10 yr old Cutie, Cushing's, Diabetes, skin infection (update: starting trilostane)

[benefr]

Dear All,

I am new here. and would appreciate feedback:

My dog was diagnosed about a month ago with cushing's, diabetes, pancreatitis, and associated acute renal failure.

We tried trilostane and stopped after a few days - the advice was to first stabilize her in terms of diabetes (we are still not sure about insulin nph dosage as sugar levels went up in one episode).

Any recommendations?

What about diet? she lost a lot of weight, and I am not sure the high protein levels in Diabetes foods (such as purina DCO) are good for her.

Anyone would like to provide mentorship advice?

Thanks,

Ronen

[Roxee's Dad]

Hi Ronen,
I would like to welcome you and you pup to k9cushings. It does sound like there is alot going on. :eek: Can you tell us more about your pup.

His name, breed, weight?

What symptoms led you to take him to the vet?

What test were done to diagnose cushings, diabetes and the pancreatitis? Was there also an additional wellness panel (blooddtest)?

Can you post the abnormal results of the testing that was performed? Please include the normal range reference.

The others as I affectionately call them will be by to help you sort thru this. We have a few members also dealing with multible issues and are slowly working their way thru this.

We also have a sister forum that deals with k9diabetes, we have quite a few members active in both forums because thier pups have been diagnosed with cushing's and diabetes. From what I understand diabetes and along with pancreatitis can give a false diagnosis of cushing's (not always):( but can certainly contribute to higher cortisol levels.

http://www.k9diabetes.com/forum/index.php

Hang in there, it's the holiday's and it may be a bit slow around here for a few days but help will be along. In the meantime you may want to check out our resources section to be better informed. You are the only advocate for your companion and the better informed you are, the better you can speak up for your pup.:)

http://www.k9cushings.com/forum/forumdisplay.php?f=10

[Squirt's Mom]

Hi Ronen,

Welcome to you and your baby! :)

Goodness! What a lot to be dealt all at once! :eek: Bless your heart!

Of the things diagnosed with, put Cushing's on the back burner for now...it is the least of your concerns today. For now, focus on the pancreatitis. Until the inflammation there is under control, the specific testing for Cushing's could easily be skewed. More importantly, pancreatitis can be fatal if not quickly and properly treated. If I'm not mistaken, this will also make the BG much more difficult to regulate. Once that condition has been stabilized, then we can move on to the others.

While you are getting the pancreatitis under control, please do post the test results to date along with the units of measurement and normal values for each lab. I also hope you will join our sister site, k9diabetes; they are the experts on that disease!

I am sure this has been just over-whelming for you, but don't be discouraged. You will not have to take the journey alone, we will be here to help you in any way we can. So keep your chin up!

Hugs,
Leslie and the girls - always

[BestBuddy]

Hi Ronen,

I agree that the diabetes is the thing to work on first.What breed is your dog and what weight? I'll just give you a few basics about the diabetes, nph insulin is usually give 12 hours apart at 1/4 to 1/2 unit per pound dosage. Two meals a day usually of equal amounts to be fed before each injection. Once this all settles down you can look at the food and adjust slowly to get better regulation.

I am away with family this weekend but if you pop on over to the diabetes board http://k9diabetes.com/forum/forumdisplay.php?f=2 I am sure there will be some help if you have problems.

Jenny

[littleone1]

Hi Ronen,

Corky and I would also like to say hi and welcome to a wonderful group of very caring, supportive and knowledgeable people.

They have already given you good information and links. I hope all goes well for you and your furbaby.

Terri

[Harley PoMMom]

Hi Ronen,

Welcome to you and your furbaby from me and my boy Harley. My oh my, you do have your hands full, so many issues at one time. :eek: I am hoping you have a cushings savy vet or IMS (Internal Medical Specialist)? And if not, please don't worry, many of us don't either. :eek: Thank God for this forum, altho we are not vets, but there is years of collective experience and knowledge about cushings from people on this forum.

Re; the pancreatitis, was this diagnosed before the diabetes or after? And how was the pancreatitis diagnosed? The reason I'm asking is because some predisposing factors that cause pancreatitis may be high fat, low protein diet and other diseases (Cushing's disease, diabetes mellitus). But Acute pancreatitis may produce temporary diabetes mellitus.

We really need more information about your pup so we can give you better and accurate feedback. The more we know about your pup the better we are able to help you help your furbaby.

Hugs,
Lori

[Franklin'sMum]

Hi Ronen,

Just wanted to pop in and also welcome you and your boy :) I'm sorry your sweet girl is having so many issues, but you have found a group of truly amazing people with a huge amount of kindness, knowledge and experience. I honestly don't know where I would be without this forum and people.

Jane and Franklin xx
________
Druidism advice (http://www.religionboard.org/druidism/)

[benefr]

Dear All,

Thank you very much for the caring responses! Roxy's Dad, Squirt's Mom, BestBuddy, little1, Harleypomom, Franklin'sMum: Thanks for following my thread, and providing your valuable advice.

Here is the story:
About a year ago we noticed our dog less willing to go for walks, and hair didn't grow much after got trimmed. In addition, potted belly and overwheight look.

About 5-6 weeks ago my dog (She is a mixed little cutie, looks somewhat like Coker Spaniel) stopped eating.

Vet indicated Creatintine 5.5 (!) and high sugar levels.
She got fluids, started with regular insulin, Pancreatitis test showed positive, and then we started with nph in a process to stabilize sugar levels (dosage ran from 5 units to 13).

As she got better (Thank G-D), after a few weeks, we started with trilostane (ACTH test indicated Cushing's), but we stopped after at some point her appetite went down again - and test showed kidney failure again, probably given to very high sugar levels).

She is on the right track now (TG), and we are trying to determine correct nph humulin levels (we moved from 9 recently to 13 units, as glucose jumped from 300 to 700, and now it's 400).

We do sugar blood tests every two days, and don't really use keto sticks.

Diet: we recently put her on DCO, with occsaional chicken breast and rice (and sometimes some cottage cheese and/or yogurt).

does anyone have recommendation in terms of good diets for cushing, or factors that can excerbate situation? Does anyone have experience with Purina DCO vs. other foods? (could it be that DCO causes some constipation?).

What about a good time to start trilostane or the other drug ? any preference?

Thanks!!!
--Ronen

[sunimist]

Hi Ronen, and welcome from me too. :)

I am not sure of the time frame in all the events, but is the pancreatitis controlled now? I didn't see it mentioned in your last post about how it was approached and treated.

Like the others have said, I would focus on getting the diabetes well regulated before starting cushings treatment. It (cushings treatment)is the least priority right now, IMO.

BTW, what is your little cutie's name?

Shelba and Suni

[Harley PoMMom]

Hi Ronen,

With your furbaby's special issues and needs you might want to look into getting a diet formulated for her, if it is feasible. Here are two that I recommend.


Hi Christine,

I don't know if you are still contemplating home-cooking but if you are here is a post from Cushy to another member about Dr. Remillard, and I've included Monica Segal too, now Monica, as far as I know is not a certified veterinary nutritionists.



Monica Segal, AHCW


Monica Segal is certified in Animal Health Care through the University of Guelph with studies in animal nutrition,physiology, diseases and parasites, as well as pet care.
She writes featured articles in many publications throughout North America. Monica conducts seminars and workshops by invitation, hosts an Internet discussion group at K9Kitchen, and authored a book called "K9 Kitchen, Your Dogs' Diet: The Truth Behind The Hype," published in June 2002. Her second book, "Optimal Nutrition" inlcudes a foreword wrtten by Ana Hill DVM, PhD and was published in 2007. Monica lives in Toronto, Canada, with her husband Morley and dogs, Cassie and Tori.

Nutritional Philosophy

Each dog is an individual and needs to be fed that way. Itchy skin, runny eyes, gastrointestinal problems and a myriad of other complaints can often be traced to dietary sensitivities. Certain breeds and individuals are predisposed to particular ailments that may be addressed by dietary modifications. Addressing disease may require a unique change in diet plans.

Respecting the needs of individual dogs translates to feeding a diet that supports uniqueness. The notion of there being one perfect way to feed all dogs is a myth. Some will thrive on an all raw diet, others will do best on cooked foods while yet others will do well eating a combination of both. The choice is based on the dog owner's comfort level with a particular method of feeding and the dog's tolerance level of that choice.


http://www.monicasegal.com/

Harley is on a diet formulated by Monica Segal, but he's only been on this home-cooked diet since 10/31/09. So far he is doing really well, but it still too early to tell.

Hope this helps.

Love and hugs.
Lori


Karen,

Just another idea I thought you might like to know about. I don't know if you'd be interested in this, but if you are looking for help with formulating a good homemade diet for Jed, maybe you and your Vet can work with Dr. Rebecca Remillard, who works at the Angell Memorial Vet Hospital in Boston.

