relevant — so even on an empty stomach, it’s fine to give.

It’s worth noting that although some sources suggest withholding the drug, this advice does not come from medical endocrinologists or from Boehringer. In fact, they strongly disagree with withholding it. Doing so increases the risk of hyperglycaemia and could precipitate an EKA (euglycaemic ketoacidosis). Since the drug has a duration of action >24 hours, withholding it doesn’t really assist in interpreting BG on the day either — it just adds risk.

What blood glucose monitoring would you recommend pre- and during the procedure?

If Senvelgo is given as normal, the glucose levels should remain within the normal range throughout, as the drug keeps glucose below the renal threshold and there’s no insulin involved, so the risk of hypoglycaemia is negligible. Ideally, BG and ketones should be checked before sedation, during the procedure, and again before discharge — but assuming ketones are <2.5 at the outset, everything should stay within normal limits.

Are there any sedation agents you would particularly avoid?

There’s no need to avoid any particular sedatives, provided the patient is stable on Senvelgo and is ketone-negative. The usual caution around medetomidine in insulin-treated diabetics doesn’t apply here — the transient hyperglycaemia it causes would only be a concern in patients where insulin dosing is affected. In this case, there’s no insulin on board, so that effect isn’t clinically significant.

Thanks again for raising such a great clinical question — it’s really helped clarify things, and I know I’ll be adjusting my own approach in the future based on this.

Scott

Hi Emma,

This is a really interesting question.

In terms of fasting and blood glucose monitoring, I would still recommend a shorter fasting period if possible, around six to eight hours rather than the traditional twelve, to minimize the risk of dehydration or ketone production, given the ongoing glucose loss through the kidneys. Baseline blood glucose should absolutely be checked pre-sedation, and regular monitoring during the procedure (every 30 to 60 minutes depending on the length and depth of sedation) is advisable. True hypoglycaemia is rare in Senvelgo-treated patients compared to those on insulin, but they can be vulnerable to dehydration and ketogenesis, so ketone monitoring would also be sensible if practical.

When it comes to medication handling on the day of sedation, based on both human recommendations and cautious extrapolation to cats, SGLT2 inhibitors are typically withheld on the day of surgery or sedation to reduce the risk of complications such as dehydration or diabetic ketoacidosis. Therefore, I would recommend skipping the Senvelgo dose on the morning of sedation and resuming it once the patient is eating and drinking normally again post-procedure.

Thinking about sedation protocols, medetomidine is often used cautiously in diabetic patients because of its insulin-inhibitory effects and potential to cause transient hyperglycaemia. However, in a Senvelgo-treated cat, this concern is somewhat less pronounced because blood glucose control is managed independently of insulin secretion. That said, any major shifts in glucose can still be problematic, so I would advocate for using low-dose medetomidine with a plan for reversal using atipamezole, or considering alternative protocols based on the cat’s cardiovascular status. Opioids such as buprenorphine, benzodiazepines like midazolam, and agents like alfaxalone are all safe and useful adjuncts in this context, given their minimal impact on glucose metabolism.

Of course, there are many factors that can affect glucose control around sedation, including stress, fasting, the type of sedation used, and underlying disease. These patients, particularly those on Senvelgo, often still retain some background endogenous insulin secretion. It is not typically an absolute insulin deficiency, which can offer a degree of metabolic flexibility. I would argue that as long as we are monitoring carefully, any abnormalities can be identified early and corrected appropriately, reducing the overall risk.

Finally, to make sure we cover all bases, I am also reaching out to Laura Bree, who spoke at our recent CPD event and has extensive clinical experience with Senvelgo, to get her perspective on best practices for sedation in these patients. I would love to hear what the drug company had to say as well, so please do share their advice when you have it.

In summary, I would recommend a shorter fasting period, omission of the Senvelgo dose on the morning of sedation, careful peri-procedural blood glucose (and ketone) monitoring, low-dose or reversible sedation protocols where appropriate, and a general emphasis on hydration monitoring. I would love to hear what the drug company advice was!

Scott 🙂

Hi Georgia,

Yeah, it’s such an interesting discussion. I think I’m not uncomfortable with the idea of using insect protein. There’s definitely a sustainability piece to it as well. As long as we can demonstrate clear nutritional value, I think it really opens up that broader conversation about protein sources in animal food and how different cultures view them.

You know, we would generally find the idea of horse meat pretty unacceptable in the UK, whereas it’s considered quite normal in parts of Europe like Germany. Even something like kangaroo is very popular here, but it’s not necessarily something everyone in Canada would find palatable. And then, of course, there are places where dog meat is still consumed, which really highlights how subjective and culturally dependent these attitudes are.

I think it’s a fascinating wider discussion about what is considered “acceptable” protein, and insect protein feels like a logical, sustainable evolution.

Scott 🙂