high BG numbers: is Terra having a persistent rebound?

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KarenAmelia

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I could use some advice. Terra's spreadsheet attached. I took a break from testing BG for a few days after she had a low day and I thought she was on the way out. She rallied - it may have been a virus, undiagnosed, but it was emotionally draining and I needed a break from the ear pokes. Vet suggested starting her again at 1.5 unit after her bad day. After 4 cycles on 1.5, I talked with vet and he suggested increasing to 2.0 unit, saying that 1.5 was low. I've begun testing again and was startled to see 584 on today's PMPS.

Read another recent thread in which chronic rebound was mentioned. I wonder if the erratic numbers, which my vet thinks could mean that Terra isn't responding to the Lantus - (and he even suggested going to another insulin, prematurely, I think) - could be an indication of persistent rebound? How do you handle chronic rebound? Do you hold steady on a lower dose that doesn't produce a bounce even if it doesn't bring the numbers into the normal range? Do you hold steady on the higher dose that brings the numbers into the normal range for a while but produces a bounce? Does the cat's system eventually stop bouncing, or...? I've read the stickies on Lantus protocol but I did not learn answers to these questions. If a cat who's used to BG in the 400s can bounce from a drop to 200s, then how do you eventually get the numbers down to the normal range?

I dont' have enough data on the spreadsheet to make a determination at this point, but I have a hunch the 2.0 units may be too much for her. I'll do a curve tonight and see what it shows, and I know it needs a few days to settle (new dose wonkiness ) but would it be bad for her to keep her on the 2 units for a few days if she's bouncing? What if I misread "wonkiness" as a bounce when it's really not?
 
I'm sorry I can't help, but I posted a link to your thread over in the Lantus forum. Hopefully someone over there can give you some advice. Until then...hang in there!
 
hi karen!

all those crazy numbers you're seeing are a result of the dosing changes. lantus likes consistency. 12 hours apart, same dose given consecutively for several days straight. i'd just guess that all of those red and black numbers are from dose changes, or possibly bouncing from having hit low numbers. hard to know more than that without seeing more of the in-between numbers.

i like to use this metaphor - if you can think of the spreadsheet like a jigsaw puzzle, the preshot numbers are like having the edge pieces. the mid-cycle numbers fill out the picture. what we have for terra is an incomplete picture. if you have at least the preshot numbers and a mid-cycle number we'll be able to tease apart the situation and give you better advice. lantus dosing is based almost completely on whatever the lowest point is that the cat got to in the previous 6-10 cycles. we test at preshot to make sure the cat is safe to give insulin to.

if terra were mine, i would either park at 1.0 units or 1.25 units and i'd make certain to get a preshot test before every shot and a mid-cycle test. i'm having this deja vu feeling that i may have said that before to you, though. not sure. you don't need your vet to do the tests and if you do them at home you'll save yourself money and have more/better information. i understand feeling sympathetic about her ears, but i also know that this is absolutely the only way to keep a cat on insulin safe. when we see numbers all over the place, there's a good chance the numbers are going low as well. safety is always our first priority. she probably feels crappy having her bg go zinging up and down, too.

i know how hard it is. truly! i just don't know what else to tell you except what i see, and hopefully the information will be helpful to you. :YMHUG:
 
Sienne and Gabby said:
The issue of "chronic rebound" is one that has come up periodically. I've done a significant amount of research (two lit reviews using medical and veterinary databases) into the topic. The most that can convincingly be said is that the concept is at best, controversial. The original research was done in 1938. It has never been replicated in either humans or felines. I posted this in a Lantus user's condo a while 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. Some of what I quoted was specific to the question Marje was raising but it is pertinent to the issue that Venita raised.

While there is very little information about Somogyi (i.e., "chronic" rebound), what we do know is that cats will experience a bounce. This is not a chronic situation, though. To me, that is the differentiation -- bouncing vs. "chronic rebound."
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I think what you are seeing is due to a couple of things. Lantus likes consistency. Lantus is what's called a "depot" type of medication. The insuin depot is what gives Lantus its duration, overlap between doses, and it's cumulative action. When you change doses without allowing enough time for the depot to catch up, you end up with less than ideal numbers. I think the frequent dose changes are contributing to high numbers. Whether or not your are following a tight regulation protocol (the dosing protocol most people use on the Lantus board), increasing by 0.5u may be too large of an increase. When you are seeing nadirs that are under 300, we typically increase by 0.25u. We also allow any dose to settle for at least 3 days before evaluating its effectiveness.

I don't know all of Terra's history or what information others have provided. I hope this makes sense. If you've not had a chance, you may want to look at the starred sticky notes at the top of the Lantus board. The information there may give you a better feel for how the insulin is supposed to work.
 
I'll hold my questions until after I get a curve tonight. I know it's impossible to say what to do without more data. As for changing doses by .25 U, the syringe is so small I feel lucky to get a good guess on .5 increments. I have seen the photos that are posted for different markings but it is really difficult for me to read .1 or .2 increments on the syringe.
 
yeah, those syringes are teeny tiny, aren't they? some people put a magnifying glass wherever they draw up the insulin. the important thing isn't so much what the dose is, it's that you are consistent in what you give every time and you just do the best you can with trying to get something close to a .25u change. vets never tell people to adjust in that small of increments, because they don't think people can do it. but a big dose change is like hitting a fly with a 2x4 instead of a flyswatter. way overkill and giant splatters. sorry for that image! ;-) :lol:

i wouldn't have believed it but some cats are so incredibly responsive to insulin that they will have different numbers with a change of 1 drop of insulin. i know. impossible to believe. except that it happens.
 
you don't have to do a full curve, but any mid-cycle numbers will help. we usually encourage people to get one mid-cycle test in each cycle of the day. that's enough over a few days to be able to see more about what's going on.
 
Karen,
Here's something you can try - IF you can get a magnifying glass, take a used syringe, and use some food coloring to color some water. Draw the water up into the syringe past the point where you want to set your dose, and slowly squeeze out the water until you get to that spot (the .1 or .25 or whatever you are trying to fine tune too). That way, you only have to do it once and it can serve as a "template" for the next few days at that given dose. When you fill the next insulin shot syringe with the Lantus, you can use the colored water syringe as a template that you can match with the lantus dose, and you'll know it's right and consistent from one shot to the next...

Carl
 
KarenAmelia said:
As for changing doses by .25 U, the syringe is so small I feel lucky to get a good guess on .5 increments. I have seen the photos that are posted for different markings but it is really difficult for me to read .1 or .2 increments on the syringe.
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Yes! My husband was doing Akbah's shots, but when I asked him if he could give 2.5, he handed me the syringe. He is long sighted. Luckily, I get more and more short sighted every day @-) so I can see what I'm doing with 0.25 changes. But still its guesswork because there always seems to be a little bubble of air in the measuring space.
 
Also, rather than pushing the plunger, twist it. If you turn the plunger like a dial, it's much easier to fine tune a dose than when you push the plunger.
 
Just got another BG. At +5 she's at 400, and at PMPS she was at 584. I'm setting my alarm to get a test at +7.

With the syringes, there's a lot of parallax. A minute shift in your viewing angle makes a big difference in the apparent position of the plunger. That's my problem. I just opened the pack of syringes with .5 unit markings. Those will be a bit easier to work with.
 
Karen,
In one of the Lantus sticky threads, there are some great close-up pics of some syringes that show you how to get the dose "just right". I don't remember which sticky it is but I saw it earlier tonight when looking something else up.

Carl
 
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