Rudy may have Cushing's

[RudyW]

Rudy, an 11 year old Shih Tsu, was diagnosed a diabetic in April this year. His BS had been under control with 6 units of insulin twice a day.
Two weeks ago his urine sugars began to rise unexpectedly (no change in diet) and I slowly increased his insulin to 7.5 units and the urine sugars remain very high.

We took Rudy to the vet today and advised him about the increased urine sugars and also advised him that Rudy has become very sluggish, has lost muscle control (trouble going up and down steps), significantly decreased eyesight, and significantly increased thirst and hunger. The vet weighed him and advised that he had gone from 23 lbs in April to 17.75 lbs today. He also observed that although Rudy looks thinner, his belly appears bloated. It's the vet's opinion that Rudy also suffers from Cushing's or another adrenal malfunction. He will be tested for Cushing's on Tuesday.

Do these symptoms appear to be consistent with Cushing's?

[caroleh]

I am new at this Cushings disease so I am just here to give you support cause I know you feel as I do at this point " in the dark". I thank God for finding this site and my advice before you have to see the vet is to read up on as much info about the disease as you can. It not only will educate you but also put you at ease that the word " Cushings" is not a death notice for your pet. i hope you will continue to update us with your updates on Rudy. We can compare notes and learn from one another. Good luck, Carole

[AlisonandMia]

I see that Natalie has replied to your thread at K9D (http://www.k9diabetes.com/forum/showthread.php?p=33002#post33002)

I totally agree with what Natalie says about the difficulties of diagnosing Cushing's in an uncontrolled diabetic - and with the fact that the signs and symptoms of uncontrolled diabetes overlap hugely with the symptoms of Cushing's.

In a previously well-regulated diabetic that has recently started to develop uncontrolled bg it is usually best to try to find another possible cause before embarking on costly Cushing's testing (which may well result in false-positive or inconclusive results). Some common causes sudden onset of regulation problems can be rebound from too much insulin (too much insulin can actually cause high BG); urinary tract infection (may not necessarily be otherwise obvious); skin infection; and inflamed cataracts or an eye infection. Basically almost any concurrent illness can send a diabetic seriously out of whack and these other things are more common than Cushing's so should probably be looked for first.

From what you say about Rudy's behavior, it sounds like his diabetic cataracts could be inflamed and painful and this alone could be the reason that his BG has recently become uncontrolled.

Alison

[RudyW]

Thanks Alison. Rudy is being tested as we speak. Unfortunately, I did not get a chance to read your post before we dropped him off. I would like to have questioned the vet regarding the cataracts because Rudy is rubbing his eyes a lot. I will discuss the cataracts when we go back for the test results, which should be available in 1 to 3 business days.

The vet reported that his BG at 9:30 this morning was 231. Rudy ate his usual food and was given 7.5 units of insulin at 8:30am. At 2:30 pm his BG was 750. Vet thought the increased pm readings were an indication of an underlying problem in addition to diabetes.

[apollo6]

Like the other members said if Rudy has diabetes that should be addressed first. My Apollo only has cushing for now. He has hind leg weakness, at first did lose some weight but I upped his food intake a little, has the pot belly( due to loose of muscles from cushing) had extreme increase in thirst, skin lesions,flaky skin, dark skin, red spots on front of paws, heat intolerance, lost most of hair on tail, also on ears, hair loose on both sides, appetite was always big. He has had some improvements: some hair regrowth, skin lesions have stopped, some of the blood panel readings have gone done,( but still needs to go down more)still weakness in hind legs.
What tests are you getting?

[RudyW]

Vet called today to advise that the results of the dexamethasone suppression test strongly indicate an adrenal/pituitary problem. The upper level of the normal cortisone range is 7.9. Rudy's 2 hour reading was 8.2 and then 9.6 after 4 hours (should be suppressed by the dexamethasone). The only way to test the adrenal glands is to do a sonogram.

He recommended that he set up a dosage of a relatively new medication (I will know the name and dosage later this afternoon) which addresses problems in both the adrenal and the pituitary glands and is safer than a similar drug that works in a similar fashion. If the new drug works, it will be an easy and relatively inexpensive way of solving the problem. We will know if it works within a week or two.

Thanks for your support and I will keep you posted.

