8/29 Charlie AMPS 371 +2 439 +4 416 +6 427 +9 418 PMPS 380

Yesterday

Shoot, I assume?

How much? 1.5 units? Or less/more?

Please read yesterday's condo quickly as dose increase to 2 units last night led to low numbers.

 

Re: 8/29 Charlie AMPS 371

Shoot 1.5u Jill.

Please let me know you see this and then I have some other thoughts.

Hope you got some rest.

 

Re: 8/29 Charlie AMPS 371

Just saw it. Sorry I did not get a +11 this morning but I overslept due to serious sleep deprivation lately. My partner did the +12 and is waiting for word on what to do next. 1.5?

 

Re: 8/29 Charlie AMPS 371

Yes...1.5u. We discussed it while you were sleeping. Glad you got a little extra sleep.

 

Re: 8/29 Charlie AMPS 371

Part of the issue with last nights cycle was Charlie was clearing a bounce. Add a little extra insulin and you see that fast drop. While it can take a cycle or two for a dose to kick in, and in Charlie's case, they tend to kick in quick, it looks like the bounce clearing didn't help.

I hope you are beginning to feel better, Jill, and they are figuring out what is wrong.

 

Re: 8/29 Charlie AMPS 371

You did great yesterday, now it's time for us to get some sleep. Ni Ni

 

Re: 8/29 Charlie AMPS 371

I am so tired it's not even funny. Work is going to be a real bear this morning. Missing coffee terribly at this moment. The night before last, I got 3 hours sleep. Last night was, as you know, also a rough one.

Thank you for all your help. Charlie literally just jumped off the wall in a mini fit of excitement.
????

With this sleep deprivation, I may be bouncing off the walls later too.

 

Re: 8/29 Charlie AMPS 371

Hi Jill!

Wow, I missed the excitement! You did great though!!

Hugs
Jane

 

Re: 8/29 Charlie AMPS 371

Whoo! Glad you got Charlie back on track. Good job. Hope you get caught up on your sleep soon!

 

Re: 8/29 Charlie AMPS 371

You did do great last night! I hope you can perhaps have a short work day and try to get a nap.

Perhaps just smell the coffee

Have a good day. Bed time for me now that all is ok there.

 

8/29 Charlie AMPS 371 +2 439 +4 416

Thanks guys. Time to go earn a paycheck.

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 back in the bounce z

I understand there's more relaxation going on at home than at work today. Good for you, Charlie. You must be so annoyed with these bounces & their yo-yo effect.

 

Re: 8/29 Charlie AMPS 371

Hi Marje - a question on what you mean by "clearing a bounce" ... are you saying that when Charlie's adventure started last night with his low values, it was at least partially because his values before that were peaked and maybe on their way down from previous high (bounce) values? I'm just learning the lingo as we have bouncy Leo as well. Thanks! Lisa

HI Jill - glad all is well - working after a long night that sure is tough. But at least you have peace of mind that he's ok. Although I just woke up, so you're probably coming home now!

 

Re: 8/29 Charlie AMPS 371

Got it in one, Lisa. When a bounce clears (i.e. when the glucagon and conterregulatory hormones released by the liver in response to a low/fast/low&fast drop are cleared out of the system), the BG-Rise that happened during the bounce stalls and reverses. Sometimes, that reversal happens quite fast, meaning that even if the bounce itself lasts for a while (up to three days), when it starts clearing, the BG can drop pretty fast (and pretty low, as the insulin does what it's supposed to do at the same time). In Charlie's case, a bounce was clearing making the BG drop (which is normal), and there had been an insulin increase (and one that was too large, at that), so there were two strong forces (bounce clearing AND extra insulin) pushing the BG down.

Hang in there today Jill! Tonight we recharge :mrgreen:
Jane

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 back in the bounce z

Clear that bounce Charlie! You have been doing greaat Lisa. I hope you have a great day!

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 back in the bounce z

Good morning Jill,

Sorry I missed all the fun last night :shock: but I'm hoping tonight is a little better for you guys! Dangit, that Charlie sure is cute!!!! :smile: Anyways, I got a little bit more sleep than you, but I'm still dragging like a dead camel. (not really sure where that came from...sleep deprivation! :lol: ) I'm seriously considering trying the old "tape the eyelids open" method or maybe the "toothpick to keep the eyes open" trick. Wishing you the best and sending you coffee smells!

