Timon (14.5 y/o Pug) Intro and Updates (cushings, diabetes & pancreatitis)

[tymbaa29]

Hi everyone, I am a recent new member to the K9Diabetes site with a 14 year old pug who was diagnosed in October 2008 with diabetes. I have been chatting alot through that site regarding Blood Sugar levels and Ketones. I am excited that there is a "cushings" site that I can also access.

Since November, Timon has been experiencing problems with elevated sugar levels and ketones in his urine. He was tested for Cushings in November during a hospitalization and tested negative.
I took him to a Internal Medicine specialist in December as he continued to experience alot of problems: high sugars, urinating alot, drinking alot, belly looked swollen. He had an ultrasound done which showed no problems, and the IM conducted an adrenal panel that was sent to Univ. Of Tenn. IM suspected atypical cushings.

:)While waiting for the test to come back, Timon experienced a set back and ended up in the hospital for 14 days with pancreatitis and ketones that shot up to 4+. While there the adrenal panel results came back and Timon was diagnosed with Cushings and started on Lysodren 1/4 of a 500mg tab, 2x/week. While in hospital, it was lowered to 1x/week after an ACTH test.

He was released on 1/18/10 home with trace ketones and still on 1/4 of 500mg tab 1x/week. Since he has been home, ketones are gone, sugars have lowered, but we are still working to get him into the 200-300 range. His ACTH test done just prior to coming home showed normal cortisol levels but elevated 17-hydroxyprogesterone level.

Timon had a follow up ACTH test done on Weds and the results are as follows:

Pre test: 1.2
Post test: 12

IM wants to see post test result between 5 & 8 so he decided to have me give Timon 1/4 tablet Lysodren two times a week instead of one time a week.

I am not really familiar or comfortable yet with this issue so I am interested to see what others think about his plan of action.

Barb

[frijole]

Welcome! Can you tell us if the U of TN results DID confirm atypical cushings? If so do you have the test? Usually Dr. Oliver has specific instructions included on them. I trust this man as he is an expert.

Dosing is different dependent upon which type of cushings it is. So please let us know and then we can better comment.

Glad you found us! Kim

[tymbaa29]

Hi, I was able to get a copy of the test results from UOT. Here they are:
Each test will have a baseline result first then the Post ACTH result:

Cortisol: 6.6; 74.2
Androstenedione: 0.21; 1.75
Estradiol: 61.1; 58.3
Progesterone: 0.15; 1.8* (high)
17 OH Progesterone: 0.03; 3.85* (high)
Aldosterone: 19.6; 286.4

Results indicate presence of increased adrenal activity (marginal-mild)
Comments: (History: diabetic unregulated). Typically several steroids are elevated, not in this case. Deviation from reference ranges are mild-moderate:

Hugo Eller, D.V.M., Ph.D
Consultant, Clinical Endrocrinology Service

Barb

[Harley PoMMom]

Hi Barb,

Welcome to you and Timon from me and my boy Harley. I am so sorry for the circumstances that brought you here but so very glad that you found this forum.

My boy Harley has PDH Cushings plus elevations in all of the intermediate/sex hormones. When my boy had his first UTK full adrenal panel done in April only his estradiol was elevated so his treatment plan consisted of melatonin and the flax hulls with lignans.

Sept. UTK full adrenal panel showed different results for my boy :eek: everything was elevated, even his cortisol but because my boy has pancreatitis too, his GP conferred with Dr Oliver about his case. It was decided to start Harley on a low-maintenance dose only of Lysodren given 3X a week along with his melatonin and lignans.

Harley's GP is taking this slow with him because of his pancreatitis, she and I both know if his pancreas decides to rear it's ugly head, well then...one can't give Lysodren to a sick pup. So, we are hoping by doing it this way we are letting his body get used to this drug...so far so good! :)

IMO, I don't why they want Timon cortisol so low, from his UTK results: Cortisol: 6.6 (2.0-56.6) 74.2 (70.6-151.2) and his last stim: Pre test: 1.2, Post test: 12; he is within the healthy ranges for a normal dog.

