Intro/Hello! & Bouncing vs. Somogyi Effect

Hello everyone. I realize I never wrote an intro post, so here it is... in conjunction with some questions regarding bouncing vs. somogyi overswing.

My boy Bubba was diagnosed with diabetes in September 2022. I am so lucky to have such a cooperative & patient little boy... he takes his ear jabs with gusto and sits still for his insulin shots. I've had him since he was a wee 4lb kitten, so this diagnosis was devastating to say the least. He has been fed raw food his whole life - so nutrition isn't an issue for him, in the context of what is appropriate food for diabetic cats. He has no history of DKA or ketones. I'm a nurse... so I have the diabetes education and am comfortable with checking sugars & administering insulin.

After a few rocky starts on caninsulin, then lantus, then back to caninsulin - since Jan 5 2023 we have been on lantus. We started with the SLGS protocol for about 2 weeks with no significant decrease in BG #s/nadirs. Then on Jan 19 2023, we switched to the Tight Regulation protocol - with slow progress since then. You can view Bubba's insulin history on the 'Nov/Dec 2022' & '2023' tabs on his SS. I have been graciously guided by @Bandit's Mom & @Wendy&Neko and a few others, so thank you! If anyone else has any input, I appreciate your thoughts!

Having said that, while Bubba's vet is supportive of the TR protocol, they're apprehensive with increasing the dose every 3 days (as per the TR protocol) - instead they advise pet parents to adjust the dose every 5-7 days. On Jan 29 & 30, Bubba finally had some blue & yellow #s - and in the following days expectedly experienced some bouncing - unfortunately, Bubba hasn't seen any blues or yellows since then Thankfully, the last 1-1.5 weeks, Bubba has experienced a decrease in water intake & urine output, and seems to be less hungry overall (still has a good appetite/completes all of his meals).

When I described his bouncing phenomenon to my vet, they responded to be careful with it and that it sounds similar to the somogyi overswing. They suggested I hold Bubba's dose - which was 3.25U (at that time) for another week, or return to the previous insulin dose (3U) for another week. Her reasoning is that since the blood sugars drop too much/too fast, this could indicate that the insulin dose is "too high" - hence holding the current dose, or reverting back to previous dose... however, this contradicts the "bouncing effect" as described on the FDMB.
I bring this up as I hope someone could unpack the differences between bouncing & the somogyi overswing for me? Just so that I better understand the difference between the two, in the context of feline diabetes.

From what I understand so far, is that since Bubba was experiencing high BG #s for so long, that he eventually developed glucose toxicity - of which higher insulin doses are required in order to achieve appropriate nadirs. And if I were to follow the advice of my vet/somogyi overswing (by holding the 3.25U dose, or decreasing to 3U) - Bubba would continue to experience high BG #s - correct?

Bubba's thread from today: https://www.felinediabetes.com/FDMB/threads/02-02-bubba-amps-389-3-5-331-9-407-pmps-401.273737/

Somogyi overswing link my vet sent here: https://www.merck-animal-health-usa.com/vetsulin/cats/the-somogyi-effect

Great article on rebound hyperglycemia here which effectively debunks somogyi overswing LOL: https://journals.sagepub.com/doi/full/10.1177/1098612X15588967#:~:text=Rebound hyperglycaemia (also termed Somogyi,be common in diabetic cats.

Thank you for your time!

Bubba's SS:
https://docs.google.com/spreadsheets/d/1lqTm8ESOUq93x2dFowG7w0WzXaJyPElWAqgnr8B9Tys/edit?usp=sharing

 

Just so you know, Symogyi is a hot button here, It has been disproved as something that occurs in cats (and humans). "Symogyi" was surmised based on a small study on humans with fast acting insulins decades ago. Unfortunately a lot of vets were taught that it was a thing. And it looks like some websites haven't caught up either. Here is a link to article by the same authors who first published the TR protocol. Rebound hyperglycaemia in diabetic cats.pdf That is the same paper you linked last.

Trust the protocol, it's worked for hundreds and hundreds of cats here. And yes, if you decreased the dose, he'd continue to be stuck in glucose toxicity.

 

Thanks Wendy ... I appreciate your input! The somogyi overswing (as described via the link my vet sent) sounds so similar to the bouncing effect (as described here on the FDMB).... I was just confused as to why the protocol/follow up for either are so different! Decrease/hold dose vs. increase dose
Having said that, I'm very thankful for the knowledge of you and @Bandit's Mom thus far

 

I have been curious as well to better understand the different biological mechanisms involved in bouncing vs. somogyi (having read previously that somogyi has been de-bunked)!

 

The difficulty with Somogyi is that there is no research replicating the original 1938 paper. And frankly, good luck finding the paper as it wasn't published in a mainstream medical journal. (It was published in the Weekly Bulletin of the St. Louis Medical Society.) With Somogyi rebound, the high BG levels are found in the morning as a result of lower levels in the evening. The original publication did not differentiate between Somogyi and dawn phenomenon (which involves a rise in BG due to waning insulin levels and a normal surge of growth hormone/corticosteroids in the early morning hours to prepare the body for the stresses of the upcoming day). More recent studies involving continuous glucose monitoring have noted that the high BG in the AM is most likely due to insulin wearing off or that BG levels remained low and did not result in hyperglycemia as would be predicted with Somogyi rebound.

The other issue is that the paper is decades old. The current long acting insulins work very differently than what was available in 1938 and trying to generalize from an insulin like Novolin to an insulin like Lantus is not sensible. The study was done on a very small sample and has never been replicated. Further, it would require generalizing from humans to felines. The paper by Roomp and Rand suggests that Somogyi is not applicable to cats that are prescribed Lantus.

