8/10 Bob PMPS=296, +3=287 Advice please??

Good evening LL!

I was up every hour testing Bob last night so I slept most of the day! Ugh! Not sure why, but I just though I should check Bob in the middle of the night so I set my alarm and there he was going down. DANGIT!!! I've learned to dread the green because of the proceeding highs for 3 or 4 days.

So, I spent about an hour researching the Symogi effect and how to STOP it. This will NEVER stop if I continue to give the same dose of insulin or keep going up. Mainly what I read was that the Symogi effect s caused by an overdose of insulin. One article said when you suspect the symogi effect (it's been quite obvious for some time!) then I should decrease insulin by 50-75%. Makes sense to me, but my only concern is Bob remaining high while he is bouncing. His ketones are up to .8 and although I've seen that's not serious yet, it's freaking me out.

Has anyone read or seen anything similar?

How low did he get, you are missing days of his SS the advise people will need to know this and please put a ? mark in the post so it will get noticed better.How much insulin is he on now and what are his numbers so that you can get the advise you need. Sorry don't have a good answer for you with out knowing his history.

Hey Linda - his ss is updated. How weird - maybe it's not updating on the other end or something. I'm going to close it and reopen. And I also had ?? in the subject line - not sure why you didn't see them. All kinds of crazy going on....

I think Bob's cycle looked pretty good! If it were me, I wouldn't reduce. He WILL stop bouncing...eventually. As Carl says, cats bounce. Until they don't.

I can see the SS. Out of curiosity, what type of high carb did you give Bob last night? Is he eating the wet food gravy?

I think you are just seeing a bounce, there's not been any research proving Symogi in cats. And it's been a while since he's seen green so his liver is nervous.

Dara:

This is where I climb on my soapbox. I posted this in Marje/Gracie's condo in December of 2010:

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.

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So, the bottom line is that there's no research on chronic Somogyi rebound in cats on Lantus. The research that does exist regarding the phenomenon in humans is limited and is not compelling. Climbing off of my soapbox.

I could also link you to numerous condos where the issue of bouncing has been discussed and where people reduced the dose in an effort to prevent bouncing. In a nutshell, what usually happens is the cat sits in high numbers and the potential for glucose toxicity increases thereby making it harder to get numbers to come back down without more bouncing. What we frequently see is that as the dose is increased, you often end up surpassing your current dose and you've lost considerable time in getting your cat into better numbers as a result of the dramatic dose reduction.

As frustrating as it is, cats bounce until they don't. Bob's number were looking good at higher doses. I suspect he is going to need more insulin to flatten out his cycles and for his pancreas to get used to lower numbers.

Hi Wendy - he will eat the Cats in the Kitchen pumpkin jack splash which is all tuna, or actually, he will lick the gravy up. I only gave him the 2 TBS, which is progress for me! I didn't throw down the whole bag.

I'm surprised because most of what I read said cats are particularly susceptible to symogi effect, more so than dogs or humans. I think I'm going to look up a cat endocrinologist (is there such a thing?) and at least try to get a phone consult.

Hi Nikki - It's easy to say to wait out the bouncing, but he's never going to stop because he's green 1 out of every 4 days and the rest of the time he's incredibly high - his liver will NEVER be used to the green at that rate. The ketones are starting to build up and I'm back to crapping my pants. I have to try something different than what I've been doing.

There are veterinary endocrinologists. They may not work specifically with cats, though. If they can provide you with empirical research and not just anecdotal information, I'd love to get the citations.

Also, I'm differentiating between bouncing and chronic Somogyi rebound.

Hey, you hold the syringe. I'd just hate to see Bob's ketones continue to go up and him not have enough insulin on board. Whichever you choose, good luck!

Hi Sienne - ok, so we are talking about the same thing right? Symogi effect is bouncing, right? Just want to make sure I understand that.

So, I have some questions so I understand what is going on here.

