Hello! Newly Diagnosed Pet - Diabetes and Cushing's (Lysodren) [Archive] - Canine Cushing's Information and Support Forums

Bonniemom

02-09-2010, 08:25 PM

Hello everyone. I'm glad to have found you.
My 10-yr-old spayed Yorkie was recently diagnosed with both diabetes & Cushing's. She is not responding that well to the mitotane. I don't have copies of her lab work but I was told that we need to get her level down to 1-5 & she is still a little over 10, whatever that means. She was originally over 30. We are on our 4th week of trying to mitotane & I am getting very frustrated. Her glucose is all over the chart & we cannot get it within normal limits. She is now on 9 units twice a day & she only weighs 10 pounds, so that's a lot. The vet has mentioned something called Utrecht Protocol which was suggested to her by a doctor at University of TN medical school. From what little I can find on the internet, I think it totally destroys the adrenal glands, which I suppose means I'd have to give her steroid supplements since her body won't be able to make the cortisol. I am stressed & confused because she is my precious baby & I want to help her. This has been going on since right after Thanksgiving. She looks like a typical Cushing's dog with the big potbelly & the weakness in the legs & change in hair color & thickness. Ultrasounds have not picked up any adrenal tumors. Has anyone else had problems with Mitotane not working?
Thanks!

littleone1

02-09-2010, 08:49 PM

Hi,

Corky and I would like to welcome both of you.

You have found a wonderful group of very caring, supportive and knowledgeable people.

I'm sorry that I don't have any advice or information to give you, as I have not had any experience using Mitotane. I'm sure others will be along that will be able to give you some information about it.

Terri

StarDeb55

02-09-2010, 08:50 PM

I would like to welcome both you & your baby! I'm really sorry to hear about all of the problems your little one has been having. We have several members who have experience dealing with both medical issues, so hopefully they will be along. I have zero experience with diabetes but now have had 2 pups with Cushing's, both successfully treated with lysodren (mitotane), so I will focus my questions in that area. We do ask a lot of questions of our new members concerning your little one's medical history, but that just helps us to give you the most specific feedback we can from the group's collective experience.

The first thing I would like to ask is what is your name & your little one's name? It's a little more personal than saying "heh, you". You have given us a good start by telling us about your pup's symptoms. Could you check with your vet about getting copies of all of your baby's labwork & posting the results for us? We ask this not to critique or 2nd guess your vet, but we have seen diagnostic mistakes made with pups usually due to a lack of experience on the vet's part. When you get those results, please post all Cushing's diagnostics, along with any general labwork that was done such as a super chem panel. On the general labs, please post only the abnormals along with normal ranges & reporting units. Could you tell us the names of the Cushing's diagnostics that were done? These might be an ACTH, low dose dex suppression, high dose dex suppression, or even an abdominal ultrasound.

When it comes to using lysodren, have you been doing what is called a loading period with your baby? This is where you split the dosage into 2 equal doses given twice per day, until signs of loading occur. Can you tell us the exact dosage in mg. that you have been giving, along with your baby's weight? It does sound like you have had at least one ACTH done after starting the lysodren since you say the cortisol values have come down. How long had you given the lysodren when that ACTH was done? On average, most dogs take about 5-8 days to load with lysodren. The important point here is "on average", our pups do not read the book as to what they are suppose to do & how they are supposed to react to the medicine. We have members whose pups have loaded in as little as 2 days, we have had other pups who have take a month to load. I believe Frijole, one of our administrators, schnauzer, took about a month to load.

When it comes to the protocol your vet's Utrecht protocol discussion, what the aim is to make the dog permanently Addisonian where the adrenals are not producing any cortisol. The pup would have to be on oral steroid supplementation permanently along with regular monitoring of electrolytes, sodium & potassium. This protocol is commonly done in Europe as it appears most vets over there feel that Addison's is easier to treat than Cushing's.

Please answer as many questions as you can right now. Post the results as soon as you are able to get them. We are here to help in any way we can.

Debbie

maggiebeagle

02-09-2010, 08:51 PM

My Maggie was treated with Trilostane, but I'm sure someone that has treated with Mitotane (also called Lysodren) will be along soon with more information. There are many "parents" that have dogs with Cushings and diabetes so you are not alone.
My Maggie lived three years after her Cushings diagnosis and died at age 15, a normal life span for a beagle.
Meanwhile, welcome :D.

AlisonandMia

02-09-2010, 09:03 PM

Hi and welcome from me too.

My dog was treated very successfully with mitotane (Lysodren) but we did have initial problems bringing her cortisol level down. It took her a month to load. This was partly because the dose the vet originally prescribed was on the low side and partly, I believe, because she was a "slow loader". Once we got beyond that things went very smoothly though and she did really well on Lysodren. She wasn't diabetic so there was no particularly urgency to get the cortisol down to a healthy level - apart from the fact the slow loading was stressing me out!

What dose of mitotane is Bonnie on and how often are you giving it to her? How long have you been giving it for? If her cortisol has gone from 30 to 10 then you definitely making progress, so don't lose heart!

When you are lowering the cortisol level in a diabetic dog it is usually expected that they will become much more sensitive to insulin so sudden hypoglycemia is a danger during this time. Are you testing her BG at home? If you are able to do this it would be really great.

