? 03/20 - Vet is now on board with TR, and question

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Amanda & Shmee

Amanda & Shmee

Member Since 2018
http://www.felinediabetes.com/FDMB/...ions-on-what-i-should-do.192715/#post-2152090

Hello, I just wanted to give an update regarding to the thread above, and I have a question. My vet looked into TR and is now on board! This was her response;
"I did some reading on the tight regulation and I am OK with you doing it this way. The only issue I have is that I don't agree with the person in the link you sent me saying that the Somogyi effect does not happen in cats. It definitely does happen, I've seen it and if you keep giving insulin these cats will end up becoming severely hypoglycemia and can die. Therefore if the blood glucose is running low and suddenly jumps up super high, or suddenly jumps up and stays high, do not give more insulin and call us.
I want to make 100% sure Shmee is on a diet with < 7% carbs. There is a good website - www.catinfo.org - that has a list of tons of canned foods and the protein and carb% (you need to look at the % dry matter, carbs should be under 7%). I think all the Fancy Feast Classic and non-gravy foods fit this.
It has been quite a while since I have had a cat go into remission, mainly due to the fact that you are one of the first owners I've had at Emerald that is willing and able to pay for Lantus insulin, feed the appropriate diet, and take blood glucose levels at home. Sadly I have not had many owners be able or willing to do what is needed to achieve remission, and regulation is the only goal. In the past I have used Lantus in a different way, starting high and then decreasing, and achieved remission that way as well as starting low and working up, as long as the cats were eating the appropriate diet. I could not give you a percentage. I think achieving remission is more an owner driven outcome. The main goal is to get the blood sugars below 200 for as much of the day as possible, this is below the threshold where sugar spills into the kidneys. Glucose is toxic to the pancreas, and the faster the blood sugars drop and the more consistent they stay below 200, the pancreas can recover. Please note if there is another disease process going on that is either triggering the diabetes or is causing insulin resistance, then remission can normally not be achieved. If Shmee's liver values are not decreasing back to normal with the decreasing blood sugar levels, I think we need to get an ultrasound to see if there is anything else going on.
To minimize trips to the clinic, it would be helpful if you got a baby or pet scale and weighed Shmee at home once a week, so we can monitor his weight gain or loss. I got mine off Amazon. Don't try holding him and weighing him and you on your scale then subtracting your weight, that is OK for a rough estimate of weight but not the exact numbers we need.
I am happy that you are not having to give him the mirtazapine to get him to eat. That is a very good sign. I do think some cats lose their appetites with very high blood sugars.
Let me know when you get his next curve and see if you can get his weight as well. You can bring him into the clinic for a weigh-in anytime, no charge, if needed."

Side note about the Mirtzapine (the appetite stimulant) - she was mistaken and this is untrue. I unfortunately am still giving it to him, but way less than what he was getting before. He used to get it every two days, then every four days, and this last time he went six days without having to have it. By the end of the sixth day, i decided to give it to him because he was eating less than normal that day, and he is losing weight so I wanted to keep his appetite up. I am hoping that his appetite still gets low every once in a while due to having high numbers, and not due to something worse being wrong with his liver (he had extremely high liver levels in the beginning, then they went down after my switch to FF wet food, and now he is on Denamarin so I am hoping the next test shows reduced levels again).

My question about TR - - As you can see I have gotten one blue number since upping him on Monday to 2.25. On the tight regulation forum as well as the Tilly's Diabetes website, it says to increase by .25 if the nadir is above 200, but it doesn't say what to do if the nadir is under 200 (other than to hold the dose for 4-5 days). I assume I increase by .25, correct? And I keep increasing every 3-5 days until I see the nadir under 100 correct? At that point is when I would start to reduce by .25?

Thank you for your help and I hope everyone has a nice night.
 
Sounds like you have a really great vet! :woot: Consider yourself lucky, it's not always easy to find one as open minded about FD. Despite several published medical journal articles discounting somogyi, I've yet to find a vet who will let go of what they were taught in school about it. They have continuous glucose monitors which can prove what happens overnight with BGs and high waking glucose can be from a bounce, postprandial response or dawn phenomenon, but it certainly isn't always from a silent hypoglycemic episode at night. Oh well. I wouldn't hold it against her. ;)

So you would keep increasing under you see a green nadir and your cat is spending a good amount of time in greens and low blues. You try to keep a good dose as long as possible and only decrease if a) cat goes below 50 or b) cat has all green numbers for a week.
 
