Gordy, 13 yr old Diabetic/Cushing's dog (Update: Gordy has passed)

[jlapro]

Hello,

Our 13-year-old dog Gordy (a Gordon Setter) has just been diagnosed with pituitary based Cushings. He also has diabetes, with diagnosis in February of 2008. It's been many years since I've last had a Cushings dog (also pituitary - died in 1998) so I'm hoping to get some helpful feedback from this list.

Gordy's blood sugar has been out of control for a while. We first took him to an internist (endocrinologist) in January at suggestion of our primary care vet. At that time he had a screening for Cushings (urine cortisol/creatinine ratio)and it came back negative. We had suspected Cushings because of high BG, high water intake, frequent UTIs and voracious appetite at odd times. His insulin dosage is 28 units b.i.d. and Somogi effect was pretty well ruled out by mid February.

He went back to internist last Friday, had an ultrasound that showed both adrenals enlarged, with diagnosis of possible Cushings as well as a small nodule on thyroid or parathyroid.

On Monday of this week, he was back at specialty clinic for low dose dexamethazone test, which came back POSITIVE for Cushings (the internist declined to do the ACTH stim test at that time). A concurrent T4 test came back with low thyroid.

On Tuesday, I picked up Trilostane tablets and Gordy was started on them on Wednesday a.m. - dosage 120 mg (two 60mg capsules).

Some of the folks on my vetpet list questioned the dosage as high - recommended UC Davis protocols rather than manufacturer's (and internists) dosage, which would mean lowering the dose to 30 mg/day

I queried the vet on this - he said he was willing for me to use UC Davis protocols if I wanted, but he did not recommend them and felt the dosage he prescribed was best for Gordy. I've decided to stick with the internists recommendation - the high cortisol/BG is taking a real toll on Gordy, and he has always tolerated medications well with no side effects.

He is scheduled for bloodwork and ACTH stim test next Friday, 4/2.

So... would like feedback from list members, particularly about the dosage and possible dangers to watch out for over next week.

P.S. forgot to mention, Gordy weighs 63 pounds - has maintained this weight for years.

[AlisonandMia]

Hi and welcome to you and Gordy.

Has Gordy ever been well regulated and what dose of insulin was he on in the past?

Cushing's is often very hard to diagnose in a diabetic as the signs and symptoms have so much overlap particularly urination and thirst and appetite. And diabetic dogs will very, very often test positive on Cushing's tests because of the physiological stress of the uncontrolled diabetes even if they don't actually have Cushing's. This is a particular problem with the LDDS test and usually the ACTH stim test is a better test for a diabetic for this reason.

The typical picture with a diabetic that has developed Cushing's some time after becoming diabetic is that previously-effective doses of insulin are no longer effective and increasing the insulin does not give sustained improvement. Of course other things (like infections) can produce this effect too.

With treatment of Cushing's the insulin requirements usually drop dramatically so it is usually recommended that the insulin dose the decreased significantly (usually by at least 1/3) when cortisol-lowering meds are started. Have you been advised to reduce his insulin? If the cortisol goes too low (as can happen with treatment sometimes with any dog) then the BG can really crash as this makes them exquisitely sensitive to insulin so be very watchful! In fact some of the weakness and illness that a non-diabetic dog has with low cortisol is often related to lowish BG because low cortisol = low BG.

The dose of trilostane (120mg once a day for a 63lb dog) looks right and is in line with Dechra's recommendations - however there would certainly be nothing wrong with a starting with a more cautious dose and quite a few vets are coming to prefer to "start low and go slow". How cautious you need to be may well depend on how much you can be with your dog or not during the day and how much you can monitor it. The cortisol-lowering effects of trilostane do seem to often "kick in" around the third to fifth day of dosing in many dogs. How is Gordy going now?

Good luck and keep us posted.:)

Alison

PS: Do you home test his BG?

[jlapro]

[QUOTE=AlisonandMia;27843]Hi and welcome to you and Gordy.

Alison: Has Gordy ever been well regulated and what dose of insulin was he on in the past?

Judy: Yes he was pretty well regulated for first year and a half. He of course started off on a fairly low dose, but went up to 28U by end of about 8 months

Allison: The typical picture with a diabetic that has developed Cushing's sometime after becoming diabetic is that previously effective doses of insulin are no longer effective and increasing the insulin does not give sustained improvement. Of course other things (like infections) can produce this effect too.