Hopefully the others will be along shortly to voice their opinions as well.

Just remember you are not alone on this journey anymore, we are here for you and we will help you and Timon in any way we can.

Love and hugs,
Lori

PS. I added the normal ranges for Timon's UTK cortisol from Harley's last sheet.

[tymbaa29]

Hi, I did ask the IM for the last ACTH result report so I could take a look at it and it does indicate a normal response to ACTH. Under the interpretation there is reference to what would be considered "hyper"adrencorticism, "hypo" adrencorticism, etc. There is also this reference: Post-Lysodren: Pre and post cortisol levels after Lysodren loading or while on maintainence Lysodren should be between 1-5 ug/dl.

For now I am assuming his thought to have Timon's level post ACTH closer to 5-8 is tied to that reference.

When Timon was hospitalized and on lysodren 2x/week (for one week only), his 1st ACTH after initiating the med had a pre that was low and post was normal, so IM moved him to 1x/week out of concern for Addison's.

Barb

[Franklin'sMum]

Hi Barb,
Welcome to you and Timon from Franklin and me :) My knowledge of Cushings is still in the early stages, and I know nothing about the effects of diabetes with cushings, so please bear with me.
: Post-Lysodren: Pre and post cortisol levels after Lysodren loading or while on maintainence Lysodren should be between 1-5 ug/dl.

For now I am assuming his thought to have Timon's level post ACTH closer to 5-8 is tied to that reference.
Barb

I'm a trilo parent, but from what I have read on Lysodren, 1-5 ug/dl seems to be the recommendation for treatment of pituitary and adrenal cushings. If the pup has atypical, and the cortisol is in range for a non-cush pup, I don't know why your IM would like to lower his cortisol level further.

There seems to be a protocol for treating regular cushings, and a slightly different protocol for atypical cushings (with regular you want to lower the cortisol, and atypical you only want to lower the intermediate steroid/sex hormones.)

I'm sure somebody with more knowledge and experience will be along soon to give you more info.

Again, welcome

Jane and Franklin xx

PS. I love the name Timon... The lion king?
________
Biancababe (http://www.girlcamfriend.com/cam/Biancababe/)

[Harley PoMMom]

Hi, I did ask the IM for the last ACTH result report so I could take a look at it and it does indicate a normal response to ACTH. Under the interpretation there is reference to what would be considered "hyper"adrencorticism, "hypo" adrencorticism, etc. There is also this reference: Post-Lysodren: Pre and post cortisol levels after Lysodren loading or while on maintainence Lysodren should be between 1-5 ug/dl.

Barb

Hi Barb,

Dogs that have been properly diagnosed with Conventional Cushings, meaning having a elevated cortisol, which your Timon does not, and being treated and controlled with Lysodren should have a pre and a post between 1-5 ug/dl. It should also state on Timon's ACTH test the reference ranges for a "Normal Response To ACTH" for a "Canine." On Harley's ACTH test these reference ranges for a Normal Response is 5.5-20.0 ug/dl. So with Timon's post from the UTK panel of 7.4 and his most recent ACTH stim test of a post of 12, Timon is well within the Normal Response reference ranges. Harley's last UTK post stim was 262.8 ng/ml or 26 ug/dl, as you can see he is above the Normal Response reference ranges for a canine, so Harley's is being treated with Lysodren and we are trying to get his cortisol to a post of 1-5 ug/dl.

For 5 months Harley did not have elevated cortisol and had only elevated estradiol, so we only treated the elevated estradiol, it is only recent, Jan 4 to be exact :p that Harley started his Lysodren journey, because of his cortisol becoming elevated.

Dogs need cortisol in their body, it helps them deal with stress, illness and almost everything in their body needs this hormone. Cortisol only becomes harmful to a dog when it is elevated and this has to go on for a long period of time.

IMO, If I were you, I would talk this over with your IMS, and I would email Dr Oliver also, explaining everything about Timon's issues. I have emailed Dr Oliver many, many times and have gotten very quick responses back.

