10/9 Zeke - Help - Considering Abandoning LL

Could Zeke's ss be indicating that he's experiencing a somogyi effect due to overdosing and that we're actually giving him too much insulin and need to reduce the dose instead of increase? My husband is concerned that this is the case and is very much pushing that I not increase insulin but actually decrease to 1u. Your thoughts please? If you can provide links to medical guidance that speaks specifically to the somogyi effect and how you conclude based on the BG data obtained on your cat what is the right course of action - i.e., increase/decrease insulin.

Thanks,
Laura and Zeke



Zeke's previous condo

Re: 10/9 Zeke - Dose Too High? Dosing Question

I don't have years of experience, but it looks to me like he's bouncing. I'm looking at the nadirs you're getting, and that's your North Star. You were getting nadirs that were not low enough previously, so you upped the dose. Now you have so far, when you ignore the bouncing days, got a decent nadir. So hold the current dose, and see what his nadirs are once he stops bouncing.

Re: 10/9 Zeke - Dose Too High? Dosing Question

There have been numerous discussions of chronic Somogyi rebound on the board. This is from a post to Marje/Gracie's condo some time ago:

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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This is also a post from a follow up discussion in Gracie's condo that has links. I'm not sure if all of the links to the old board are functional, though.

From my perspective, there is insufficient evidence to indicate that Somogyi, if it in fact exists, is present in cats -- especially cats that are getting a long-acting insulin like Lantus or Levemir.

Re: 10/9 Zeke - Dose Too High? Dosing Question

Hoping Zeke gives you a nice surf very soon. Have a good day.

My husband is putting pressure on me to abandon the Protocol. He's concerned with the high numbers on Zeke's ss and thinks I'm overdosing Zeke. He thinks we need to reduce. He's also stated that when he looks at Zeke's ss he doesn't see a cat he feels will go into remission. Any advice? Is there anything you think I could say that might help to persuade him to give it more time? I'm still also not clear if Zeke needs an increase at this time or not.

Your cat is bouncing.
He's not getting too much insulin.
In fact, it appears you are giving him a great dose.

Bounces happen often and are part of the healing process, so you have to accept them, and they are in fact something positive.

Zeke's body is used to being uncontrolled. So when he starts getting low numbers, like you did recently, the liver FREAKS OUT and makes the cat have high blood glucose readings. What to do when that is happening is

- nothing-

A bounce can take about 3 days to clear. During that time, you have to be patient.

Feline diabetes is almost counter-intuitive at times, until you get used to what is going on with your cat's body, and the healing process. Being on this protocol is your cat's best chance at becoming well.

Let your husband know this.

I hope he will give this more time.
What I see on your ss, is that when Zeke gets low blues, he bounces to reds.... and when he gets greens , he goes black....
but he seems to clear those bounces rapidly. It doesn't take him days to come back down.

I'm betting that on 10/7, he went lower after that 132 at +5..... and then boing...

Bouncing is frustrating.... especially for a cat that does a rainbow slide across many floors.... but Mr. Zeke isn't as dramatic as some of the ss's here.

You could "steer" with food when you catch the lows to help his cycles be less dramatic.

I'm with the crowd.
I don't see that his dose is too high.
I just see that he needs more time for his body to re-learn not to react. ( dumping glucagon)
Everytime he gets a low blue or high green.... it is another healing moment for his pancreas.
He will get more and more of those as he progresses.

His dx wasn't very long ago either. His dose isn't very high. And he's already visiting the blues and occasional greens.
His chances are quite good really.
But backing off will prolong the process and could hinder his chances.

I really think you are right on course.


As a contrast for your DH, I'm pretty sure I caught FD quickly with my own girl.
She just turned out to be a flat liner.... and surfed and worked her way down the dosing scale without drama.
But it took 100 days.


We can't predict how long Zeke will take. There are some here that it took 2 years, but they made it otj nonetheless.

I hope you will stay with us.
You've got more experienced eyes here with the collective. And there have been so many make it to remission because of the help here.

I'm curious on what basis your DH is making his observation.

There is no "rule" regarding how long it takes for a cat to reach remission. There's also no way to tell when a bouncy cat will hit the "right" dose and everything falls into place. Take a look at these SSs. All of these cats went into remission -- in their own time and in their own way. You can't force a cat to do what you want their numbers to do. It's our kitties who are leading this sugar dance.