Have you been advised to reduce his insulin? If the cortisol goes too low (as can happen with treatment sometimes with any dog) then the BG can really crash as this makes them exquisitely sensitive to insulin so be very watchful!

Judy: Yes we've been told that, but were not told to reduce immediately. We are familiar with BG crashes and we do test at home. Since he started on the trilostane I've been testing him several times a day (we normally test 3 times daily - I've upped it to every 2 - 3 hours).

The dose of trilostane (120mg once a day for a 63lb dog) looks right and is in line with Dechra's recommendations - however there would certainly be nothing wrong with a starting with a more cautious dose and quite a few vets are coming to prefer to "start low and go slow".

How cautious you need to be may well depend on how much you can be with your dog or not during the day and how much you can monitor it. The cortisol-lowering effects of trilostane do seem to often "kick in" around the third to fifth day of dosing in many dogs. How is Gordy going now?

Judy: His BG is still quite high and he's still drinking a lot. There is almost always someone home with him, there are three of us in family and especially now he will not be left alone. We have decided for now to stick with the internist's dosage. I think we need to get his BG under control ASAP as the cortisol/high BG is really taking a toll. I forgot to mention (I think) that he has had frequest UTIs, he just finished antibiotic from last one.

Good luck and keep us posted.:)

Alison

[AlisonandMia]

The effects of a single trilostane dose usually peaks 2 - 6 hours after the dose is given so that is when the BG is most likely to dip.

Here's a link to another thread where a dog with pre-existing diabetes is being treated (very successfully) with trilostane: http://www.k9cushings.com/forum/showthread.php?t=1738

Sounds like you are doing a great job! Thirteen must be getting up there for a Gorden Setter?

Alison

[jlapro]

yes,

Thirteen years is at the outside range of average lifespan for a Gordon, but we're really hoping he can stick around for a couple more. He is on the smaller side for male Gordon Setters.

[labblab]

Welcome to you and Gordy from me, too!

I only have time for a quick note, but I do want to pass along one more thought regarding Gordy's trilostane dosing. While it is true that Dechra's printed information recommends a starting dose of 120 mg. for a dog of Gordy's weight, I discovered through a recent conversation with one of their U.S. technical reps that they are now verbally recommending that all dogs be started at the lowest end of their published dosing range: at 1 mg. per pound. So in Gordy's case, that would be approx. 60 mg. Since your trilostane is in the form of 60 mg. capsules, it would be possible for you to start out at that lower dose, should you choose to do so.

If your or your vet have any interest in talking directly with Dechra with questions about Vetoryl, you can contact their rep., Dr. Allen, at their Overland Park, KS office: http://www.dechra-us.com/page/contact-us. I am confident that he will be more than happy to talk with either of you about Dechra's most current dosing recommendations.

Whatever you decide to do, good luck and keep us updated!
Marianne

[k9diabetes]

Just hello from me - I'm glad to see you here as I have a great deal of trust in these folks when it comes to Cushing's disease. My diabetes forum is kind of a "sister" forum to this one.

I know you are frustrated as Gordy has been struggling for a long time and that you are getting a lot of different opinions here and at the vet pet list.

It is a lot to take in and it can be very difficult not only to sort out what to do but also to challenge a veterinary opinion, especially one from an expert, with conflicting information or different expectations.

I don't know if you will have to challenge your veterinarians' opinions and recommendations or not. You may decide that your wishes and their wishes line up perfectly.

But I want to support you if you feel in your gut that they are going down a road you are not comfortable with. You are Gordy's most important advocate and you know Gordy better than any living being on the planet.

Sometimes there are three or four potentially right ways to go about treating something like Cushing's disease and considering which one is right for Gordy should always always include your input.

Our dog was seen by an endrocrinologist at a veterinary teaching hospital for his difficult-to-control diabetes. That expert told us to do something and our general practice vet did not want to go against his advice so he wanted us to do the same. But I knew in my gut that it was the wrong road for Chris.

That was the point at which I decided... my dog, my decision, my standards.