If 1.5 units of insulin is causing Bob to go very low into the greens every 4 days, wouldn't increasing his insulin just make it go even lower? When Bob was on 4.5 units of insulin, he stayed pretty high and straight, but he was also on 20% carb dry food. When I switched him to the no carb YA food, he started going really low and then the bouncing started. I'm not referring to the week he was on the wet food. I don't think he was eating enough that week. It only makes sense to me that when his liver stops releasing the glucose and he goes way too low, it's because he's getting too much insulin all due to the fact that he's no longer eating carbs.

I'm not being argumentative, I just want to understand what is going on....

(((Dara)))

Sienne beat me to it as I had gone to the very condo she referenced and copied the information for you.

I don't know if it will help you to know that I have been where you are. All I wanted was to believe I could control Gracie's diabetes and I could stop the bouncing and get her into green all the time. I increased the dose on bounces. I tried decreasing the dose to get Gracie to flatten out. Mike and I let every bounce drive us berserk and every green number made us ecstatic. We were on such an emotional roller coaster that it wasn't funny. Please take a few seconds, click on Gracie's SS link and then click on the Lantus tab. Gracie and Bob could have the same SS. I had days that I would get up and test and shoot her and then go back to bed because the numbers drove me insane. A few times, we thought she might be going OTJ...well, more than a few times....but she didn't.

Bob is in not in Somogyi. Even if Somogyi were to exist (and I am one who does not believe it has been documented in cats scientifically), Bob is not chronically overdosed. I actually think he was just starting to look pretty decent on 1.5u. If you are concerned about ketone, the worse thing you can do, if there is a ketone issue, is decrease the dose. However, I believe, from his SS, that he's not in the range where he's actually showing ketones. I think Jill posted the links for you the other day.

I, personally, have taken Gracie's dose down and waited six cycles to see if she was overdosed. I let the depot drain and guess what? She was in ridiculously high numbers (for her). And then we had to fight the glucose toxicity to get her back into green. It rarely works to take the dose down. From the bottom of my heart, I have to tell you that you cannot let the bouncing drive you crazy. I know it's hard; I know it's frustrating. Please look at these SSs:

Mocha's SS. On insulin 22 months, bounced until the last three weeks before she went OTJ.
Leo's SS. I never thought Leo would go OTJ but he did!
Gobble's SS. Another one that I was ecstatic when he went OTJ.

Please take a breath and take time for you. Be happy about the green and ignore the rest. You can't make the bouncing go away.

Dara....the bottom line on the food is the best food for a cat is the one it will eat. I hate to see you so frustrated and upset over this. If you cannot get him to eat anything other than YAZC, feed it to him. Adjust his dose so he his nadirs are maybe blue while you figure out if the YAZC works for him and until you can see a pattern.

Just saw your questions to Sienne. Somogyi and bouncing are not the same. Somogyi results from a chronic overdose. Bouncing is just the liver getting used to normal numbers.

When a cat is not getting enough insulin, you see high, flat numbers. When you get a breakthrough dose and they start coming down into lower numbers (not even really low but lower than what the liver is used to), the bouncing can start. Bob is no different than other cats in that respect. So you then dose for the nadirs, ignore the bounces. Don't chase the numbers. Let the numbers come to you. It works....it really does. You reached his breakthrough dose and numbers started coming down PLUS you got rid of the HC dry food.

Sending a big hug. Did I just prattle along or does it make sense?

No, that's another misconception. Simple answer. Symogi rebound is the theory that too much insulin causes prolonged high numbers, without the drops into normal numbers. Bouncing is the liver reacting to lower numbers than it is used to and temporarily releasing glucagon and counter-regulatory hormones raising the numbers for a few cycles.

Thanks Marje - I'm just so stressed about leaving. I leave on Thursday night and I don't know what to do. I feel like if I leave him at 1.5, then he will go really low one of the nights I'm gone (like he did last night) and nobody will be here to check him. Or, if I decrease his does, he will go so high that he will have a ketone issue. Not sure how fast that happens, but I don't want it to happen while I'm gone.