Here's a little blurb about her on the Angell Memorial website:
http://www.mspca.org/site/PageServer?pagename=nutrition_Team (http://www.mspca.org/site/PageServer?pagename=nutrition_Team)

She is a Board Certified Veterinary Nutritionist (DVM, Diplomate ACVN) and in addition to her job at Angell Memorial, she also has a website http://www.petdiets.com (http://www.petdiets.com/) where she does offer consultations and formulation of diets for pets with medical conditions.

I've never used her service, but I did know someone (online at another e-group) who consulted with Dr. Remillard in person at Angell Memorial in Boston, and she was very happy with the homemade diet that Dr. Remillard created for her dog.

Here's some info about Dr. Remillard's services from her website:

https://www.petdiets.com/Consult/default.asp (https://www.petdiets.com/Consult/default.asp)


Our Expertise:
We specialize in making sound dietary and nutritional recommendations for dogs and cats with medical conditions. Your pet may be sick and not eating the recommended diet well. Your pet may have more than one medical condition for which there is no single best commercial pet food. We make recommendations and formulate diets based on current principles of dietary management and the pets' food preferences. We offer choices based on the known current scientific literature and our clinical experience.

This is a Nutritional Consultation through your primary care Veterinarian:
Your primary care veterinarian as a vital partner in the care of your pet. Legally, we must work through your veterinarian because we do not have a primary doctor/patient/client relationship with you. We work as a specialty consultant to your veterinarian. Our recommendations will be sent directly to your veterinarian for review and you will be notified when the information has been sent to his or her office.

Client Education:
We also consider client education an important part of our mission and service. We provide you with the most current information specific to your pets’ medical condition(s) in an understandable prose written specifically for pet owners. Pets only need one nutritional formulation (one recipe) however, food substitutions are offered when appropriate.

Recommendations:
We fax our written recommendations to your veterinarian for review. You will be asked to provide this contact information. We will complete our recommendations generally within 10-14 business days of receiving confirming medical information from your veterinarian. Our charge for a personalized Nutritional Consultation is $250 for your first pet, but then discounted ($100) for your second pet or discounted further ($50) for the third pet in the same household IF different diet formulations are required. Most times, we can design a diet that accommodates more than one dog or cat in the household.

This fee covers product research, review of medical information and a diet formulation. It also covers all questions you may have about our diet recommendations. Food substitutions are always offered if appropriate. Please understand there is an additional charge of $100 to reformulate another homemade diet if you should later request a change in ingredients, foods or supplements that were not previously specified or if the pet should develop another medical condition.

Note that she provides different kinds of dietary advice (commercial diets, homemade diets, or a mix of the two) depending on what you ask for:

https://www.petdiets.com/popup/popup.asp?url=body.asp&sT=Types of Nutritional Recommendations (https://www.petdiets.com/popup/popup.asp?url=body.asp&sT=Types of Nutritional Recommendations)

You may only want specific commercial product recommendations for the pet. Each letter of recommendation will include specific product names, our reason(s) for suggesting those products, our order of preference (if there is one) and the recommended amount to feed the pet.


You may only want a homemade diet formulated specifically for a pet or you are feeding a homemade diet and want to know if it is complete and balanced, and appropriate for the pet's condition. Each letter of recommendation will include a recipe using both metric and common measurements on the amount of each food ingredient to feed the pet per day. The recommendations also include specific and easily obtained nutritional supplement(s). We also provide information on the preparation and storage of the food, monitoring of the pet and veterinary instructions. All diet recipes are guaranteed to be nutritionally complete and balanced according to current scientific information and our clinical experience.

You may want recommendations that consider both commercial and a homemade diet formulation.

As you can see, Dr. Remillard's service is not exactly cheap, and the client's Vet has to also agree to work with Dr. Remillard as a consulting Specialist, but if you are interested, I don't think it matters that you are in Canada and Dr. Remillard is in the States. You and your Vet can communicate with Dr. R. via e-mail and/or fax, I'm sure, or via long distance phone calls if necessary.

[lulusmom]

Hi Ronen,

Cushing's is probably the most difficult canine disease to diagnose and diagnosing a diabetic dog or one that has an underlying non adrenal illness is even more difficult. The reason for this is that no one test is 100% accurate so multiple tests needs to be done for validation and often times for differentiation between pituitary and adrenal based cushing's.

Pancreatitis and uncontrolled diabetes can increase circulating cortisol levels, yielding false positive acth stimulation test results as well as skewing other diagnostic tests. Additionally, cushing's, diabetes and pancreatitis share a lot of the same abnormalities found in bloodwork, urinalyses and clinical symptoms. For all of these reasons, your vet should not have confirmed a cushing's diagnosed based solely on the results of one acth stimulation test, especially if all testing was done at the same time. Others have already asked that you obtain copies of all test results and post the results here. I personally have some concerns regarding the cushing's diagnosis so the more information you can provide, the better we can share meaningful feedback.

I also agree that getting the diabetes regulated takes priority. If a dog has cushing's, getting diabetes under control is not always easy. If gaining control is fairly easy, chances are your baby may not have cushing's. With respect to when is the best time to start back on the Trilostane, I would say when you are 100% sure that your vet has done sufficient testing under optimum conditions. Optimum conditions would be when your baby's pancreatitis has totally resolved and the diabetes is well controlled. Who knows, when both of those conditions are totally controlled, your dog's symptoms may resolve entirely in which case, the cushing's diagnosis should be questioned.

I believe John and Jenny have already provided you with a link to our sister forum, k9diabetes.com, and I strongly recommend that you become a member there as well. It's great having the best of both worlds.

Glynda

P.S. While cushingoid dogs do well on a high protein, low fat diet, I don't believe this diet is appropriate for a diabetic. The folks at k9diabetes.com are probably a lot more knowledgable on a proper diet for your baby.

[benefr]

Dear Suminist and Harley's Mom:

Pancriatitis: it seems we are over it? (at least simptomatically?).

Thanks for the suggestions for nutritionist.

By the way, I just noticed that about a month ago when she was hospitalized she got 7 units NPH and had a sugar level of 330.
Now she gets 13 units and she is on 400!

How could it be? Does it mean she wasn't balanced at the time? or could it be because she eats more food now? (she wasn't very "hungry" at the time...).

?

Thanks.

[benefr]

and thanks Glynda!

[Harley PoMMom]

Hi Ronen,


Pancriatitis: it seems we are over it? (at least simptomatically?).
My boy Harley has pancreatitis, it was discovered on his first ultrasound and I never knew he had it :eek: He is 13 years old and I have no idea as to how long he has had pancreatitis, all I do know is that I missed the symptoms the first time and now I am trying to make darn sure I don't make that mistake again. Once your pup has pancreatitis...it's a lifetime disease, but it is managable, especially if caught early.

My boy Harley's last cPLI results were 468 (0-200). Was a cPLI or cPL test done on your pup to confirm pancreatitis? If so, could you post the results here. The cPLI and the cPL test for the lipase enzyme that is for specfic for the pancreas only. Harley does not show any symptoms of pancreatitis either and on his chemistry blood panel his amylase and lipase enzymes are within normal ranges, (amylase and lipase enzymes are connected to the pancreas and other parts of the body innternally).

If you could post any/all results from any and all tests you have had done on your pup this would really help us give you accurate and better advice.

Hugs,
Lori

[benefr]

Thanks Lori!

I think in our case it was acute pancreatitis - the results at the time (over a month ago) said: "CPLI POSITIVE (Weak)." I don't think she has it now.

[It may be a good idea to try to get from hospital the numbers - if I get them I'll post them here...].

Does Pancreatitis have treatment beyond antibiotics, low fat levels and fluids?

Anything else I should do?

Thanks! and may Harley too feel well soon !!!

--R

My boy Harley has pancreatitis, it was discovered on his first ultrasound and I never knew he had it :eek: He is 13 years old and I have no idea as to how long he has had pancreatitis, all I do know is that I missed the symptoms the first time and now I am trying to make darn sure I don't make that mistake again. Once your pup has pancreatitis...it's a lifetime disease, but it is managable, especially if caught early.

My boy Harley's last cPLI results were 468 (0-200). Was a cPLI or cPL test done on your pup to confirm pancreatitis? If so, could you post the results here. The cPLI and the cPL test for the lipase enzyme that is for specfic for the pancreas only. Harley does not show any symptoms of pancreatitis either and on his chemistry blood panel his amylase and lipase enzymes are within normal ranges, (amylase and lipase enzymes are connected to the pancreas and other parts of the body innternally).

If you could post any/all results from any and all tests you have had done on your pup this would really help us give you accurate and better advice.