It was not easy to take the little bit of experience we had at the time and hold it up against an expert in the field with years of experience who was saying very strongly that he was right and we were wrong. But I knew in my heart that is what we had to do.

It was a turning point for Chris - that decision. His diabetes management got better and better and better from that day forward because we advocated always for him and we expected every doctor who saw him after that to treat us as an important part of the treatment team and as the ones who ultimately decided whether we treated something aggressively, conservatively, or at all.

So follow your heart and your gut feelings in terms of Gordy's medication and the veterinarians' approaches. If something feels wrong, don't be shy about voicing your concerns and expecting them to be taken seriously.

As many have mentioned here, there is more than one way to dose the trilostane. More than one test that can help fill in the diagnostic picture. So more than one "right" answer.

The endocrinologist can be an expert in this disease (as our endocrinologist was supposed to be an expert with diabetes) but you are an expert on Gordy and that's a very important part of the puzzle. Where there are options, you should be given those options with their pros and cons and be a part of the process of deciding which option is best rather than dictated a treatment option.

We were dictated a treatment option that was too conservative for our goals and opted for more aggressive efforts to regulate Chris' diabetes.

Most of all, I hope Gordy is doing well and that all of this discussion about dosing winds up being unnecessary because Gordy does GREAT on his current meds and that his blood sugar falls into line.

You guys have been through a lot I know and if anyone deserves a break, it is you and Gordy.

Best wishes,

Natalie
k9diabetes@gmail.com

www.k9diabetes.com/forum (http://www.k9diabetes.com/forum)

[jlapro]

Natalie said:
"We were dictated a treatment option that was too conservative for our goals and opted for more aggressive efforts to regulate Chris' diabetes"

Natalie

The sentence you wrote above summarizes my actions with Gordy - the only difference here is that I believe the vet is right this time, and that the treatment protocol being advocated by some folks on this forum, and many folks on vetpet, is too conservative for Gordy.

We must get his blood glucose under control - every day that the high BG/cortisol floods his system his major organs are being assaulted. I believe that this is far more dangerous than a possible drug reaction.

Also, even though for most of his life Gordy was pretty healthy, he has had to take many medications throughout and has never had the slightest reaction to anything. Oh, I do remember ONE time he went dangerously low on BG. We rubbed his gums with karo syrup and he was back to normal in short order.

As I said previously, Gordy's age is already on the far side of his breed and size average lifespan. Even with that he has continued to be active and vital. OK, when his BG is really high he's a sad doggy, but he is a fighter who wants to live, and anything now is a gift.

Thank you for your support.

Judy

[k9diabetes]

Lucky you that Gordy tolerates meds so well. :)

Chris was exactly the opposite - he would have a reaction on cat-sized doses of meds and some of his doctors didn't really get that.

One of the many things I loved about his cardiologist is that she got that about him right away. She would never say "that can't be."

I have often thought that with diabetics on trilostane twice daily dosing might be useful in keeping their blood sugar and insulin requirement consistent throughout the day and night. It seems like there is the potential for a much sharper drop in blood sugar during the 6-12 effective hours of that medication if it is given once daily.

I would be interested to see what Gordy's blood sugar does in the morning and in the evening on once daily dosing to see if there is a difference in levels.

Have you seen any drop in blood sugar yet?

Natalie

[jlapro]

I want to add that today is day 4 of his treatment. His BG is being tested every two hours during the day and so far it is not coming down, but according to someone else on this forum, 2-6 days ?? is the average for seeing impact.

Judy

[jlapro]

I think that if all goes well and we start to see a drop in BG, the internist vet will move him to twice daily dosing. I see the current once day dosing as an attempt to jumpstart the process. He has appointment for ACTH stim test and bloodwork next Friday.

Judy

[BestBuddy]

I started to see improved BG numbers with Buddy within a few days. His first ACTH test showed his cortisol had dropped significantly which I should have taken more seriously (that's another story). I think that the BG is related to the amount of cortisol and as soon as that starts coming down then the BG numbers follow.

We reduced Buddy's insulin about 20% (I think) on the first day and with us it was a good thing because I am sure he would have had a hypo a couple of days in on the trilo. Home BG testing will keep you in control.

Good luck
Jenny

[jlapro]

well, it is now the end of day 5 since we started the trilostane, and Gordy's BG numbers have stayed high. We haven't reduced his insulin for that reason, but we are testing his levels several times a day. He has had no side effects from the trilostane at the 120 mg dosage.

