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[Appa and Susan]

Ummmm....
Unless my laptop is misbehaving, I'm seeing data only through 2/14 on your spreadsheet. Can you update for the last couple of days?

We removed the sensor on the 14th. It was not consistently reading, and we felt pretty good that it worked for that long. So we are going to do a glucose curve with the AlphaTrak3 in about a week or so and see where we are. I have a post above that has the details of our conversation with the vet.

 

[Sienne and Gabby (GA)]

Forgive me if I'm misunderstanding but you still need to be collecting test data. For the safety of your cat, you need to get a minimum of 4 tests per day. You need to test before giving a shot to ensure it's safe to give insulin. You also need to get a minimum of one test during both the AM and PM cycles to make sure that numbers are in a safe range and to determine how well the insulin is working. It will allow you to assess if a dose increase or reduction may be needed.

If you are following SLGS as your dosing method, you also need to get a curve once a week. This is something you can do at home. If you take your cat to the vet for a curve, you'll end up spending a fortune for tests. In addition, many cats are stressed by being at the vet's office. The stress causes a false high blood glucose reading which may cause the vet to suggest an unnecessary dose increase.

 

[Bron and Sheba (GA)]

I agree with what Sienne has said.

I talked to Dr. Vet - he was concerned about the low glucose numbers, but when I told him that I had checked with the AlphaTrak3 and confirmed they were not actually low (over 100) we decided to stay on the 3U for now. He commented that too high an insulin dosage can contribute to bouncing. The plan is to do a BG curve at home in a week or so and see if there is still bouncing (if we can, bouncing doesn't seem to happen every insulin cycle). He would be fine with going down to 2-1/2 U.

I have to disagree with your vet on this. Too high a dose can drop the BG too low but amongst the reasons cats bounce is not because the dose is too high. If you read the bouncing explanation in post 38 you will see why cats bounce. Cats need to get used to normal numbers again and they will bounce until they do. If you reduce the dose as the vet says all you are doing is stopping the cat experiencing the normal numbers and you are leaving them in chronically higher BGs all the time.

 

[Appa and Susan]

@Bron and Sheba (GA) @Sienne and Gabby (GA)

We are not reducing the dose. We are going to give it a week or so, and do a glucose curve. I am keeping a very close eye on Appa, and I've tested with the BG meter every time I thought there might be a problem. So far nothing has ever been below 112 (even when the Libra2 said 55). His behavior doesn't indicate hypoglycemia - he is actually becoming more playful and energetic, including right before meals, where he does a lot of pacing around and polite meowing to make sure I know it is mealtime. I am most concerned after the insulin shot, but so far... no symptoms.

I had an uncle with Type 2 Diabetes who had all the long term complications. Glaucoma, kidney failure, neuropathy, amputations. He died in his 50s. I understand the seriousness of this disease, both the short term immediate danger of hypoglycemia, and the long term complications.

My vet was talking about a specific cat who's owner was adjusting the insulin on their own and went to a dosage that was much too high. The cat was then swinging between very high BG and very low BG, as described The Somogyi Effect on the Merck Vetsulin site. Maybe this is not the same as bouncing.

I really appreciate the knowledge and support I have gained here, but I actually trust my vet - he has a lot of diabetic cats in his practice and he has been very responsive when I have had questions.

 

[Sienne and Gabby (GA)]

Just an FYI --

Somogyi has never been proven in cats. It is based on a study conducted decade ago of a small number humans who were not on a contemporary type of insulin. The results were never replicated and are considered questionable, at best. Roomp and Rand did a study of cats on Lantus and the existence of Somogyi was again disproved. This is a summary of their published study.

 

[Appa and Susan]

Somogyi has never been proven in cats. I

ETA - my vet described the phenomena without calling it either "bouncing" or "Somogyi effect" - but his point was if Appa was really getting hypoglycemic on the 3U, then we should reduce to 2-1/2U and do a glucose curve in 1-2 weeks.

I am unclear as to the difference between Bouncing and Somogyi Effect

• Bouncing - Bouncing is simply a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast.The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones. The end result is a dumping of "sugar" into the bloodstream to save the cat from going hypoglycemic from a perceived low. The action is often referred to as "liver panic" or "panicky liver". *Usually*, a bounce will clear kitty's system within 3 days (6 cycles).

and Somogyi Effect:

• The blood glucose concentration falls rapidly or approaches hypoglycemia ... following the injection of insulin.
• In response to a declining blood glucose concentration in the central nervous system, adrenaline and subsequently cortisol, glucagons, and growth hormone are released.
• These hormones increase blood glucose concentration (through gluconeogenesis, release of glucose from hepatic glycogen, and increased peripheral resistance to insulin).

This sounds like the same phenomena to me. A fall in BG levels triggers a response that increases BG that is inappropriate.

