Re: 8/13 Michael AMPS 295 +6 293
Hi Paula,
I wanted to answer your PM here. And no, of course I didn't mind the pm. The policy here is that people giving advice do so in public. That way, others can learn from it, or correct things if we've got some information not quite right, or add to it if needed. It just provides better quality advice to people.
Paula said:
Hi Julie,
I hope you didn't mind me Pming you, but thought you might be interested in what the Vet emailed me when i asked her why she only wanted me to give 1u if M was 300 or over. Not to give shot if below 300. This is her answer.
"The reason is to try to avoid something called the smoygi effect where they BG gets too low and then his body tries to compensate which causes a jump in the BG."
I thought maybe you might be able to understand what her thinking is; which will help me explain to her why I disagree on the dose. I don't have enough knowledge to give a logical explanation.
Thanks,
Paula( you can PM me)
Let me try to explain it as best as I can. You can ask questions to clarify anything that's confusing. I don't mind if you want to copy and email this to the vet.
There are 3 occasions when a cat might have higher blood sugar numbers but it doesn't mean that they need more insulin.
1. Chronic Rebound - this is probably what is referred to as a Somogyi Effect. Dr. Somogyi did research on a very limited number of people, i believe in the 1920's-30's, and determined that when someone is taking too much insulin the body will compensate by releasing hormones and stored sugars to keep the blood sugar high. We don't use the term Somogyi because even the definition seems to vary. We can identify chronic rebound however, when a cat has had inappropriate dose increases, either too quickly or in too big of increments. For example, it's not terribly uncommon for us to have a cat arrive here at FDMB on something like 10u of insulin and BGs solidly in the 300's or higher. If the cat started at a dose that is appropriate for its weight (1.5u per kg of lean body weight) and the dose was adjusted according to the Tight Regulation Protocol (0.25u-0.5u every 6-10 cycles), then we can suspect the cat has a high dose condition (acromegaly, cushing's disease, insulin autoantibodies.) However, if the cat was started at 5units and increased by 1u increments, we would suspect chronic rebound.
2. Bouncing - this is similar, but the difference is that the high blood sugar is the cat's natural response to a range lower than they are used to, or responding to a too-fast drop in blood sugar. Some people call this Somogyi as well.
The difference is that Bouncing is a temporary condition that lasts 72 hrs or less from an appropriate dose and Chronic Rebound is a sustained response from a too high dose.
New Dose Wonkiness, Failed Reductions & Bouncing
BOUNCING
Here is an example of a bounce from someone's recent condo:
you can spot a bounce this way (this only took me 6 months to learn and a bunch of people explaining it! i'm a slow learner!)
yesterday morning you had a 215 - then it went 235, 271, 270, and then 308 this morning - basically straight up. no curve. and then look backwards in the ss and the night before was that sweet little 148 12 hours earlier.
if you imagine that night-time cycle, starting at 148, kitty probably went down in a nice little curve, hitting something under 100 mid-cycle. that lower-than-usual number would've shocked her body. they get accustomed to whatever range they're in, and any sudden dip lower can set this off.
"HELLO WE"VE GOT A 911 HERE- KITTY'S GOING DOWN!" yells Mr. Liver. Fortunately, mr liver has a storehouse of counter-regulatory hormones and stored sugar (in case kitty needs a little nommy sweets in the middle of the night) and when Kitty gets into a range of numbers lower than usual, Mr. Liver lets loose with the sugar and the hormones and sends Kitty on a rocket to the moon. this is the cat's body's protective mechanism to keep the cat from becoming hypoglycemic. unfortunately, mr liver doesn't seem to know that anything above 40ish isn't a crisis and it will do this regardless of the range of numbers, even at 200 if the cat has become accustomed to 400.
A second cause of a bounce is if a cat drops very quickly. 100 points in an hour, for example, regardless of the range the BG number is in, can cause a bounce as well.
So, what to do now? don't increase the dose because of these higher numbers. once this bounce clears, which can take up to 3 days of high numbers if mr liver is super-active, then if you had increased the dose, it would be too high. you are entering the phase of treatment that we say requires "Patience Pants." when you think you're seeing a bounce, you have to wait it out, then you can see what the dose really does. You will know the bounce has cleared when you start seeing numbers you were seeing before - like that 148 again.
3. New Dose Wonkiness.
Same link as above
Jill & Alex said:
The Tight Regulation Protocol with Lantus or Levemir describes what we've fondly dubbed "New Dose Wonkiness" (
NDW) here in LL:
"Many cats will occasionally react to an increased dose with increased BGs - within the first 2 to 3 days after an increase, usually lasting for less than 24 hours. Nobody really knows what the reason for this phenomenon is (perhaps a "panicky liver"?) - hold the dose and ignore the fluctuations."