Love and hugs,
Lori

[littleone1]

Hi Barb,

Corky and I would also like to welcome you and Timon.

I'm glad you found us. Everyone is very caring and supportive. Many of our family members have a great wealth of knowledge and experience.

I hope all goes well for Timon.

Terri

[Squirt's Mom]

Hi Barb and welcome to you and Timon! :)

I am very concerned that Timon has been given Lyso. Based on the results posted here, he does not need that drug. In fact, it can be fatal. Please, DO NOT give Timon any more Lyso until you can get an explanation from the IMS as to why he is wanting to lower a perfect cortisol score. Timon's cortisol is NOT elevated so he does NOT need the Lyso. By using the Lyso, Timon can be made Addisonian, which is the opposite of Cushing's. The Lyso can kill the adrenals to the point they cannot regenerate and as a result cannot produce the cortisol the body needs to survive.

We all have cortisol in our bodies. It is a natural hormone that is necessary for survival. Cortisol allows us to deal with stress for one thing and without it our bodies cannot cope. The adrenals are vital in the production and release of cortisol when the body is in need. If the adrenals are killed by the Lyso, then they cannot respond as they should.

I am very concerned as to why your IMS has given this to Timon. Do they think it will help with the diabetes?

Again, please do not give any more Lyso to Timon for now. Based on the UTK panel, all he needs is lignans and melatonin. What treatment did UTK recommend?

I am glad you found us and hope to learn more as the time passes. Sorry the first contact is rather negative, but I am really concerned about this. :o

Keep your chin up!
Hugs,
Leslie and the girls - always

[tymbaa29]

Oh boy, I certainly do not want to panic with the Lysodren. I will follow up with my IM. I have read that Lysodren can be used to treat elevated sex hormone levels, which Timon did have (progesterone and 17 OH progesterone) . He is on a low dose right now based on input I have received... I believe the IM does feel that the plan is helping with his diabetes, based on a conversation I had with the clinic on Thursday.

Since I am new to this site, how can I reach Dr. Oliver. I would love to share information about Timon with him and see what his thoughts are.

Is there someone who is dealing with just elevated sex hormones?

Timon had a brother, Pumbaa (another pug), who passed away last September. I did not originally start out with naming Pumbaa after the Lion King character. I did love the name!! When Timon came along, the name just fit him perfectly..... They were quite a pair growing up together....I do miss Pumbaa terribly.

I also had a boxer, Chyna, who collapsed suddenly in May and passed away also. It has been a very sad year for me... As with Pumbaa, she is missed so much.

Barb

[tymbaa29]

Oops....found Dr. Oliver listed right on my Adrenal Panel results....I am going to send him an e-mail.....

[Squirt's Mom]

Hi Barb,

I'm glad you are contacting Dr O. He is a saint! I know he will be able to help you and Timon.

My Squirt is just Atypical, tho they first thought she had the pituitary form. I think all of her intermediates are elevated except for on, but can't remember which right now. :rolleyes:

Sometimes estradiol can be produced in areas other than the adrenals and this is where the lignans and melatonin come in. Lyso will lower all other intermediate hormones with the exception of estradiol when it is produced outside the adrenal. But the use of Lyso is not typically the first defense but rather the last, especially when the cortisol is normal. After several months on the lignans and melatonin and the levels are still not lowered, then the Lyso is added as a maintenance dose only - no loading with Atypical use of Lyso.

IMHO, checking Timon's cortisol via a regular ACTH is a waste of money and can lead to an overdose as the cortisol is NOT the hormone out of balance. Typically, the pup is tested after 3-4 months on the lignans and melatonin via another UTK panel so that all the hormones involved are seen not just the cortisol.

Don't panic over the Lyso...let me do that. :p:o Talk with Dr O and your IMS so that you have a clear picture of what Timon needs and you understand what the docs are doing. We'll be here with you to help you along and always to listen.

