5/30 Tiggy prelim vet report

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Wendy&Tiggy(GA)

Wendy&Tiggy(GA)

Member Since 2011
Previous condo

Initial bloodwork was normal with fructosamine in the normal range - showing excellent control. Vet was surprised by that. I wasnt because all the dose increases have been controlling him best I can. Said Tiggy needed to drink more water though.

No evidence of a UTI although the culture isnt back yet- he thinks it will be clear.

Vet asked again if Tiggy was eating or drinking excessively.. any idea what his thoughts are here?

Also Tiggy was acting super weird last night but I wonder if it was the vet visit that did it. He literally sat in the lower hall and howled for a few hours almost non stop. I went down and checked on him a few times and he stopped when he saw me just looked back as if to say "what". I tested his BG to be sure nothing unusual was going on. He went back to yowling as soon as my head hit the pillow. Didnt eat much either overnight which is odd. This morning he also didnt greet me when I got out of bed - was lying on the living room floor instead.also odd. Anyway I am in the office today so I will call my DH later to see if he is still acting odd.

Wendy

PS I got a sneaky feeling this is going to be a $700+ "inconclusive" suite of tests again....
 
I am very surprised that a fruc test would show he was in excellent control. I'm surprised, too, that you would have one done...you have much better data.

Did he check his thyroid levels....minimum fT4 and tT4. Tiggys BGs aren't high enough that he should be PU/PD from that but if the vet is asking that question, I wonder if he is thinking thyroid? Yowling is a symptom of hyperT but you said Tiggy isn't PU/PD?

Did he do the acro/IAA tests?
 
I am very surprised that a fruc test would show he was in excellent control. I'm surprised, too, that you would have one done...you have much better data.
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well maybe with his blues and greens every second day it averages out as good? The test was part of a package deal thing or i wouldnt have bothered.

Did he check his thyroid levels....minimum fT4 and tT4. Tiggys BGs aren't high enough that he should be PU/PD from that but if the vet is asking that question, I wonder if he is thinking thyroid?
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I dont know. I sent him an email

Yowling is a symptom of hyperT but you said Tiggy isn't PU/PD?
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he drinks a bit more when his BG is high but then goes back to normal when its normal. He doesnt normally yowl except when he is carrying around his toy lion but with his lack of energy the last month or so, he hasnt been doing that. Plus he put on 0.8lb.. didnt lose it.
 
vet just emailed me with an odd question "Are you just basing the dose increases solely on his blood glucose levels?"

wonder where he is going with this..
 
He may be thinking pre-shot vs nadir and not understand the TR protocol.

Another possibilirt is cognitive dysfunction syndrome.
 
Wendy&Tiggy said:
vet just emailed me with an odd question "Are you just basing the dose increases solely on his blood glucose levels?"

wonder where he is going with this..
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Of course you base it on nadirs not simply blood glucose levels. Important distinction.

What was the actual fructosamine reading?
 
I got a response from the vet - see below. Any idea how I answer this???

The issue here is that these clinical signs can be a sign of low blood sugar. Giving more insulin when you see a spike can cause the insulin to drop very low and then spike high as the liver releases sugar to maintain a minimum sugar level,. You wold see this spike and think not enough insulin so increase.. This simply causing more dips and spikes.. It's called symogi effect. We usually base an insulin increase on clinical signs: increase drinking, thirst, polyphagia weight loss. Lets wait on all test before making any more insulin changes..
 
Show the testing logs and the protocol. If he's not going too low and he's not up into the blacks ever, then I don't think he's in Somogyi. And you aren't knee-jerk upping the dose in response to spikes.
 
I don't think he is either but I need to find a way to explain that to him. I emailed him the protocol and even handed him a printed copy yesterday.
 
Take out some graph paper. Use a week or two of data. With AM & PM time along the X axis, you might plot several days using different colors, or just put the data points on showing that it isn't going too high, ever. (because you know what you are doing!!!!)
 
I told him Tiggy wasn't going too high or too low but he still thinks tiggys "pattern" of lows followed by highs and being independent of shot time (no normal lantus curve ever) are indicative of somogyi. I don't think he can distinguish between somogyi and a very bouncy boy. To him bounce = somogyi.

Do we have any reports or anything that spell it out and ezplain why a bounce isn't somogyi?
 