 

Thanks @Sienne and Gabby (GA)! If I understand the difference correctly - Somogyi's theory was very narrowly defined as a drop to hypoglycemia during the night that causes morning hyperglycemia? Whereas 'bouncing' is a more generalized response of the body to raise blood sugar after a BG drop either too low or too fast- at any point in time?

 

Here’s an article on rebound hyperglycaemia
https://journals.sagepub.com/doi/10.1177/1098612X15588967?icid=int.sj-full-text.similar-articles.3

 

Thanks @bubbasmom! From what I understand that paper is basically de-bunking the Somogyi effect in cats.

I'm still confused on the differences between Somogyi/rebound hyperglycemia (defined in the paper as: "hyperglycaemia caused by the release of counter-regulatory hormones in response to insulin-induced hypoglycaemia")

vs. bouncing (defined in a sticky as: "a natural reaction to what the cat's system perceives as a BG value that is "too low". "Too low" is relative. If a cat is used to BGs in the 200's, 300's, or higher for a long time, then even a BG that drops to 150 can trigger a "bounce". Bouncing can also be triggered if the blood glucose drops too low and/or too fast. The pancreas, then the liver, release glucogon, glycogen and counter-regulatory hormones.")

...I must be having a very dull moment Or is bouncing is the same as Somogyi?

 

No prob. From what I gather, bouncing occurs when the cat’s blood sugars have been high for so long and the cat is so used to being high, that when you start to introduce insulin and the blood sugars begin to decrease… the liver, pancreas etc panic and release those hormones that cause an increase in blood sugars.
Like with my boy, he’s so used to being so high all the time when he gets a nice blue or yellow number I don’t see those numbers again for a while. So irritating LOL

found this random link to someone blog about their diabetic cat.. they also references the FDMB lol
https://sugarcatdiary.wordpress.com/2020/01/08/day-9-bounce/

they mis-stated 6 cycles as being 6 days… but it’s actually 3 days (2 cycles per day)

 

Oooooh I think I understand now (maybe?!?)--

Somogyi is saying "the insulin is pushing the cat's BG too low (true hypo), such that it's body reacts out of necessity to save itself (hyper)"

whereas bouncing is "the cat is so used to having high BG, that any perceived lows can cause it's body to over-react (when most times it wasn't really necessary)"
?

 

That seems a reasonable understanding?? maybe @Sienne and Gabby (GA) and @Wendy&Neko could confirm/clarify? or tag anyone else who may be able to confirm/clarify

this article also describes the effectiveness of using intense glucose control aka TR using lantus
https://journals.sagepub.com/doi/10.1016/j.jfms.2009.04.010

this section from the same article above perhaps also describes 'bouncing' if I understand it correctly:

"A previously undescribed phenomenon was observed in approximately 1/4 of the cats that recently had their insulin dose increased, which consisted of inexplicably higher blood glucose concentrations for the first 2–3 days after a dose increase, without a preceding hypoglycaemic blood glucose concentration being detected. The cause of the effect was unknown, but a low-grade counter-regulatory response might have been involved."

 

That's the phenomenon we call New Dose Wonkiness. It is not bouncing. More info here: New Dose Wonkiness (NDW) and failed reductions

 

Do we have you thoroughly confused yet?!!

My understanding of Somogyi is that it was described as an overnight phenomenon: insulin is dosed at night, numbers drop and then rebound and are high in the AM (i.e., "rebound hyperglycemia). The recommendation is to reduce the dose. There is some conflation with dawn phenomenon and frankly, I don't know if dawn phenomenon was adequately defined or even acknowledged in 1938.

What we call "bouncing" is a more generalized phenomenon. It's not constrained to a particular time of day or night. It's also a more relative term. A cat that may be accustomed to BG numbers in the 400 - 500s may bounce if numbers drop quickly into the 200 - 300s. Likewise, a cat that may be used to spending time in the 200s may bounce if numbers drop into the 50s.

We do not suggest reducing the dose if a cat is bouncing. There are other feline diabetes groups on the web that will offer this advice. We've seen way to many caregivers follow those instructions only to have their kitty sitting in high numbers for even longer. It's not a good strategy and yet another strike against a poorly researched construct like Somogyi.

And then, as Wendy noted, there's New Dose Wonkiness -- a term only used here!

 

Thanks @bubbasmom @Wendy&Neko and @Sienne and Gabby (GA)! This has been helping.

Somogyi: Insulin dose is too high causing BG to drop too low, bodily response = raise BG ---> lower the dose (not recommended unless a true low # was observed per TR or SLGS guidelines). Theorized to occur mostly overnight.

Bouncing: body perceives BG as too low even though it is truly not, bodily response = raise BG ---> maintain the dose (since the body is over-reacting to a false alarm) unless a true low # was reached per TR or SLGS guidelines.

New Dose Wonkiness: higher BG numbers a day or two after a dose increase (possibly due to a similar mechanism as bouncing, but this is unclear) ---> maintain the dose (as true #s should shake out over a few cycles).

 

@Erin Ethan -

You're mostly correct. A bounce can occur as you describe it but also if a cat legitimately drops into low numbers. If a cat drops below 50, I would suspect there may be a bounce. Bounces also tend to level out once a cat becomes more accustomed to being in better/lower/normal range numbers.

Erin - I didn't get your tag. I suspect it's because you put two tags together. The website is a bit glitchy with tags. It's best to put one on a line to ensure the person gets your tag.

 

@Sienne and Gabby (GA) Noted re: tagging!

Makes sense re: a bounce also potentially happening from a truly low # (& if this is observed a reduction may be warranted).

 

Q

yes that’s it! I knew that too when I read the article about a week or so ago… my 5hr sleep and Swiss cheese nurse brain mixed it up hahaha