Hugs,
Leslie and the girls - always

[frijole]

Oops....found Dr. Oliver listed right on my Adrenal Panel results....I am going to send him an e-mail.....

Fantastic! This guy is a very special person. He helps people all the time. I think he knows that sometimes vets need a little extra help with cushings - especially atypical.. and so he does this on his own time and at no extra charge. Unheard of. You can trust him to respond and be honest.

Keep us posted on what you hear! Kim

[Harley PoMMom]

Oops....found Dr. Oliver listed right on my Adrenal Panel results....I am going to send him an e-mail.....

This is great! Please make sure you give Dr Oliver all Timon's health details and test results, especially his ACTH post test results...the more details you can give him the better his advice will be.

Best of luck to you and Timon and I'll be watching for your updates!

Love and hugs,
Lori

[tymbaa29]

Hi, I received a response back from Dr. Oliver last evening (I am very impressed in how prompt he was). I shared Timon's history which included diabetes with unregulated high levels, hospitalization, Ketone levels, pancreatitis, and cushings. I also sent him the adrenal panel results from UTK (showing normal cortisol levels and elevated progesterone & 17 OH progesterone levels and the most recent ACTH results.

His reponse included the following:

My input: ACTH this past Weds showed a normal response to ACTH: Corisol Pre 1.2 and Post 12.7. IM wants to move to Lysodren 1/4 of 500mg tab 2x/wk instead of 1x/wk to bring the post ACTH results closer to a 5-8 range.

>>>This sounds reasonable to me. Five to eight ug/dL is not excessively low for cortisol. >>>The current Lysodren dose is very conservative, so I don't think moving it up to 2X per week will hurt. Especially since cortisol levels currently are normal, and not suppressed.

My input: Timon does seem to be feeling better and we seem to be on our way to getting his BGs lowered.. No side effects from Lysodren; however, I am concerned about his cortisol levels going low with 2x/wk lysodren.

>>>I don't think you will see this; it's still a conservative dose. Plus, your internist will keep tabs on the cortisol levels at appropriate times. It sounds like your internist knows what he's doing.

He is certainly a great resource. Thank you for pointing me in his direction.

Barb

[gpgscott]

Hi Barb and welcome.

There are several points here I want to try to clear up for you.

I am glad Dr. Oliver responded and is comforatable with the treatment for now.

What you may not realize is that Lysodren is a very safe med with almost no known side effects. It affects almost exclusively the adrenal cortex which is where most of the cortisol is made. It does have the effect at lower concentrations of affecting the two progesterones and this is why it is recomended as a treatment without what is known as a loading dose when the cortisol is normal or nearly so and the progesterones are elevated.

Lysodren like all drugs has what is referred to as a half-life in the dogs system. This is the length of time it takes for blood concentration to fall by 1/2, there are studies with general rule concerning this but all animals vary some in their metabolic function. The reason for periodic ACTH particularly early on in treatment is to ensure that the Lysodren is not slowly building to a concentration over a period of time which will cause a lowering of cortisol.

What are commonly referred to as side effects of Lysodren are in fact side effects of low cortisol brought on by the improper administration and monitoring of Lysodren.

It is clear Dr. Oliver is pleased with the treatment you have received so far and you now know how accessible he is. Sounds like you have a very fine Dr.

Best to you and Timon.

Scott

[tymbaa29]

Hi Scott, thank you for the additional information. I did need to understand better how the treatment with Lysodren helps lower the progesterone levels while not causing the cortisol levels to go too low. I also now have a better understanding of "loading" versus non loading.

Our goal (mine & IM) is to get Timon's BG levels regulated between 200-300 for now. We are not quite there yet.

Barb

[acushdogsmom]

Hi Barb,

Maybe I can also help you to understand a bit better about the way Lysodren is used in Pituitary (or adrenal) Cushing's (where the cortisol production is high) vs the way it's used in "Atypical" cases (where the cortisol production is not high).