So, if you were me, what would you do with his dose right now and what would you do during the time I'm gone?

funny I can see it now :lol: not sure what was up stupid computer's :lol: glad everything good now. :smile:

Hi Dara,

I just want to say that on Vet #2 with Tigger, we started Prozinc 1 unit 6/8/13. (after 3 weeks of oral Glipizide with Vet #1). After only 3 days, on 6/10/13 Tigger touched Green. My vet said that because Tigger dropped below 100 I had to reduce the dose to .5.

Members on this Board advised against that reduction, but I freaked out & followed the vet's advice & reduced the dose.

Tigger's numbers after that went up. And up. And stayed up.

It wasn't until 7/23/13 (6 weeks later :evil: ) that he touched green again.

By reducing the dose when he was showing momentum - precisely the worst time - I effectively let Tigger hit a brick wall. I can only hope now that I haven't ruined his chances of going OTJ because of that mistake.

I didn't mean to hijack your condo, I just wanted you to see what unwarranted reductions cost me. Yes, I was worried about Symogi at the time, too; now I understand what other members have been explaining above. I'll take the green over the pink, red, or black any day.

Also, with regard to Bob, I'd like to ask the more experienced members if, in addition to bouncing is it possible Bob's pancreas is also 'sputtering'? :?: :?

Hi Suzanne! YOu aren't hijacking my condo - I appreciate any feedback.

I know a lot of people are dealing with the same thing. this has been one of the most frustrating things I've ever had to deal with. ANd when I'm stressed, I become quite dramatic. ohmygod_smile

Hope Bob's pancreas isn't sputtering - unless that's a good thing. :lol:

dara, take the time to read through these two threads i have bookmarked about bouncing/somogyi:

http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=78047#p843366

http://www.felinediabetes.com/FDMB/viewtopic.php?f=9&t=55306

they may help...

Hi Dara,

A "sputtering" pancreas is a good thing the way I understand it, but I think it's related more to regulated cats - in my layman's terms (I'm sure others will weigh in with a better explanation - PLEZ ANYTIME, GUYS!) it's when the pancreas starts working again, producing some insulin, but in a haphazard manner-not always working or not working or not working entirely - hence, "sputtering".

I'm getting in over my head, coz' I'm a Newbie & I don't like to put both feet in my mouth at the same time!

Suzanne,
That's not a bad explanation of "sputtering pancreas" at all.
It's definitely NOT one of these moments:
:lol:

And no, a sputtering pancreas isn't a "bad thing". Just random and confusing at times. It's a good sign when things start working well again, even if it's not quite 100%

I think you did an excellent job of describing "sputtering"!! As the pancreas heals, it starts to produce it's own insulin, but not in a regular pattern...so you are right on!

Dara, my advice is to take a deep breath, continue to give the same dose and watch for the next several days. If the more experienced members here think you need to decrease Bob to keep him safe while you're away and unable to test starting Thursday, I'm sure they'll be the first ones to tell you to decrease it...Nobody wants you to lose momentum with Bob's readings, but everyone will also want him to be safe while you're not able to test as much.

We ALL understand your concern and worry, but in my opinion, there's no better advice than what you're getting here. Bob is still fairly new to all this, and his pancreas and liver haven't seen anything close to normal numbers for quite awhile...it's going to take some time before they get "used" to those lower levels and stop panicking.

It'll be OK!!

I'm not really sure how you tell, in a cat that bounces, whether the pancreas is sputtering. I gave up wondering if Gracies was because if it doesn't sputter enough for her to go OTJ, I still have to give her insulin although I might be able to give her less.

I looked closely at Bobs SS and here is what I see:

He gets low and starts a bounce and then you take his dose down by alot. So now he's bouncing and he doesn't have enough insulin to clear the bounce.

The more insulin he had on board, the less he bounced and the faster he cleared it.

7/28 he went low in the a.m. You cut his dose waaaay back. He bounced for the full six cycles, you took the dose up on 7/31, the depot refilled, he came down on 8/1. You cut the dose way back. He bounced another six cycles.

