need Lantus input from the pros

[3cats]

I posted a few weeks ago on the general board about having problems getting my cat, Fred, regulated on Lantus. (viewtopic.php?f=28&t=64927) He started on Lantus 1/9 , got up to 4 U bid and then reduced to 3.5 U bid and at around 8 weeks was not getting any significant reductions in glucose (note I was not home testing, so all I had were weekly, random #s). I've been reducing his dose to rule-out rebound/Somogyi and just starting home testing with any regularity about a week ago (still not a pro at it like some of you - so, sorry I don't have all the numbers to fill-in on a spreadsheet).

There is kind of a pattern of cycles where 1 shot appears to have little or no effect and then the next shot works better; the pattern is also that he goes lower within the 1st 4 hours of the shot and is climbing back up the rest of the day (which seems odd because he eats near the time of shot which should raise the glucose and because Lantus is not supposed to have a peak effect like that). (For example, yesterday he had a drastic drop after a.m. shot 578 to 279 in 4 hours, then today's a.m. shot is not having much effect; and on 3/9 the a.m. shot basically had no effect and then after the p.m. shot, he went from >600 to 282 in 8 hours.) Could it be that his body fights it when the levels drop so drastically/quickly causing it to dump glucose to get the numbers higher and then he is insulin-resistant for at least a cycle (like the Somogyi effect) (and if so, does that mean he is on too much insulin) OR is that just evidence of diabetic insulin-resistance and the fluctuations are from his body working in spurts OR is something else going on?

3/1 @ 3 U bid
451 amps
369 +4
593 pmps

3/2 @ 3 U bid
595 amps

3/3 @ 3 U bid
>600 amps+5.5

3/4 @ 3 U bid
547 amps

3/5 @ 3 U bid
567 amps
552 +2
>600 +8
___(start reducing dose to rule out rebound)

3/6 @ 2.5 U bid
>600 amps
509 +2.5
551 +6.5

3/7 @ 2.25 U bid (may have only given .25 for pm (fur shot)
>600 amps
482 +10.5

3/8 @ 2 U bid
562 pmps+9 (4 am)
578 amps+4
448 +10.5

3/9 @ 2 U bid
555 amps
550 +4
587 +6.5
534 +6
>600 pmps

3/10 @ 2 U bid
282 pmps+8 (3 am)
560 amps
460 +4
477 +8
500 +10
* (pm shot given 15 min’s early to help account for time change next am)

3/11 @ 2 U bid
456 pmps+8 (3 am)
578 amps *(gave 45 min’s early due to time change)
279 +4
382 +6
481 +10.5
476 pmps+3.5

3/12 @ 2 U bid
509 amps
458 +3

(Additional Info: Fred is 15 lbs. He eats after his a.m. shot and an hour or so before his p.m. shot; each meal, he eats about 1.5 oz. chicken baby food, 2 oz. FF chicken classic with 1 oz. added water and occassionaly gets a bite of Purina DM dry from other cat's bowl; he sometimes eats another 1-2 oz. of FF later in the morning. No increased water in-take at this time (he did have it early-on), no increased urine, no keytones in urine tested yesterday.)

Adding Spreadsheet.

 

[Ann & Tess GA]

Hi, not too many on the board right now. We'll try to keep you bounced up until the evening traffic starts.

Have you read through all the stickies at the top of the board? I know there is a lot, but there is important info there.

A few things to consider:

He eats after his a.m. shot and an hour or so before his p.m. shot

We try to take food away 2 hours before shot time. We want a BG reading w/ no food influence and it takes about 2 hours to get things settled.

just starting home testing with any regularity about a week ago (still not a pro at it like some of you - so, sorry I don't have all the numbers to fill-in on a spreadsheet).

You have plenty of numbers to get a SS started. It really helps to look at the overall picture. We always get a preshot test to be sure numbers are not too low to shoot. At least one test during the cycle is needed to determine the nadir. You don't need to do as many as some of us do and it doesn't need to be at the same time either. Another good test to get in is 1 or 2 hours before the shot. That way when you do the preshot test you can see where the numbers are heading, up or down.

I've been reducing his dose to rule-out rebound/Somogyi

Lantus dose changes need to be held for 6 cycles in order for the shed to fill or drain depending on which way you were going. So you are unlikely to have really accurate results during those periods. Every time you change it the countdown starts over. You were changing the dose every 2 or 3 cycles.

Could it be that his body fights it when the levels drop so drastically/quickly causing it to dump glucose to get the numbers higher and then he is insulin-resistant for at least a cycle

Yes, cats do bounce from sudden changes in BG or just going lower than their body is used to, it doesn't need to be extremely low. The liver senses levels it is not accustomed to and releases a form of glucose and hormones to protect the brain from hypo, even though the numbers may not be that low. They gradually get used to being in healthier numbers.

Hang in there others will be along soon. In the meantime, do try to setup you SS.

 

[Marje and Gracie]

Good morning!! Ann has given you some very good information. We also appreciate the numbers but it would help us immensely to see the "patterns" (because we like to look at cycles as waves of action) if you could please do a spreadsheet. The link on how to create a spreadsheet and link it to your signature block is here: Spreadsheet. This is an invaluable tool for you but also for us in helping you to identify what might be happening.

Just so you know, Somogyi has not been specifically identified, scientifically, as occuring in cats. Somogyi is due to a chronic overdose of insulin. What Ann indicated and is true is that your kitty is probably going lower than his liver is used to. And yes...as she said, this causes a dump of counterregulatory hormones and glycogen into the system. Unlike Somogyi where you would take the dose down, we tend to not do that for bouncing unless we actually see tests that show the cat has gone below 50 (for a newly diagnosed cat).

As cats stay in high numbers like this, the liver gets used to it so any number that is lower....even a number in the 200s, can trigger the liver response. We call this "liver training school" and almost all cats do it to some degree at first. The important part is to get mid-cycle tests so we can see how low kitty is going to trigger the bounce. Bounces can take up to 72 hours or six cycles to clear but not all do...every cat is different (ECID). Once we see the bounce clearing, we can determine if a dose increase (dosecrease) is warranted.

Could we please get your name? Please let us know what other questions you have but we sure would appreciate the SS Thank you.

 

[3cats]

Ann & Tess, I am working on getting a spreadsheet up now. If you notice, I don't do a pmps because of the timing of his dinner - I try to get a reading just before feeding dinner (usually between +10 & +11). I have 3 cats and they demand dinner at their usual time, so I'm trying to work around it.

 

[Marje and Gracie]

You absolutely must get a PMPS test. Some cats will drop lower between +10 and PMPS; my own cat is an example. She might drop as much as 70 mg/dl between +10 and PMPS. One our our requirements for this protocol is that you always test prior to giving insulin because you have no idea what the kitty has done. You should test/feed/shoot all in about 10 minutes. Would you give insulin to your child without first making sure what his/her BG is?

I also have three cats....they all adjusted their schedules to Gracie's feeding time at AMPS/PMPS and they are doing fine.

 

[3cats]

You absolutely must get a PMPS test. Some cats will drop lower between +10 and PMPS; my own cat is an example. She might drop as much as 70 mg/dl between +10 and PMPS. One our our requirements for this protocol is that you always test prior to giving insulin because you have no idea what the kitty has done. You should test/feed/shoot all in about 10 minutes. Would you give insulin to your child without first making sure what his/her BG is?
I also have three cats....they all adjusted their schedules to Gracie's feeding time at AMPS/PMPS and they are doing fine.

I tried moving their dinner time and it wound-up that they were all essentially eating twice (having to add a snack late in the afternoon). I'm not on the Tight Lantus protocol (yet anyway), just seeking some expert advice. His numbers are so high, I'm not really worried about him dropping to hypo. - I'd be happy to just have him in the 300s at this point. If/when he gets some lower numbers I will definitely have to change shot times and/or feeding times.

 

[3cats]

I've added spreadsheet to my signature. Thanks everyone (special thanks to "Gayle Shadoe & Oliver" for helping with the spreadsheet).

 

[Sienne and Gabby (GA)]

I have to say I agree with Marje about food and your pre-shot test. If you can begin to transition now when numbers may not be low, your cat will be better prepared once numbers are in a better range.

I also think I may have posted in your Health thread about Somogyi. This is a controversial concept, at best. More realistically, none of the research has been replicated -- it was human research and none of the research is applicable to long-acting insulin, like Lantus. That said, Fred's numbers look like he needs more insulin, not less. However, it would be very helpful if you could get at least one test during the PM cycle. Many cats experience lower numbers at night. Without testing during the PM cycle, you're missing half of your data.