Amanda & Shmee said:
My question about TR - - As you can see I have gotten one blue number since upping him on Monday to 2.25. On the tight regulation forum as well as the Tilly's Diabetes website, it says to increase by .25 if the nadir is above 200, but it doesn't say what to do if the nadir is under 200 (other than to hold the dose for 4-5 days). I assume I increase by .25, correct? And I keep increasing every 3-5 days until I see the nadir under 100 correct? At that point is when I would start to reduce by .25?
Click to expand...
From the sticky on TR:
  • Hold the dose for 3 - 5 days (6 - 10 consecutive cycles) if nadirs are less than 200 before increasing the dose by 0.25 unit.
    • if your cat is new to numbers under 200, it is recommended to hold the dose for at least 8-10 cycles before increasing.
    • when your cat starts to see nadirs under 100, hold the dose for at least 10 cycles before increasing.
  • After 3 days (6 consecutive cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
Click to expand...

I would hold it for 8-10 cycles, based on the above.

You're doing a great job home testing. One suggestion: If your schedule allows, try to vary your testing times a little. I see you've been testing at +3, +6 and +9 lately. Try getting a +4 and/or +7, +2 and/or +5, etc. Think of the spreadsheet like a jigsaw puzzle. The more pieces you fill in, the clearer the picture becomes. If you can manage to get a few more nighttime tests in, too, that would be awesome - many cats go lower at night than in the daytime. One of our veterans likes to suggest you drink a big glass of water before going to bed so you'll have to get up at some point - then you test! ;):p

I'm glad your vet is on board. Her experience with FD owners, unfortunately, is pretty typical. She sounds very sensible, but I must disagree with her about Somogyi. Here is a paper that explains why it doesn't exist in cats. https://files.acrobat.com/a/preview/12b09de3-a924-4b4e-a927-23de66b3d485 Unfortunately, as Stacy just mentioned, most vets still think it does exist. It's still be taught in vet schools today. :rolleyes:
 
Since Shmee has seen his first blue, you would hold this dose 8 cycles, unless he starts showing you some green before the end of the 8 cycles.

One clarification on the paper Tricia has linked, the paper shows it is very rare on cats that were started at a safe dose, home tested, and when following a protocol with the goals of tight regulation control.
 
Wendy&Neko said:
One clarification on the paper Tricia has linked, the paper shows it is very rare on cats that were started at a safe dose, home tested, and when following a protocol with the goals of tight regulation control.
Click to expand...
Yes, the important take-away from this document is rebound is rare in cats treated with Lantus when using a protocol aimed at tight regulation.

 
Stacy & Asia said:
Sounds like you have a really great vet! :woot: Consider yourself lucky, it's not always easy to find one as open minded about FD. Despite several published medical journal articles discounting somogyi, I've yet to find a vet who will let go of what they were taught in school about it. They have continuous glucose monitors which can prove what happens overnight with BGs and high waking glucose can be from a bounce, postprandial response or dawn phenomenon, but it certainly isn't always from a silent hypoglycemic episode at night. Oh well. I wouldn't hold it against her. ;)

So you would keep increasing under you see a green nadir and your cat is spending a good amount of time in greens and low blues. You try to keep a good dose as long as possible and only decrease if a) cat goes below 50 or b) cat has all green numbers for a week.
Click to expand...
I think there is confusion between Somogyi (dawn phenomenon) and bouncing with most vets. The vet here sounds like she is talking about bouncing but calling it Somogyi.
 
Generally speaking, the term somogyi is often used when a cat's number dive because the cat is thought to be over dose.

Bouncing is a term we've used to describe a natural reaction to what happens when the cat's system perceives as a BG value that is "too low". From the "New to the group?" sticky:

"Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles)."

 
Jill & Alex (GA) said:
Generally speaking, the term somogyi is often used when a cat's number dive because the cat is thought to be over dose.

Bouncing is a term we've used to describe a natural reaction to what happens when the cat's system perceives as a BG value that is "too low". From the "New to the group?" sticky:

"Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles)."
Click to expand...
So why do websites call Somogyi the dawn phenomenon and that it's high numbers in the morning? I find that so confusing as bouncing does the same.
 
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