He tried to clear the bounce on 8/4 but he just didn't have quite enough insulin to clear it and stay green but it was enough green to make his liver panic. Then you took the dose back up to 1.5u, got some nice greens, but cut the dose back today.

If you are worried about having him so low from the 1.5u, I'd take him up to 1.25u and leave him for at least 6-10 cycles depending on whether he's blue or not. Resist the urge to change the dose unless he either goes below 50 or he becomes high and flat.

Wow, Great discussion!

Dara, I just read the links that Jill provided above. Awesome, awesome stuff. Much discussion from the past two years on "bouncing" and I learned a huge amount from it. Definitely put it on your "to read list". ;-)

I have to agree with what Marje just posted too. I think "settling" on 1.25u, and keeping it there unless Bob throws you a really low number is a great idea.

Here's just my take, and it comes from someone who did not use Lantus, but rather used PZI...

I think you have been looking at this like a "PZI/Prozinc" person would look at it. Those insulin types work much differently than the "L" insulin types do. And adjusting the dose like you have been doing is much more in line with how the "P" insulins can and sometimes are dosed. In fact, it is the way I dosed Bob a couple years ago.

I think that many people tend to look at insulin like it's a "drug" instead of a hormone. Almost like it's a pain med. "If I take one pill, it'll knock out the pain for 6 hours", so "if I take two pills, it should knock off the pain for twice as long, or it'll knock the pain out a lot more for 6 hours than one pill would". And that's sort of how Prozinc/PZI work. If I got 250 points of drop with Bob on 2u, then I'd think "well, I'll get less of a drop if I cut the dose in half, and I'll see those results THIS CYCLE". And for the most part, that worked for Bob. He rarely got the same dose two shots in a row.

But PZI is a "in, and done" insulin. It works for 8-10 hours, and then it is "gone" from the cat's system. So you CAN adjust the dose, based on the preshot numbers, and with a specific "nadir" goal in mind. And see how it does. And if you see a lower preshot, you can shoot less, or a higher preshot you can shoot more.

BUT - Lantus doesn't work that way. It depends on a depot, and on a consistent dose. And when you make adjustments to the dose, you usually don't see "instant" results in the following cycle. The depot needs to readjust itself to the new dose. And if you adjust the dose too often, or too much, it's extremely difficult to figure out exactly what the heck is going on.

I have seen that it is very hard, when thinking of one type of insulin, to adjust your way of thinking towards the way another insulin works. I've seen people switch from Prozinc to Lantus and sometimes it's "easy" to switch. Other times it's really hard. And the requirement seems to be that you need to "forget" what you learned from using PZI and relearn the way that Lantus works. I know you haven't used Prozinc, but what I sense is that you are at times "thinking" like a Prozinc user as far as how the insulin works, and how/when a dose is adjusted.

The greatest benefit, in my opinion, to using Lantus/Levemir is that a protocol that is pretty straightforward EXISTS!!! To me, using the "L's" is easier than using the P's, because there is a set of guidelines that tells you exactly what to do based on the data you collect every day. It indicates when and by how much a dose should be adjusted. The difficult part, again in my opinion, is being able to "trust" what the protocol tells you that you should do, and when. Low numbers are scary, no doubt. Especially the first time or ten you see them :lol: And shooting insulin into a low number? Double scary!!! But what amazes me is how well it works once you get beyond that doubt or fear. Again, I've never done it myself. But I have watched people do it every day for over a year, and I've looked at a zillion spreadsheets to see how it works.

One last thing about bounces. Bounces are a GOOD THING! Bounces show you that the instinctive internal system in your kitty's body that nature provides is actually working the way it is supposed to work. Not too many people like the fact that cats bounce, and they can drive you totally up a wall when they keep happening. But they are a GOOD THING, and just a part of the process. They don't happen forever. If they did, cat's would never go OTJ, right? But it seems to me that cats go OTJ just about every week here, and there's a couple who just did, and a couple who will be having parties in the next few days.