He has been in better shape in terms of his mobility and when his BG stays high, his appetite is ravenous. We have to keep all food products locked up tight - biggest problem is the cats food (we have two). We feed them on the kitchen counters (have done that for years) because Gordy has always been a cat food thief. He's been worse in the past week. Today he managed to grab the feeder that we use for dry food. There wasn't much in it for precisely that reason, but he did get about 1/4 cup.

We've been feeding him green beans in between meals. If anyone has a suggestion for low carb doggie snacks would be appreciated.

I plan to call his internist on Monday and see what he thinks is going on.

[BestBuddy]

There are no set rules with diabetics (or any of our dogs for that matter), it may just be that Gordy will take a bit more time to regulate again or it could be that the cortisol is not yet being controlled.

The next ACTH test will give you something to work with.

Jenny

[jlapro]

in the last two days, Gordy has shown a lot of improvement - it appears the trilostane is working. His BG has been in the mid 100s in the a.m. (and it's been a looong time since he had numbers close to that at any time of day.) He's been more active too.

His BG does rise during the day to the mid or high 300s before last shot and actually he was high - over 600 - at 10 p.m. last night, probably because I fed him almost an hour before he got his shot. Won't do that again.

It's my understanding that the curve is supposed to be inverted, though, in otherwards he might go from 200 down to 100 during day. Our internist vet has told me not to lower his insulin (28U b.i.d.) unless he goes below 100. We are testing him frequently during the initial trilostane dosing (every 2 hours during the day) to make sure he doesn't crash.

His appetite has been voracious (he gets that way sometimes when he's high too) and we've been trying to just give him green beans between meals (he has been eating canned food only (no kibble) for the past month, at the recommendation of our primary care vet.

[k9diabetes]

Hi Judy,

We see curves in all kinds of different shapes. Quite a few dogs at the forum have mountain shaped curves with lowest blood sugar at mealtimes and all higher levels in between.

I'm personally a big fan of mountainous curves because you always know how low the blood sugar is going to go and don't have to worry.

I've even seen a few doubled humped camel curves!

I personally don't care what shape they come in - valley, mountain, or camel, if the blood sugar stays in a good range, I'm happy.

Really glad to hear that Gordy's seeing some improvement! :)

Natalie

[jlapro]

Gordy had his ACTH stim test on Friday, April 2, as well as blood chem panel. I got the results back yesterday. (by friday he had been on the Vertoryl (trilostane) for 10 days.) The results showed his cortisol well controlled. The blood tests showed normal for everything, including kidney function, except for an elevated calcium reading. The calcium may relate to a possible benign nodule on his parathyroid gland.

However, in the three or four days since the testing, his blood glucose (he has diabetes) has been creeping up again to between 350 to over 500 during the day/evening.

I spoke to the internist yesterday about this - he could seen no reason why this would happen other than another possible UTI (he came of the antibiotic for his previous UTI right as we were starting the trilostane). We were using human equivalent of Baytril, which is Cipro - if he needs it again this time I will use Baytril.

Internist suggested that since Gordy's been off antibiotic for over 10 days, we should retest for UTI, and I have an appt. tomorrow with our reg. vet to do a sterile urine draw to test for this (internist said sterile draw was necessary). so.... would appreciate any comments, especially from folks with diabetic dogs. Gordy is eating, etc. but seems weaker in general.

I'm also interested in any supplements folks might reccomend.

Judy

[k9diabetes]

If he does have a UTI - and I agree that a sterile draw is the best way to be sure whether there is an infection - have them culture it and do a sensitivity test of various antibiotics to make sure to use one that will work. There are an awful lot of resistant bacteria out there these days.

I think it's also good in these kinds of cases where the UTI keeps coming back to do an extra long course of antibiotics - I think three weeks or four usually works best.

Some folks do supplement with cranberry I think... it's not something I've ever done as Chris wasn't prone to them. You might check with the folks on the diabetes forum (www.k9diabetes.com/forum (http://www.k9diabetes.com/forum)) about what they are using.