Hugs,
Lori

[Harley PoMMom]

Hi Ronen,

I am so hoping that your pup, which by the way we never did get her name :eek:, does have only acute pancreatitis and it never rears it's ugly head again.

Susy, one of the moderators here, had posted this link to me in my thread, and I believe it is a pretty informative one on pancreatitis.


Pancreatitis
Causes, symptoms, diagnosis and treatment of pancreatitis
Pancreatitis can be a serious acute condition, or just a chronic pain.
Article by Mary Straus published in the Whole Dog Journal, November 2008

http://dogaware.com/wdjpancreatitis.html

Hope this helps.

Love and hugs,
Lori

[frankie]

Hi,

My dog(Frankie) has cushings, diabetes, and hypertyroidism.
I do know how frustrating to get to know all at once.

Frankie is on Anipryl for last 3 weeks, and he is more energetic now.
His diabetes is not in full control, but almost there with Vetsulin.
Yes, my vet also said we need to control his diabetes first since it is like catching two rabbits at once.

I am pretty new here too, but I believe that folks here will help and guide me. I think we need more patience a while to get everything controlled.

Good luck and don't forget that you are not alone. :)

[frankie]

Ah, one more thing...

The glucose level fluctuates in the beginning.
Frankie got even higher glucose level when we first started treatment (Vetsulin), but now it is little more controlled.
I had a dog with diabetes for 4 years till last year, and she was the same.
We need to struggle with the glucose level in the beginning.

Best wishes~!!

Frankie's mom.

[k9diabetes]

Best would be to get a copy of all of your dog's tests from the vet and post the actual values with reference ranges.

There are signs in what you have written so far that your dog may in fact have Cushing's disease. Perhaps the trilostane did not agree with her or she was given too much.

So please also post the dose of Trilostane she was given and the results of any tests of her cortisol and other levels after that.

Natalie

[sunimist]

Hi Ronen,

Pancreatitis can be a serious acute condition, or just a chronic pain.
Acute pancreatitis is indeed a serious and scary thing that requires immediate hospitalization with IV fluids. The pet gets nothing by mouth for at least 24-36 hours (and depending on the severity it is sometimes days) while on fluids, and the electrolytes are monitored closely.


http://en.wikipedia.org/wiki/Chronic_pancreatitis


Chronic pancreatitis is a long-standing inflammation of the pancreas that
alters its normal structure and functions. It can present as episodes of
acute inflammation in a previously injured pancreas, or as chronic damage
with persistent pain or malabsorption.



http://www.vetinfo.com/dpancrea.html


It is unusual for acute pancreatitis to cause acute diabetes mellitus and unusual for chronic pancreatitis to lead to diabetes mellitus, but there are cases in which these things happen. These complications are much more common in dogs than in cats. It is particularly important to be aware of the possibility of diabetes occurring with severe acute pancreatitis and just as important to remember that this is usually a temporary situation. It is critical to monitor insulin needs very closely if an attempt is made to correct high blood sugar using insulin in a dog with acute pancreatitis, in order to avoid the risk of shock due to an over dosage of insulin when the islet cell function returns and the pancreas begins to make insulin normally.

Most dogs with pancreatitis benefit from fluid therapy designed to keep their electrolytes within normal ranges. Low potassium levels are a common problem in dogs with pancreatitis but high potassium levels can also occur and are more dangerous for the dog. Keeping a dog well hydrated makes him or her more comfortable and aids in the recovery from pancreatitis, as well.

High fat diets, especially in combination with low protein intake, appear to contribute to the development of pancreatitis. A single high fat meal may cause pancreatitis in a pet whose normal diet is moderate or low in fat. And here is a very good link.
http://merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/23402.htm

Shelba and Suni

[CarolW]

Ronen - I gather you're the person I met on an email list about diabetes - so glad you found your way here, and to the k9diabetes forum as well.

I've subscribed to your thread, so I can be informed on how you and your dog are doing.

Wishing you all the best,

Sun, 27 Dec 2009 22:37:43 (PST)
-- Carol, with Kwali (RB) and Kumbi (dd)

[benefr]

Dear All:

Thank you very much for the helpful info!

Thanks Harley PoMMom (&/Lori)- I may want to recheck the pancreatitis. I really appreciate the dietary info. Frankies Dad - thanks for the input.

I guess I should monitor closely, and try posting some results here for feedback.

Hope things move better for all.

Thanks!

R

[benefr]

Dear All,

My Mixed little Dog (cutie) has diabetes and cushing's (acth positive) and is treated with 15 units of nph insulin twice a day.

The vet recommends "not fixing a what is aint broken" and not treating with trilostane or anapril. Yet, I'd like to get my dog out of cushing's.

Any suggestions? any natural remedies which we should consider?

THANKS

Ron

[Squirt's Mom]

Hi Ron,

Welcome to you and Cutie! :)

I'm not sure what stage Cutie might be at with the Cushing's....could you tell us what signs she has been showing or how she came to be tested for Cushing's in the first place? Also, if you could get copies of the ACTH and general lab work and post those results for us that would help a great deal.

My Squirt did not have many signs when she was first diagnosed but I continued the testing anyway and she was started on Anipryl. As it turned out in her case, she had a tumor on her spleen that caused all her cushing's testing to come back as positive for PDH. The signs are very important in diagnosing and monitoring treatment so if Cutie is not displaying any of the signs, or few signs, then treatment is usually not recommended.

Cushing's is a very slowly progressing condition so there is no need to rush into treatment just now. First make sure the diagnosis is absolutely correct...one test is usually not enough and makes me very nervous for a pup to start treatment based on a single test because Cushing's is difficult to diagnose. My Squirt is a point in case.

Getting Cutie "out of Cushing's" is unlikely unless she has an adrenal tumor and is a candidate for surgery - then she could be cured. Other forms are life-long. But they are very manageable!

As for natural remedies, there are things you can do that will help but please don't waste your money on things like Cushex or Supraglan....they are a hoax. Once we see the test results of the CBC and ACTH I may be able to offer more specific ideas in this area. What are you feeding her?

I am sure others will along soon to wish you welcome and share their experiences with you, too. I am glad you found us and hope to learn much more in the future about both of you.

Hugs,
Leslie and the girls - always

[labblab]

Hi Ron,

Welcome back to you and Cutie. You'll see that I've combined your new thread posted today with your original thread about Cutie dating from December. This way, all the information that you have already given us about Cutie will be available and "stored" all in one place. This should make it easier for our members to be able to give you the best feedback that we can!

Once again, welcome back. :)
Marianne

[benefr]

Dear Leslie and Dear Marianne,
Thanks for replying!

I don't have the acth results but we are sure she has cushing's - beyond the general symptoms, she also "looks" it in light of her thinning hair etc.

I do have a new problem for which I'd appreciate the advice of anyone who deals with cushing's and diabetes:
When cutie (mixed little dog, 12.4 Kg) got diagnosed with diabetes and cushing's about 3.5 months ago, we started with nph insulin dosage of 7 units. then we moved up to 12 15 and now 17 units!
unfortunately, her fructoseamine test suggest an average glucose level of 700!

how could it be? Is it the cushing's that prevents from the insulin to get her to the glucose levels we were looking for?

THANKS,

Ron and "Cutie"

[BestBuddy]

Hi Ron.

In my opinion if Cutie has cushings it is going to be near impossible to get good (or any) regulation with the diabetes.

Is the BG 700 because that would be just way to high or is 700 the number on the fruc. test? As for you vet saying don't fix what isn't broken I think it is broken if you haven't been getting some sort of regulation with the BG.

At 12.7kg and 17iu you are giving a pretty high dosage and it doesn;t seem to be working. This may have been answered earlier (sorry) but are you using U40 syringes for the Caninsulin and giving 17iu in them.

Have you had another ACTH done since you started insulin?

Jenny

[lulusmom]

I don't have the acth results but we are sure she has cushing's - beyond the general symptoms, she also "looks" it in light of her thinning hair etc.

I do have a new problem for which I'd appreciate the advice of anyone who deals with cushing's and diabetes:
When cutie (mixed little dog, 12.4 Kg) got diagnosed with diabetes and cushing's about 3.5 months ago, we started with nph insulin dosage of 7 units. then we moved up to 12 15 and now 17 units!
unfortunately, her fructoseamine test suggest an average glucose level of 700!

how could it be? Is it the cushing's that prevents from the insulin to get her to the glucose levels we were looking for?


Hi Ron,

I realize that you don't have copies of tests done to diagnose cushing's at the moment but could you please get them from your vet and post them here? I just reread your thread and it appears that only an acth stimulation test was done to diagnose cushing's; however, that diagnosis may be questionable because of the pancreatitis.