We have a "sister site", K9Diabetes, where you can get great support on the diabetes side of things as well as info on home testing (if you need it). Here's a link:http://www.k9diabetes.com/forum/

Alison

Bonniemom

02-09-2010, 09:54 PM

Thanks for all the welcomes & I will try to answer the questions as best I can.
My name is Kim & the dog with the problem is Bonnie. I also have her littermate, Belinda, who is not having any medical problems at this time. I posted their picture on my profile if you'd like to have a look at my two princesses.
Bonnie first started having some peeing accidents in the house around Thanksgiving. She is prone to UTIs ever since she was spayed due to the lack of estrogen causing the bladder sphincter to relax too much & allowing bacteria in. I also noticed she was drinking more water. I collected a urine sample & took it to the vet. She did have a UTI but also had glucose in the urine. We then did a complete blood panel & found that her liver enzymes were double what they should be. At that point we did an ultrasound to check the liver & all the abdominal organs. Liver was normal but gall bladder was enlarged & full of sludge which was backing up into the liver & throwing the enzymes off. So we started her on Urusidoil (not sure of spelling) to treat the gall bladder sludge. I was told to give her this med along with antibiotics for the UTI & check back in a week or so. We repeated the ultrasound & found that a great deal of the sludge was gone so we are still using this med since it is working. Liver enzymes are coming down closer to normal. Blood sugar was over 500 at this point so we started Vetsulin. I've had a diabetic pet before so I was pretty educated about all that is involved & was comfortable with giving the injections, so that didn't panic me too much although I was sorry Bonnie was having to experience diabetes & all the symptoms.
Glucose was not responding well to ever-increasing doses of insulin so the vet did ACTH for Cushing's which was positive. Bonnie had also developed the potbelly by then & her water intake & urine output were becoming almost continuous. Her hair has always been thin but it seems thinner now & it has become lighter in color. We began mitotane treatment at I think 90mg twice daily & rechecked ACTH after 7 days. She had dropped from 30 to around 10 so we did another week & rechecked but still at same spot. We did several more days & rechecked again & still at same spot but glucose was down to 232, which was better than the 461 of the previous week. The doc at University of TN then advised 10 days of 100mg & recheck, which is scheduled for Monday the 15th.
Bonnie was previously taking estrogen supplement for her leaky bladder but she had begun peeing in her sleep several times a week & the vet switched her to Proin. After researching Proin I found that it shouldn't be given to diabetics so we stopped it as of yesterday & will recheck glucose on Saturday to see if the Proin was keeping it from falling within normal levels. We also did another ultrasound to check the adrenal glands. The left one is normal for sure but the right one was hard to see because of the swollen stomach was casting a shadow on it. We will also recheck this on Monday on an empty stomach but the vet feels it will be normal also as it has not stood out in any of the 3 ultrasounds she's had, so she feels it is not enlarged with a tumor.
I don't have a copy of the labs but I will ask for them when I see the vet on Saturday, also she will give me the info on the Utrecht Protocol. I am wary of it as it seems wrong somehow to completely destroy the adrenals. I don't want to do more harm than good. But I am totally committed to doing whatever I can to give Bonnie the longest & healthiest life possible. I consider these dogs of mine as my children & would do anything I could for them. I previously had a poodle of 15 yrs who had a hereditary eye disease which caused him to be nearly blind, diabetes, an enlarged heart, asthma & a collapsed trachea so I know what is involved in making my life revolve around a medication schedule. I am willing to adjust everything in my life to revolve around Bonnie's care because I love her so much! I just want to make sure I am making the best decisions for Bonnie since she cannot make them for herself.
She is currently on 9 units of insulin twice daily, a very large dose for a dog her size. Both my Yorkies are large for their breed as far as their build goes, they are taller & longer than the breed standard. Bonnie weighs 10 pounds but has never been overweight so losing weight would probably not help the glucose. She never had any weight around her belly until the Cushing's started as she has always been very active. I think if we get the Cushing's under control we will probably be able to get the glucose where it should be.
The expense has been hard, of course. This is a bad time for us financially but I'd sell all my furniture & sit on an orange crate if I had to. You dog lovers know what I mean. I'm 40 with no kids & not likely to have any, so these dogs are my kids.
I appreciate any advice you can give. I'm happy I found this forum. I will post the lab results when I get them from the vet & since you guys are more experienced, hopefully you can decode them for me. Thanks so much!

StarDeb55

02-09-2010, 10:11 PM

What is Bonnie's most recent weight? We need to know that because the lysodren dose is calculated in mg./kg. of body weight. One suggestion, when it comes to ultrasounds, it's very important that they been done on a high resolution machine to make sure the adrenals can be clearly visualized, so you might want to double check with your vet about what type of US they have.

Debbie

PS- Forgot to ask one very important thing!!! Did your vet go over what the symptoms of a possible low cortisol crisis are? This is extremely import when treating with lysodren as it is a long acting drug, staying in the body up to 48 hours. Did your vet give you prednisone to have available in case she should show signs of a low cortisol emergency?