Natalie

[lulusmom]

It would be great if you could get the results of the acth stim test and post them here. Isw Gordy on once or twice daily dosing of trilostane? If a dog has diabetes, a lot of vets that deal with both conditions will a dog on twice daily dosing so that the cortisol is controlled throughout the day. Trilostane starts to lose it's enzyme blocking ability around 8 hours and while some dogs remain symptom free throughout the night, some don't. Even if a diabetic dog remain symptom free, the cortisol in the latter part of the day can increase quite a bit and drive up the bg.

[BestBuddy]

Hi,

Just wondering, sorry if you have already mentioned this, but what insulin are you using?

I'm clutching at straws because of Buddy's experience. We were using Caninsulin and Buddy had been well regulated for around 4 years before the cushings dx messed it all up. For a short time when Buddy's cortisol was in the right range it all went well until it seemed that the Caninsulin just was only lasting around 6 hours.

There were other things going on at the time (too low cortisol) but we changed to NPH and the BG leveled out again and all was fine.

Jenny

[jlapro]

Thank you for all the responses. The internist gave me the results over the phone yesterday, but did not give actual values. I will call office tomorrow and ask them to fax or email them.

In answer to the type of insulin Gordy uses, it is Novolin NHP (relion brand, sold only by Walmart but made by Novo Nordisk).

Also, I forgot to mention two things internist also looked at his eyes and did an exam on Friday. Gordy is pretty much blind now, as a result of diabetic cataracts. We had suspected as much - he is able to see some light and shadows. I didn't notice till after I read the evaluation, but internist also said Gordy had a 'mild heart murmur.' Can this be a result of Cushings, because no other exam has ever revealed this.

Judy

[k9diabetes]

You know, I wonder if maybe he's having a longer than usual response to the Stimulation of the ACTH test. In normal dogs it's not a problem but in diabetics it can raise their blood sugar for quite a while afterward. Chris' blood sugar was significantly higher for a full 48 hours after an ACTH test.

If that's the case, the blood sugar should eventually normalize again on its own.

The trickiest part of diabetes is how many things can raise their blood sugar - infections, allergies, and inflammation all commonly raise it. The cataracts as they mature will tend to cause inflammation and he will need eye drops to keep the inflammation under control.

Natalie

[jlapro]

Gordy had a sterile urine draw on Wednesday to rule out UTI (he had been on cipro for three weeks before he started on the trilostane). This morning his BG spiked from 150 at 10 a.m. (first good reading in several days) to 550 at 12 noon (we are doing a curve). I'm actually hoping it's a UTI - as least that's something we can address.

I did get the info from his ACTH stim test a week ago, will try to post later today.

Judy

[k9diabetes]

While I think rebound can be overdiagnosed in diabetic dogs, with Gordy starting at 150, that's certainly a possible explanation for the high number later.

Trilostane could drastically change how he responds to insulin so you might see low blood sugar at a different time than you used to or a deeper drop than he used to get.

If you can, do a very detailed curve from premeal until his blood sugar hits bottom and see if it's maybe going very low at some point.

Natalie

[jlapro]

Gordy has been doing better the last few days - his BG has not always been great, but much better. I'm going to need to order more trilostane (Vetoryl) shortly and hoped to order it online to save money. The two places I've seen it so far are 1800petmeds.com (which I've used before for other meds) and valleyvet.com. valleyvet.com is like $30 cheaper (at $69.99 for 30 60mg capsules) for same amount and dose, and I don't understand how this could be. If anyone else orders online or has experience with valleyvet.com could share their experience I'd appreciate it.

Judy

[frijole]

Judy, I can tell you a bit about Valley Vet! They are located in Nebraska about 40 miles from me. They specialize in pharmaceuticals - started out with livestock and added pets. They are a legit company. Owner is extremely religious - signs outside of the building. I wouldn't hesitate to order from them. Kim

[jlapro]

Gordy's internist raised his insulin last Friday after we faxed this BG readings over five day period. He's now on 30 units of Novolin N b.i.d. I thought it was helping, but today he's been pretty high all day. He has another ACTH stim test next Friday, April 30th.

I did not post the results from his last ACTH Stim test, on 4/3 after 10 days on trilostane 120 mg daily, but here they are: comments welcome.

