7/3 Papaya AMPS=540 +5=238 New vet

[Amy & Papaya (GA)]

Papaya's condo for May 31, sorry it's been a while!! Today's an icky high day after a week of mostly blues and greens.

Okay sorry a long time since I posted. Progress is slow so there hasn't been much to say . . . but there is progress. So this is a long post to catch up on everything.

Since June 1 I've switched to feeding Papaya at PS, +1.5 and +3 with the balance as a before-bed snack or during the day if she'll eat it (but she usually won't if I'm not home). There were no dramatic improvements, but I think the +3 feeding is helping to level things out a bit. Over the last 10 days I have been seeing more yellow/blue/green preshots, actually had to stall three times in the morning when her BG was unusually low, and it's been below 50 a number of times so I am trying a decrease. We've been going back and forth between 2 and 2.25 units since January :roll: She always has a good appetite and is pretty purry and cuddly, so I'm trying to not stress too much about the roller coaster numbers because she's feeling reasonably well most of the time.

I'm also happy to see that even though Papaya is still walking very awkwardly on her hocks, she is more determined to walk around on her own and a bit more stable. A couple months ago she was about as moblile as a throw pillow, and I was carrying her to the litter and then back to the couch or bed. A few times the poor thing actually sort of fell on her face stepping out of the litter. Now she protests if I pick her up and instead stomps off on her own, and has been moving around to different parts of the room or bed just because she wants to, not because she has to go to the litter. She'll even get up and walk slowly to me across the room if she sees me holding her brush. So hopefully that's the methyl-B12 starting to kick in.

So why I really had to post today was that Papaya had a scheduled check-up with the vet, but the tech phoned yesterday to let me know that the vet I like has left for another city! The other vet at the practice is really clueless about feline diabetes and we just about ended up in a shouting match the one time Papaya and I saw him! So I opted to try the new vet who has just been hired there. I kind of had to chuckle to myself, he had to get a tech to help him with the glucometer - I thought maybe I should offer to do it for him? Then he jabbed some giant vein in Papaya's ear to get blood which has left an awful looking bruise . . . BUT I think he'll do fine . . .

because when he was looking at all Papaya's spreadsheets trying to figure out why she is so unstable (his first question was whether she was eating regularly, I guess some of the low numbers worried him), I said "I know not all vets believe in rebound, but . . ." and he jumped in to agree and to explain Somogyi! Hooray, the vet I didn't like laughed in my face when I suggested that was the reason for some of the high numbers, and even the vet I did like didn't really believe it wasn't just because she wasn't getting enough insulin. So maybe this guy is more up to date. He really wants me to do a full curve, I think he worries I'm missing some low numbers? Quite possible I guess so I'll do a full curve one of these days to make him happy. I showed him the food charts to explain why what I'm feeding is as good as their prescription food, and he agreed Fancy Feast is cheaper anyway so why not go with it.

Also even though I've cut Papaya's food back by 1/4 to 1/2 can a day, she has gained weight. The vet thought that was positive, since she's obviously making better use of the food. I think the only challenge is going to be understanding each other's accents - I kept having to ask him to repeat himself, and from something he asked on the way out that I'd already mentioned earlier maybe he doesn't understand me too well either. So I'll have to make an extra effort to make sure we're both on the same page, but overall I think he'll be good to work with, which is a relief.

Phew, it's into hot summer so Papapa and I are both sitting on the bare hardwood today (no A/C). Keep cool, everyone!

 

[Marje and Gracie]

Re: 7/3 Papaya AMPS=540 +5=238 New vet, understands Somogyi!

Hi Amy

Actually, I'm not a believer that Somogyi exists in cats. Somogyi and bouncing are two entirely different things. The concept of Somogyi is based upon a chronic overdose. Bouncing is the livers response to any lower number or a fast drop in BG but the BG doesn't have to go really low for bouncing to occur.

Here is some great info from Sienne on Somogyi:

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, EA., et al., Lancet, 1980, pp 279-282, In search of the Somogyi effect wrote:
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.

 

[Sienne and Gabby (GA)]

Re: 7/3 Papaya AMPS=540 +5=238 New vet, understands Somogyi!

Papaya certainly likes to bounce. I want to do some thinking about Papaya's SS and see if I can get a few other experienced eyes t0 take a look, as well.

 

[Amy & Papaya (GA)]

I wasn't trying to start a Somogyi debate. I just meant that no vet I have run into yet will even consider the idea that Papaya's numbers go crazy-high BECAUSE they went low. All I hear on this board is bounce, bounce, bounce to explain high numbers but the concept seems to be scoffed at by a lot of vets.

Any ideas are appreciated, Sienne. Papaya has been on insulin quite a while and you would think things would have stabilized a bit by now.

 

[Amy & Papaya (GA)]

And just to add to the "whole cat" report, Papaya's fur is lovely. My dad can't get over how good she looks. I think when people know she's diabetic they expect to see some miserable-looking creature, but she is shiny and no dandruff or excess shedding. It's just her legs that are really weak.

 

[Sienne and Gabby (GA)]

I notice a change in the texture of Gabby's coat when she's in low blues and greens!

One thing that I want to remind you of is if you are going to hold the dose for 3 drops between 40 - 50, that's fine. However, if Papaya drops below 40, it's an automatic reduction. It looks like you didn't reduce after Papaya tested at 38.

What %-carb food are you giving Papaya? If you're still feeding the FF, I wonder if using a food that's slightly higher in carbs may flatten things out a bit.

 

[Marje and Gracie]

Amy

I wasn't trying to start a debate on Somogyi. I wasn't aware you had been given info.

What I would like to do is to add on to Sienne's observations in order to help Papaya.

Yes, Papaya is a bouncy little girl. While you cannot stop the bouncing....her body must do this...you can help her minimize it to some extent.

First, I would get a +2 test every single cycle that you can. Part of the reason Papaya is bouncing so high is because she is diving.
5/5 a.m. cycle has a pretty good drop from AMPS 382 to +5 36
5/13 a.m. cycle drop 360 to 90 at +4

If you do the +2 test and her BG is similar to the preshot, it's likely to be a normal, active Lantus cycle. If the +2 is much less then the PS, it's likely to be a very active cycle with a possible early drop.

If you feed a higher low carb food, as Sienne suggested, it could help you slow down those dives early in the cycle.

Manage the curve with food----> flatten the curve------> adjust the dose, if necessary

Second, if she is dropping into low green you should be feeding the curve and testing until she has rising numbers with no food influence.
6/13 p.m. cycle she had a decent drop and you quit testing; she could have gone lower.
6/14 p.m. cycle, same thing but she got into the 40s and bounced up into the 400s which tells me she "might" have gone lower.
6/26 p.m. cycle she dropped to 50, no further tests, and she was 596 at AMPS. How low did she go? 40? 30? 20?
6/31 she dropped to 41 but no further tests until PMPS

Third, I would get spot checks every single cycle. Papaya has shown you she can drop from the 300s to the 40s in one cycle (6/14, 6/22).

Fourth, I think if you really tried to get Papaya either on the TR protocol or the Start Low Go Slow Approach, you might see her doing better. I don't think you are using this insulin to its maximum potential to benefit Papaya. I wonder if perhaps a insulin like Prozinc or PZI, if you can get it compounded, would provide you with better results.