Alison made an excellent point. You have gotten Bonnie's cortisol down by about 60%, so you are definitely making progress. I think you will get there but it's going to take a little longer than average from the sounds of it. Normal cortisol for our cushpups is 1-5 mg/dl, & this is what you are shooting for when you are loading. The normal range for a healthy pup is much different so don't get them confused or let any of your treating vets get the 2 ranges confused. I say this because we have seen vets try to use a healthy pups normal cortisol range when treating cushpups, it's not totally unusual.

AlisonandMia

02-09-2010, 10:40 PM

My vet discussed the Utrecht Protocol with me too. Like you I find it somewhat repugnant - a bit like ripping out all someone's teeth and giving them falsies. I can see, however, that in some situations it could be the best thing (like it can be with the teeth too) but usually it isn't necessary. I have read it being recommended for diabetic Cushing's dogs, though, which is possibly where your vet is coming from. Theoretically it could give more predictable cortisol levels (because all corticosteroids are being given artificially) so I guess that is the attraction, however we've seen quite a few diabetic Cushing's dogs do well on standard protocols.

A couple of things do worry me about using the UP on a diabetic though. As I understand it, the Utrecht Protocol necessarily involves giving additional steroids while giving the high-doses of Lysodren (to avoid an addisonian episode - dangerously low cortisol with electrolyte imbalance). I would think this could cause dangerously high BG for a while until whenever the dog's own cortisol production ceased. To not give the steroids would be even more risky. You may want to ask the vet about this issue. Personally (and this is me personally), I'd consider the Utrecht Protocol to be a last resort if more conventional use of Lysodren fails to give stable cortisol control over a period of time.

I see that Bonnie has had a fair few ACTH stim tests over the last few weeks - have you noticed that her BG's go high in the couple of days following the test? This is very normal as the test causes a surge of cortisol which creates insulin resistance. When you are accessing how her diabetic control is going you probably need to take this into account. Even a non-Cushing's diabetic dog will typically have high BG numbers in the days following an ACTH stim.

I see she was started on Vetsulin - has your vet mentioned the upcoming (and in fact present) problems with this insulin becoming unavailable? It was withdrawn from the market by the FDA a few months ago with existing supplies still being allowed to be sold - however no more will be supplied to the market for the foreseeable future. Most dogs have been, or very shortly will be, switched to another insulin, usually NPH, a human insulin.

Just one other little thing - with regard to the gallbladder problem, has her sister been checked for that too? I was just thinking with them being litter sisters, Belinda may have the same issue, even if it is asymptomatic at the moment.

Alison

Bonniemom

02-09-2010, 11:10 PM

Thanks, I did not know about Vetsulin being taken off the market. That's upsetting since the vet had been having much better results with it than with human insulin. Back when my other pup had diabetes I had to use Humulin U for him. He never went above 3.5 units twice a day. His was pretty well under control, of course he didn't have Cushing's. He developed diabetes at the age of 13, I think, & lived to be almost 15 & passed from other problems.
As to the question of BG being higher after the ACTH tests, what they usually do when I take her in is get the blood for the glucose right away before doing anything else. Her numbers were not coming down very well even before we did the ACTH testing which is what led to them thinking she had Cushing's. They also have to take the blood for the glucose right away because she gets very stressed at the vet's. She's really attached to me & spoiled to death so it's hard for her to be in a strange place. Bonnie follows me everywhere, even to the bathroom. She has a bed in every room so she can stare at me while lying comfortably in bed! Belinda goes to the bathroom with me too but it's only so she can try & pull toilet paper off the roll. I haven't been to the bathroom by myself in 10 years! (haha) When we go on vacation we either take the dogs with us or my mother-in-law babysits them at our house. I'm afraid the stress of being at the vet's also increases her cortisol level.
On the up side, her water consumption & peeing are coming more under control which I think is a good sign. I put puppy pads down in the laundry room for her to use. That way she doesn't have to try & hold it or have accidents on the carpet. She's doing well with those except for when she puts her front paws on the pads & forgets that her rear end is still hanging over the floor! But it's vinyl flooring in there so I just clean it up if she misses.
Today she seems to be resting comfortably & has played with her favorite toy several times. Her appetite today was more normal & not like she was starving to death, so maybe we're getting close. I am watching her very carefully. I had not been given anything in case the cortisol fell too low so I will ask for some meds to have on hand. I looked up the symptoms of that so I'd know what to look for. I only work 4 full days a week & have only a five-minute drive so that lets me be with her more to observe how she is.
I will keep you updated as things progress. Thanks for all the concern & advice!

AlisonandMia

02-09-2010, 11:19 PM

If her appetite is more normal now and the drinking and peeing more reasonable (and the playing with a toy) then it sounds like she could well be loaded - which means you don't want to give any more Lysodren until you can get another ACTH stim test done. Those signs also suggest that her BG may be better too which also makes it more likely her cortisol is now in the desired range. Only way to be sure though is an ACTH stim test.

It is possible she isn't loaded yet, but it is much safer to stop giving the Lysodren until you are sure rather than to over shoot and have low cortisol and, with a diabetic, dangerously low BG with it.

How long was it again since the last stim test?

Alison

PS: Do you home test for BG levels?

Squirt's Mom

02-10-2010, 11:29 AM

Hi Kim and welcome to you and Bonnie! :)

I just wanted to drop in and say, "HI!" and that I am glad you found us! You are in good hands with Alison and all the pros here, of which we have many.

