Somogyi Effect

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Somogyi Effect

During sleep, you are without food (fasting) for hours. It makes your blood glucose drops, proportionally your insulin level also reduced. At the same time, glucagon level raises, which instruct the liver and muscles to ramp up glucose supply.

Fasting can elevate cortisol levels, which in turn raises blood sugar. So, for someone with blood sugar regulation issues such as diabetes, fasting may make their blood glucose worse.

What is Somogyi effect?

 Somogyi phenomenon is due to your body’s reaction to midnight hypoglycemia. Since the patient is sleeping, they don’t feel the hypoglycemic symptoms such as tiredness, shakiness, tremors, or confusion. This low blood sugar is undesirable. Thus your body reacts to this with an overshoot of counterregulatory hormones such as glucagon, epinephrine, growth hormone, and cortisol. It makes the liver to dump hepatic glucose, which raises morning blood glucose level even up to 300s. Additionally, counter-regulatory hormones may cause insulin resistance for about 12 to 48 hours.

Fasting blood sugar level is elevated in reaction to the preceding low. Thus Somogyi effect is also called as rebound hyperglycemia.

The patient is succumbed to increase the insulin dose still more; this leads to further more hypoglycemic episodes. A vicious circle leads to increase, and increased insulin doses occur with extremely unstable and brittle diabetes.

High dose insulin / Missed meals --> Hypoglycemia at midnight --> Body adjusts by releasing cortisol, glucagon, etc. --> Hyperglycemia in the morning --> Treatment is by insulin dose modification.

What causes Somogyi phenomenon? Causes of Somogyi phenomenon may include wrong insulin treatment (dose or timing) or missed meals/snacks.

What are the symptoms of Somogyi rebound? At night, if you wake up few times sweaty with rapid heart rate indicates adrenaline shoot-up and rebound hyperglycemia. But, unfortunately, evidence shows type 1 diabetes do not wake during hypoglycemia episodes.

When & who discovered Somogyi effect?

In 1938, in a group of unstable diabetics study, Dr. Michael Somogyi and Kirstein noted over treatment with insulin could be a cause of extreme hyperglycemia and improper control. This phenomenon of rebound hyperglycemia; hypoglycemia followed by hyperglycemia is known as the Somogyi phenomenon.

Prevalence of Somogyi Phenomenon

Prevalence of Somogyi phenomenon is about 12.6%, but often goes undetected! Somogyi effect is less common as compared to Dawn phenomenon.

About 10% of insulin-treated diabetics, fall into the brittle or unstable diabetics. Somogyi phenomenon is rare; occurs in diabetes type 1 and less common in type 2. It is more commonly associated with type 1 diabetes because it is associated with little endogenous insulin production and relying on insulin.

Diagnosis of Somogyi phenomenon

How do you detect Somogyi effect? The best method to detect Somogyi is continuous blood glucose monitoring. However, it is not yet widely used. Alternatively, you can detect it by testing your blood glucose more often, say 8 to 10 times with your blood glucose meter specifically more often during pre-dawn.

If you are experiencing high fasting blood sugar level even after increasing your night time insulin dose, then it might be Somogyi phenomenon. If you are experiencing hyperglycemia that does not respond to your treatment as expected, then it is most probably due to Somogyi effect. To confirm diagnosis check your blood sugar at 2 or 3 am, if it is low, then it confirms the diagnosis of the Somogyi Effect.

I am not sure, if the morning hyperglycemia is due to Dawn or Somogyi effect, what to do? The simple lazy way is to a slight decrease in the insulin dose at night. If there is an increase in blood glucose level in the next day morning, then it is Dawn phenomenon. If the glucose level is normal or decreased in the next day morning, then it is Somogyi phenomenon.

Treatment & Management

How do you treat Somogyi effect? Somogyi phenomenon recommends a gradual reduction in the insulin dose to achieve stable blood sugars, decreased urinary glucose excretion, and effective diabetic control. If the Somogyi phenomenon is wrongly detected, reduction in insulin dose will only aggravate the hyperglycemia.

The best treatment option is to prevent the hypoglycemia from happening. For this, you need to reduce evening or bedtime insulin dosage.

Additionally,

  • You can take bedtime snack high in protein, moderate in fat and low in carbohydrate to avoid midnight hypoglycemia. For example a piece of toast with peanut butter, or some cottage cheese, or yogurt, or some nuts and a small piece of cheese.
  • Always manage your glucose level slightly higher before going bed.
  • Take blood glucose test between 2 to 3 a.m. and check how effective is your treatment and consult your doctor, if you need any changes such as type and dosage of insulin, oral medication.
  • Substitution your regular insulin with an immediate-acting insulin analog, such as Humulin lispro, may help you. Still, it is not firmly established.

Liver dump can happen if you take insulin (or other insulin stimulating medications) without an adequate amount of carb may end up with low blood sugar level. So it is important for you to balance medication with the proper quantity of carbs, this usually requires testing to arrive right quantity for you.

Similar to medication, excess amount of exercise not balanced with an adequate quantity of carb end up with liver dumps. Carbohydrates are not enemies for people with diabetes. Instead, you should learn when and how to take them for beneficial results.

It looks complicated at the beginning, but over time, you start learning to balance it correctly. You just need some testing with patience and interest to learn.

For many diabetic’s insulins is not working to their optimal level; it is because of injecting insulin in the skin area affected by lipo hypertrophy. The most used insulin injecting area may develop fat build-up. Therefore, you must rotate your insulin-injecting site often.

Somogyi controversy!

SOMOGYI's concepts were not universally accepted. Because studies using continuous glucose monitoring show, a low glucose does not precede a high glucose in the morning during the night. Reference: Nocturnal hypoglycemia in type 1 diabetic patients: what can we learn about continuous glucose monitoring? Diabetes & Metabolism, 2007: 33: 360-365.

Somogyi phenomenon has documented in great detail; the exacerbation of diabetes by excess insulin action. Still, there is controversy about its existence. Asymptomatic hypoglycemia is the one reason the Somogyi phenomenon has not widely accepted. Somogyi effect is controversial and difficult to prove its presence or absence. 

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