symogi effect / hypoglycemic rebound

[Amity Island]

Good evening to you all,

I was reading an article on line which I came across recently and I was hoping..... does anyone have any views, opinions or experience on the symogi effect / hypoglycemic rebound? Is this something people are unknowingly experiencing, e.g finding it very difficult to control their blood sugars, constantly trying to make corrections to no avail? The article says the classic symptom of trying to make an additional correction of a hypo rebound high (and the ongoing cycle this then creates) is hypothermia (which is easy to measure) and that it is the sole factor that proves the symogi effect. Basically you'd constantly feel cold as you are trying to fight against the bodies only way to increase your bodies low blood sugar by the liver releasing glucogen.

It's not that well known or accepted in the healthcare profession. Hypos can happen at any time of the day and can also happen without symptoms sometimes, through the night even, this can result in glycogen being released from the liver to pick the blood sugar up rapidly. This leaves a morning high, feeling cold all day and headache. The dafne course did mention not to make a correction dose after a rebound, leave this to the next meal. The problem being, without a cgm or libre, most professionals would immediately say its your basal insulin running out early or your basal dose is not high enough. I know some people do get a dawn effect blood sugar rise sometimes, but this is not a hypoglycemic rebound.

I was just wondering if this could be the/one of the causes (besides pancreas still working sometimes) of "brittle" diabetes? From what the article shows, you can get into real difficulties if you are not aware of this, you get into a vicious cycle, by increasing your corrections and basals to try and rectify this (which will never work), as doing so will actually make the situation worse and worse.


I found this article quite good on the subject - link below. Basically says people who are taking too much insulin as a result of trying to mistakenly correct an untreated rebound high needs to reduce their basal gradually over time.
http://www.stat.yale.edu/~jtc5/diabetes/rebound_phenomenon_review.pdf

https://www.diabetesselfmanagement.com/diabetes-resources/definitions/counterregulatory-hormones/

I'd really appreciate any comments on this subject.

 

[mikeyB]

My comment is that it’s very contested, this Somogyi effect. It’s making something simple over complicated. And I always correct a rebound high if necessary. It’s not a mistake, it’s is simply a BG reading to put right. What’s wrong with doing that?

The web appears to be awash with this lark. I’ve managed 23 years of pragmatism, some on the forum a lot longer. Seems to have served me well.

 

[KARNAK]

The web appears to be awash with this lark. I’ve managed 23 years of pragmatism, some on the forum a lot longer. Seems to have served me well.

I`m afraid I agree with @mikeyB, who can tell you how your daily situation is? Surely we are all different and through learnt knowledge we know how to cope with a situation that may make us aware of how we feel, Hyper /Hypo and adjust our BGLs to enable us to control that problem. If the problem continues we take further advice whether that be Dr, DSN or HCP or any other person who can explain how to deal with it. We don`t have to agree with the answer but we usually get a positive result using this forum. There is so much knowledge available usually through personal experience but the decision is an individual choice. As always there is going to be controversy about how affected people re
act.

I'd really appreciate any comments on this subject.

There is a problem with Amity post sorry for singular rather than the plural name but surely there is a conflict of opinion which needs to be addressed? I would be very happy to understand why? I would also be interested to understand if an individual plus parents who have children with some form of Diabetes

symogi

Should they become involved in a situation were a certain statement compromises their outlook on life but has no impact on the end result Control of a personal regime of BGL is better than just jabbing when you feel ill, sorry its a bit long winded but I feel a bit passionate about the subject and hope all are aware of the reasons why we take control of our situation. Take care.

 

[Amity Island]

Hi again,

Very interesting this Somogyi Effect. More surfing the net, I've been trying my best to get a definitive answer on this 😎. This is what I can find. There is actually lots of information on the somogyi effect and it is well accepted by and taught to many professionals.
.
Firstly, hypo (hyper) rebound (not dawn phenomena) is something that T1's have been reporting for years. Secondly, there was a study done a few of years ago (link below) which showed conclusively by the use of continuous glucose monitors in patients particularly with T1 that Somogyi Effect is real. More importantly, from the pieces I've read, seems that the people who have had a Somogyi Rebound have been advised that because of the release of various reactive hormones to an undetected hypo, the body needs time to settle back down. This can take anything from 12 hrs to 3 days. This is done not by increasing bolus insulin (you could have insulin resistance for many hours) or giving corrections, but by going very light on carbs for a day or two, without any bolus for those light snacks plus a bit of exercise if necessary to keep b.s levels safe.