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

gpgscott

02-10-2010, 12:37 PM

Welcome from us also.

I still can't find your little ones current wt. and I am uncomfortable with the process of loading for X days. I am not a Dr. but have seen untold numbers of pups here and when the right loading dose is administered the loading period can be as few as two or three days and as long as a month. Each pup is unique in this regard and the people who have the greatest success with the least stress on their pups are the ones who rely on relief of symtoms as a sign of loading rather than an arbitrary number of days.

I am putting a link to Lysodren loading information at the end of this post, it is from our resources area where you will find lots of medically reviewed information about Cushing's

Best to you both.

Scott

http://www.k9cushings.com/forum/showthread.php?t=181

lulusmom

02-10-2010, 01:23 PM

Scott, I just noted that Bonnie weighs 10 pounds and started loading at 90mg twice a day which is approximately 40mg/kg. The loading dose was increased to 100mg twice daily which is 44mg/kg.

gpgscott

02-10-2010, 01:35 PM

Thanks Glynda, I missed it in my reading of the thread.

So that dose is right in the recommended range, I still am in Alison's camp though in that if you see reduction in symptoms or any sign of overloading such as weakness, loss of appeteite, vomiting you stop administering the Lysodren at once.

Best wishes. Scott

Bonniemom

02-11-2010, 01:34 PM

Apparently Bonnie's lessening of appetite was a false alarm because by bedtime she was "vaccuming" the kitchen floor for crumbs & begging for treats. She has also eaten voraciously during her meals since. She eats then licks her bowl clean & then checks Belinda's empty bowl & licks it clean too.
The trouble with judging her water consumption is that her symptoms are complicated by diabetes. I can't tell if she's drinking less because the Cushing's is getting under control or if it's because her blood glucose is getting under control.
She is supposed to get glucose checked Saturday morning & the ACTH Monday morning. Do you think that's too far away? I think this will be her 4th or maybe her 5th ACTH at $200 each. I had to close out a savings account & also withdraw money from a life insurance policy to pay for all her tests, so I'm having a struggle right now with making sure we don't overmedicate her but also not repeating tests too soon before the medicine has a chance to work. My husband's business was severely affected by the economy & he's trying to get a second job right now to try & catch our bills up, so I'm having to watch Bonnie very closely for any sign that it is time to retest. If I see indications that it is time, I will call the vet right away & not wait for the test on Monday. Also, I am watching for signs of Addisonian crisis in order to administer meds for that if necessary. It's very stressful because I want to do the best I can for her. Maybe the vet would let me work out a payment schedule under the circumstances since I've been a client for 15 years.
Is there anything I'm not doing that I should be doing, in your experience? This is all new to me & I'm reading everything I can about Cushing's, plus Cushing's complicated with diabetes. My girls eat nothing but organic dog foods from the health food store & also home dog food recipes that I sometimes make. Are there any foods or supplements that help or that I should avoid?
I welcome everyone's advise & opinions. Thanks!

frijole

02-11-2010, 02:43 PM

Hi Kim, I just re-read your thread and it seems like you are trying to do two things at the same time - control the diabetes and reduce cortisol levels. This is difficult because you can't be sure what is being affected by what.

Typically it is suggested to try to get the diabetes under control first. THEN you treat the cushings. I think this would reduce the number of acth tests you would have to do.

Perhaps it is too late for this but if you feel confused it is only because you have a right to. Is the diabetes under control yet? Perhaps I missed something.

Good luck, Kim

Bonniemom

02-11-2010, 04:36 PM

The blood glucose is still not where we want it. It started at over 500 & dropped slowly into the 300s, shot back up to the 400s, then came back to 232. I don't know why it would have gone back up at one point unless the Cushing's caused it. We started at 2 units of insulin twice a day & are up to 9 units twice a day now. Bonnie also gets very stressed when I take her to the vet which I know can elevate blood glucose but I doubt it would add 100 points to it. It was only after we couldn't get the diabetes under control that the vet decided to check for Cushing's in case that was why the glucose wasn't coming down like it should. It has never yet fallen into what would be a really good normal range, although we were pleased to see it at 232. Apparently the doctor at University of TN thought the glucose wouldn't come down to normal until we got the loading phase of Lysodren over with.
The vet is going to give me copies of everything when I go on Saturday so I will be able to give you her results in more details once I actually have them in front of me. Yes, this is a confusing disease & I am hesitant to do the Utrecht Protocol & cause Addison's disease. It seems strange to me to cause one disease to cure another.

StarDeb55

02-11-2010, 06:56 PM

Kim, my former IMS & I briefly discussed the Utrecht protocol for Harley as she had another cushparent actually request that the protocol been done to here recently diagnosed pup. The IMS agreed to do this, but my response was that I was basically pretty appalled. I told her that "He!! will freeze over, before I allow that to be done to any of my pups". She apologized for suggesting it, but I think she may have done it as I had already been down this Cushing's path before with my first boy & she was probably thinking that I did not want to do it, again.

Debbie

Squirt's Mom

02-11-2010, 07:26 PM

Hi Kim,

Is Bonnie by any chance on glucosamine or a glucosamine/condroitin supplement? I ask because glucosamine is an aminopolysaccharide comprised of an amino acid - glutamine, and a sugar - glucose.