• Gobbles
• Mocha
• Max

There's also no guarantee that any cat will go into remission. It's what we all strive for but following the protocol isn't a guarantee. There was an experienced member here who kept telling me that in her eyes, Gabby looked like one of those kitties that would go into remission quickly. I can't tell you how hard it was as I realized that wasn't the case. I constantly felt like I was doing something wrong. What I've learned is that it's up to the cat.

Lowering the dose for a cat that tends to bounce rarely yields the outcome that you want. What typically happens is that the cat sits in higher numbers. You risk glucose toxicity developing which makes it harder to get numbers to come back down. You end up raising the dose, usually higher than where you before. And, ultimately, you lose time. A cat has a better chance of remission the less time that's elapsed since diagnosis. Using an approach that many contemplate and I've yet to see work means that by wasting time, you reduce the chance of remission.

Laura

I urge you to not abandon the protocol. You and Zeke have not been doing this very long and his SS does not look that different from many we see. Sienne has given you some good examples. Here is another:

leo

Kirsten Roomp, one of the authors of the TR Protocol, had this to say on Somogyi and rebound checks (which is what you would be doing if you lowered the dose):

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.

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Dr. Lisa (she is the feline nutritionist who developed our food charts) also said this about warranted versus unwarranted rebound (an unwarranted rebound is the same as a bounce):

Lisa DMV said:

Unwarranted = the body overreacting to a lower - but still very safe - number that it is simply not 'used to'…..a number that is still higher than we want. I digress again…and this was covered in another thread…but sometimes the distinction between the two (warranted vs unwarranted) is not made. Or, the distinction is made but the dose is lowered on an UNwarranted rebound which I do not necessarily agree with.

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I'd also like to show you the SS of a cat where a rebound check was done. At the top of his SS, click on the "Jan-May 13" tab. Scratchie was seeing nice blues/greens around 5.25u and then the dose was dropped to 1u as a rebound check. Look how much time he has spent in hyperglycemia. What happens is the glucose toxicity builds and, very often, the dose has to go up even higher than before the rebound check in order to reach a breakthrough dose.

Please read this post on Glucose Toxicity.

Finally, the way the TR Protocol is designed, if you increase and decrease per the protocol, you can't overdose the kitty. It's the larger increases (e.g. 1u) and missing reductions that can potentially cause an overdose.

I hope this helps, Laura. It's truly been my experience that continuing up the dosing scale per the protocol until you reach that breakthrough dose is the best path.

I know it isn't easy to say (or hear), but you need to tell your husband he's "wrong"?

Zeke is doing what every cat I've ever seen on insulin has done. He's bouncing. Not "somogyi", just plain old bouncing.

His spreadsheet really doesn't look that bad. Did he just start on Lantus in August? If so, this is hardly "too long" to even consider that he won't go into remission. Listen, my cat, Bob the Blob, was on PZI (not Lantus) for 10 weeks. His numbers were a heck of a lot worse than Zeke's spreadsheet. At least for about 5 or 6 weeks. Then "something clicked" and four weeks later, he was off the juice. That was over 2 years ago. He's still off the juice. But my real point is that 10 weeks was FAST. A lot faster than many kitties. The cat that always sticks in my mind (and Sienne linked you to her SS) was Mocha. Almost 2 years. At that point, many people would have given up. Peter and Devon just kept plugging along. I think Mocha has been OTJ for longer than Bob has been.

To me, it just looks like Zeke is a normal kitty. The insulin is obviously working. There's greens and blues on your spreadsheet. And the pinks and reds are just "normal". LIke I said, every cat does this.

I also think that it looks like his best cycles were back when he was on 1.5 and 1.25u doses. Lots of blues and greens. And he bounced back then just like he's bouncing now. The only difference to me is that back then, the bounces seemed to clear faster. Now it looks like they take a little longer to clear. Back then it looks like his AM cycles were more often than not "better" than the PM cycles. Now it looks like he's going lower PM than AM. But I fail to see anything on the SS that says "too much insulin" is being given. I think that the only real issue is that you haven't gotten to Zeke's "breakthrough" dose yet. If you continue to follow the protocol, you'll get to that dose. Taking him back down in dose, IMHO, is just going to set him back, could lead to glucose toxicity, and could make him more resistant to insulin.