~Deborah

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 back in the bounce z

Hello all! I do not usually post here, but wanted to get everyone’s input on the following, related to Charlie:

On August 8, I wrote to Dr. Jacquie Rand at the Queensland University about Charlie’s situation, her inability to regulate -- as I am fascinated by this spreadsheet. Though I did not hold out much hope for a reply, to my great surprise, this morning at 5:09 am Dr. Rand responded. At the time I wrote to Dr. Rand, Charlie was receiving .5 units. I described the pattern of Charlie’s blood glucose readings and also provided a link to Charlie’s spreadsheet for Dr. Rand to review.

This is Dr. Rand’s reply:
------
“Dear Melanie: Thank you for your kind words about our work. I am just glad to know it has help cats and their owners. Your friend might get some good help from the German Diabetes-Katzen Forum (http://www.diabetes-katzen.net/forum/) in ongoing dose adjustment. The type of curve you are describing is very common. Very often it resolves by itself, but there are a couple of things that can be tried – decreasing the dose to see if it is likely a Somogyi effect, or change to detemir which is longer acting in some cats.”

Warm regards,
Jacquie
--------

Following Dr. Rand’s lead about possible Somogyi, this morning, I located a chapter in the British Small Animal Veterinary Association’s Manual of Canine and Feline Endocrinology (2012 edition). In it, Chapter 23, five blood glucose curves are illustrated -- cats presenting with unstable diabetes. The five curves illustrate a) an appropriate response to insulin; b) minimal response to insulin, insulin resistance, or stress hyperglycemia; c) inadequate response to insulin; d) response to insulin but inadequate duration of effect; and e) rapid decline in glucose concentrations in response to insulin, with marked rebound (Somogyi overswing).

I charted Charlie’s blood glucose readings from last night and this morning on a graph and compared it to those in the BSAVA manual. Charlie appears to be a very close match to illustration e). Please see attached image to compare.

Question: Do you think Dr. Rand’s comments have validity in this situation, and does anyone feel that a dose decrease, rather than increase might have been tried – the option that Dr. Rand indicated?

Thanks to all.

Melanie

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 back in the bounce z

Jill - sorry to hi-jack your condo with this discussion!

Melanie - You may or may not be aware of how controversial the whol notion of Somogyi is, and how sceptical many of us here are of its existence? The research apparently documenting its occurrence was originally conducted in the late 1930s (1938, I believe), and more importantly, it has never been replicated (unless I've missed some significant new findings, or their mention). That research was not done using Lantus (or Levemir). What I believe, and what others also posting here in Jill/Charlie's condos believe, is that Charlie started on a dose of insulin that was too low (0.5u), allowing glucose Toxicity to become a complicating factor, making it harder for what would normally have been an effective insulin dose to bring down those high BGs. Decreasing the dose of insulin (i.e. giving it less of a chance to break through glucose toxicity and related persistent high BGs) would have allowed Charlie to become even more (detrimentally) accustomed to the high-range BGs, putting her at greater risk for organ damage, ketones, etc. The recent dose mishap aside, I believe that the current plan - to continue increasing Charlie's dose in accordance with TR protocol (see also the Tilly "version" of the TR protocol) - is the best way to approach Charlie's case and a likely method with which to make sure she makes progress and approaches (and eventually achieves) regulation. IMHO, as I said.

Jane

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 back in the bounce z

Hi Jane! I certainly respect your opinion in this regard. Most of the current veterinary literature I have been reading, though, does mention the existence of Somogyi related to cats. I did see some controversy of whether it exists in humans, so understand the disagreement. My thinking is that, if Dr. Rand who helped develop the TR protocol, believes it is a possibility, then shouldn't it be something worth investigating?

I did find a study from 1986 (Rebound hyperglycemia following overdosing of insulin in cats with diabetes melitus) where rebound was documented using PZI. But you are right, I didn't find anything related to Lantus (I don't believe Lantus existed at the time of the 1986 study). The 1986 study is referenced by the American Animal Hospital Association in their current literature: "Be aware that chronic insulin overdose may not only result in clinical hypoglycemia (seizures, coma), but also the development of sustained hyperglycemia and insulin ineffectiveness following secretion of insulin antagonists (catecholamines, glucagon, cortisol, growth homone) that combat hypoglycemia."