Cotisol (2 samples)
Tube labeled prepre
Tube labeled post
Cortisol pre 2.2 ug/dl
Cotisol post 4.5 ug/dl

Interpretation of ACTH stim test:
Normal response to ACTH (canine) 5.5-20 ug/dl

Judy

[BestBuddy]

Hi Judy,

I just want you to be aware that the ACTH results for diagnosing a dog with cushings is different to those for treatment.
Treating with trilostane the levels can be between around 2-9 for the post sample depending on the dog.

Your post number is 4.5 which is great but I am a little worried that you have dropped too quickly in the first 10 days. If you are continuing with the same dosage of trilostane then I would be concerned that Gordy has dropped too low. How is he feeling?

Jenny

[jlapro]

He was doing pretty well the last few days, but since yesterday his blood glucose has been pretty high (he was actually Hi (over 600) for a four hour period. I'm considering having taking him in for a test for UTI.

Judy

[k9diabetes]

I have been posting to Judy over at K9D that it wouldn't hurt to check the UTK panel to make sure Gordy doesn't maybe have elevated sex hormones that are being further elevated by the Vetoryl.

Given the low ACTH numbers at 10 days, I would want to be extra extra certain there was no rebound from too much insulin. I know curves were done.

Did you guys do a curve every day for 5 days Judy?

Could you post the results of all those curves either here or at K9D?

If there is absolutely no sign of low blood sugar anywhere in those curves, then it seems like checking to make sure the Vetoryl isn't dropping the cortisol low but raising the other hormones would be worthwhile.

Natalie

[jlapro]

ok,

I'm pasting the curves for the last few days. We tried for every two hours but weren't always able to make it.


18-Apr
388 8:00
590 10:00
419 12:50
363 4:36
338 7:42
492 9:36
19-Apr 293 8:14
285 11:00
511 2:28
514 4:40
493 6:50
404 9:10
20-Apr
431 12:33 am
388 9:44
392 2:00
328 6:40
430 11:55
21-Apr
487 5:26 am
Hi 9:49
Hi 12:00 pm
497 2:00
374 4:30
355 6:30
492 8:34
Hi 10:45
22-Apr
536 12:30 am
478 8:00
490 10:10
530 12:25
339 3:00
225 5:15
594 8:00
HI 10:07
23-Apr
569 12:05 am
363 8:18
453 10:00
511 12:15
372 2:04
415 4:00

[labblab]

It is with sadness that we have learned that Gordy took a turn for the worse last week, and needed to be released by his loving family.

We extend our deepest sympathy to Judy and the rest of Gordy's family. And we have added Gordy to our special memorial list of honor. He is now surrounded by our other beloved Cushpups.

In loving memory of a brave boy,
Marianne (forever Barkis' and Peg's and Luna's mom)

[BestBuddy]

RIP Gordy.

Jenny

[John II]

Dear Judy,

I am so sorry to hear of Gordy's loss,
my thoughts and prayers are with you.

[littleone1]

RIP Gordy. Bless your heart. You are now free from all pain and suffering. Now you can enjoy life once more.

[sunimist]

R.I.P sweet Gordy. I am so sorry Judy. I know your heart is shattered into a million pieces.

Prayers and ((((hugs))))

Shelba and Suni

[Carol G]

I am so sorry for your loss -- my thoughts are with you.

Carol

[Casey's Mom]

So sorry to hear of your loss of Gordy, RIP sweet soul - godspeed.

Love and many healing hugs to you Judy,

[Franklin'sMum]

Judy,

I'm so sorry

Jane, Franklin and Bailey xxx
________
SATURN I4 ENGINE (http://www.chevy-wiki.com/wiki/Saturn_I4_engine)

[Spiceysmum]

So sorry to hear about Gordy. Thinking of you.

Linda and Spicey

[zoesmom]

Judy -

I am so sorry about Gordy. He fought a brave battle and you were equally brave, to release him for that final journey. Sue

[ChristyA]

I am so sorry for your loss. Just know Gordy is in a place where he is feeling better.
Christy

[Bichonluver3]

Dear Judy,
Even though we are fairly new and didn't get to know Gordy, we know how you must miss him. From his picture, we can see he was a beautiful dog and from what I have read, he was also so courageous and a fighter. Now he is able to run free. God bless you both. Our hearts and prayers are with you.
Carrol & Chloe