OK, it's 3:30 AM, I'm rambling, and I hope at least some of this makes sense and helps you out.

Carl

Thanks everyone!!!! My head is spinning a little but I got some reading to do today. I stared at his ss and saw that he did have better numbers on 1.5 and when he went low, it really wasnt that bad - he was at 52 but it was toward the end of his cycle. He prob would have started going up without me giving him the high carb.

So I thought I would do 1.5 for 6 cycles. If he goes down to 52 again, I may adjust him to 1.25 before I leave and then we will get something in between the 98 on 1u and the 52 on 1.5u.

I REALLY REALLY appreciAte all the discussion about this. I think It helped me understand things better.

Dara:

FWIW, I always reduce Gabby's dose when I travel. There are just so many variables at play with any cat that the only way I can be comfortable when I'm not the person testing is to reduce the dose. Gabby won't let anyone besides me test, so that's a factor that I take into consideration. I do have a very experienced vet tech who cat sits but she comes by twice a day. I'd rather have Gabby in higher numbers and be safe than my being constantly worried that she was going to take a nose dive.

Lkldcatlady said:

Thanks everyone!!!! My head is spinning a little but I got some reading to do today. I stared at his ss and saw that he did have better numbers on 1.5 and when he went low, it really wasnt that bad - he was at 52 but it was toward the end of his cycle. He prob would have started going up without me giving him the high carb.

So I thought I would do 1.5 for 6 cycles. If he goes down to 52 again, I may adjust him to 1.25 before I leave and then we will get something in between the 98 on 1u and the 52 on 1.5u.

I REALLY REALLY appreciAte all the discussion about this. I think It helped me understand things better.

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YES!!!! This is what I like to see - you took the discussion to heart, studied your spreadsheet, and made a decision based on what your spreadsheet tells you. Great job! For what it's worth, I think you have made a good decision. You have had a recent diet change, so I think it is worthwhile to be a little on the cautious side while you figure out how that is affecting Bob (but not *too* cautious so he loses momentum). Picking a dose and holding it for at least 6 cycles will give you a good baseline for whatever decisions you make later on.

How long will you be gone? Usually we do suggest reducing the dose if the caregiver is out of town. Usually we suggest lowering to a dose that has a line to measure to. 1 unit might be a good choice, but since you have a few days before leaving I would gather data and see what the numbers say.

Thanks Libby - I guess I was so focused on the bounces I wasn't really seeing everything. Plus, I kind of need my hand held sometimes to understand what I'm seeing.

I'll be gone for 4 nights - Thursday through Sunday nights. I'll see how he does on the 1.5 and post again on tues night to see if I can get some advice on his dose when I leave.

Dara --

How about posting on Wed. morning to ask about dose, etc. before you're traveling? A lot can change in a day.

Who will be caring for Bob while you're gone?

Well that sound of made you head spin reading all the info, i know you will remember a 3rd of it :lol: can be alot sometimes, try to relax your doing great...

Sienne and Gabby said:

Dara --

How about posting on Wed. morning to ask about dose, etc. before you're traveling? A lot can change in a day.

Who will be caring for Bob while you're gone?

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I can do that. A friend of mine will be staying in my apartment. I posted on today's condo today was her first "training day". I think I traumatized her with all the instructions. She did pretty good though. I also have my parents and another friend who is a nurse stopping in to check on Bob.

mtncat58 said:

Well that sound of made you head spin reading all the info, i know you will remember a 3rd of it can be alot sometimes, try to relax your doing great...

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I read it all and got the basics! I think I'll be reading it again! I think I was confused about bouncing vs. Symogi effect. Thought they were the same thing.

Dara! Bob's condo has evolved into a very interesting and extremely informative collaboration. I have learned a lot from it. Thanks to you and all the contributors.

Frosty said:

Dara! Bob's condo has evolved into a very interesting and extremely informative collaboration. I have learned a lot from it. Thanks to you and all the contributors.

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Glad to hear it!! I actually feel better about things than I have in a long time. I'm definitely going to bookmark this condo!