Just thought that since Dr. Rand is a pioneer in the field of feline diabetes, and if she believes Somagyi exists (and specifically recommended it as an option related to Charlie's case), then maybe we should rethink the issue as well. Again, though, I sincerely respect your opinion and experience in this matter.

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 back in the bounce z

Melanie:

Can you please upload your references (including citations) -- the British Small Animal Veterinary Association’s Manual of Canine and Feline Endocrinology (2012 edition) and the 1986 paper -- so we can all take a look? My experience with book chapters is that they often don't go back to original research. The 1938 paper by Michael Somogyi has perpetuated the existence of this phenomenon but when you go back to his original paper which suffers from some significant flaws (small number of subjects, urine glucose was measured vs. blood glucose), coupled with the lack of subsequent replication, it raises considerable questions as to the reliability of the results. As you rightly observe, long-acting insulin was not available at the time of the 1938 and 1986 papers so there's no way to assess the generalizability, as well.

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 back in the bounce z

Hi Sienne. Sure, here they are. I had to split the 1986 study into two parts as it was two large to upload (exceeded 1 MB). The first document contains the study and most of the references, though as stated earlier they used insulin other than Lantus (PZI and another one). The second document is just the last page of references.

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 back in the bounce z

Here are a couple more references: Chapter 23 from the British Small Animal Veterinary Association's manual (2012 edition) that speaks to this; and an article written by Dr. Michael Schaer, a Professor in the Department of Small Animal Clinical Sciences here at the University of Florida (where I work) that discusses Somogyi (or as he calls it "posthypoglycemic hyperglycemia"). I plan to follow up with Dr. Schaer to see if he can add any more to the discussion.

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 back in the bounce z

Thanks for taking the trouble to post those, Melanie, we appreciate it! Good to be reminded to keep, well, an open mind (I stand fast by my opinion though :mrgreen

Hugs
Jane

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 back in the bounce z

I understand. I am just trying to look at this with "fresh eyes" (as we say in my job...LOL! ), trying to gather data and understand the consensus of opinion from the board as well as veterinary researchers like Dr. Rand -- trying to understand why she and others may think like they do - and what if anything we can learn from this.

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 back in the bounce z

Hi guys .. what a night you guys had, but you handled it like an old pro I hope you can find some time to get some much needed rest .. hang in there, you're doing awesome!

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 back in the bounce z

Melanie -- thanks for the links.

I don't believe the 1986 case report is particularly good examples of outcome data -- at least by not current research standards. There are very few controls in place which make comparison of the results for each of the 6 cats difficult. For example, the cats are on different insulin or insulin is switched and not switched at a standard point in treatment, there's no standardized feeding schedules (essential for NPH especially), in some cases the dose changes were based on urine glucose measurement which is notoriously unreliable, etc. Not surprisingly, one cat had seizures due to being given 22u of NPH. Concluding that reducing the cat's dose in response to rebound hyperglycemia in that cat is a stretch -- the cat was overdosed and in a situation like this, numbers will shoot up (if the cat survives).

The authors don't refer to Somogyi. They do reference rebound hyperglycemia. The question in my mind is how are they differentiating between what we call a bounce versus Somogyi? Chronic rebound is rare with a long-acting insulin such as Lantus or Lev. I've not done the research with respect to shorter acting types of insulin. Extrapolating from the human research, the evidence for the presence of Somogyi phenomena is questionable, at best. What we have seen in this forum is that reducing the dose based on a bounce only leaves the numbers in higher ranges. You may end up with a flatter curve but it's a high, flat curve. Then, you potentially have to struggle with glucose toxicity and concerns regarding your cat being above renal threshold. Once you raise the dose to offset the higher numbers, you often end up having lost time and frequently having to raise the dose beyond where you were in the first place.

I tend to think most cats experience bounces. They vary with regard to how long the bouncing persists and how large the range from low to high is. This is an another instance of ECID. I'm very comfortable with the notion that cats bounce -- until they don't.