About the only thing that is likely to prove it is to back off the dose long enough to show the numbers go higher. If you decrease the dose by 0.25, it should show up pretty quickly as higher average numbers if he's wrong. Just be on alert for ketones, and document water and food consumption.
 
First, you are the one holding the syringe. You can politely nod and say, "Thank you." to the vet and do what you know is right for Tiggy and what you're comfortable with.

Second, (climbing on to soapbox) ask your vet if he can provide you with the citations for the empirical research on Somogyi. Not opion pieces and not a paragraph out of a text book. Ask for research papers that have been published in reputable vet journals. Thee is not any convincing research. I posted this in Gracie/Marje's condo about 2.5 years ago:
Sienne and Gabby said:
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.

Gale said:
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.
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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.
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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.
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Your vet is doing what a lot of people do -- not distinguishing between a bounce and chronic Somogyi rebound. (Stepping down off of soapbox)
 
Got a response from the vet... Looks like he is moving away from the somogyi theory?

It is generally accepted that we do not want to achieve normal blood sugar level in diabetic cats (50-130) as it leaves to little room for error. The minimum safe level would be somewhere around 90-100 with max value in the 250-275 range. Cats will tolerate a higher level than dogs without side effects such as diabetic neuropathy. That being said if we then use a range of 100-250 for " acceptable or well controlled then go back to the graph.

Using these guidelines anything in the green is too low. Blue would be the absolute minimum we would want to see. Yellow would be ok if it stays below our max of 250. The occasional spike of blood sugar above 250-275 is not a big deal as long as it is not staying there for days at a time.

Go back and look and look at Jan 8-10. At 4.75 units we had far more blues than yellows. When the insulin was increased to 5 units on Jan 14 we started to see more yellows. Sometimes we miss a low green (remember all greens are two low) and these will lead to a higher than normal yellow. As the amount of insulin given was increased the number of greens increased ( not good) as did the number of yellows that would be outside of our range for max (250-275).

I would still wait until the bloodwork is back but consider the above. My thought would be to decrease his insulin by to 6.5 units and leave him there for a week at least. Give him 4-5 days before measuring a blood sugar ( each time he sees you coming with a needle he gets stressed and maybe his blood sugar goes up alittle). If you plot his sugars we may find more blues and yellows that keep us in the 100-250 range. Use clinical signs ( starving, increased drinking and urinating weight loss as a guide) and resist the temptation to make any changes to his insulin based on one or two blood glucose levels.
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I know I hold the syringe. I am going to ignore this and keep Tiggy going at least until the bloodwork is back. If he isnt IAA or acro then maybe all bets are off and I will give his theory a go.

All the same though I would love your thoughts on what he just said.. so I can reply sensibly! This is a great opportunity for "educate a vet"!

Wendy
 
I know this may be picky, but "generally accepted" by who? Where's his research evidence? How does this relate to cats that go into remission? I don't think what he's saying necessarily makes sense. I suspect he's thinking in terms of a cat where remission isn't a goal. Even with tight regulation on Lantus, numbers in the greens are safe IF you are home testing. I suspect your vet is more familiar with insulin other than Lantus and that most of the caregivers seen in his practice don't home test.
 
wow - then what do I do about Maui - she has been green the past four years and sits around 70 most of that time..... :o - does this mean she's in danger and I don't know it! :o nailbite_smile


sorry, just had to say it..... :-D
 
And what about Oliver who tested positive for acro and IAA but he's off insulin and gets lots of greens?

If you are dosing and getting the majority of the time in 50-150 all the time, just like a cat getting no insulin, the fructosamine test would give a nice low number meaning the cat is well regulated..... I don't think your vet knows anything specific, so I hope you have the IGF-1 and IAA tests getting done now.
If the vet has the link to your ss, let the vet watch how well you manage the BG with insulin... the vet may learn alot from your actions and decisions. Your test numbers should help him to get other clients to test and get good results like you.

I am not really accustomed to any of the vets that saw Shadoe and Oliver telling me what to do in the way of dosing, but I never asked them. Instead, I informed them what I was doing and why.... kept them in the loop so they were OK.

Gayle
 
Glad he's backing off Somogyi.

Somogyi, whether one believes it exists or not (and I agree with Sienne), is indicative of a chronic overdose which causes very low numbers followed by high spikes. When faced with that Somogyi response, I ask how they explain a cat that bounces off blue numbers or a quick drop which does not result in a low number.
 
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