If Cutie does have cushing's, the diabetes is likely to be very difficult to get regulated until you get the cortisol down to an acceptable level. Cortisol counteracts insulin, altering glucose metabolism and everything is in harmony if the levels of circulating cortisol are normal; however a dog with cushing’s is pumping out too much cortisol causing excess glucose to be produced with increasing elevation of blood sugar which makes the need for insulin greater. I therefore don't understand why your vet would tell you to not fix what ain't broken and not recommend treating with trilostane or anipryl if he truly thinks Cutie is cushingoid based on adequate testing and clinical symptoms.

At this point, if my dog was in the same position as Cutie, I would want to make sure that adequate testing is done to properly diagnose cushing's. That would entail getting a fresh acth stim test as well as an abdominal ultrasound to validate the acth stim test, if it is consistent with cushing's this time around. Once properly diagnosed, I personally would want to start treatment with either Trilostane or Lysodren. Unfortunately, there is no natural treatment that will effectively reduce cortisol levels. Anipryl is not a good choice for a dog that has concurrent diabetes as it is only effective in dogs with a tumor in the pars intermedia lobe of the pituitary. Unfortunately, only a very small percentage of dogs have a tumor in this area. Additionally, Anipryl has no effect on an adrenal tumor.

That's just my two cents worth.

Glynda

P.S. I see that Jenny was posting while I was typing and am happy to see that we agree. Jenny has experience with diabetes and cushing's so you can take what she says to the bank.

[benefr]

Dear Jenny,

The BG is 700 because that's what the fructosamine test shows.

We did the ACTH a few months ago - and she is also symptomatically cushing looking.

Unless if you suggest otherwise, I think there could be two reasons for her high BG levels in spite of high nph dosages:
1. Cushing's is excaerbating.
2. Sumugyi effect? Since fructosamine only presents the AVERAGE BG levels in the last 2 weeks, could it even be Sumugyi rebound effect? could we be giving her too much insulin?

Thanks,

Ron


Hi Ron.

In my opinion if Cutie has cushings it is going to be near impossible to get good (or any) regulation with the diabetes.

Is the BG 700 because that would be just way to high or is 700 the number on the fruc. test? As for you vet saying don't fix what isn't broken I think it is broken if you haven't been getting some sort of regulation with the BG.

At 12.7kg and 17iu you are giving a pretty high dosage and it doesn;t seem to be working. This may have been answered earlier (sorry) but are you using U40 syringes for the Caninsulin and giving 17iu in them.

Have you had another ACTH done since you started insulin?

Jenny

[benefr]

I just replied to Jenny's post - thanks.

That's intended also for you... THANKS.;)


Hi Ron,

I realize that you don't have copies of tests done to diagnose cushing's at the moment but could you please get them from your vet and post them here? I just reread your thread and it appears that only an acth stimulation test was done to diagnose cushing's; however, that diagnosis may be questionable because of the pancreatitis.

If Cutie does have cushing's, the diabetes is likely to be very difficult to get regulated until you get the cortisol down to an acceptable level. Cortisol counteracts insulin, altering glucose metabolism and everything is in harmony if the levels of circulating cortisol are normal; however a dog with cushing’s is pumping out too much cortisol causing excess glucose to be produced with increasing elevation of blood sugar which makes the need for insulin greater. I therefore don't understand why your vet would tell you to not fix what ain't broken and not recommend treating with trilostane or anipryl if he truly thinks Cutie is cushingoid based on adequate testing and clinical symptoms.

At this point, if my dog was in the same position as Cutie, I would want to make sure that adequate testing is done to properly diagnose cushing's. That would entail getting a fresh acth stim test as well as an abdominal ultrasound to validate the acth stim test, if it is consistent with cushing's this time around. Once properly diagnosed, I personally would want to start treatment with either Trilostane or Lysodren. Unfortunately, there is no natural treatment that will effectively reduce cortisol levels. Anipryl is not a good choice for a dog that has concurrent diabetes as it is only effective in dogs with a tumor in the pars intermedia lobe of the pituitary. Unfortunately, only a very small percentage of dogs have a tumor in this area. Additionally, Anipryl has no effect on an adrenal tumor.

That's just my two cents worth.

Glynda

P.S. I see that Jenny was posting while I was typing and am happy to see that we agree. Jenny has experience with diabetes and cushing's so you can take what she says to the bank.

[BestBuddy]

Somogyi is a possibility or it could also be cushings. A BG curve would give you some more info. Something isn't working.

I was told by Buddy's specialist that the "average" insulin for a dog is their weight in kg. There are always exceptions to the rule with some needing less and others more.

Sorry I messed up and misread but now understand that you are using NPH. Are you giving injections and meals 12 hours apart? What are you feeding?

Jenny

[benefr]

OK - this for those of you who know about diabetes:

Dear All,
So we did the Glucose curve over a day ago.

First test was done just before she ate at around 9.15 AM, and then we gave her 17 units of NPH (she gets them with food twice daily).

The results (between 9 am and 9 pm) are as following:

Hour Glucose
9 200
11 109
13 141
15 187
17 232
19 196
21 146

What I don't understand is how at about 17:00 ("17") without any insulin injection the glucose started dropping.
Could this be in fact Somogyi? To trigger a Somogyi how low does the Sugar have to go for?

The Vet suggested we lower from 17 to 15.

Any ideas?

Thanks,

Ron

PS
actual blood drawing times were somehwat different - they weren't very precise in test taking times.

[AlisonandMia]

I see you are a member at K9Diabetes (http://www.k9diabetes.com/forum/).

Although some of us have had experience with diabetes I think you may be able to get more feedback and answers to your diabetes-related questions if you post what you just posted here over there as well.:)

Alison

PS: Here's a link to your thread at K9Diabetes: http://www.k9diabetes.com/forum/showthread.php?t=1535

[BestBuddy]

Hi Ron,

That curve looks pretty good. Not all curves are valley or even mountain shaped and each dog will be different. Great control of a diabetic dog is keeping the BG at or under 180 for the "most" part of the day. You really are just about there.

A rebound is typically when the BG drops quickly (more than 100 per hour) sometimes dropping too low and the body overreacts and pushes the BG high.

It's like a race with food and insulin trying to get them to work at the same pace. It may just be that the food just ran out by 1700 and the insulin kept going.

I can't see why you would want to drop the insulin to 15 when you are not getting low BG's and no sudden high swings either.

I really think you are at the "tweaking stage" rather than needing to make major changes.

Jenny

[benefr]

Dear Jenny,

Thanks a lot for the advice!

Alisonandmaya: thanks - I may post it there as well (good idea...;)).

How do you explain the high fructoseamine?

[benefr]

oops I forgot to mention:
we did the curve because we had done a fructosamine test about a week ago that suggest average glucose levels of: 700 in the previous three weeks.

how could it be? how would we correlate the curve and fructosamine?

[BestBuddy]

Ron,

Buddy and I lived with diabetes for over 6 years but we never did a fructosamine test. It was no use to us because it only gave a one figure average from the last few weeks and there was no way of telling if there were any lows that may have cause rebound.

Testing BG at home would solve the problem. Not sure what your thought are on this but it is so much cheaper, less stressful on the dog and gives you so much more info on what is happening with the diabetes. I must confess I resisted home BG testing because it scared me for many years. We just managed with ketodiastix and a willing vet but things change as they usually do and I needed to learn how to home BG test and wow once I did I couldn't believe how easy it was and how much more in control I was.

Just ask the question over at k9diabetes and many will offer advice and help.

Jenny

[benefr]

Thanks.

Not sure how prepared I am for daily blood tests.

I am not always with cutie (although I am the one administring the insulin) - and it sounds scary drawing blood everyday.

Is there a no pain easy way? buying the glucometer is a possibility....

R


Ron,

Buddy and I lived with diabetes for over 6 years but we never did a fructosamine test. It was no use to us because it only gave a one figure average from the last few weeks and there was no way of telling if there were any lows that may have cause rebound.

Testing BG at home would solve the problem. Not sure what your thought are on this but it is so much cheaper, less stressful on the dog and gives you so much more info on what is happening with the diabetes. I must confess I resisted home BG testing because it scared me for many years. We just managed with ketodiastix and a willing vet but things change as they usually do and I needed to learn how to home BG test and wow once I did I couldn't believe how easy it was and how much more in control I was.

Just ask the question over at k9diabetes and many will offer advice and help.

Jenny

[BestBuddy]

Ron,

It really isn't that scary. Doing the blood tests at home is just like humans pricking their finger to get a drop of blood to test. The vets will draw the blood out with a needle in the vein but we don't have to do that thank heavens.

The glucometers can be fairly cheap and have rebates, some are better than others because you want one that is easy, basic and requires a tiny drop of blood and of course the testing strips for that model are easily obtained and not too expensive.

Their are many places you can get a drop of blood from your dog (check out k9 diabetes) it is just your choice where it is easiest for you and Cutie. I used the inside of the lip, others use a spot on the tail and others use ears and calluses on legs.