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 +6 427 +9 418 PMPS 3

Good points Sienne! You are a walking encyclopedia on this! LOL! I know the 1986 study did not have direct relevance to Charlie but included it as it was referenced by the AAHA in their statement related to chronic insulin overdose causing sustained hyperglycemia and insulin ineffectiveness. Also good question about the terminology: how are others differentiating the term bounce from Somogyi or rebound. I hope to get more info from Dr. Rand on this as she was the one who mentioned Somogyi in her email. I didn't see the term "bounce" used in the medical references - mainly Somogyi which appeared to be used (at times interchangeably) with rebound. I also saw a reference to the "dawn phenomenon" related to a surge in growth hormones that could cause blood glucose to rise independent of other factors - though not sure if that has any reference to this situation.

Also another point I forgot to mention below and unsure of its significance is that I did average Charlie's BG readings for each of the dose increases - .5 through 1.25 and saw a pattern of BG increases with each successive dose increase. This seemed unusual to me (I am a financial and business analyst by profession). When I examined the numbers for my own cat, as a comparison, I saw just the opposite -- for every dose increase, it resulted in a corresponding average decrease to the average BGs for my cat but not for Charlie. This was not a scientifically accurate assessment as Jill does not have readings for every hour of the day; still she has many and I used the averages as a crude fructosamine test, so to speak, for each dose level. Has anyone else seen that phenomenon - rising BG averages with dose increases?

Again, I am just reporting not interpreting. I do not typically post here, but felt that I had an obligation to pass along the suggestions sent to me by Dr. Rand related to this case; and also provide any potentially relevant information I had collected, in the hope that something therein might be of help to Charlie in the future. Thank you all for listening.

Melanie

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 +6 427 +9 418 PMPS 3

over the years, there has been much discussion and debate on the subject of somogyi rebound, chronic rebounding, and bouncing. it's really too bad we no longer have access to Think Tank threads on the "old" board. we've lost some great info and discussion!

Dr. Rand (researcher, University of Queensland) and Kirsten Roomp (one of the laypersons, who along with other members of the German Diabetes Katzen Forum developed the Tight Regulation Protocol) presented the following Abstract to the 2008 ACVIM:

The Somogyi Effect is Rare in Diabetic Cats Managed Using Glargine and a Protocol Aimed at Tight Glycemic Control.
K Roomp, J Rand

ABSTRACT

The Somogyi effect is defined as hyperglycemia caused by the release of counter-regulatory hormones in response to insulin-induced hypoglycemia, and it is widely believed to exist in diabetic cats. However, studies in human diabetic patients over the last quarter century have rejected the common occurrence of the Somogyi phenomenon. The aim of this study was to determine the frequency of the Somogyi effect in diabetic cats treated with glargine.

Fifty-five cats diagnosed with diabetes mellitus were included in the study. Data were collected over 20 months, and were obtained from owners who joined the online German Diabetes-Katzen Forum, and followed a protocol of intensive blood glucose regulation using glargine. The aim was to achieve euglycemia (50-100 mg/dL as measured using a portable blood glucose monitor) using twice daily insulin dosing. Owners performed an average of 5 +/- 2 blood glucose measurements per day, and supplied spreadsheets recording all blood glucose concentrations.

Two different definitions of the Somogyi effect were used, and all cats were examined for occurrences of each type. The Somogyi effect with insulin resistance was defined as a blood glucose concentration of =50 mg/dL, followed by a fast, steep rise in glucose concentration to =400 mg/dL and/or concentrations that were at least 150 mg/dL above the usually measured higher concentrations for that cat. The two subsequent insulin doses showed almost no glucose lowering effect, and the glucose concentrations remained elevated for =24 hours. The classical Somogyi effect was defined as a blood glucose concentration of =50 mg/dL was measured, followed by marked hyperglycemia (=300 mg/dL) within 4-10 hours (which would also be the time of the next insulin dose). Food intake was not controlled for, but all cases were excluded in which owners documented having given substantial high-carbohydrate meals and/or glucose to counteract hypoglycemia.