In the Pituitary or adrenal types of Cushing's, the dog is given a fairly large dose of Lysodren (usually 50 mg/kg per day) for several days or more (often up to a week or so) to get the cortisol production down to less than 5 ug/dl. Levels around 2 or 3 ug/dl are commonly aimed for in these cases. This daily dose is called "loading".

Once the cortisol levels are down to less than 5 ug/dl, the dog is then given a weekly dose, usually somewhere around 50 mg/kg per week, typically aiming to keep the cortisol production well below 5. This is called the maintenance dose, because it is a dose usually used to try to keep the cortisol levels at the low levels achieved with the loading.

By the way, my dog had Pituitary Cushing's and he was loaded at 50 mg/kg per day. We maintained him at cortisol levels of around 2 or 3 ug/dl for more than 6 years. He did wonderfully well and had no side effects at all. You wouldn't have even been able to guess that there was anything wrong with him, even with his cortisol at the low levels we had to keep them at. When Lysodren is properly dosed and monitored, it is a safe and effective treatment.

Your Timon has been diagnosed with "Atypical" Cushing's, where the cortisol production is normal but some of the other intermediate adrenal hormones are out of whack. And in cases like Timon's, some Lysodren given weekly (without any initial daily loading period) can control the other out-of-whack hormones because in addition to cortisol, Lysodren also lowers progesterone, androstenedione and 17-hydroxyprogesterone levels. It will also slightly lower the cortisol production, because the Lysodren works by eroding away some of the adrenal cortex where all of these hormones are made, and the Lysodren can't lower the intermediates without also lowering the cortisol somewhat.

How much of the adrenal cortex is eroded away is dependant on the dose etc, and I wouldn't be worrying, if I were you, about Lysodren overdose at all. Your IM Specialist seems to know just how to manipulate the dose and how often to test to make sure the cortisol doesn't go too low.

I read at Natalie's diabetes board that Timon weighs 21 lbs, which is 9.5 kg. So if Timon is getting a weekly Lysodren dose of 125 mg once or twice a week (125 mg total or 250 mg total) that works out to either 13 mg/kg/week or 26 mg/kg/week, neither of which is exactly a high dose - in fact, if you compare that with the 50 mg/kg/week that dogs with the more usual kind of Cushing's receive, Timon's Lysodren dose is really very low.

And Timon never went through a daily loading period either, so his cortisol production was not way down at around 2 or 3 ug/dl before starting on the weekly dose. Which is why, I suspect, Dr. Oliver sees no problem with the dose and the way your IM Specialist is proceeding. :)

Although Timon's Internal Medicine Specialist Vet is aiming for a post-ACTH stim test result of 5-8 ug/dl, he/she knows perfectly well that if Timon had the more usual kind of Cushing's (PDH or Adrenal Cushing's) you'd be aiming for a much lower cortisol ACTH post test number and would be using a much higher dose of Lysodren, too.

Although I don't know much about regulating a diabetic dog, I'm thinking that maybe your IM Vet is also taking into account the bg levels, and how lowering the cortisol to between 5-8 ug/dl would affect the insulin dose and the blood glucose. Cortisol is an insulin antagonist, so reduction of circulating cortisol concentrations usually reduces the insulin requirement by diminishing insulin resistance. In other words, reduction of cortisol production enhances insulin effectiveness to some degree.

Oh ... I meant to also add this:

One of the first ever cases of Atypical Cushing's that we saw here was someone named Bonnie and her beautiful dog Crissy.

Crissy was diabetic and was also diagnosed with atypical Cushing's and although most of the time these days we tend to see no loading in atypical cases, Crissy was actually loaded on Lysodren and maintained for years on Lysodren the same way as dogs with PDH would be. If I am remembering correctly, in Crissy's case they actually did aim for the 1-5 ug/dl range (less than 5 ug/dl) just like with regular Cushing's treatment, and Crissy did well for many years on that protocol.

I'm not saying that's the way that Timon's treatment should be done, just pointing out that Crissy's cortisol production was kept as low as any other Cushing's dog and she did just fine with her cortisol that low, so I don't think there's any need to worry that if you do get Timon's cortisol down to somewhere around 5-8 ug/dl that it would be too low.