The concept of "
New
Dose
Wonkiness" is
NOT applied to higher numbers which may be seen
after a dose reduction.
There is no "NDW" following a dose reduction nor do we hold a reduced dose 6 cycles (as done with dose increases) to "fill the insulin depot".
"Settling time" does not apply to dose reductions. We don't wait for a reduction to "settle".
When you see numbers trending higher after a dose reduction we immediately return to the last "good" dose as described in the
The Tight Regulation Protocol with Lantus or Levemir:
"If the cat will not stay in the normal range after a reduction, immediately increase the dose again to the last good dose."
Hope this helps...
Web MD - Dawn Phenomenon & Somogyi Effect
For people taking insulin for diabetes, blood sugar levels are often elevated in the morning. This is likely caused by inadequate amounts of NPH/Lente insulin before dinner or at bedtime. High morning blood sugar is referred to as either the dawn phenomenon or the Somogyi effect.
Dawn phenomenon. The dawn phenomenon is the end result of a combination of natural body changes that occur during the sleep cycle and can be explained as follows. Between 3 and 8 a.m., your body starts to increase the amounts of counter-regulatory hormones (growth hormone, cortisol, and catecholamines). These hormones work against insulin's action to drop blood sugars. The increased release of these hormones, at a time when bedtime insulin is wearing out, results in an increase in blood sugars. These combined events cause your body's blood sugar levels to rise in the morning.
Somogyi effect. This condition is named after the doctor who first wrote about it. It is also called "rebound hyperglycemia." Although the cascade of events and end result -- high blood sugar levels in the morning -- is the same as in the dawn phenomenon, the cause is more "man-made" in the Somogyi effect (a result of poor diabetes management). The term refers to pattern of high morning sugars preceded by an episode of hypoglycemia (usually with no symptoms, but night sweats can be a sign). Your blood sugar may drop too low in the middle of the night, so your body counters by releasing hormones to raise the sugar levels. This could happen if you took too much insulin earlier or if you did not have enough of a bedtime snack.
The thing that I would emphasize is that because we are testing at home, these circumstances are readily visible to people who are experienced with feline diabetes. If a cat is following the Rand/Roomp Tight Regulation Protocol, started at an appropriate dose, including hometesting and feeding low carb canned food only, you don't have to worry about being overdosed.
What we know from a lot of collective years of experience, is that the way to get a cat to stop bouncing, reacting to normal numbers as though they are hypoglycemic, is to keep putting them into normal numbers (50-120 on human glucometers) so that they will "remember" that these are normal healthy numbers. Cats will, in fact, stop bouncing most of the time. Some don't, and will bounce their way all the way into remission, but many will stop bouncing. Lantus works best at lower numbers, which is why we encourage shooting the regular dose into normal numbers, as long as a person is monitoring. The process of working off of insulin and becoming diet-controlled includes this step.
Here is a discussion on
Shooting Low that includes some spreadsheets of cats who have recently gone off of insulin and become diet-controlled. You can look for the transition in the cycle that happens when a cat gets the full dose of insulin (that was appropriately worked up to, according to the TR Protocol) into a preshot that is green (100 or less).
I would encourage your vet to look at
Tight Regulation Protocol, especially the link about 5 paragraphs down from the top of this page to the PDF that is called "Management of Diabetic Cats Using Long-Lasting Insulins." That is the only treatment protocol for diabetic cats that has been published in a professional veterinary journal. That is the guideline that we follow here at FDMB in the Lantus/Levemir Tight Regulation Protocol Insulin Support Group.
The disadvantage to shooting only if your cat is over 300, is that you are likely encouraging larger drops in blood sugar and it actually encourages bouncing, rather than eliminating it. Shooting progressively lower numbers will keep a cat under renal threshold (the threshold where the kidneys can no longer deal with the blood sugar and damage begins to them) and protects the rest of the cat's body from the ravages of high blood sugar.
Lantus also works best when the dose is given consistently, most of the time every 12 hrs. when you change doses or skip doses, you can cause wonky numbers while the Lantus depot readjusts to the dose changes. Understanding that Lantus is a depot insulin, and it works differently than the previous generation of insulins is really important. Lantus dosing is based upon how low a dose gets the cat's blood sugar to, with little weight given to how high the preshot is. That style of dosing was more appropriate with the older type of insulins, not the long-lasting Lantus/Levemir types.
ok - I've written a small book here. *whew*
Please let me know how I can clarify!
Julie