Asymptomatic or biochemical hypoglycemia was common and most cats (93%) had blood glucose concentrations > 40 to <50 mg/dL measured at some point during the study, 84% had glucose concentrations > 30 to <40 mg/dL, and 51% had some glucose concentrations > 20 to <30 mg/dL.
Although biochemical hypoglycemia was common, the Somogyi effect was very rare in this cohort of diabetic cats. Based on the criteria for the Somogyi effect with insulin resistance, only 4 single events were identified in 4 different cats. The classical Somogyi effect was more common: fourteen cats (25%) had curves consistent with this definition with a median of 3 events per cat (range = 1-11 events per cat). This represents a median of 2.4% of blood glucose curves that were measured in the affected cats, if one curve is considered to be measured every day (range = 0.5%-7.7% of curves measured per affected cat).

We conclude that that the Somogyi effect is rare in cats treated with glargine on a protocol aimed at tight glycemic control, despite the frequent occurrence of biochemical hypoglycemia.
Journal of Vet Internal Med, vol. 22, #3

the Tight Regulation Protocol has been published in the Journal of Feline Medicine and Surgery. on Kirsten Roomp's Tilly's Diabetes Homepage where the Tight Regulation Protocol is described, Kirsten specifically states,

"Be aware that experimental studies in human diabetics over the last 15-20 have rejected the existence of the Somogyi effect (sometimes also called rebound). In cats, no studies have ever been done which properly demonstrate that such a phenomenon exists. Therefore, adjust the dose as described above, focusing on the nadir: don't do so-called rebound checks, as they only lead to unnecessary (and unhealthy!) hyperglycemia."

imho, whether somogyi rebound exists or not becomes irrelevant when following the Tight Regulation Protocol... using an appropriate initial starting dose as well as taking increases AND reductions in the systematic and methodical manner described in the protocol. if these guidelines are followed, a cat will not become over dose... leading to the so-called possibility of somogyi rebound... "if" it exists. if these guidelines have not been followed, there is a real possibility kitty has become over dose.

copying and pasting my comments on this subject from another thread:

suze, one of the first things those who are trying to help do is look at "how" the kitty arrived at the current dose. vets are famous for suggesting increases in full units. those are usually the kitties who have the best chance of becoming over dose... that and the ones who were started at too high of a dose to begin with. that's what we look for. edited to add: missed/not taking appropriate reductions can also result in a kitty becoming over dose.

on a side note: this is where the weight based formula described in the TR protocol comes in handy even if it's simply used as a tool to check to see if the starting dose was set too high. one thing to remember with the weight based formula... ideal weight is used rather than actual weight EXCEPT in the case of an underweight kitty. when a kitty is underweight the actual weight is used to determine the starting dose. kitties with initial starting doses that were too high or who have been increased too quickly or in large increments... these are the kitties who remain at risk for being over dose. their caregivers will sometimes see improvement when dropping the dose when seeing reds or blacks on their spreadsheets.

you did NOT do that with pumba. you mostly traveled up the dosing scale in 0.25 unit increments... except the few "fats" added to the dose. heck, you even went back down to 0.5u and started over again.

pumbaa is a bouncer, that's all. lots of cats are bouncers. pumbaa is not over dose. at this point he's also lacking duration due to the recent dose reductions.

bouncing always gets a bad rap. here's a discussion from one of Jetta's daily threads on bouncing that puts a slightly different slant on the subject: http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=55306.

"bounces" from numbers a cat who is not used to being in lower numbers is a very different thing from a cat with very high numbers due to being over dose.

by using the very logical and methodical dosing approach with lantus OR levemir as suggested in the TR protocol... we do not do rebound checks. we shoot right through the bounce... training the liver to eventually accept these lower numbers as "normal". why? because the body has been in high numbers for so long... it forgot what "normal" really feels like. by giving kitty the insulin required to pull the numbers down, we're helping his body "remember" how it feels to be in the normal range. consistency is the key in overcoming the bounces... and it takes time. more time for some kitties than others.

generally speaking, when it's been determined the cat is not over dose (see above), all we see when so called "rebound checks" are done (checking for the possibility of too much insulin) with lantus or levemir kitties is the caregiver finding it necessary to go right back up to the dose they were at weeks or even months later. seems to me it's just a whole lot of wasted time, money, and effort... not to mention the possibility of complications developing along the way from kitty spending more time in hypERglycemia unnecessarily.

ok, so you've previously indicated you're not following the TR protocol, but the premise remains the same.