Hugs,
Leslie and the girls - always

Bonniemom

02-11-2010, 09:07 PM

No, Bonnie does not take any type of glucosamine supplement. She has not had any arthritis problems & so I have never given it to her. She tore a knee ligament last year & had surgery on her knee & the x-rays showed really no arthritic changes. The only thing she is on is her prescription meds. Thanks for telling me about the glucosamine because I didn't know it.

AlisonandMia

02-11-2010, 09:16 PM

It is really hard to tell what is going on with a dog with both Cushing's and diabetes - particularly when you are trying to get them both under control at the same time. As you know, and have seen, the symptoms overlap to a huge extent.

I think the one thing that will really, really help you and keep your little one much, much safer through this difficult stage is for you to learn how to home test her BG. It will also save you a lot of money and give you the most accurate picture of what her BG is doing.

So go have a look at our "sister site", K9Diabetes.com. They have a support forum just like this one (but with the emphasis on diabetes) and lots of info including videos on home testing. Here's a link to the forum: http://www.k9diabetes.com/forum/ and a link to some of their info on home testing: http://www.k9diabetes.com/forum/forumdisplay.php?f=15 and this one http://www.k9diabetes.com/forum/showthread.php?t=960 has links to videos.

I think the biggest risk to Bonnie at the moment is that her cortisol will be lowered (as desired) and, as a result, her insulin dosage will suddenly be way too much and she will have a serious hypoglycemic episode from which her body will have trouble recovering. If you are home testing then you will be able to keep an eye on the BG levels and very likely head off any difficulties early.

Alison

Bonniemom

02-15-2010, 01:20 PM

I've been back to the vet's & Bonnie's glucose is still in the 230s & cortisol is still over 10. Her ultrasound was normal. The vet was finally able to get a good look at the right adrenal & it looked fine, just as the left one did. She has been on 4+ weeks of Lysodren & we cannot get her loaded. She has been on 100mg for the past couple weeks, she weighs right at 10 pounds. The vet says she thinks the only thing I can do now is the Utrecht Protocol which the vet at U.T. recommended because she is not responding & her case is complicated by diabetes. I asked about trying Trilostane or another medicine. She said she was willing to try it if I wanted but that she doubts it will be any better due to this being a complicated case.

I need counseling on this as I know I need to make a decision fairly soon on this & I don't want to do the wrong thing. The vet says Addison's will be easier to treat than the Cushing's/Diabetes mix & that we could probably get the diabetes well under control on a much lower dose once we induce Addison's. I hate the idea of causing a disease but if it really is easier to treat, & also less costly, & if it will make her feel better, then I may have to go this route. I also don't really understand how the chemical ablation is done. The only info I've found on the internet makes it sound like you do it with Lysodren, & considering we can't even get her loaded with it, I'm not sure it will work.

This is confusing! She was so healthy until now & such a peppy little dog. I just want her back to her normal little self. She seems depressed to me although she will still play with her favorite toy several times a day. We like to play fetch with it & she still enjoys that.

Any advice on this would be so appreciated right now! Thank you!

Squirt's Mom

02-15-2010, 03:25 PM

Hi Kim,

It makes me sick to think of intentionally making a pup Addisonian but I am not a vet. There are those who deal with Addisons on a daily basis who may be able to help you understand better what you will be getting into if you choose this route. Here are some links to groups and sites that can help you:

Addison’s*

http://canineaddisonsinfo.com/
http://k9addisons.com/faqs/
http://pet-diseases.suite101.com/article.cfm/addisons_disease_in_dog
http://www.inmetrodetroit.com/pets/dachshund/frederick/addisons.htm
http://www.vetinfo.com/dencyclopedia/deaddisons.html
http://www.addisondogs.com/support/group.html
http://pets.groups.yahoo.com/group/AddisonDogs_/
http://canineaddisonsinfo.com/Support.html

Please keep in touch and let us know how things are going and what you decide to do.

Hugs,
Leslie and the girls - always

Nathalie

02-15-2010, 03:59 PM

Hello Kim,

I don't think anybody can make a prediction whether or not Bonnie would respond well to Trilostan based on Bonnie's poor response as Lysodren works by erroding the adrenals so the adrenals can only produse a limited amount of Cortisol. Trilostan in comparison blocks the excessive production of cortisol. I would be interrested how your vet came to this conclusion.

My dog Phillip who we are treating with Lysodren had no problem loading but I am having a hard time finding an adequate maintenance dose that keeps the cortisol within the desired range. My vet consulted with an internal med specialist and she suggested to switch to Trilostan as he might respond way better do to the different mechanism by which the Trilostan works. Unfortunatly this is not an option for us because of finances - but if it was not an issue I personnaly would give Trilostan a try first if finances allow it. I too at one point considdered making him Addisionion but after reading up on it and speaking to some people that actually lived with an Addisionion dog I learned it comes with it's own set of possible complications. So for me it would be a a last resort type of option to considder as once you went that route there is no return unlike using Lysodren or Trilostan where when stopped the cushing's symptoms will return full force but no permanent damage has been done.