"Avoid an untreated night time hypo in the first place" seems to be popular "advice" on many threads. Easier said than done!

That's all folks! that's all I can find on the subject.

If anyone has any further info, research or studies please tag a link on.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653544/
https://nursingschoolofsuccess.com/episode12/
https://en.wikipedia.org/wiki/Chronic_Somogyi_rebound

 

[trophywench]

Well I've not made a study of it but have always been told to not correct rebound highs at the very least before the next mealtime but preferably the one after that. It works for me and I'm still here anyway.

 

[SB2015]

Another thing that can be useful is to manage the treatment of a hypo, when you are aware of them. I know that this is not the same as when it has gone unnoticed and the liver has dumped its glucose. However I now have jelly baby scale with which to treat my hypos, so that I don’t overdose, and start the inevitable yo yo effect of treatment, correction, treatment, correction, ...

 

[Amity Island]

Well I've not made a study of it but have always been told to not correct rebound highs at the very least before the next mealtime but preferably the one after that. It works for me and I'm still here anyway.

Jenny, thanks for your reply, that corresponds with what I understand on treating a rebound (ie you don't treat/correct) it at least not for many hours have passed).Exercise is an option to a correction dose, if your levels are little bit high.

 

[mikeyB]

Not for me it isn’t, I can’t exercise. So what am I supposed to do? This isn’t how the normal human body works, insulin is produced to keep BGs within range. The ideal T1 control imitates that, particularly with insulin pumps. That’s the ideal, not wandering around with a high BG because you had a hypo hours before.

 

[Amity Island]

Not for me it isn’t, I can’t exercise. So what am I supposed to do? This isn’t how the normal human body works, insulin is produced to keep BGs within range. The ideal T1 control imitates that, particularly with insulin pumps. That’s the ideal, not wandering around with a high BG because you had a hypo hours before.

Hi Mike, thanks for your reply. I think all DAFNE course advises is you don't make a correction after a hypo, the correction is offered at a later meal. The reason being, sometimes, but not always the body kicks out various hormones which can sometimes leave the body insulin resistant for a good few hours. So taking more insulin than the meal requires may cause further reactions from hormones. Obviously, everyone and every event is different, but to play it safe DAFNE advise a correction later on. There's a link here about temporary insulin resistance.
https://www.ncbi.nlm.nih.gov/m/pubmed/2903616/?i=3&from=/2043222/related

 

[mikeyB]

Well, that’s a realistic study isn’t it. Starving for 24 hours, an intravenous infusion of insulin, then an intravenous infusion of insulin, glucagon and somastatin. That’s starting with a theory, then manipulating the metabolism to prove your point. Arse about face.

Just like real life, isn’t it? I’ll just carry on as I am, thanks, untroubled by insulin resistance, as I have done for years.

You should learn how to read such reports. In essence, they say what they are doing imitates what happens in the body, then use the result to show what happens in the body. Aye, right.

 

[trophywench]

Yeah but getting on the see-saw of hypo -hyper -hypo-hyper is far too likely for me personally Mike hence if I do get to the stage when it absolutely can't stay that high any longer, and it WAS caused by hypo-hyper, and I haven't left it long enough for ME eg it's bedtime - I only have half as much insulin as I actually need.

 

[everydayupsanddowns]

Firstly, hypo (hyper) rebound (not dawn phenomena) is something that T1's have been reporting for years. Secondly, there was a study done a few of years ago (link below) which showed conclusively by the use of continuous glucose monitors in patients particularly with T1 that Somogyi Effect is real. More importantly, from the pieces I've read, seems that the people who have had a Somogyi Rebound have been advised that because of the release of various reactive hormones to an undetected hypo, the body needs time to settle back down. This can take anything from 12 hrs to 3 days. This is done not by increasing bolus insulin (you could have insulin resistance for many hours) or giving corrections, but by going very light on carbs for a day or two, without any bolus for those light snacks plus a bit of exercise if necessary to keep b.s levels safe.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653544/

Contrary to the conclusion of the 2015 study you posted, my understanding was that rather than confirming its existence, increased use of CGM has increasingly demonstrated that Somogyi is very very rare, and may not really exist at all in any meaningful way.

I certainly saw a presentation at the Diabetes UK conference in 2015 from Prof Stephanie Amiel (an internationally recognised expert in hypoglycaemia) which showed that in T1D counterreguatory hormone response, especially overnight diminishes with time. The brain physically adapts and changes with each exposure to hypoglycaemia to 'perform better'. These are changes that can be measured and more intensively managed diabetes (with increased exposure to hypoglycaemia) is associated with a lower counterregulatory hormone response - especially ay night. See also: https://www.researchgate.net/public...g_continuous_glucose_monitoring_in_daily_life

My own CGM observations (intensively managed T1D for 27 years with some impaired awareness of hypoglycaemia) shows that I can drop below 4 overnight and stay there for several hours with no apparent hormone response/uptick at all. I sometimes see some big, mysterious rises during the day which *might* be liver dumps, but not at night.

Additionally, I *can* get a massive rise in BG overnight, but this is more usually associated with late digesting carbs (eg delayed by fat) or changes in my insulin needs, which can often be quite significant day-to-day. A JDRF study with people on closed loop pumps showed significant differences in overnight insulin requirements (+/- 200%) with no obvious precipitating cause.

I used to see significant differences from bedtime to breakfast and assume it had happened, but personally I'm yet to see any evidence of Somogyi actually happening in my own CGM data.

 

[everydayupsanddowns]

Interestingly, on a related note... I saw some tweets from the OneTouch Sports Weekend recently, where Ian Gallen (I think it was him) was talking about glycogen being released during anaerobic exercise.

The analogy was that this was emptying a piggybank and people had to realise that they would have to 'pay it back' ie that glucose would be taken up by the liver/muscles later on directly without the need for insulin as the stores were restocked.

Not sure if that helps your thinking!

 

[Amity Island]

Interestingly, on a related note... I saw some tweets from the OneTouch Sports Weekend recently, where Ian Gallen (I think it was him) was talking about glycogen being released during anaerobic exercise.

The analogy was that this was emptying a piggybank and people had to realise that they would have to 'pay it back' ie that glucose would be taken up by the liver/muscles later on directly without the need for insulin as the stores were restocked.

Not sure if that helps your thinking!

Hi Mike, thanks for your comprehensive reply. Do you think this taking back the glucogen later is the reason why the DAFNE course recommends applying a correction dose at a later meal? Or is it more to do with some insulin resistance post hypo?

 

[everydayupsanddowns]

Hi Mike, thanks for your comprehensive reply. Do you think this taking back the glucogen later is the reason why the DAFNE course recommends applying a correction dose at a later meal? Or is it more to do with some insulin resistance post hypo?

My understanding of the DAFNE advice is that by instructing people to only act at the next meal they avoid over correction and dose stacking. So people see a reading in the teens 90 minutes after a meal (perhaps caused by dose timing or food/insulin absorption mismatch) panic and whack in a big correction even though they have plenty of insulin on board and would have been back in range or close to it after 4 hours.

By limiting corrections to mealtimes only doses will be 4ish hours apart and should have mostly finished acting (though will have a bit of ‘tail’ left. Earlier corrections can overlap peak insulin activity too (aka dose stacking) which can add further confusion into the mix.

I don’t think hormones or resistance are anything to do with it as far as DAFNE is concerned. It’s just trying to protect people against panic boluses.

Those of us who do correct between meals often use complex rules of thumb to work out how much if any insulin is needed, and for me it’s usually aiming to get me back towards 9 mmol/L which is where I should have been. But if I have activity coming up or suspect other weirdness sometimes I just let the double figures run for a bit.