He's concerned with the high numbers on Zeke's ss and thinks I'm overdosing Zeke.

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If you were overdosing Zeke, he would be getting very LOW numbers, and going into hypoglycemia (which can kill your cat).

If you start giving Zeke less insulin, he can chronically have too much sugar in his urine, which can lead to ketosis (which can kill your cat).

My cat crashed from exactly that - from having too much sugar in his urine over a long time, because he wasn't getting enough insulin.
It almost killed him.
It was extremely painful for him.
I had to rush him to a 24/7 veterinary hospital.
He spent 5 days in intensive care.
I cried on an off the entire time, especially when I'd get to visit him for 20 minutes and they'd wheel him in all hooked up.
It cost 5 thousand dollars.
It damaged his internal organs needlessly which now puts him so much further behind.

Then I decided to stop being stubborn and ignorant and thinking I know better than people with over a decade's experience, and came here and started following the protocol.

At first it was hard to understand.
I did not understand bounces, or much else.

After a couple of months, I saw my cat lift his head and look at me with a light in his eyes like "I'm back".
He now can jump and run again, which the vets said he would never be able to do again.

My vet has never heard of this protocol and has only given me bad advice, not because she's a bad person, but because she doesn't know any better.
Does your husband know better?
Are you willing to gamble with Zeke's life?

I am guessing that your husband feels frustrated and simply wants to DO SOMETHING. This is completely understandable, because treating feline diabetes is really frustrating at the beginning. It gets easier. One of the chief things about it is that the healing happens on your cat's time, on Zeke's schedule and you have to be patient about it. His liver is going to freak out for a while until it learns how to be healthy again. You have to be patient and let this happen. There's nothing you can do to hurry it along. So keep that in mind. And when you feel low or frustrated...we're here.

Turn to us, because we're a large and caring community of people who are all in various stages of the process, and we're an excellent shoulder to cry on. We celebrate our successes, and help one another understand, and make the right decisions to help our cats' health.

Hi guys ... I'm sorry that you guys are feeling so frustrated .. we've been there .. all of us on this board have been there!! As others have stated, it took mocha two long years on insulin before she said, nope .. I'm done with the "dire-beasties"! And she was! It just clicked one day, like I had read and seen on here so many other times before .. and so many other times before I thought, well if these people kneeeeeeeeeeeeewwwwwwwwwww how to get their cat's OTJ why the heck won't they just tell me how to do it!! But then I realized that no, they didn't know how to get their cat's OTJ .. yes, they knew of the best WAY to get their cat's OTJ (protocol) but that didn't mean they knew how to do it, and it would just get done .. it's a combination of knowing the protocol, following it the best way you can, and working patiently with your cat ... I hope that makes sense, and it's not just ramblings!!

It can be a long frustrating road .. and that's here, in LL, with the help and advice and comfort of all these other furparents who are going through the same thing .. I cannot even begin to imagine what it would be like going at this alone ...

We all implore you to NOT abandon the protocol. You came here for guidance, help, and support, and that's what we're all trying to give for you. We don't want Zeke to suffer any maladies of any kind. We want to help you help Zeke get better, and give you the peace of mind that you know you're doing the right thing by Zeke in helping him feel better.

This protocol works. Granted, I've been giving my cat shots for 3.5 years already, and we're heading to her 4th year next March. She went up to 5.25u BEFORE she decided that she didn't want that much. Your cat may or may not need that much before he decides that he wants to go back down. You don't know that. Nor does your DH. Only Zeke can tell you what he needs, and right now, he needs insulin. In order for the #s to go down, you need to go up in doses per the protocol. I've been told that many times, and I'm telling you that is what Zeke needs. If you decide to abandon the protocol, Zeke's going to continue to mope around, stay very close to the water bowl, and constantly be drinking, urinating, peeing, eating more because his body needs it, and may get other health issues, like ketones.

I'm NOT trying to scare you, believe me. That's the last thing we would want. You really have to think about the reality of the situation. Some cats can take years to become OTJ. It's not a miracle that it'll happen overnight. Either it will, or it won't, and that's the reality that we all face, myself included. Only Zeke can tell you through his #s what he needs, and doesn't need. Zeke may take a short time, or he may take a long time, or he may never be OTJ. You don't know that. All you can do is provide the best possible care for him, and make him feel better each and every day.