Jenny

[lulusmom]

Question(s) for Jenny and others who have experience with dogs diagnosed with cushing's and diabetes.

I just went back through Ron's thread and see that the cushing's diagnosis was based solely on one acth that appears to have been done at the same time Cutie tested positive for Pancreatitis. In my opinion, this places the cushing's diagnosis in question. Trilostane was administered for a short time but discontinued because Cutie stopped eating. Unfortunately, an acth stim test was not done to rule out low cortisol as the reason for Cutie's inappettance. The vet opted to "not fix what ain't broken" and discontinued Trilostane treatment indefinitely.

I know very little about diabetes but am trying to get up to speed because we seem to be seeing more members with both conditions and I feel so ignorant. :o Am I correct in assuming that when you do a 12 hour curve, you want to see readings at each interval to remain consistently between 100 and 200, preferrably at around 180 or a bit less, as Jennie mentioned? In looking at Cutie's readings, they look pretty good considering the cushing's is uncontrolled. Would you typically be able to achieve these types of results in an untreated cushingoid dog?

Glynda

[BestBuddy]

I can really only answer in my experiences with Buddy but here goes.

Before Cushings Bud was well regulated usually having BG's 70-200 and had been like this for several years. When cushings appeared his BG was all over the place up and down for no reason and then settled into the 200-400 range with the occasional drop back to 70.

The renal threshold is 180 so the more time spent under this number (not too low of course) is better for the dog.

The trouble there is no black and white details on how to treat diabetes because each dog is different and eats different, uses different types of insulin and plays/exercises differently.

Food makes the BG go up and insulin brings it down so the idea is to get them working in partnership to stay around 180 in a perfect world.

I wouldn't think that Cutie would be able to get those numbers if cushings was still at play.

Jenny

[benefr]

Yes - 12 hours apart.

I am feeding Eukonuba Glucose control and chicken breast+vegetables (barley+and sometimes some zuchini+green beans). 50% Eukonuba +50% home food.

Sometimes I may give her a spoon of cottage - around mid day.

Suggestions?

Tx


Somogyi is a possibility or it could also be cushings. A BG curve would give you some more info. Something isn't working.

I was told by Buddy's specialist that the "average" insulin for a dog is their weight in kg. There are always exceptions to the rule with some needing less and others more.

Sorry I messed up and misread but now understand that you are using NPH. Are you giving injections and meals 12 hours apart? What are you feeding?

Jenny

[benefr]

Dear Jenny and Glynda,

Thanks for the response.

Jenny - do you know of any good videos showing how to draw blood for dogs? what don't vet's use these spots?

Thanks again

[BestBuddy]

I think you are doing a great job already. The numbers you are getting would make some who have been treating for years very jealous.

The food may just need a little tweaking, maybe it is a simple as changing the ratio of prepared and home cooked just a little like say 60% of one and 40% of the other and see what that does to the next curve and then if it isn't any better try it back the other way.

For great info on the testing sites I would head over to k9diabetes because Natalie has some great tips and videos. I really don't know why most vets use a syringe in a vein, maybe it is a more accurate reading but once you start testing it is wise to do a prick test yourself at the vet and use your meter and then get the vet to do their test and compare numbers so you know if your meter is a little out and can add or subtract to get accurate numbers.

Jenny

PS I would never have thought that Buddy would have let me hold his lip up for the prick and blood test but he did. As I said it took me 4 years before I tried BG testing and that would have been the only regret I had was that after I started testing I realised how much I had missed out on knowing what was happening. It really is a great feeling and gives you so much confidence when you know you can test at any time. There is a knack to it but I am sure you can learn.

[benefr]

Dear All,

Cutie has Cushings, and Diabetes and used to have pancreatitis.
She is Ten mixed dog, looks like a cocker spaniel, but with very little hair now (due to cushing's). Diagnosed about 6 months ago.
Getting 19 Units of NPH insulin and some antibiotics.

In the past week, after a wiered episode of sudden raise in Blood Glucose (700!), we noticed in several locations-- "patchy" areas on her skin.
When you touch/squeeze the area - GREEN Puss comes out. When you try to clean it, THE SKIN IS PILLED and you are only left with felsh.
Vet suggested some corticosterioed+antio biotic lotion, as well as some antibiotics - BUT THEY DONT HELP.

ANY SUGGESTIONS? why does it happen? please help!!! I am very worried.

Thanks

Ron

[lulusmom]

I just went back through Ron's thread and see that the cushing's diagnosis was based solely on one acth that appears to have been done at the same time Cutie tested positive for Pancreatitis. In my opinion, this places the cushing's diagnosis in question. Trilostane was administered for a short time but discontinued because Cutie stopped eating. Unfortunately, an acth stim test was not done to rule out low cortisol as the reason for Cutie's inappettance. The vet opted to "not fix what ain't broken" and discontinued Trilostane treatment indefinitely.
Glynda

Ron, I posted this back in March. What has transpired on the cushing's front since then? Still no treatment? Any further testing for cushing's? If Cutie has uncontrolled cushing's, I am not surprised that glucose is out of control; however, I would think that it would have been difficult to maintain any control as long as excess cortisol is pumping out of Cutie's adrenals.

Going further back in your thread, I noticed that an acth stim test was done but you never posted the results. Could you post those results now and also post any more recent bloodwork or urinalyses that has been done.

I noted in reading back through your thread that that your vet did little testing on Cutie to reach a "consciencious" diagnosis of cushing's, plus it looks like the only test that was done, the acth stim test, could have been a false positive reading due to possible pancreatitis. I believe you treated Cutie briefly with Trilostane but discontinued when she quit eating and was vomiting and had diarrhea. Is that correct? At that point, I believe you discontinued the Trilostane and your vet said; "don't fix what ain't broken". I'm not sure what that means but if Cutie actually has cushing's and is exhibiting symptoms associated with cushing's, then a diagnosis needs to be confirmed at which time your vet should discuss treatment with you. The skin issues Cutie has could very well be a condition called calcinosis cutis which is a bear of a condition to gain the upper hand on, especially if cortisol is allowed to go unabated.

Here is a link to a good article on calcinosis cutis:

http://veterinarymedicine.dvm360.com/vetmed/article/articleDetail.jsp?id=659278&pageID=1&sk=&date=

Here is a link to pictures of a dog named Augie. Augie had a severe and rapid spreading case of calcinosis cutis.

http://www.k9cushings.com/forum/album.php?albumid=189

Here is a link to pictures of another dog named Sabre who also had calcinosis cutis.

http://www.k9cushings.com/forum/album.php?albumid=97&pictureid=783

Has your vet done skin scrapings, punch biopsies or cultures to determine exactly what Cutie's skins problems are?

Glynda

[benefr]

Dear Glynda,

Thank you very much for the informative links! Doctor did not do a biopsy and I am going to ask him to do it!

I also want him to do an infection analysis as Cutie is getting antibiotics but still lots of green puss.

Any other suggestions? Vitimains? any thing else this could be?

Finaly, did I post this thread in the right place? I am not getting any feedback other than you...
Thanks

Ronen

[benefr]

PS
Cutie has a lump in the chest- are there documentations of hypecvorticosteriodism (cushing's) due to lump and not due to adrenal or pituitary tumours?

just wondering




Dear Glynda,

Thank you very much for the informative links! Doctor did not do a biopsy and I am going to ask him to do it!

I also want him to do an infection analysis as Cutie is getting antibiotics but still lots of green puss.

Any other suggestions? Vitimains? any thing else this could be?

Finaly, did I post this thread in the right place? I am not getting any feedback other than you...
Thanks

Ronen

[benefr]

Quick Update:
Asked Vet if it could be calcinosis, and whether we should do biopsy as the severity of this thing is getting worse.
Vet says:
1. It is not calcinosis as I don't see any calcium deposits (he thinks it is dermatitis with infections somehow related to cushing's).
2. Biopsy is bad idea- because is requires anasthesia, but even more so -- it would not change the possible treatment, it will show various bacteria and we target those with broad spectrum antibiotics anyway.
3. He suggested adding another antibiotics, and switching the original one to pill form instead of liquid.

Any input would be apreciated! (Should I give her zync tablets? I head its good for skin. Also, what about ps100?).

[lulusmom]

Hi Ron,

Yes, you have posted in the right place. This is vacation time for a lot of folks so it may appear that I'm hogging the board :D but som the others will be chiming in soon, I'm sure. Calcinosis cutis is a symptom of cushing's but it's pretty rare so most of us have no first hand experience with it and must rely on those that have. Angela, Sabre's mom, and one of our moderators, has a lot of experience with it and I'll PM her to make sure she sees your post.