Don/Rudy

[Squirt's Mom]

Hi Don,

Those LDDS results do indicate hyper adrenal activity...but that alone does not confirm Cushing's. I would strongly recommend the ultrasound at the very least to take a look at the adrenal glands as well as other organs.

Hyper adrenal activity does not always indicate Cushing's...the adrenals can become over active for many reasons. My Squirt tested postive on 5 cushing's specific tests for elevated cortisol but she did not have true Cushing's in spite of this. She had a tumor on her spleen and when it was removed, the cortisol returned to normal. Please, do not rush into treatment based on the results of one test.

The "new" med your vet is talking about is more than likely Trilostane, or the brand name Vetoryl. It was recently approved by the FDA for use in the USA, however it has been approved in Europe and other countries for years and has been used here for years as well - it was simply ordered from those countries with approval.

I want to address something you vet has said about Trilo - that it is safer than the other drug, Lysodren. This is simply not what two+ years of being on this and other forums and reading the information available on the drug prove to be true. Trilo has just as much potential to damage the adrenals as Lyso does. It has just as much potential to cause an Addisonian crisis or permenant Addison's in a cush pup as Lyso does. Please don't be mislead into thinking your baby will be safe with Trilo just because it is different. The safty of Trilo depends on the same thing the safty of Lyso does - a vet who follows long established protocols for diagnosing, treating and monitoring treatment, who educates the parents on what to look for in treatment, and who listens to those parents; and parents who are diligent, and who educate themselves on the condition and type of treament their baby is on. Those are the only things that makes either drug safe. ;)

There are several other ways to test the activity of the adrenal so I'm not sure what your vet meant by that. There is the HDDS, ACTH, UTK panel and ultrasound. Of these tests, the ultrasound and UTK panel are two I would certainly consider if I were you before I started any medication as powerful as Trilostane or Lysodren.

Keep us updated on how you procede.
Hugs,
Leslie and the girls - always

[RudyW]

Thanks Leslie. We appreciate all the information you provided. The medication is indeed Vetoryl (30mg). He wants us to start now and call in daily to report any changes. I think we will follow his recommendation and monitor Rudy closely.
I will keep you posted.

[frijole]

Just wanted to confirm what Leslie said. Because it has only been out a few years it is new to some vets. They do tend to think it is easier and less risky but we get the emergency calls here online when dogs get into trouble.

Lets talk about the dose of 30 mg. The recommended dosing amounts have been changed (lowered) and they vary depending on the protocol your vet is following. We have found sometimes that dogs are started too high because vets are working with info that is outdated.

Just to be sure... could you please give us your dog's weight? This will help us verify that you are starting at the lowest possible recommended dose. Please also confirm that you were given prednisone to give in case of emergency and complete instructions on using the drug.

Thanks!! Kim

[MyRudy]

The vet weighed him and advised that he had gone from 23 lbs in April to 17.75 lbs today.

My own Rudy was recently prescribed 60 mg of Vetoryl and he weighed 44 lbs at the time. He did fine for the first week, but was lethargic, not eating or drinking much and could barely stand up going into the second week.

Please keep a close eye on him and give him the medication with a meal (I was not told to do this and think it makes a difference). Also, please be sure to have prednisone on hand in case he needs it. When I called my vet on day 11 to describe Rudy's condition, he prescribed prednisone for me to give him. Within a day he was much better, although still not eating. It is now 10 days later and he still is not eating like he was before.

[RudyW]

Thanks for information. Will call vet tomorrow and discuss prednisone. Received general instructions on treating Cushings, but nothing specific on Vetoryl; however, vet urged me to call if I notice any unusual changes. He also wants to see Rudy again in one week.

We always put Rudy's medications in his food because there is nothing he will not eat if it is in his food.

We also need to keep in mind that Rudy was diagnosed a diabetic in April and was under control until two weeks ago when he went out of control, most likely a result of Cushing's

[frijole]

Signs that a dog's cortisol has gone too low are diarrhea, lack of appetite, lethargy. You will want to schedule an acth test to check the cortisol levels. This will tell you if the dose is high or low enough. Any signs of disinterest in eating, or other symptoms - do not give the trilo. When in doubt - come here and ask. The prednisone mimics cortisol and is necessary in an emergency of making your dog feel normal in an hour or two. Without it you would have to go to the vet and it always happens in the middle of the night on a weekend.