 

[Sienne and Gabby (GA)]

In "classic" Somogyi in humans, this happens overnight. The issue is that for advocates of Somogyi, they believe that it was "proven" decades ago based on one human study with a small number of subjects. That study has never been replicated and Somogyi has essentially become an urban myth. When Rand & Roomp attempted to demonstrate Somogyi in cats, they were unable to do so. The insulin used in the human study was not a insulin that is contemporary -- the original study was in 1938. It is not feasible to generalize the results of the original study to Lantus which has an entirely different pharmacology. Further, for a bounce, the cat's blood glucose does not need to be approaching hypoglycemia. A bounce can be triggered by a hypoglycemic or near hypoglycemic event, a relatively fast drop in numbers, or the cat dropping into numbers its body is no longer used to.

 

[Appa and Susan]

Exciting news! We did a glucose curve with the AlphaTrak3 and Appa's numbers were so low that Dr. Vet thinks he likely has entered remission. Dr. Vet recommended withholding insulin and doing another glucose curve in a few days (so we don't have a week of uncontrolled BG), and then doing a curve in a week.

I've updated the numbers in his spreadsheet and adjusted the color coding for a feline BG monitor. His pre-shot numbers were 85 and 88, and his nadir was 62. At no point did he exhibit any clinical signs of hypoglycemia, although when I saw the lower numbers I did give him more to eat, including some kibble which is 15% calories from carbs.

I was really surprised to see numbers this low, given that previously his numbers were mostly over 400 and bouncing around a lot.

I realize that there will be disagreement with what my vet has advised, and criticism of what I have done so far. But I just wanted to share this (to me) exciting development, and hopefully get some emotional support.

 

[Bron and Sheba (GA)]

Hi Susan
This is not a criticism. And I do want to support you but I don’t think this is the best decision for Appa.
My concern is Appa is getting great numbers with the 3 unit dose. That does not mean he is in remission. It means you can start to reduce the dose of insulin gradually while still supporting g the pancreas as it heals. If you stop insulin from 3 units to zero units, you might get a short remission but I can almost guarantee Appa will fall out of remission and then it be much harder to get back into remission.
If
I would be reducing the dose to 2 1/2 units from 3 units and continuing to test closely.

 

[Appa and Susan]

Hi Susan
This is not a criticism. And I do want to support you but I don’t think this is the best decision for Appa.
My concern is Appa is getting great numbers with the 3 unit dose. That does not mean he is in remission. It means you can start to reduce the dose of insulin gradually while still supporting g the pancreas as it heals. If you stop insulin from 3 units to zero units, you might get a short remission but I can almost guarantee Appa will fall out of remission and then it be much harder to get back into remission.

I would be reducing the dose to 2 1/2 units from 3 units and continuing to test closely.

We are doing a BG curve today. Pre-feeding BG with Alphatrak3 was 56mg/dL. So we would not have been giving him a shot no matter what. It's been 60 hours since his last insulin dose (2-1/2 U Lantus).

Clinically, he is running around the house with great enthusiasm and murdering cat toys, eating with gusto, and having normal pee and poop.

 

[Appa and Susan]

Hi Susan
This is not a criticism. And I do want to support you but I don’t think this is the best decision for Appa.
My concern is Appa is getting great numbers with the 3 unit dose. That does not mean he is in remission. It means you can start to reduce the dose of insulin gradually while still supporting g the pancreas as it heals. If you stop insulin from 3 units to zero units, you might get a short remission but I can almost guarantee Appa will fall out of remission and then it be much harder to get back into remission.

I would be reducing the dose to 2 1/2 units from 3 units and continuing to test closely.

We have now done two BG curves since we took Appa off insulin last week per our vet's recommendation. His pre-meal BG levels are below 100mg/dL, and the highest value we have gotten has been 110mg/dL. Mostly its been in the 80s and 90s.

When I read the FAQ on this site for when to withhold insulin it says: "Below 150 mg/dl (8.3 mmol/L), don't give insulin." I assume this is still the current recommendation, although the FAQ in question is from 2008. I can't see continuing insulin, per your recommendation, as it would seem to invite a hypoglycemic event.

We plan to keep him on the same diet - wet food only. And to do another curve in 3 months, and spot checks when warranted.

I've removed the spreadsheet as I'm not looking for advice or recommendations. I'm really happy Appa seems to be in remission, and I hope it will last.

 

[Bron and Sheba (GA)]

I wish you and Appa all the best.
I would not leave it 3 months to do a curve.
I would test once daily and then weekly for a while to check all is ok.
He will always be a diabetic, just diet controlled.

 

[Appa and Susan]

I wish you and Appa all the best.
I would not leave it 3 months to do a curve.
I would test once daily and then weekly for a while to check all is ok.
He will always be a diabetic, just diet controlled.

Yes, he will always be diabetic, our vet has said the same thing. We will definitely be spot checking, especially if anything looks amiss, or if its a really stressful day, or if we have to change his diet for any reason. We have to get his ears looked at; its important that he doesn't wind up with chronic ear infections, we have to get him a dental when all of this settles down, and we have to manage his constipation (emergency visits are stressful and expensive). He will always be a very special cat, and worth all the effort.