I'm not certain as to what you should be seeing with calcinosis cutis, especially if it has turned bacterial. Hopefully, Angela can share her observations with you. I will say that I have never been pleased when my vet(s) have said "I think it's this or I think it's that" and thrown antibiotics at it to see if it helps. If my doctor told me he thinks I may have this or that, I'd tell him that if he can't figure it out for certain then give me a referral to someone that can. I guess what I'm saying in too many words is that you may want to consider taking Cutie to a dermatologist. Believe it or not, derm vets are usually much more knowledgable of cushing's than a general practitioner.

If your vet thinks this infection is cushing's related, why has Cutie not received further testing to confirm a cushing's diagnosis so that if it's excess cortisol that is causing the problem, treatment can be initiated?? I want to reiterate that one acth stim test done concurrently or on the tail of a pancreatic episode cannot be assumed to be reliable, especially if no other testing was done to validate it. Other testing would be the LDDS and/or an abdominal ultrasound.

Has your vet diagnosed the lump on Cutie's chest? Estradiol is the only adrenal hormone that can be found in other bodily tissues, in particular adipose tissues, which is another word for "fatty" tissue. If Cutie's lump is a Lipoma (fatty tumor) then it is possible that a dog could have cushing like symptoms due to excess estradiol being generated by that lipoma. I was never able to find any research on this but I had a long conversation with my cushdogs' old internal medicine specialist. He said he had a patient who was diagnosed with atypical cushing's by the University of Tennessee, based on physical symptoms associated with cushing's, as well as an adrenal panel showing some serious elevation in estradiol. This dog also had a significant lipoma which the IMS surgically removed. He said after that lipoma was removed, all of the dog's symptoms resolved and the estradiol normalized. I hope that helps.

[Sabre's Mum]

Hi Ron

I just have a moment to post .. off to work soon and dinner to cook.

With Sabre, his calicinosis cutis appeared in a slightly raised, slightly whitened skin and non-uniform in shape ... sorry the best description I can give at this point in time! They were not obvious hard lumps at all ... this developed over time. He lost hair in these areas (along with considerable other areas of his body), and these areas became more suspectible to infections which we controlled with anitbiotics, shampoos, betadine, epitoic and so on!

Before we were aware of his calicnosis cutis he had pyoderma around his anal area. Sabre's pyoderma were pustles which popped and oozed. We did do a biopsy on three areas - around the anus, one area on his side and one where he developed a raised area at an injection site. From this they did see some calicification (just did not put two and two together at this stage) and found out that we needed two very powerful antibiotics. His anal area in time developed two hard calcium deposits which remained during treatment.

Calcinosis cutis in it's early stages does not look like the textbook pictures and most vets have never seen a case in their lifes.

Sorry if this sounds disjointed as I am multi-tasking to do this post! I will be back tomorrow (in my part of the world 5.40pm here now) to cover things a bit better!

Angela and Flynn

[Sabre's Mum]

Hi Ron

A couple of things that I will add to the above post. From my experience, and comments made by Sabre's vet at the intial stages, skin conditions can be very hard to manage. I have not thoroughly read every post in your thread but see that a cushings diagnosis has not been confirmed and treatment has not been undertaken. In my opinion this is necessary. Sabre's skin conditions - and in particular the calicinosis cutis - only came right when he was treated with Lysodren.

As I touched on briefly ... it is so important to target the antibiotics. Without an anitbiotic sensitivity test we would not have been able to manage Sabre's pyoderma - he was on antibiotics for about 3 months. Along with the antibiotics we used medicated shampoos every three days and diluted iodine to try and keep the area dry.

If you have any further queries please ask away.

Angela and Flynn

[apollo6]

Dear Ronen,
Welcome
My Apollo has had buts of pancreatitis throughout his life. The usual diet suggestion is low fat, below is what I give Apollo. Ask your vet. I never had Apollo on Purina so I can not give you input. But you do have other issues you are dealing with that need to be addressed first, as the other members have said.

A.M-low fat cottage cheese, Greek nonfat yogurt,chopped egg white
, low sodium turkey slice, supplements

NOON- long WHEAT grain rice, cooked chicken, teaspoon canola oil,

AFTER 4P.M-cooked potatoes with skin, chicken
Nutri Deni minichew or Greenie
Have alternated with organic baby food-summer veg with pumpkin, turkey with veg, spinach.
Slice apple, sometimes blue berries, honey melon
But check with your vet before you do anything. We need to get the little fur ball to a healthy weight first. We'd love to see a picture of your little one if possible. Click User CP, left upper corner, in you profile, then on left side near bottom ,click Aviator, and add your picture.

[benefr]

Thanks! (not sure I am seeing the posts right, as I am just seeing 2 of yours)=
Vet says sensitivity test would be useless as skin conditions show lots of types of bacteria. So he basically provided wide-targeting antibiotics (2 different pills). He also says he doesn't think it is calcinosis because it doesn't look like it (should I post pics?).
he says its "dermatitis" due to cushing's. Does heat bring about more cushing's -? I dont understand the sudden cushing upstream.
Also, has anyone tried chinese medicine with success to treat cushing's?
Thank you so much for feedback.


Hi Ron

I just have a moment to post .. off to work soon and dinner to cook.

With Sabre, his calicinosis cutis appeared in a slightly raised, slightly whitened skin and non-uniform in shape ... sorry the best description I can give at this point in time! They were not obvious hard lumps at all ... this developed over time. He lost hair in these areas (along with considerable other areas of his body), and these areas became more suspectible to infections which we controlled with anitbiotics, shampoos, betadine, epitoic and so on!

Before we were aware of his calicnosis cutis he had pyoderma around his anal area. Sabre's pyoderma were pustles which popped and oozed. We did do a biopsy on three areas - around the anus, one area on his side and one where he developed a raised area at an injection site. From this they did see some calicification (just did not put two and two together at this stage) and found out that we needed two very powerful antibiotics. His anal area in time developed two hard calcium deposits which remained during treatment.

Calcinosis cutis in it's early stages does not look like the textbook pictures and most vets have never seen a case in their lifes.

Sorry if this sounds disjointed as I am multi-tasking to do this post! I will be back tomorrow (in my part of the world 5.40pm here now) to cover things a bit better!

Angela and Flynn

[benefr]

Thanks LulusMom!

Where can I read more about estradiol elevations due to lump? is this atypicl cushing's? would trilostane help in such cases?

Thanks again,

Ron


Hi Ron,

Yes, you have posted in the right place. This is vacation time for a lot of folks so it may appear that I'm hogging the board :D but som the others will be chiming in soon, I'm sure. Calcinosis cutis is a symptom of cushing's but it's pretty rare so most of us have no first hand experience with it and must rely on those that have. Angela, Sabre's mom, and one of our moderators, has a lot of experience with it and I'll PM her to make sure she sees your post.

I'm not certain as to what you should be seeing with calcinosis cutis, especially if it has turned bacterial. Hopefully, Angela can share her observations with you. I will say that I have never been pleased when my vet(s) have said "I think it's this or I think it's that" and thrown antibiotics at it to see if it helps. If my doctor told me he thinks I may have this or that, I'd tell him that if he can't figure it out for certain then give me a referral to someone that can. I guess what I'm saying in too many words is that you may want to consider taking Cutie to a dermatologist. Believe it or not, derm vets are usually much more knowledgable of cushing's than a general practitioner.

If your vet thinks this infection is cushing's related, why has Cutie not received further testing to confirm a cushing's diagnosis so that if it's excess cortisol that is causing the problem, treatment can be initiated?? I want to reiterate that one acth stim test done concurrently or on the tail of a pancreatic episode cannot be assumed to be reliable, especially if no other testing was done to validate it. Other testing would be the LDDS and/or an abdominal ultrasound.

Has your vet diagnosed the lump on Cutie's chest? Estradiol is the only adrenal hormone that can be found in other bodily tissues, in particular adipose tissues, which is another word for "fatty" tissue. If Cutie's lump is a Lipoma (fatty tumor) then it is possible that a dog could have cushing like symptoms due to excess estradiol being generated by that lipoma. I was never able to find any research on this but I had a long conversation with my cushdogs' old internal medicine specialist. He said he had a patient who was diagnosed with atypical cushing's by the University of Tennessee, based on physical symptoms associated with cushing's, as well as an adrenal panel showing some serious elevation in estradiol. This dog also had a significant lipoma which the IMS surgically removed. He said after that lipoma was removed, all of the dog's symptoms resolved and the estradiol normalized. I hope that helps.

[lulusmom]

Hi Ron,

I'm sorry but as I mentioned in my post, I could not find any published papers regarding estradiol producing lipomas. This came up in conversation with my dog's old internal medicine specialist, Dr. Macon Miles. If your vet would like to consult with Dr. Miles and discuss Cutie's case, you can find his name, mug shot and contact information here: http://www.aercvet.com/miles.html Dr. Miles is an awesome internal medicine specialist and he is extremely knowledgable of both typical and atypical cushing's.