becoming over dose, whether stemming from an initial starting dose that's set too high, dose increases with inadequate data to support the decision, failure to take appropriate reductions, and/or inappropriate adjustments to the dose in increments of 0.5 unit or more often lead to what is commonly referred to as somogyi rebound. all too often, we see glucose toxicity set in under these circumstances. it becomes a vicious circle.

when this happens a caregiver has two options:

• they can lower the dose and will sometimes see favorable results. however, more often than not we see caregivers who opt for this approach end up taking the dose right back up... often having to surpass the dose kitty was on weeks or even months later because glucose toxicity has set in... allowing kitty to remain in hypERglycemia... leaving the door wide open to other complications such as ketones/DKA and possible organ damage.
  
  although, there are circumstances when dropping the dose makes purr-fect sense. these include, but are not limited to a change from a high dry carb diet to a wet low carb diet, an insane starting dose, a caregivers limitations, a fractious kitty, etc. each of these situations has to be looked at individually and analyzed to figure out the best course of action.

• they can continue making dose adjustments according to the guidelines outlined in the Tight Regulation Protocol. eventually, this action will cause a break through by overcoming the glucose toxicity which has set in. monitoring carefully is a must.

bottom line...
i look at results and the results we see in this forum from caregivers following the Tight Regulation Protocol with lantus or levemir is phenomenal. most of the spreadsheets i've seen where caregivers are doing rebound checks when following the Tight Regulation Protocol make me sad.



fwiw, just my thoughts...

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 +6 427 +9 418 PMPS 3

Very interesting and illuminating discussion!

As a newbie, I can't contribute to the diabetes portion of this discussion, although as an engineer, maybe a thought about this analysis. You're right to wonder if an average is as useful if there are not the same number of readings every cycle and if the readings don't fully capture the curve. It may be more appropriate to make these comparisons using an area-under-the-curve method rather than averaging individual datapoints. Having every value would be great, but with some extrapolation, integrating may give more useful results. That might also correspond better to the information a fructosamine test provides.

Just a thought.

Lisa

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 +6 427 +9 418 PMPS 3

yes, we often see this phenomenom. we refer to it as "new dose wonkiness". i know, i know. such a scientific term! :lol:
the tillydiabetes web site makes mention also:

"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."

if you'd ever like some assistance or help with ninja, please join us.

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 +6 427 +9 418 PMPS 3

Really interesting discussion. Thanks to all for taking time to explore this topic.

Ella & Rusty

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 +6 427 +9 418 PMPS 3

Hi Jill! To clarify, the topic of Somogyi came up because Dr. Rand mentioned it in an email to me as a possibility in Charlie's case. I asked her to look at Charlie's spreadsheet and she replied, "The type of curve you are describing is very common. Very often it resolves by itself, but there are a couple of things that can be tried – decreasing the dose to see if it is likely a Somogyi effect, or change to detemir which is longer acting in some cats." I know there is a great deal of controversy here about the existence of Somogyi but since Dr. Rand mentioned it herself, I felt I had a responsibility to bring that forward. I am not, myself, an expert in this topic and have never heard of detemir. I did ask Dr. Rand for further clarification related to Charlie and if she replies I will post that as well.

I do understand that cats react to an increased dose with increased BG's for 2-3 days after increase (mine often does), but didn't really understand why Charlie's overall averages were higher for the entire duration of each dose, whereas the averages for my cat went down (which is what one would expect: higher dose, lower average BGs). But I agree with Lisa's suggestion about reevaluating the data using a different method as possibly accurate.

So today I have learned that Somogyi is a hot topic, up there with religion and politics, even if Dr. Rand says it herself. LOL!! Thanks all!

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 +6 427 +9 418 PMPS 3

No worries, once you have studied more spreadsheets you will see that this is actually a very normal pattern with a cat that has not reached his/her breakthrough dose yet. Glucose toxicity starts to set in and it can require increasing doses to get ahead of the toxicity. Then one day, all of a sudden, there will be green and lots of it! It's a thing of beauty and happens almost every time. Charlie is just getting started on Lantus and he's doing fine!