Good Luck and keep us posted.
Nathalie

BestBuddy

02-15-2010, 04:06 PM

Hi.
Are you still using Vetsulin? If you are then I certainly would try a change to NPH. It's something you can do with very little cost and it in my opinion is worth a try. Vetsulin does not work well with some dogs and there have been problems with it as well. Just remember that NPH has a much different working profile to Vetsulin so it would be advisable to start the NPH at a much lower dose that you are on now.

As for the cushings, you say it is still over 10, much over??? I don't remember what number you started at but it must be an improvement. Nothing wrong with going slow as long as you are still getting improvements.

Jenny

lulusmom

02-15-2010, 08:23 PM

I’m sorry that you’re having such a tough time stabilizing both conditions. It’s hard enough dealing solely with cushing’s so I can only imagine how incredibly frustrated you must me. There are usually three reasons why a dog seems to be resistant to lysodren. 1) The loading dose it too low, which doesn’t seem to be the case here; 2) the dog has an adrenal tumor, which also doesn’t seem to be the case as multiple abdominal ultrasounds showed normal adrenal glands and 3) the dog was misdiagnosed and does not have cushing’s. Unfortunately, we have nothing to go on for the third scenario as you have not posted the results of the diagnostic testing that was done by your vet to correctly confirm the cushing’s diagnosis.

In addition to seeing the results of the diagnostic tests, there are a number of other things that I am curious about. I’d like to list those items so that perhaps you can provide more information or clarify.

1. It seems that most, if not all, of Bonnie’s symptoms can be attributed to either diabetes or the UTI that was diagnosed at the onset of all of her problems. Aside from the muscle wasting that is responsible for the pot bellied appearance, an enlarged liver and being overweight are really big contributors as is an enlarged bladder due to increased water intake. Bonnie has no enlarged liver, is not overweight and I didn’t see where you mentioned anything about muscle weakness, especially in the hindquarters. Dogs with cushing’s do not develop a pot belly quickly. Like the disease itself, it’s a very graded process. When did you notice the pot belly and has it improved?

2. You mention that at the onset of this, an abdominal ultrasound showed a lot of sludge in the bladder which your vet attributes to the elevated liver enzymes. Bonnie was prescribed Ursodiol and a recheck showed that the sludge was gone and liver enzymes were close to normal. Was this before Bonnie was diagnosed with cushing’s?

3. You mentioned that at some point that glucose was not responding well to ever increasing doses of insulin and that by that time Bonnie’s drinking and peeing were constant now and she started to develop a pot belly. It was at this point that your vet decided to test for cushing’s. Diabetes is a very likely non adrenal illness to yield false positive results on the ACTH stimulation test and the LDDS test. I also see that Bonnie is really stressed at the vet’s office and stress can do the same. False positives are less likely with the ACTH stimulation test but still very much possible.

4. I see that your vet prescribed vetsulin despite the fact that the FDA, as well as the manufacturer, have advised that supplies will soon be exhausted and vets should not be starting any newly diagnosed patients on vetsulin and those patients that are already on it should be transitioned to a new insulin. Have you asked your vet why she prescribed vetsulin despite these warnings and have you asked your vet if perhaps the problem the FDA found with the stability of vetsulin could be the reason for your inability to gain control of the diabetes? Here is a link to the manufacturer’s frequently asked questions.

http://www.vetsulin.com/dog-owner/Vet_ProductAlert.aspx

In our experience, it is very, very rare that a vet in the U.S. would recommend selective destruction of the adrenal cortex simply because it’s pretty risky. I’d be pretty scared to agree to that without increasing to at least the maximum recommended loading dose. As I recall Bonnie was getting approximately 44mg/kg daily and the upper recommended range is 50mg/kg. If Bonnie’s last post stim was only a tad over 10, then I’d opt to increase the dose and continue loading. It will be easier to assess Bonnie’s progress once you post the results of all acth stim tests.

So here we are with sweet Bonnie who has symptoms that can be attributed to diabetes as well as cushing's, the diabetes can skew the results of an acth stim test, which is a real concern because nothing in the abdominal ultrasound is consistent with cushing's, plus she appears to be highly resistant to lysodren yet no adrenal tumor is evident, plus she is on an insulin that is known to have stability problems which could be the culprit for your inability to control the diabetes. Whew!! Can you tell I'm concerned about a correct diagnosis? :)

I look forward to hearing back from you.

Glynda

StarDeb55

02-15-2010, 08:32 PM

There is one other thing that I don't believe anyone has mentioned concerning a possible switch to Trilostane. You will have to have a 30 day washout period from the lysodren, before beginning trilo.

