Info NEW!!! Chronic Somogyi Rebound: Myths and Facts

[Marje and Gracie]

The term to describe a specific pattern of hyperglycemia, chronic Somogyi rebound, first appeared in 1938 and was named after Michael Somogyi. It was based on a very small sample of humans where urine glucose was measured. The “research” (loosely termed) appeared in a local St. Louis medical publication - not a major medical journal. The results have never been replicated and have been contested in recent years. Even though chronic Somogyi rebound has not been better documented even in humans, doctors often advise patients to decrease the dose to alleviate the issue.

Consequently, the entire idea of Somogyi in humans is controversial. An article in Wiki provides a relevant summary as it relates to humans. The conclusion states:

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.

Raskin (1984) stated, “The failure of the Somogyi phenomenon to occur puts insulin-dependent diabetic patients at increased risk to potential lethal consequences of nocturnal hypoglycemia.”

Most recently, a discussion by medical professionals, Reyhanoglu and Rehman, 2023, regarding Somogyi in humans states:

Somogyi proposed that when blood glucose levels drop too low during the late evening, activation of counterregulatory hormones such as adrenaline, corticosteroids, growth hormone, and glucagon may be observed, leading to activation of gluconeogenesis and resultant hyperglycemia in the early morning.

However, more recent studies involving continuous glucose monitoring (CGM) have disputed this theory. Also, clinicians have observed that patients with early morning hyperglycemia tend to have high blood glucose measurements at night rather than low. As a result, the debate continues in the scientific community regarding Somogyi's theory. Moreover, recently proposed mechanisms of morning hyperglycemia include nocturnal growth hormone secretion, hypoinsulinemia, and insulin resistance associated with metabolic syndrome.

With cats, there has been little research and only recently has it been done with the longer duration insulins like Lantus or Levemir. However, veterinarians often advise clients their cat is in chronic Somogyi rebound when the cat is just bouncing off a low number or a fast drop in the blood glucose (BG). These veterinarians then recommend the dose be lowered.

In the FDMB, we have repeatedly found that lowering the dose, when the cat has not actually earned a reduction per the regulation method being followed, results in the cat staying in high BG numbers, wasting time while going back up the dosing ladder, and increasing the potential for glucose toxicity.

Roomp and Rand (2015 and 2017) concluded, after a study of glucose curves in 55 cats:

In summary, in humans, the frequent occurrence of the Somogyi effect has been refuted, and in a study of glargine-treated diabetic cats, blood glucose curves consistent with insulin-induced rebound hyperglycemia were very rare, despite the frequent occurrence of biochemical hypoglycemia. It is important to recognize that the fluctuations of blood glucose concentration occur commonly in the first weeks, and more rarely months, following the initiation of treatment with glargine, and can be mistaken for the Somogyi effect. However, these fluctuations generally resolve with time using consistent dosing.

Further, as long as the caregiver (CG) is systematically increasing (and reducing, when required) the dose according to the method of regulation being used, giving too much insulin is avoided.

In summary, chronic Somogyi rebound, as previously stated is a term used to describe hyperglycemia in the morning after hypoglycemia the night before. Often this was attributed to a chronic overdose of insulin and the recommendation was for the insulin dose to be decreased. As this document has shown, current evidence indicates chronic Somogyi rebound does not exist.

Many new members ask what the difference is, then, between chronic Somogyi rebound and what we call “bouncing” in the FDMB.

Bouncing, as we use the term in the FDMB, is the increase in the BG due to a fast drop of the BG (this does not have to be a fast drop from high to low numbers) or a drop to a lower BG than the cat’s body is accustomed. This also does not have to be a drop to a hypoglycemic BG. Many cats will bounce, initially, when the BG drops, for example, from 300 to 150 over the course of a cycle. The cat’s body has become accustomed to higher BGs and the BG of 150, in this example, causes the liver to release counterregulatory hormones and glucagon to raise the BG back to what it deems a “safer” BG.

If a CG is unsure of what constitutes bouncing or any other pattern of low BGs followed by high BGs or vice versa, please ask on the appropriate forum so experienced members may accurately interpret the BGs and spreadsheet.

An excellent discussion within FDMB is within this thread, specifically Post 28:


REFERENCES CITED

Raskin, P. The Somogyi phenomenon. Sacred cow or bull? Arch Intern Med. 1984 Apr; 144(4): 781-7.

Link: https://pubmed.ncbi.nlm.nih.gov/6370162/

Reyhanoglu G, Rehman, A. Somogyi Phenomenon. StatPearls Publishing 2023 Jan.

Link: https://www.ncbi.nlm.nih.gov/books/NBK551525/

Roomp K, Rand J. Rebound hyperglycemia in diabetic cats. J Feline Med Surg. 2016 Aug; 18(8): 587-96. doi: 10.1177/1098612X15588967.Epub 2015 Jun 4.

Link: https://journals.sagepub.com/doi/full/10.1177/1098612x15588967

Rand J, Roomp K. The myth of Somogyi and how I adjust insulin. World Small Animal Veterinary Association Congress proceedings 2017.

Link: https://www.vin.com/apputil/content...&catId=113455&id=8506497&ind=344&objTypeID=17