Update (June 26, 2026): 2026 AAHA Feline Diabetes Guidelines — SGLT2 Inhibitor Patient Selection and BHB Monitoring Requirements

Bottom line.

• The 2026 AAHA Diabetes Management Guidelines for Cats (published April 2026) identify SGLT2 inhibitors and insulin as the two licensed modalities for feline DM, with SGLT2 inhibitors now an appropriate first-line option for newly diagnosed, metabolically stable cats not previously treated with insulin.¹
• Key SGLT2 contraindications per the 2026 guidelines: ketonuria on screening, systemic compromise (vomiting, hyporexia, cachexia, lethargy), significant CKD (IRIS Stage 3+), hepatopathy, or hypercalcemia — start insulin in these patients.¹
• BHB monitoring is described by the guidelines as essential: check at days 2–3, 7, 14, and 30; switch to insulin if BHB >2.4 mmol/L (with exceptions for declining BHB in cats who started above this threshold and remain clinically stable).¹
• This is a clinician-facing evidence summary. It is not a dosing protocol; confirm regimen, monitoring and contraindications against current product labeling and your formulary.

Update context

The 2026 AAHA Diabetes Management Guidelines for Cats were published on April 26, 2026. For the first time, AAHA released species-specific feline and canine diabetes guidelines separately, recognizing the fundamental differences in DM pathophysiology and management between species. The 2026 feline guidelines build on the 2018 AAHA Diabetes Management Guidelines while incorporating new evidence on SGLT2 inhibitors (bexagliflozin and velagliflozin) and updated positions on glucose monitoring and remission.

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What the 2026 AAHA guidelines say

Overview of the treatment landscape

Feline DM pathogenesis is multifactorial but most commonly involves insulin resistance (IR) placing prolonged stress on already-vulnerable beta cells, with progressive amyloid accumulation and glucose toxicity driving beta-cell loss.¹ Feline DM shares strong similarities with human type 2 DM. The 2026 guidelines note that treating feline DM relies on controlling hyperglycemia by giving insulin or an SGLT2 inhibitor, and by mitigating factors causing IR; in some cats, beta-cell function may recover sufficiently for medical therapy to be withdrawn (diabetic remission).¹

Two SGLT2 inhibitors are now licensed in the United States for use in newly diagnosed, otherwise healthy feline diabetics not previously treated with insulin: bexagliflozin tablets (Bexacat, Elanco) and velagliflozin oral solution (Senvelgo, Boehringer Ingelheim), both administered once daily.¹

Patient selection for SGLT2 inhibitor therapy

The 2026 guidelines state that clinicians should consider an SGLT2 inhibitor for any newly diagnosed diabetic cat that is eating and well hydrated.¹ A thorough physical examination and diagnostic evaluation (CBC, chemistry panel, and urinalysis) is required. Contraindications include:

• Signs of systemic compromise: vomiting, hyporexia, cachexia, or lethargy
• Hepatopathy
• Significant CKD (IRIS Stage 3+)
• Hypercalcemia
• Detected ketonuria on screening

Cats older than 7 years should be screened for hyperthyroidism before initiating therapy. As a general rule, insulin therapy is the appropriate treatment for diabetic patients who are not metabolically stable.¹

Cats with readily reversible causes of IR — such as recent depot steroid administration — are particularly suitable candidates for SGLT2 inhibitor therapy; they are more likely to go into remission and therefore particularly vulnerable to hypoglycemia if treated with insulin.¹

BHB screening and monitoring requirements

The guidelines state that BHB measurement is preferred over other methods for assessing ketosis, and that inexpensive handheld ketone meters provide quick and reliable quantification of blood BHB; BHB measurement is described as an essential part of SGLT2 inhibitor drug monitoring.¹ The currently validated ketone meter for use in cats is the Precision Xtra (Abbott).

Per the bexagliflozin package insert, bexagliflozin should not be initiated if blood BHB is >3.6 mmol/L, or if BHB is >2.4 mmol/L with a history of acidosis or renal compromise. Both bexagliflozin and velagliflozin package inserts warn not to start these drugs if ketonuria is detected; detecting ketonuria during treatment should prompt discontinuation and transition to insulin.¹

The recommended monitoring schedule from the 2026 guidelines (Table 6.1) includes BHB evaluation, physical examination, and blood glucose checks at:

• Days 2–3: If BHB >2.4 mmol/L (25 mg/dL) — switch to insulin. BHB 1.0–2.4 mmol/L — recheck in 2–3 days.
• Day 7: Review history, BHB, spot-check BG.
• Day 14: Review history, BHB, BG; expect BG <250 mg/dL.
• Day 30: Review history, weight, BHB, BG, fructosamine; expect fructosamine normalization or significant improvement from baseline.
• Every 3 months: As for day 30.

Key recommendation on in-hospital glucose curves

A notable change in the 2026 guidelines is the position that routine in-hospital blood glucose curves are no longer recommended for diabetic monitoring in cats, because stress hyperglycemia in hospitalized feline patients can significantly influence glucose readings.² Feline diabetic monitoring now emphasizes clinical signs, continuous glucose monitoring, and at-home glucose data.

Response to SGLT2 inhibitor therapy

The guidelines note that in most diabetic cats, blood glucose improves within hours of administering an SGLT2 inhibitor, and serum fructosamine concentrations are routinely within the reference range after 8 weeks.¹ Current evidence suggests assessing overall clinical response after 1 month; if the cat remains hyperglycemic with clinical signs of DM, discontinue the SGLT2 inhibitor and provide insulin therapy. The 2026 guidelines note that the incidence of remission for cats receiving an SGLT2 inhibitor has not yet been formally evaluated.³

Traditional oral hypoglycemics

The 2026 guidelines explicitly state that traditional oral hypoglycemic agents such as glipizide (a sulfonylurea) and metformin (a biguanide), routinely prescribed for people with type 2 DM, are not consistently safe or effective in diabetic cats and therefore are not recommended.¹

How this fits clinical practice

The 2026 AAHA guidelines represent a significant shift: for a substantial proportion of newly diagnosed, metabolically stable diabetic cats, an oral SGLT2 inhibitor is now a guideline-endorsed first-line option alongside insulin. The practical implication for clinical workflow is that the initial diagnostic workup — including BHB measurement, CBC, chemistry, UA, and screening for comorbidities — determines the treatment pathway. Practitioners should be familiar with the BHB monitoring schedule and the DKA/EDKA warning signs, particularly in the first 2 weeks of therapy. Always verify specific dosing and monitoring thresholds against current product labeling and the full 2026 AAHA guidelines.

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References

1. American Animal Hospital Association. 2026. 2026 AAHA Diabetes Management Guidelines for Cats — Section 6: SGLT2 Inhibitor Treatment and Monitoring. Published April 26, 2026. https://www.aaha.org/resources/2026-aaha-diabetes-management-guidelines-for-cats/section-6-sglt2-inhibitor-treatment-and-monitoring/
2. American Veterinary Medical Association. 2026. Updated AAHA diabetes management guidelines focuses on cats. https://www.avma.org/news/updated-aaha-diabetes-management-guidelines-focuses-cats
3. American Animal Hospital Association. 2026. 2026 AAHA Diabetes Management Guidelines for Cats — Section 9: Diabetic Remission. https://www.aaha.org/resources/2026-aaha-diabetes-management-guidelines-for-cats/section-9-diabetic-remission/

Changelog

• 2026-06-26: First published.