PLEASE don't quit. If you do, he'll go back to where he was before you found this board, and you'll have to start over again. It DOES work. You have to believe that. It simply takes time; how much time will depend upon Zeke.

If you decide to stay, and you follow the protocol, the next dose increase may help to give you better #s. Wouldn't you like to see that for Zeke? Hang in there, and please continue to have patience. His #s WILL improve... It takes time.

Having diabetes is not like having a cold or stomach upset. You can't just take some med and in a few days you are all better and the diabetes goes away like with a cold or stomach upset.

This is a marathon not a sprint. If you look at any of the OTJ party condos you will see that there have been over 200 cats that went into remission since 2008. While that is something that everyone wants, it doesn't happen to every cat. Sometimes the best you can get is getting the diabetes regulated and keeping the cat in safe numbers.

It's the same with people. How many humans who become diabetic later in life actually go into remission? They learn to live with it, adjusting diet, lifestyle and insulin based on the protocols. Well, it's the same for cats.

Yes, I know I can sit here and write this and you and/or your husband may be thinking well easy for you to say, I see that your cat Maui is in remission and has been for over four years. Yup that's true and it's because I "drank the koolaide" as they say and followed the advice from this board. I was also lucky that Maui really didn't bounce or have somogyi or any real complications.

But she was sick last week and when I tested her, the bg's were out of normal range. I started mentally preparing myself that she may need insulin again and that is just the facts of life when dealing with diabetes. Remission may or may not be a forever thing. Fortunately, when Maui started feeling better, her numbers came back to normal range.

I'm curious, if your husband doesn't want to follow the protocol, what exactly does he want to do and what does he hope will happen by doing that?

I will add something too. Back when Blackie was first diagnosed on March 13, 2010, she was eating the wrong kind of food, and was given ProZinc at the time. 8 units BID to be exact. Her #s were high, especially when she was at the vet's (average about 400+). The last time we took her to the vet, I suggested to the vet that I wanted to try her on wet food. Fancy Feast Turkey & Giblets at the time. The vet told me simply if I did that, we'd go up in her dose amount. She told me to leave it for a week, and if things didn't improve by then, we'd try it my way. When I got home, I started doing research on feline diabetes. Sunday Blackie was fine. I found this board that day, and I think I joined, too. The same day, someone from this board contacted me, and offered to help me home test her since I didn't know how to do that. Monday, the person came over, and Blackie was fine. The kind lady spent about 2-3 hours here showing and telling me everything that I needed to know. Tuesday morning, Blackie was fine. Tuesday afternoon, she wasn't. I noticed her walking like a drunken sailor. I immediately panicked and tested her. She was 21! I also immediately dropped her insulin to 1 unit of ProZinc (I think), and started her on the wet food that night. I called the vet the next day, and was asked why I hadn't contacted her the previous day when it happened. I told her I was busy trying to get her #s to rise. There was a pause on the phone. I asked the vet what I should do now, and she said, "Keep doing what you're doing". Since then, the vet hadn't interfered with her care. Later on, she called me up to inquire about the Lantus as she had a diabetic patient who wasn't responding to the ProZinc. I told her, and then she started the new patient on it, and was very impressed. The next time I went back in for an unrelated thing, I asked the vet how the new patient was, and she said, "That stuff works!" I told her that yes it does. She was able to get the cat regulated on 2 units BID. I also explained about the carbs, too, but that's up to the vet and the patient's owner.

Later on, the same lady from this board offered up a Lantus pen to try out on Blackie. I did. I haven't switched since. Had I NOT been here that day and seen Blackie's hypo, and had I NOT joined this group, Blackie wouldn't have been here. This board helps everyone. Yes, there are guidelines, but they're there for a reason. To do things properly, and safely.

Over time, and again more research, I learned about the food carbs, amounts, Blackie's weight, and what it'll do, or not do for her. I asked questions, and got answers. I may have asked the same questions many, many times, but you know what? These people never tire of them. You can ask the same questions over and over and they will always help you, and explain things to you so that you can understand them.

My husband has never interfered with my care of Blackie. He knows better. In fact, he's more supportive now than he was in the beginning. I truly hope that you decide to stay, and let us help you help Zeke. It's really in HIS best interest that he gets better, and at least in better #s, and get to feeling better. Frankly, I, and I'm pretty sure that the rest of the board, are very interested to see what his #s would be like in the very near future if you continued with the protocol.