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 +6 427 +9 418 PMPS 3

Melanie

One other thing I'd like to add to Sienne's comments about the 1986 study is that with any "scientific study", it is extremely important to look not only at the controls in place but also the sample size. A well-crafted scientific study should have appropriate controls in place so that all subjects start on a level playing field, it should have an identified hypothesis, and it should have a decent sample size.

I liken it to all the "studies" the newspapers are always quoting where the sample size was 300 or 1,000 for a study addressing a human condition. For instance, and this is an oversimplification, but a statement such as "studies found in 1,000 people that drinking more than three cups of coffee a day is bad for you". Contrast that to the study done on menopausal women/hormone usage and links to breast cancer. That sample size was in the tens of thousands. Still small in relation to the human population but quite large for the typical study done. IMHO.

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 +6 427 +9 418 PMPS 3

understood.

the question, as well as Dr. Rand's response, is what prompted my comments above, specifically:

becoming over dose, whether stemming from an initial starting dose that's set too high, dose increases with inadequate data to support the decision, failure to take appropriate reductions, and/or inappropriate adjustments to the dose in increments of 0.5 unit or more often lead to what is commonly referred to as somogyi rebound. all too often, we see glucose toxicity set in under these circumstances. it becomes a vicious circle.

when this happens a caregiver has two options:

• they can lower the dose and will sometimes see favorable results. however, more often than not we see caregivers who opt for this approach end up taking the dose right back up... often having to surpass the dose kitty was on weeks or even months later because glucose toxicity has set in... allowing kitty to remain in hypERglycemia... leaving the door wide open to other complications such as ketones/DKA and possible organ damage.
  
  although, there are circumstances when dropping the dose makes purr-fect sense. these include, but are not limited to a change from a high dry carb diet to a wet low carb diet, an insane starting dose, a caregivers limitations, a fractious kitty, etc. each of these situations has to be looked at individually and analyzed to figure out the best course of action.

• they can continue making dose adjustments according to the guidelines outlined in the Tight Regulation Protocol. eventually, this action will cause a break through by overcoming the glucose toxicity which has set in. monitoring carefully is a must.

fyi: insulin detemir is also known by the brand name levemir.

some cats, although not all, have experienced a longer duration on levemir. after using both lantus and levemir, i personally question across the board claims made as to the extended duration of levemir only because typically levemir does not onset until about 4 hours after the shot is given versus lantus typically onsetting approximately 2 hours after the shot is given. does levemir actually last longer or is it simply a matter of lev's action "kicking in" later thereby giving the appearance of lasting longer??? but as they say, "ECID".

libby's comment hits the nail on the head.
and as dr. Rand pointed out in her email to you... charlie's response to lantus is "very common". i couldn't agree with her more.

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 +6 427 +9 418 PMPS 3

Jill: This is fascinating. So if I am understanding you correctly, you are saying: Cases like Charlie's could be caused by a chronic low-level overdose of insulin (for various reasons) over time, and that when this condition continues long enough then "glucose toxicity" sets in, meaning the cat has developed a level of tolerance for the insulin - at which time, a reduction in insulin may or may not bring the blood glucose back into alignment. The owner could try a reduction, which sometimes works (however, exposing the cat to possibly higher BGs and DKA in the interim); but that in most cases additional dose increases are needed to break through the toxicity -- kind of like a sledgehammer effect (so to speak). Once the owner reaches the sledgehammer dose to break through the toxicity, then he/she will start to see more green numbers and can begin lowering the dose again according to the guidelines of the protocol. Am I understanding this correctly? If so, let me ask you Jill, is there a way to identify this overdose situation sooner so that a dose reduction (say, a month ago) might have resulted in a quick realignment of the BG? This is not specifically related to Charlie, but wondering about the other cats who come to the board marginally overdosed (the 25% of cats who would otherwise be diet controlled, but perhaps started by their vet on a low level, say .25 or .5, of insulin concurrent with diet change. Is there a way to spot this syndrome sooner (telltale signs) when the level of overdose is not significant? Jill, thanks so much for explaining this! Very helpful!

Jill, one final question related to this: can you speak to your position on dose reductions when the owner does not necessarily see (though suspects) that the cat may have gone below 40. That is, particularly in the early days of treatment, many owners are not able to get consistent readings but may catch, for example a pre-shot number of 48 - indicating the cat likely went lower earlier in that cycle. I am wondering if this inability to test frequently causes some owners to miss dose reductions early on, thereby setting up situations like you describe above related to chronic overdosing. Thanks again for any input on this. And thanks to Jill and Charlie for allowing us to explore this topic here.

 

Re: 8/29 Charlie AMPS 371 +2 439 +4 416 +6 427 +9 418 PMPS 3

yes and no. :mrgreen:

charlie's response to date has not been caused by what you've called a "a chronic low-level overdose of insulin". imho, charlie is not over dose. that's not to say the dose may eventually get up to or surpass the vet recommended increase to 2 units BID from 1.25u, but going up the dosing scale in a systematic and methodical manner has proven to be safer for kitty.

imho, charlie's initial starting dose was too low (based on previous data while on caninsulin). for various reasons, the dose was then held far too long (approximately 17 days). when a dose is held too long, it's very common for glucose toxicity to set in. as already mentioned, once glucose toxicity sets in more insulin is required to cause a break through.

a better example of the possibility of a kitty requiring more insulin to break through what some call the "glass ceiling" (glucose toxicity) can be found on ninja's spreadsheet. for whatever reasons, ninja was brought all the way up to 3u bid without sufficient data to support the decisions. another red flag is increasing in increments of 0.5u regardless of nadirs. these things alone *can* contribute to the possibility of any cat becoming over dose. is ninja over dose? it's impossible to draw any concrete conclusions at this point. ninja may just need more insulin than others.

unfortunately, there are no "quick" fixes when you're dealing with feline diabetes.

when i look at a spreadsheet for the possibility of kitty being over dose i begin with looking for things like an initial starting dose which was set too high to begin with, increases often/always made in increments of 0.5u or more, dose adjustments made based on preshot numbers, dose increases with inadequate data to support the decision, and/or failure to take appropriate reductions. i consider these all to be "red flags". from there i pay particular attention to the "Remarks" section on kitty's spreadsheet. if i have more questions i'll read back through the caregivers threads to help put together the pieces (it's why we ask everyone to include a WCR [whole cat report] in their daily threads. sometimes there are reasons for actions taken. put all these things together and a picture emerges.

if a cat is truly over dose it can take weeks or many months to cause a break through... which is why we're all about getting nadir checks and adjusting the dose in small increments as outlined in the TR Protocol. while reducing the dose IS an option in *most* over dose situations we've found (generally speaking) reducing the dose actually adds more time onto the process for the reasons we've been discussing (mainly glucose toxicity).

lol! we call this "reading the invisible numbers".

i have to be honest and i hope this doesn't come off as sounding arrogant. it takes an experienced eye to read the invisible numbers on a spreadsheet. i can only think of a couple of people who post in this forum who have that experienced eye. a very experienced eye only because *most* caregivers have not studied enough spreadsheets or have seen enough variations or exceptions to the rule. they also may not have a full understanding of the action of the insulin used... as it pertains to an individual cat. after all, ECID is not just a slogan. it's probably truer than any other words spoken here.

"for example a pre-shot number of 48 - indicating the cat likely went lower earlier in that cycle"...
a preshot number of 48 can be indicative of a few things. one possibility is kitty went lower earlier in the cycle. another possibility is kitty simply has a late nadir. some kitties can nadir at +12. and yet another possibility is kitty was rapidly clearing a bounce. this combined with the previous shot could cause kitty to drop low at the end of the cycle. interpreting the data correctly is imperative. in order to do that a caregiver must look back to what led up to the event. *usually* data accumulated over the last 3 days will offer a clue. we call that analyzing "waves of action". because of the cumulative nature of lantus and levemir the past explains the present in most cases. sometimes, we don't see any rhyme or reason. it's just a cat... being a cat. in any case, a drop below 50 is cause for a reduction with a newly diagnosed kitty.

on a side note: when faced with an uncharacteristically low preshot number, we usually suggest newbies drop the dose in order to be able to comfortably shoot the cat twice a day.

having said that, the first and foremost priority here is keeping kitty safe. caregivers should feel comfortable with whatever dose they're shooting. there is no fault in taking a reduction based on suspicion. the caregiver will find out soon enough if their suspicion pans out and if doesn't... no harm done. the caregiver will simply increase to the last good dose.



hope this helps...