[benefr]

Thanks!
Would it be ok if I contact the internal specialist via email (I'm overseas right now) - with a short email asking for feedback?

Cushing's has exacerbated considerably in the past 2 weeks. Beyond these skin conditions, Cutie also become more "lazy" than ever. She really has trouble walking even a little bit. Any suggestions?

Also - how has been your experience with trilostane?

[lulusmom]

Thanks!
Would it be ok if I contact the internal specialist via email (I'm overseas right now) - with a short email asking for feedback?

Cushing's has exacerbated considerably in the past 2 weeks. Beyond these skin conditions, Cutie also become more "lazy" than ever. She really has trouble walking even a little bit. Any suggestions?

Also - how has been your experience with trilostane?

If there is an email address on their website, it won't hurt to send an email, explain your situation and ask if you can correspond via email with Dr. Miles.

Both of my dogs did very well on Trilostane; however, it was prescribed by a vet that was very experienced with cushing's as well as the drug. If you and your vet thinks that Cutie's lethargy and difficulty in walking is related to cushing's, I need to repeat myself in an earlier post:


If your vet thinks this infection is cushing's related, why has Cutie not received further testing to confirm a cushing's diagnosis so that if it's excess cortisol that is causing the problem, treatment can be initiated?? I want to reiterate that one acth stim test done concurrently or on the tail of a pancreatic episode cannot be assumed to be reliable, especially if no other testing was done to validate it. Other testing would be the LDDS and/or an abdominal ultrasound.

As I recall Cutie was also diagnosed with diabetes and acute renal failure. Have you been able to control the diabetes with insulin? What insulin are you using and how much is Cutie getting? When was her blood sugar last tested and can you post the results? Any one of these three conditions can cause lethargy and weakness by themselves and then with the bacterial infection, there is not way I would automatically assume that 1) Cutie has cushing's and 2) that her current symptoms are all cushing's related.

I personally am not familiar with diabetes but I do know that if a dog has uncontrolled cushing's it can be very difficult to get the diabetes under control. Hopefully you are already a member at our sister site, www.k9diabetes.com If not, I highly recommend you become a member and take advantage of a lot of first hand experience and knowledge. It's tough enough dealing with cushing's or diabetes but when your dog has both, it can be really trying.

It would really help us if you could get a copy of all of the testing that was done to diagnose Cutie with diabetes and renal failure and post the results here. You don't have to type everything, just the abnormal values. Sorry for asking more questions than giving answers but it's difficult to provide you with meaningful feedback without having a better understanding of Cutie's recent medical history.

Glynda

[benefr]

Thanks ! points taken.
ACTH stim test showed very marked results. Since it was done shortly after a pancreatitis episode, I am going to suggest another one (dont day do it anyway as they start trilostane treatment? we are going to start one again :)).

She also looks and behaves cushings - (panting, lethargy etc.)

It took us a while to treat glucose levels (from 7.5 units of nph to 19! now - after a tough week with very high values over 600- since UTI and other infections were pretty much ruled out - we think this is cushing's related).

No serious renal signs at the moment Thank heaven.

would you recommend the LDDS and ultrasound in addition to acth? (not sure they have it here).

Vet has 2 other cushing's patients - he is not an internalist, but consults with one via phone.

Any other suggestions? UC davis protocol is the best?

Thanks !!!:)

[lulusmom]

You never posted the results of the acth stim test so there is not way for us to determine if the post stimulated number would be considered mild, moderate or severe. In any event, that test was done while Cutie was suffering with pancreatitis or shortly thereafter which make the results of the stim test suspect. While the acth stim test is less likely to yield a false positive results in the face of non adrenal illness, it can be affected so I would definitely have additional testing done before deciding to start administering the Trilostane again. You can either do an acth stim test and I personally would want to do an abdominal ultrasound. I realize you are overseas so it's possible that you aren't going to find a high quality, high resolution machine, which is what is needed.

P.S. Came back to tell you that yes, I would definitely follow the UC Davis protocol if and when you start treatment again. It's always better and safer to start low and make adjustments as you go, if needed.

[benefr]

thank you!
will follow through (results suggested strongly pituitary cushing's). I am going to rely the ultrasound suggestion as well, and hopefully upon proper basis (and additional testing as necessary) will start trilostane.

do you recommend the uc davis protocol more than the other?

thanks again

Ron

[lulusmom]

Hi Ron,

The ACTH stim test does not differentiate between pituitary or adrenal tumor so I'm not really sure what test results you have that would give you any indication as to which one Cutie may have. :confused:

There are two protocols that we refer to here. Dechra's, the manufacture of Vetoryl, and UC Davis. As I mentioned previously, I favor the U.C. Davis protocol because it's the safer way to go. Even Dechra has acknowledged that there is some disparity in their dosing recommendations in their packaging insert and their website. One of our Administrators, Marianne, confirmed this in a conversation with Dechra. Here is one of her posts to another member that I think you will find very informative:


Darn! I, too, would be concerned about starting Apollo at 30 mg. :(

The most recent recommendation of Dechra, the company that makes Vetoryl, is to start dogs off using a formula of 1 mg. per pound. So in Apollo's case, that would be 10 mg. of Vetoryl instead of 30. I found this out by talking directly to one of their technical representatives in their Kansas office. He is a vet, and his name is Dr. Allen. Either you or your vet can call him directly, as well, to get this updated information:

http://www.dechra-us.com/Default.aspx?ID=365

Your vet is probably following Dechra's published dosing "table," which does recommend 30 mg. for dogs weighing between 10 and 22 pounds. But if he would be willing to call Dr. Allen at Dechra, they could talk about Dechra's revised recommendation. And Vetoryl is sold in 10 mg. capsules, so obtaining it in that dose will not be a problem. Plus, if it does turn out that Apollo needs a higher dose, it will be easy to keep adding on additional 10 mg. increments.

I know it may not feel too comfortable "questioning" your specialist about the dosing. But hopefully he will also think it is a good idea to call the Dechra rep in order to have a direct conversation about their new dosing recommendations. Dr. Allen is really nice and happy to discuss questions with both owners and vets.

Marianne

[benefr]

Dear All,
I am grateful for the advice (thanks lulusmom!). I am posting here because somehow my previous post thread is not letting me post.

Cutie was diagnosed with cushing's about 9 months ago, along with acute pancreatitis, and diabetes.
ACTH result was 17 at time 0, and over 50 on second.

In the past few weeks, glucose levels have soared to over 600! we therefore added antibiotics, increased insulin to 19 units (from 17, and before that 7,13,15 respectively). Today we re-cheked and insulin was almost 700.

Cushing's symptoms (skin infections, and tearups, along with problems walking and heavy breathing) and insulin resistance have increased in the past 2 weeks significantly). Vet suggested starting with trilostate 30 mg, and then doing a cortisol test in 10 days. He is not familiar with UC davis or other protocols (where can I access those?).

Questions:
Is there anything else I should do? Is it normal for hot weather to so seriously interfer with cushing's and insulin resistance?

[lulusmom]

Hi Ron,

For some reason your thread was closed and not sure how that happened but I am reopening and merging your threads.

Can you tell us how much Cutie weighs and what dose of Vetoryl she was taking originally?

[benefr]

Thanks!
Cutie Weights 12 now (15 was before diagnosis and crisis 9 months ago, and 12.4 is her average).

Not sure what was the original trlisotane as it was provided by a different vet which was switched (not sure it was "vetoryl")

[labblab]

Cushing's symptoms (skin infections, and tearups, along with problems walking and heavy breathing) and insulin resistance have increased in the past 2 weeks significantly). Vet suggested starting with trilostate 30 mg, and then doing a cortisol test in 10 days. He is not familiar with UC davis or other protocols (where can I access those?).

Sorry that I have only a moment to post, but here's a link to a thread on our "Resources" forum that provides treatment and monitoring information published both by Dechra (manufacturers of Vetoryl) and also UC Davis:

http://www.k9cushings.com/forum/showthread.php?t=185

Hope this helps!

Marianne

[lulusmom]

UC Davis starts their patients on 1mg per kg. Cuties weight in kg is 5.5kg (12/2.2 = 5.5) If you look back at the copy of Marianne's (labblab) post I provided, you'll see that even though Dechra's product packaging/insert reflects initial dose of 30mg for dogs weighing 3kg to 10kg, Dr. Allen admitted to Marianne that they feel dogs should be started at 1mg per pound. As you can see, UC Davis protocol would dictate starting Cutie at 5.5mgs once daily whereas Dechra would recommend 12mg once daily.