I don't use trilo so hopefully someone will tell you if it is one week or not that you should have the followup acth test.

Good luck!

PS You can hide it in food but make sure he has eaten some food first. That way it isn't given on an empty stomach.

[addy]

The initial dosage is based on body weight (Table 6) and is given once a day with food. The dose is then adjusted based on clinical response and ACTH stimulation test results. Most patients show clinical improvement within seven days, with resolution of polydipsia and polyphagia. Re-evaluate all patients, irrespective of clinical status, within the first two weeks. At this time, perform a physical examination, serum chemistry profile including electrolytes, and an ACTH stimulation test. The timing of the ACTH stimulation test is crucial; for the results to be meaningful, it must be started four to six hours after trilostane administration

This is from our research section. Hope it helps. I think generally, they say 7 to 10 days after beginning therapy. I don't use trilostane but have read about.

Addy

[labblab]

There is a bit of variation in the testing recommendations of Dechra (manufacturers of Vetoryl) and UC Davis. Dechra advises that the first monitoring ACTH be performed approx. 10-14 days after beginning the medication. As far as we know, UC Davis recommends testing after approx. one week as Addy has said. So your vet's own testing recommendation will undoubtedly depend upon his/her own training or professional contacts.

Here's a link to our resource thread about Vetoryl/Trilostane, so that you can have the opportunity to read about both these protocols as well as a lot of other useful information about trilostane treatment:

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

Marianne

[BestBuddy]

Hi,

One thing you will need to watch (like I need to tell you) are the insulin needs once you start Vetoryl. Sometimes it works pretty quickly and you will need to be BG testing to catch it. Within a few days I had to decrease Buddy's insulin about 25%.

I always found that on the day of a stim Buddy would drop dramatically, not sure if it was the test or just the stress of the vet visit but I always had to feed an extra meal at lunchtime to keep him from having a hypo. Usually the next few days he would run a little higher before settling back into regulation.

It is a bit of a balancing act but it can be done.

Jenny

[RudyW]

Thanks everyone for the great information. Rudy showed no changes during first 24 hours after first Vetoryl dosage. However, I reduced insulin back to 6 units and urine sugar this evening was back to normal. His appetite is still good. Morning BM was soft but evening BM was normal. He is still lethargic and muscle control remains weak, but he has been that way for past two weeks. I did notice that he is now almost completely blind. If the Vetoryl is effective, can we expect any improvement in eye sight?

[RudyW]

This is Rudy's fifth day on Vetoryl and there is no change in his condition other than his sugar levels went back up after going down the first day.
Still has excess thirst, weak muscle control, and very lethargic. Still eats his dry WD but refuses his moist WD. No diarrhea. Will probably wait until Saturday before going back to the vet for testing.

[lulusmom]

Hi Don,

All dogs respond differently to Vetoryl and most are pretty sensitive to it in the first week. Rudy may still respond but there is also the possibility that he will need an increased dose at some point. There can be huge disparities in dosing from one dog to the next. For instance, one of my cushdogs weighs less than 5 pounds and she stabilized on 30mg. I've seen other dogs weighing 5 to 10 times more than her that stabilized on the same dose. You just never know.

With respect to Rudy losing his vision, I think you need to see a veterinary opthomologist, who can give you an accurate diagnosis of the problem and tell you whether it can be surgically corrected. Diabetic cataract surgery can be done if the dog is a good candidate; however, if Rudy's blindness is not a result of cataracts, the likelihood that vision can be restored is questionable.

I see that you will be having an acth stim test done on Saturday. This is perfect as you should have one done within 10 to 14 days after starting treatment. Just make sure that you have Rudy to the vet within 3 to 5 hours after you give him his morning dose on Saturday.

I hope this helps.

Glynda

[RudyW]

Thanks, Glynda. We need a little optimism at this point.

[apollo6]

On the lighter side,
Your Rudy is a cutie.
In Apollo's case, I gave him the Vetryol with his food at 8a.m. and 4-5 hours later he was tested-Ach stim.
I would call the doctor before, tell him how Rudy is doing, because the symptoms show Rudy is not doing well on this dosage- side effects:lethargic, not eating and still excess thirst and urinating? The weakness in the hind legs can stay for awhile-Apollo still has weakness. Apollo did not have any of these symptoms. He has been on the same low dosage for two months.