I have also noted that there are some Vets and IM Vets who do seem to like to go straight to a maintenance dose of Lysodren rather than starting with the flax and lignans-and melatonin type route, even in Atypical cases where there might (or might not) be some benefit to trying those types of supplements first.

[tymbaa29]

Hi everyone, thanks for the great input. I do better understand the differences with use of lysodren now..I will be moving to the 2x/wk dose this week. I will let you know how it goes.

Timon is currently at just below 20 lbs. I moved his insulin does back to 6.5 as I was getting some really low dips midway through his 12 hour period. His AM readings which were running high have been decreasing slowly since last Friday. I am happy with that.

Barb

[Squirt's Mom]

Hi Barb,

I am so glad you got to talk with Dr O and have a better understanding of your IMS' plan...so do I. :o Dr O is amazing, huh? He is a real hero to many of us here, a truly devoted, caring man.

Hope things continue to improve for Timon!

Hugs,
Leslie and the girls - always

[tymbaa29]

Hi everyone, it has been quite some time since I have visited this site. My dog Timon is a 14.5 year old pug who was diagnosed in January as having atypical cushings. He has been dealing with diabetes for about a year & 1/2. He also was diagnosed with pancreatitis in January and spent almost weeks in the hospital due to the pancreatitis, very high BG levels and elevated ketones. He has been doing well since he has come home; however, he has lost a few pounds over the last 4 months. On his recheck today he weighed in at 15.5 pounds. He was 18 pounds in January. My concern is that he has been losing about a pound a month. He is on Lysodren every 10 days for the atypical cushings and his insulin dose is 6.5 if over 300, 3 if 250-299 and no insulin if he falls below 250. He is on a low fat Purina diet (O/M) due to his pancreatitis and gets 1 can at breakfast and 1 can at dinner. I am very concerned about his weight lose and wonder if I should consider a different diet or just add something to what he already gets. I am trying to balance all three issues with Timon, not having the pancreatitis flare up, keeping his BG levels down, and keeping the cushings under control. I would appreciate any thoughts as to what I should consider.

Thank you. Barb

[Harley PoMMom]

Hi Barb!

Do you belong to our sister site, The k9diabetes Forum? If not I really suggest that you join over there because I know they can help you find the foods that will not skew with Timon's BG levels while trying to put some weight on him. As long as you stay low in fat the pancreatitis should stay in check. You might need to feed several small meals throughout the day to help gain weight and this is easier on the pancreas too.

Here is a link to The k9diabetes.com Forum: http://k9diabetes.com/forum/index.php

Love and hugs,
Lori

[tymbaa29]

I am a member of K9diabetes and will post the question there also. thank you.

[ladysmom06]

Hi Barb,

Left you a message on the diabetes board.

[tymbaa29]

Hi everyone, once again it has been a while since I have last posted on this site. I have been pretty much consumed and preoccupied with helping Timon through all of his challenges. Since I posted last, Timon is not seeing as many of the consistent high blood sugars in the am and then really low in pm. His pre and post ACTH cortisol levels are better and the IM is pleased.

My biggest challenge over the past few months is Timon's continued weight loss and his ongoing higher level PLI results. The ugly pancreatitis keeps challenging both of us. His last PLI result was 530 which is high. He is going for another plasma tx on Monday. We tried to have him gain a pound or two with a diet oatmeal, kidney beans, egg, and mixed veg in addition to his regular 2.5 cans of Purina O/M a day, but ran into a problem with some elevated blood sugars and elevated PLI. Most likely my fault as there was a problem with the Purina delivery due to Presidents day holiday so his diet changed for 3 days to the oatmeal mixture until the delivery arrived.

For those of you who may be dealing with cushings, diabetes & pancreatitis or any combination of the above, do you have any thoughts on what else I might be able to do to help Timon avoid the pancreatitis flare ups and maybe gain a pound or two?

Thank you. Barb