Debbie

Bonniemom

02-15-2010, 08:44 PM

Thanks for everyone's concern. Bonnie is not feeling well at all today & she vomited a while ago.
The ACTH was originally around 30 then dropped to 10 on the first week of Lysodren. We did another week & checked back & still at 10 so we increased her dose for another week & it was still at 10. This time it was again at 10.
The vet did not give me the info today that I needed for posting on here. I'm thinking of trying to find a specialist in the area as my vet seems to not have really any experience in this area, or not enough experience. She can't seem to give me any advice without first talking to the vet at U.T. so I am getting really uncomfortable. Is it possible to misdiagnose Cushing's with this many ACTH tests?
I think the timeline was like this: 1. She developed a UTI & I took a urine sample which also had glucose in it. 2. We did bloodwork to determine why there was glucose. 3. The bloodwork showed some elevated blood sugar & seriously elevated liver enzymes. 4. We did an abdominal ultrasound & liver & all other organs were normal but gall bladder was swollen & had sludge in it. 5. I began giving the Ursidoil for the gall bladder & we went back in about a week to repeat the ultrasoud, which looked much better so we have kept her on this med. Her blood sugar was over 500 that morning so I had the vet keep her that day & she administered insulin & observed her all day & retested in the evening & it was down in the 300s. 6. We kept trying to get the glucose down & it was coming down very slowly, still in the 300s. Follow-up bloodwork on the liver was improving now that we were getting the sludge out of the gall bladder. 7. Several weeks of insulin was still not getting the blood sugar down & she now had a potbelly. Also the hair they shaved off for the first ultrasound never grew back, which I understand is a sign of Cushing's. We tested for Cushing's & it was around 30 so we started Lysodren at 90mg. Blood sugar has improved on Lysodren & is now staying in the 230s, better but not where we'd like it. I don't understand why we can't get below 10. She has stood over her water bowl all day today like she's guarding it.
So do you guys think giving Trilostane is worth a try? I am so hesitant to give her Addison's. It seems so wrong to do that to healthy organs. Plus I'm worried that if we have somehow misdiagnosed Cushing's I will just be presenting her with additional problems.

AlisonandMia

02-15-2010, 08:48 PM

I agree with Glynda on the increasing the loading dose to at least the upper recommended dose of 50mg/kg. Different dogs need different doses - some are really sensitive to Lysodren and others are not so sensitive - which is why just about every dog here would be on a slightly different dose. Small dogs often need to be at the upper end of the recommended dosage range too. The same variation in required dose also goes for Trilostane too, BTW, but as Nathalie said the response to one drug doesn't necessarily predict the response to the other one because of the very different mode of action.

However, one reason to not want to switch now is that when you switch from to trilostane is because it is necessary to stop the first medication (Lysodren in your case) and wait for a month or so before starting the other. To use either drug too close in time to the other one is to risk serious, maybe permanent damage to the adrenal cortex. Doing that with a diabetic could be problematical because it would very likely result in a several weeks of uncontrolled cortisol production.

One thing you need to be aware of with Lysodren is that its absorption is very much affected by the amount of fat/oil in the food with which it is given. Is Bonnie on a low-fat diet because of the gallbladder problem? If she is then this could well explain the difficulty you are having getting her loaded - she may be simply not absorbing the Lysodren you are giving her well. The solution to this would be to either increase the fat level (probably not what you want to do) or to increase the amount of Lysodren given to make up for the poor absorption. Apparently even with a moderate to quite high fat meal a large amount of the actually dose does go straight through - it just isn't particularly well absorbed presumably because it is not water-soluble. I was always very careful to scoop the poop promptly for this reason!

Like the others I am concerned about the use of Vetsulin, partly because of the problem that lead to its withdrawal and even more so because of looming availability problem.

Although a BG of 230 isn't ideal it is certainly far from terrible - many dogs sit in the 300 - 400's for weeks during the regulation process, and this is dogs with no other issues apart from diabetes. Bonnie has several other issues so I think she's doing pretty well at the moment, actually and I feel you will get there eventually!:)

Alison

Bonniemom

02-15-2010, 09:45 PM

I think I'll check with my vet in the morning about Vetsulin. I've been researching it & apparently some of the vials weren't stable, which might explain why her glucose levels have been all over the map.
I didn't know you couldn't switch immediately to Trilostane, so thanks. I can also tell the vet tomorrow that I'd like the higher limit of dosage called in to the compounding clinic. We could try that for a few days & see what happens.
I also want to contact other vets in my area tomorrow to try & find one more familiar with treating Cushing's/diabetes combo. I am willing to switch vets at this point because I really feel my vet just isn't experienced enough with this condition. I've been going to her for many years but this seems to be the first difficult Cushing's case she's ever had. I can't wait for her to call the University every time I have a question. So I've looked up a list of internal medicine vets in my area (within 30 miles) & there are quite a few so I'm going to call them & see what they say.
Bonnie eats a regular diet as far as fat goes. She eats organic pet food, usually canned mixed with small-breed dry food. Would adding a little salmon oil or olive oil help?
Thanks!

StarDeb55

02-15-2010, 10:04 PM

You need to exercise caution with adding additional oil as our cushpups are prone to pancreatitis. I'm not sure if this would be appropriate with the diabetes, but several members will bury the lysodren in a small amount of full fat cream cheese. I had to be careful with Harley & extra oil as he has a pre-existing gallbladder problem. I use peanut butter, but I know with all the sugar in PB that it would be out of the question for Bonnie.

Debbie

AlisonandMia

02-15-2010, 10:30 PM

I would be wary of adding any more fat or oil. As Debbie says Cushing's dogs are a thought to be a little bit more prone to pancreatitis than other dogs - and so are diabetic dogs! Also Bonnie has gallbladder issues and too much fat wouldn'd be a good thing there either.