 

[3cats]

Basically, isn't "Somgyi" the same thing members here are calling a "nervous liver??" These excerpts from an article summarize what I have read in various journals, etc.:

"Somogyi rebound aka "Somogyi's phenomenon" is a common phenomenon in pet diabetes: When blood sugar levels drop too far or too fast, the animal will defensively dump stored glucose from the liver into their bloodstream, resulting in high blood sugar."

"Too little insulin means pre-shot blood tests are too high; too much insulin often also means pre-shots are too high. This effect is often noted by those who test their pets' blood glucose at home. It means that even when blood glucose levels are too high, simply raising insulin dosage can make things worse instead of better."

"The reason: Anytime the glucose level drops too far or too fast, the cat or dog may defensively dump glucose into the blood by breaking down glycogen from the liver. Hormones epinephrine and cortisol, as well as growth hormone and glucagon, causing temporary insulin-resistance, will also be released into the bloodstream. (If these are insufficient, hypoglycemia ensues!) The pet may be a bit less responsive to the same dose the next shot, from those other hormones. Repeating the overdose on subsequent days, and checking only pre-shot readings or urine glucose, can give the dangerously wrong impression that more insulin is needed! Remember to check occasionally at the expected nadir (low point) as well. Repeated overdose with long-acting insulins can even cause high, flat numbers all day long."

 

[Marje and Gracie]

Sienne addressed this for me when we were new. Here are her comments (btw...she has a medical library at her disposal and is very versed in conducting medical research):

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, 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.

With the little testing when he was on a higher dose, I "wonder" if his numbers were better. It's impossible to know. I"m not sure why you decreased his dose without more testing to see if he really needed a reduction. I am not comfortable making a dosing suggestion without the PMPS. It's a very important number, and granted, it could be a high number. But we have a few cats in Lantus TR ISG forum (Atlas) who often nadir at +12.

 

[3cats]

Thanks for the info. - I have read a lot of literature on the issue and agree that it is confounding.

I decreased his dose because the vet and I agreed that the higher dose he was on wasn't working correctly based on the (albiet limited) numbers we had. A decision had to be made to either go higher or lower, and lower seemed like the safer choice. He does seem to be doing better on the lower dose and not bouncing as high as he was. I guess time will tell. (Obviously, individual cats differ - my other cat became diabetic, took Lantus for 4 1/2 weeks without any (noticeable) issues, went into remission and is still doing great 3 years later.)

 

[julie & punkin (ga)]

there are also conditions that cats can have that cause a need for more insulin. my cat has one - acromegaly.

i'm running out the door, but wanted to throw that out there. we can identify a high dose needs cat over time. as you get more tests in, we'll be able to help you with it.

great job getting your spreadsheet up! hang in there and we'll try to help you unravel the puzzle.

 

[Blue]

I have 2 cats with acromegaly, one also has IAA.

Fred's numbers look very similar to my own cat's, and I was told by some on this board to take my Oliver all the way down to 1u to rule out overdosing and 'Somogyi'. His issue was neither, but dropping down needed to be done to prove to others.

You will need to be diligent in testing for ketones as you work your way back up from the lowered dose.

 

[julie & punkin (ga)]

home again and wanted to get back to you.

ann made a really good point about making sure that Fred isn't eating in the couple of hours before his shot. most of us give none or almost no food in the second half of each cycle. that lets the carbs be there when the lantus is at its most effective. i feed punkin starting with his shot and through the first 3 hours after each shot. then no food except boiled chicken treats for pokes until the next shot time.

some cats might not need it so strictly, but since you don't know exactly what's going on with fred, whether he's getting too much or not enough insulin, this is an excellent first place to start. it doesn't cost anything - it's just rearranging what you're already doing.

it's not a matter of what protocol, or even if you are following any protocol, it's just about how lantus works. we know from experience that is how to be able to see what it's doing in fred's body.

i'd like to suggest you start with that, continue with the same dose, and try to get a couple of +2 checks after both the morning and the evening shots. the reason we like to see evening cycle tests is because many, many cats have lower numbers in the evening cycle, for some reason. overall your testing is awesome! you're getting plenty of tests in overall, i just want to see what is happening at some different times.

if you can post every day we can help you get this figured out better and tell you what tests would be helpful, or let you know if we have any questions.

what do you think? can you do this?

regarding the rebound question - i think if you can try doing the above, whatever is going on will become obvious.

putting on our detective hats and pulling out our magnifying glasses to peek at Fred.