In your shoes and given that Cutie's bg is out of control, I would ask my vet to contact Dechra to get their recommendation. I will tell you that my then 5 lb Pomeranian started at 20mg once a day and ultimately was increased to 30mg before she was stabilized. My second cushdog started at 15mg twice daily and maintained beautifully at that dose. I will also tell you that vets that are experienced with prescribing Trilostane to dogs with both cushing's and diabetes may prefer twice daily dosing simply to insure that the dog has adequate control throughout a 24 hour period. Trilostane has a short half life and it's enzyme blocking ability can start to wane any time after 8 to 10 hours. Therefore a dog with diabetes on once daily dosing could see a corresponding increase in bg as the cortisol increases in the second half of the day.

I see that Marianne has provided you a link to Vetoryl/Trilostane reference material in our Resources section while I was typing. You may want to share this information with your vet.

[BestBuddy]

When you say Cutie weighs 12 are you talking lbs?

If so then Oh dear you are giving a whacking lot of insulin to such a little thing. That dosage is what I would imagine a 40lb dog would be on. If it is too much insulin then you could be experiencing rebound.

I realize every dog is different but I would imagine Cutie on about 3-4 units of insulin at 12lbs but around 12 units if she is 12kg. The other thing to consider is that you need to change insulin because it may not be working.

Jenny

PS Just gone back to the start of the thread and it is 12kg and I am starting to breathe again. I still think it could be too much insulin and you could be experiencing a somogyi rebound effect. Treating that is just reducing insulin and time.

[benefr]

Recap:
Cutie is about 10, was diagnosed with diabetes, pancreatitis (initialy?), and Cushings.
Last 2 months was on 60 MG of trilostane.

ADVICE:?
About month ago, lost of appetite until no eating two weeks ago, coupled with diarrhea so we stopped trilostane.

After a week of very little eating she got to hospital, and we almost lost her. Potassium K levels suddenly dropped and she couldn't lift her head.

Now looks better, and she has a feeding tube for a couple of days at home. She doesn't want to eat and drink (drinking might be due to overhydration, as she did want to drink a few days ago).

Ultrasound suggested pancreatitis - but I dont get it -- how long does it take for a dog to start eating after a pancreatitis episode?
She just starting to recooperating, and can stand up again, and starting to walk again (beyond general weakness, her legs hurt as the got swollen).

Is it Pancreatitis why she is not eating? What else could it be? If it is pancreatitis how much time does it take until she eats? She now gets antibiotics (2 kinds), her bloody diarrhea stopped, and gets WD through a feeding tube.

Why doesn't she drink?

I would appreciate your thoughtful advice.......

Thanks

Ron

[Squirt's Mom]

Hi Ron,


About month ago, lost of appetite until no eating two weeks ago, coupled with diarrhea so we stopped trilostane.

A loss of appetite is one of the signs of an overdose of Cushing's meds. When you see this, the med needs to be stopped immediately and the pup's eletrolytes (potassium, chloride, etc) and cortisol levels checked immediately. The fact that her potassium was so low indicates an overdose. Diarrhea, vomiting, lethargy, and weakness/trembling are also signs of an overdose leading to an Addisonian crisis. An Addisonian crisis is when the cortisol gets too low. This is a dangerous situation requiring immediate dosing with Predisone and veterinary attention.

Did your vet give you any Pred? If not, INSIST they give you some. When you saw the loss of appetite, that would have been the time to stop the Trilo (Vetoryl), give the pred and call the vet.

Please, if you ever see these signs in Cutie again - stop the drug, give Pred, and call your vet asap. You may spare her another hospital stay and save her life.

If your vet did not explain all of this to you, I am so sorry. They should have told you what could happen, what to look for and what to do if it did. Too many times vets feel that Trilo is "safe" so there is no need for precautions like Pred. They are wrong. Trilo is no safer than Lyso when it is not administered and/or monitored correctly.

When was the last time Cutie had an ACTH to check her cortisol level? If you have those numbers and would share them with us, that would help us a great deal. I HOPE she had one while in the hospital? If they did not do an ACTH then, please have one done before you restart the Trilo.

How is her diabetes behaving?

Pancreatitis can take a while to fully recover from. Does she have chronic pancreatitis or was this an acute attack? When my Squirt had an acute attack, they put her on IV fluids for about 3 days, no food at all. Once she was back home, she didn't eat or drink much for a day or so, which was fine. The fluids she had received at the hospital kept her hydrated. This may be what you are seeing with Cutie having no thirst right now but if it continues, I would certainly call the vet about this, too....when you call to get the Pred. ;) I wouldn't try to force any food or fluids just yet. The organ needs time to settle down and let the inflammation go down. Food and water will cause the organ to become active, keeping the inflammation high. Lori knows much more about this condition than I as her baby has chronic pancreatitis, and I am sure she will be along soon with her input.

Cutie's little system has been under an incredible assault with the apparent Addisonian event and the pancreatitis, so it may take her some time to get back on her feet. But if you feel she is getting worse at home, then by all means get her back to the hospital. The fact that the diarrhea has stopped is a good sign!

Please keep us informed as to her condition. Keep your chin up!

Hugs,
Leslie and the girls :D - always

[benefr]

Thanks Squirt's Mom,

Cutie hasn't eaten (other than occassional spoon) for over a week.
She has a feeding tube now for two days.

At some point - they thought it was an addisonian crisis - and gave a cortisol shot, but acth showed very high levels, and even if at some point there was such shock, at this point the steroids were up.

I am considering adding prozac, and perhaps a pain reliever (but prefer something that doesn't make em too sleepy), to add - what do you think?

How could I get more people see and respond to my original post to which you replied?

Thanks

Ron

[BestBuddy]

Hi Ron,

You haven't mention how the diabetes regulation is going. Are you still giving insulin and how much? What sort of BG numbers are you seeing?

Jenny

[Squirt's Mom]

Hi Ron,

Others will along as they see your post to give their input.


At some point - they thought it was an addisonian crisis - and gave a cortisol shot, but acth showed very high levels, and even if at some point there was such shock, at this point the steroids were up.

Can you please verify that is was cortisol the vets gave her? The signs you described are fitting for a scenario where the cortisol dropped too low, not where it was too high. Hopefully others will have more insight here.

Also, can you tell us how her diabetes is doing? Is it under control?

Hang in and I am sure there will be more input.

Hugs,
Leslie and the girls :D - always

[Harley PoMMom]

Hi Ron,

Pancreatitis is a very serious condition in our pups. My boy Harley has been coping with this illness for a while now. We moniter his pancreatitis with a Spec PL test, have they done such a test on Cutie?

Harley's GP supplies me with pain meds for him for his pancreatitis as this can be a very painful when it is rearing its ugly head, did your vet give you any pain meds for Cutie?

What is concerning me is the swelling you are seeing, I would mention this to your vet ASAP.

The feeding tube is probably providing enough nutrients for her right now but I wouldn't let her not eating go on too much longer, but if she is in a lot of pain, she will not feel like eating.

Let me know how else I can help, ok?

Re; Spec PL test: Unprecedented accuracy—With greater than 95% specificity and sensitivity*, this test far outperforms other test methodologies so you can treat confidently.

Link with info about the Spec PL test
http://www.idexx.com/view/xhtml/en_us/smallanimal/reference-laboratories/testmenu/innovative-tests/spec-cpl.jsf?SSOTOKEN=0

Love and hugs,
Lori

[benefr]

Thanks everybody

Insulin is regulated quite well, although after this episode and lack of eating and now tube feeding -- she is on 9-11 and BG of 180-280

we did the pli test in the past (months ago) and it was positive -- but on this episode we didn't because we are pretty certain in light of ultrasound and general behaviour that it is the case.

ACTH confirmed she is not on addisonian shock (or at least isn't anymore).

Suggestions?

R

PS
What do you think of Serenia vs. Pramin, and should i give morphine type pain relievers? (she is not getting any pain relievers at the moment).

[Harley PoMMom]

Hi Ron,

The Spec PL test results will show a number...Harley's last results in Sept. were 547 (0-200).


Dogs are often sent home with pain medication, such as a Fentanyl patch or Tramadol. Butorphanol (Torbugesic) is also sometimes used, but the pain relief it offers is mild and does not last very long. Controlling pain is important during recovery, so ask your vet for help if you feel your dog is uncomfortable.


http://dogaware.com/articles/wdjpancreatitis.html#recovering

Hope Cutie is feeling better soon.

Love and hugs,
Lori

[benefr]

front foot swelling went down, but beyond the general weakness her legs are weak (could be related to antibiotics? right?).

She is not getting any pain meds and occassionally got anti-nausea medication.

We will probably give her tramdol/tramadex to her tube.

I intend to also start giving her metalopramide/pramin.

My main concerns right now are her ability to walk (she has difficulty standing because of general weakness although she looks fairly alert) and her not eating/pancreatitis.

Thanks,

Ron