It would probably be best to look at increasing the amount of Lysodren you give rather than trying to add any more fat. It sounds like her diet isn't incredibly low fat or almost fat-free or anything so she will be absorbing some Lysodren. Some dogs do actually need more than the recommended mg/kg dose (often the smaller dogs) - Nathalie's Philip (not a small dog though!) is on a considerably higher dose and is doing really well on it. He just needs that higher dose either because his adrenals aren't that sensitive to it or for some reason he doesn't absorb it well - or both.

It is quite common for vets who are not that experienced to be cautious and give a dose of Lysodren which is on the low side. That is what my vet did at first and it took ages for Mia to load. It wasn't until we went to 50mg/kg that we got her loaded and kept her stable. After that everything went pretty smoothly. I gave her a bit more fat with her "Lysodren meal" than you would probably want to with Bonnie (Mia had no other issues apart from the Cushing's). If I hadn't been able to add that little bit more fat/oil then I'm pretty sure we would have had to go to a larger dose. Mia weighed just under 10lbs.

Alison

lulusmom

02-16-2010, 12:17 AM

Hi again.

I just wanted to say that I think it would be a great idea to have Bonnie see an internal medicine specialist. With Bonnie having multiple issues, overlapping symptoms and conflicting test results, I think having a specialist go over all the testing and direct appropriate treatment is a great idea. My two cushdogs have multiple conditions; however, luckily neither have diabetes and I drive 50 to 60 miles to their internal medicine specialist for peace of mind.

Bonnie may very well have cushing's but my concern was that only one diagnostic test was consistent with cushing's and that test can be skewed by diabetes, plus her symptoms could be from either diabetes or cushings. I feel better knowing that you saw definite improvement in the BG with the lysodren and also that Bonnie's coat on her belly never regrew after the ultrasound. This is very common with cushing's; however, it is also common with hypothyroidism. Did your vet rule out hypothyroidism?

Bonniemom

02-16-2010, 01:46 PM

I have an appointment for Bonnie on Friday with an internal medical specialist. I'm taking him all her labwork & ultrasound results & he will go over them & examine her. We also discussed the Vetsulin which he will probably change due to the problems with it. He currently has quite a few patients with both diabetes & Cushing's & they are under control without causing Addison's, so hopefully he will be able to help me.
Bonnie takes Lysodren liquid that's made at a compounding pharmacy, so I have to give it with a syringe at mealtime.

Nathalie

02-16-2010, 02:50 PM

I am just checking in from work and I am so glad for you that you are able to see a specialist. :)
I have been treating my Phillip pretty much on my own with the help of this group BUT we don't have diabetes to further complicate things and it has been very tough at times and I certainly would not have been able to do without the help of people on this board.
Anyhow, glad you found someone and I hope he/she has lots of experience, impeccable bed-side manners and does not charge too much:D;)
Nathalie

Bonniemom

02-19-2010, 08:22 PM

Lots of things have been going on. Bonnie saw the internal specialist today & I am really glad I went! I was gonna post all the lab results from her former vet but according to the internist the testing my vet did was basically meaningless because he says she didn't do the ACTH properly. He read through all her records & the medication list & was appalled. He said I did the right thing in taking her off the Proin for incontinence because it should never be used in a diabetic patient. I had told my vet that & she acted like I was crazy but Proin's own website says so. The new doc never prescribes it even in a healthy patient because it's kinda like using speed or pseudo-ephedrine & was pulled by FDA for humans because of risk of stroke. The Vetsulin will be changed when we get new test results Tues. because he thinks she is probably just resistant to that particular type. No 10 pound dog should need 9 units twice a day. He couldn't believe her vet ever started her on Vetsulin. He says the Utrecht Protocol is ridiculous & he has never once in his 25 years of practice EVER had to make a dog Addisonian in order to get their Cushing's/Diabetes under control. He has some doubt as to whether she even has Cushing's but he is going to run tests himself on Tues. He didn't want to mess with her insulin or anything until we do that because the weekend is here & he was afraid she might have problems over the weekend. This new doc seems very nice & very competent. He said he didn't like to say anything about other doctors but I could tell he was upset that Bonnie might have been treated for a condition she may not have, and especially that anyone would suggest making her Addisonian without doing further testing and exploring much less invasive options.

Having the potbelly makes me lean towards thinking she might actually have Cushing's but he also said various other conditions could cause her to gain weight, such as a thyroid problem or potentially even the diabetes.

It's funny but Bonnie has felt much better ever since I decided on Monday not to take her back to her regular vet. She's been almost like her normal self.

My former vet is so fired!!!! I am upset & angry that she couldn't even perform an ACTH properly. I didn't really understand all the jargon about what was wrong with her tests but he said there was no way on earth you could diagnose Cushing's the way she did it. What if I hadn't been the type of pet owner who researches & questions things & had taken my vet's word as gospel & gone ahead with the Utrecht Protocol when apparently I will probably never need to? Makes me wonder how many other pets are being harmed there. I've been a client for 15 years but I'm taking both my girls to the new doc from now on. Bonnie even likes him & she usually is very scared at the vet's. Her urine had been dark on the puppy pad & to my shock she actually produced a urine sample for them! She has never done that for anyone but me before. She didn't have a UTI & there was no glucose in the urine. It was a little dark but that's all. PH was good.