I really hope you'll stay here.

For some Lantus-using bouncy cats, switching to Levemir may reduce some of the bouncing (see Lucien of nckitties, for example). Levemir is another depot insulin, so you continue to follow the protocol. And you may still get bounces, though perhaps not as high.

I'd wait until you finished your vial or pen, though, as both Lantus and Levemir are costly.

I wouldn't jump to switch insulins. I think you need to give Lantus at least six months.

While I think levemir is a fabulous insulin and it has really helped Gracie, I can show you many SSs of bouncy cats who switched from Lantus to lev and are every bit as bouncy. I'm not saying don't switch. I'm just saying, give the Lantus some time and if you do decide to switch, understand you might see the same bounciness.

I think Lucian stands out as one that flattened out a lot...but he does still bounce.

I don't post much anymore due to time constraints but I lurk on the board. I hope you will reconsider your decision to leave LL. Tuffy was a very difficult kitty. 27 1/2 month on insulin. We spent the first 9 months on Health. She started on PZI and after 3 months the vet switched her to Lantus.On health she had worked up to 10 units BID. With the help of LL and all the committed members we switched to LL forum and reduced the dose to 7 units. Gradually we worked our way down the dosing scale, with mega assistance and many instances where we had to go up again. It was not an easy journey. She stayed high for months. When we finally got the dose down, she would bounce for days. As she started doing better, she would drop to very low numbers. We had quite a few nights where we had PJ parties and I had to work the next day. Tuffy went OTJ when I never expected it and I don't think many others did. Tuffy is no longer in remission, I was hospitalized for 3 days and she stressed out, went DKA and now we are back to the sugar dance. She is still bouncing and dropping, would I give up, NO. The resources and support here are fantastic. I never became discourage with the assistance I received here.

I tend to be very conservative but I think I would increase Zeke's dose to 1.5. He was doing better on that dose. I was often told if you let them stay in high numbers they build resistance. I'm sure others will provide some input regarding his dose.

I hope you continue with LL and the board. This is a fantastic resource and support group. Good luck. I hope Zeke starts to "stop bouncing". That is a wish we all have at one time or another.

Laura

I definitely think you should raise his dose to 1.5u starting tonight. He's gotten some green but you've got plenty of room to take the dose up to bring the overall curve down. IMHO.

I believe in the Protocol and I want to continue with it. However, there are personal circumstances (at this time) that are complicating continuing with this course of action. However, I am working on ironing out those issues. Thank you all for your replies. The information provided is greatly appreciated. I definitely have extreme confidence in the FDMB community and the support and guidance its members provide.

Hang in there!

Maybe print out the Roomp and Rand article for him?

Laura --

We'll help in whatever way we can.

I think you've been given some excellent information, & I agree with everyone else on the Board.

When Tigger first started on Prozinc, the 1st day @ 1 unit (3rd day total) he got a 93. Unfortunately my vet (at that time) had me cut the dose from 1 unit to .5 & wanted me to hold it @ .5 for 1 month. I cut the dose - against the advice of Board members - then regretted it, & started back up the next day but the momentum was lost & it took 6 weeks to get back to numbers below 100.

Tigger still bounces alot, but as we get into a certain dose range, he also reaches good healing nadirs. We've had to go up & down with doses a few times because the reductions haven't held, but each time we go back up within a certain range Tigger's numbers get better for longer periods, which I feel is an improvement. Even my husband agrees. I figure the more we do this, sooner or later we'll level out & Tigger will stop bouncing.

Even if Tigger never stops bouncing, I know TR is healthier for him.

I hope you are able to stick with the protocol and give it some more time. Yes, it's alot of work, but volunteers here will support you & help you through the tough times, laugh & cry with you & stay with you on low nights providing blow-by-blow advice. I don't think you can get that from any vet, even the best. The information you receive here will often be more detailed than anywhere else & you can tailor it for your needs as time goes & you get a greater sense of Zeke's cycles & patterns. You're still a newbie, I imagine it took Zeke awhile to become diabetic - it will take awhile to reverse those effects. Please try & have patience & give it more time to work.

I'm glad you're going to stay, Laura! We're here to help you get Zeke better. The protocol DOES help, and there are success stories because of it. Zeke may be one of them, and all you can do is try. Lord knows I'm still working on it. :lol: