3/23 Atlas PMPS 22, 39, +2 91 (Vet Visit)

[Beth & Atlas]

LAST KNOWN CONDO

I am posting this information for insight?

Atlas's vet has diagnosed the regulation problems as SOMOGYI EFFECT.

Well, as far as I know/learned somogyi is not a real phenomonon. But...Attie did earn a reduction tonight anyway... ohmygod_smile even with a vettie trip to discuss his dosing and management.

Dear Dr. does NOT want to change insulins, but wants to decrease dose as he has observed Attie's chart of numbers shows a particular pattern. Every 8-10 days he drops out low. Then it doesn't hold(my complaint in my last condo). He is strongly believing this indicates somogyi and the reason I can't increase the dose safely. He also took into account the entire years worth of records and is suspecting Attie's propensity for late nadirs is compounding the problem.

So we're heading back down the scale to 2.0 units and are to hold it for 3 weeks to a month . He also says that it can take 5 days or longer in some cats to fully clear the bounce hormones, not just 72 hours. He seems to think I will continue to get these oddball "low events" and I am to notify him and we'll likely drop the dose by half units or Attie starts to flatten out between 250-325. We'll discuss the results in as either low blips continue to show up or at the end of 3 weeks to determine if a new insulin is indeed the right decision.

In all the years with diabetic cats...this is the first time I've ever had one actually get diagnosed as somogyi and told to decrease the dose fairly significantly.

 

[Sienne and Gabby (GA)]

I was just thinking about you!! Below is a post from one of my posts in Gracie/Marje's condo.

The topic of Somogyi came up some time before you joined the Board. Both Jill and I did a lot of lit searching. I have access to both a medical and veterinary library system. For a theory that has so many people convinced that it is a factor in human as well as in feline diabetes, there is an amazingly small amount of research on the topic. The earliest paper by Michael Somogyi, is from the 1930s and was not published in a widely recognized medical journal (i.e., it was in the Weekly Bulletin of the St. Louis Medical Society). Note that this was a report based on 5 human subjects and urine glucose, not blood glucose was measured. More recent reports note that Somogyi's observations have not been reliably reproduced under controlled conditions.

Although some patients had a very rapid fluctuation from hypoglycaemia to hyperglycaemia, we found no evidence that changes in counterregulatory hormone levels were responsible.The preceding interval of hypoglycemia was often prolonged, which implied defective homeostasis, and the difference between the patients with apparent rebound and those without could not be explained in terms of circulating levels of cortisol, growth hormone, or glucagon. Other workers have noted very variable changes in growth-hormone and cortisol levels after acute hypoglycsemia in unstable diabetics. We did not measure catecholamines and cannot rule out the possibility that they were partly responsible for the difference between our groups. However, the evidence presented here suggests that free insulin is the major factor involved.

The bold is mine. It points out that there is no evidence for what the vet is suggesting about "stress" hormones (i.e., cortisol).

In addition to the dearth of empirical research, there is even less that pertains to cats and none that addresses Somogyi phenomenon in the use of Lantus. Given that the presence of Somogyi is believed to be associated with doses that are raised in too large of an increment, it is surprising that this IM vet would not be an enthusiastic supporter of the Queensland/Rand tight regulation protocol. (FYI - there is another TR protocol and the vet may have assumed this was the one you were referring to.)

This is a link to info on Chronic Somogyi Rebound on Wiki. I would draw your attention to the section on Controversy:

Although this theory is well known among clinicians and individuals with diabetes, there is little scientific evidence to support it. Clinical studies indicate that a high fasting glucose in the morning is more likely because the insulin given on the previous evening fails to last long enough.[5] Recent studies using continuous glucose monitoring show that a high glucose in the morning is not preceded by a low glucose during the night.[6] Furthermore, many individuals with hypoglycemic episodes during the night fail to wake due to a failure of release of epinephrine during nocturnal hypoglycemia.[7] Thus, Somogyi's theory is not assured and may be refuted.

This information pertains to humans, not cats. However, the phenomenon was based on humans and extrapolated to felines so I'm going to presume the issues with the paucity as well as quality of the research are the same.

I would love your vet to show you the empirical research on Somogyi. Most of what's out there are anecdotal reports that are not reproducible. From what I can tell, Somogyi amounts to an urban legend.

 

[Ella & Rusty & Stu(GA)]

Hi Beth and Attie,
Wow on the 22 and wow on the vet's suggestions! I hope you get some feedback. (edit: I see that Sienne just posted! good!)
Maybe a switch to Levemir would level Attie out? (but if your vet is adamant about not changing insulins, it might be difficult to get a script) (you could always take a vacation in Canada and just buy some--no prescription required in Canada).

Good luck and good weekend.

Ella & Rusty

 

[Beth & Atlas]

Sienne, you are preaching to the choir ...

Although I do understand what my vet is trying to say and is defining it as Somogyi.

I can't increase Attie's dose, his dose overall does need to go up according to the protocol. But...here I am again tonight with a 'low event.' We'll drop for a few days and it won't appear to hold and according to the protocol we should go back up..and 8-10 days we'll do back down...

Something is wrong and considering Attie's dose was down to less than 0.50 u before he got sick...

I am not going to rule out chronic overdose.

 

[Dyana]

(((Beth)))) just hugs. and skritches to Attie cat_pet_icon

.......we've been doing this a long time, too.

 

[Beth & Atlas]

Hi Beth and Attie,
Wow on the 22 and wow on the vet's suggestions! I hope you get some feedback. (edit: I see that Sienne just posted! good!)
Maybe a switch to Levemir would level Attie out? (but if your vet is adamant about not changing insulins, it might be difficult to get a script) (you could always take a vacation in Canada and just buy some--no prescription required in Canada).

Good luck and good weekend.

Ella & Rusty

Well, we're both (vet and I) more or less are on the same page to a degree. He isn't crazy about changing off of a good insulin, that we've been on for over a year.

He was talking about Attie's late nadirs into the 13th/14th hour of the cycle and that the overlap duration may be too long. Again adding a conflicting ingredient to the mix of his suspected somogyi effect. As we say when we stall and decrease the dose it compounds and if we shoot too early it is like a dose increase, he suspects shooting into Attie's overlap may be acting like that 'dose increase' too. Which if it proves out...then we need to change insulin.

Which again, all points to a dose reduction.

As he says...a few weeks to check isn't going to hurt Atlas at this time. :roll:

 

[Beth & Atlas]

Well, I've got to get some shut eye this evening.

I have two very large labs who are going to be looking for me ...very early in the morning...

I'll catch up here tomorrow.

I-) I-) I-)

 

[julie & punkin (ga)]

it all sounds very stressful, beth. a lot of the bouncy kitties have switched to lev with good results.

i hope attie settles down for you!

 

[Marje and Gracie]

Wow.....lots of interesting info on your condo.

I can only say the switch to lev has really helped Gracie...wish I had done it sooner.

Thinking of you all and watching with interest.

 

[Vyktors Mum]

As he says...a few weeks to check isn't going to hurt Atlas at this time. :roll:

No harm in trying the vet's approach to see what happens, it will be most interesting to watch (that was a please post hint :smile: ), I really hope it works for Atlas and if not then your vet will be on board with changing insulins, but if part of his problem is late nadir then maybe Levemir is not the way to go as that nadirs even later than Lantus...