Rudy, Rude Dog, Rudalicious...just started lysodren

[Rudy's Mom]

Yup, my Rudy goes by many names, the 3 mentioned are just the tip of the iceberg. :)

Sooo, let's sum his situation up as succinctly as possible:
-10 year old (guessing since shelter rescue 8 years ago) neutered German Wirehaired Pointer Mix (when shaggy everyone says he's more Irish Wolfhound Mix)
-down to 59# (heaviest 78# prior to being diabetic)
-diagnosed diabetic June 2006, switched from Vetsulin to Humulin-N this January
-initially diagnosed with Cushing's two years ago, started Trilostane, bad reaction, took him off after that AND finding out from Idexx specialist that diabetic dogs who are not well regulated can test false positive
-excessive panting/increased drinking/incredible appetite/thinning hair issues all pushed for retesting of Cushing's
-diagnosed (urine cortisol/creatnine ratio test AND ACTH stimulation test) this past Tuesday, started lysodren Thursday night (1 1/4 tablets twice daily)

Phew, did I get it all in there? :) I had posted previously on the K9 Diabetic forum (I think under the same name??), but couldn't remember my password, etc., so haven't been there in ages. I vaguely remember there being this forum, so am THRILLED to have tracked it down again. I've worked at animal hospitals (front desk) for most of the past eleven years, but despite my access to doctors, info, testing, etc., there is NOTHING like picking the brains of others who have their own pets going through something like this, as well as having them as a support system for those rough times, too.

As I mentioned, we started lysodren on Thursday night, with initial plans at 1 1/2 PO BID, but our primary doc said Rudy's borderline for that dosing (weight) and since he's diabetic opted to lower it a bit to 1 1/2 AM, 1 PM. So our Thursday night dose was 1 1/2 tablets. I was prepared for the worst during the night (fear of the unknown and all that ;)), but it went pretty well, and actually Rudy's unabated panting actually decreased drastically...woo-hoo!

Next morning (Friday) was 1 pill, but back came the panting and a marked increase in urination. I read more info online and consistently read equally divided dosing would be best, so switched to 1 1/4 AM and PM. Friday evening Rudy's left eye developed what appeared to be Horner's Syndrome (based on a diagnosis of that with his right eye over a year ago...it comes and goes in the right eye, based on how he's doing). The increased urination and drinking about 4 cups of water in a 24 hour period continued, so I took him to work with me Saturday morning (1 1/2 tablets in the AM) where two of the vets agreed it was Horner's and also that it was highly unlikely to be related to the lysodren treatment. Rudy's eye was really bad yesterday (almost half of it covered), but today it's better, although panting continues.

So, that's the story of Rudy and his mom, thus far on our Cushing's adventure. I won't even bother apologizing for the length of this initial posting since I know getting the most info out there in one shot the better, right? ;) I'm sure it goes without saying, but I would love, love, LOVE any insight from those of you who have done the lysodren treatment, especially how these loading days went for you and your beloved 4-legged kiddo. Have many of you had the panting issues? Anyone else reading this who has a diabetic/cushing's kiddo? Yup, misery loves company, and we KNOW we wouldn't change a thing about any of this because we'll do whatever we need to for our furry kiddos. :) Thanks for reading this!

Laura :)

[AlisonandMia]

Hi and welcome to you and Rudy - here's a link to your thread at K9D:

http://www.k9diabetes.com/forum/showthread.php?t=1580

Alison

[Rudy's Mom]

Hi and welcome to you and Rudy - here's a link to your thread at K9D:

http://www.k9diabetes.com/forum/showthread.php?t=1580

Alison

Hi Alison, and WOW, aren't YOU the magic one?! Awesome! Hmmm, would it be too much to also ask for you to cure Rudy of his Cushing's and diabetes? ;) Seriously, thanks for the link.

Laura

[AlisonandMia]

How has Rudy's BG control been going. Diabetic dogs with Cushing's will just about invariably have pretty much uncontrollable BG. What dose of insulin is he on?

Alison

[Rudy's Mom]

We REALLY lowered his his BG when I started cooking for him several months ago, once we realized how much his BG would drop when I had him OFF of the dry food (was on Royal Canin Calorie Control High Fiber). We'd put him on the canned version of it when we thought he had kennel cough, and his BG went way down. I've felt EXTREMELY uncomfortable with the pet food industry since the pet food recall, so despite the extra time involved, I feel much better cooking for him.

His numbers were pretty good, high 100s-mid 300s, and consistent for several months (this is after months of getting him better regulated on Humulin-N from Vetsulin), but a few months back I came home from work, he wobbled out the door, then basically collapsed at my feet. I rushed him back to work, thinking he had some neurological issue, but his BG had gone down to 50!!! We've had issues since then of being low one day, then higher the next...and that continues. That being said, he's been showing "HI" on his Alpha Track (anything above 500 just shows as "HI") the past two days several times, with the lowest number since starting lysodren on Thursday night, being mid-300s. I'll be taking him into work tomorrow to see what his primary vet has to say. I'm really at a loss on the constant panting issues, which I'm getting in my face right now as someone who just finished his dinner and lysodren is staring me down at the computer. His doc (and research I've done) has said that diabetic dogs tend to have their insulin needs lowered drastically, so we've dropped his insulin down from 16 units BID to 15 units, but I think I'll pop him up to 15 1/2 in just a couple minutes when I give him the insulin, since he's been so high these past days.

Thanks for your interest, Alison. Off to inject the poochie!

Laura

[BestBuddy]

Hi Laura,

I dealt with diabetes and cushings together for a short while. It took a bit of juggling.

Buddy had been diabetic for many years before cushings so we had a pretty good handle on that but the few months before treating the cushings his insulin was raised from about 4 to 6 units and his normally good BG was all over the place, usually high. When we got the cortisol under control we had to reduce the insulin back to about 2 the first week, within a few weeks we gradually increased back to 4iu when his cortisol started to stabilize.

I know that others have said it took quite a while (months I think) before they could reduce the insulin. Every dog is different and the face that you are testing at home will be a great tool to keep a check. If you see that those BG's are staying high and not coming down then I wouldn't worry about dropping the insulin until you need to. In saying that we didn't use Lysodren so I can't give you any insight on how the meds will interact on different days.

Jenny

[Rudy's Mom]

I dealt with diabetes and cushings together for a short while. It took a bit of juggling.y

Jenny, I do believe there's a place in the circus for us as jugglers, don't you? ;)

[Rudy's Mom]

Okay, so it's been 4 1/2 days of the lysodren (started Thursday PM), and since Rudy's water and eating habits don't really leave him as one who will let us know about being loaded via changes on that front, I'm wondering how much sleeping may/may not play a role in lysodren loading?? Rudy's panting, and need to urinate (we're talking as often as every 45 mins.) have made for sleepless nights, but last night, and for a good chunk of the night prior, he's sleeping for 3-5 hour chunks. (HEAVEN for me!) Since his diabetes is the added factor in all of this (with BG running high lately), his primary doctor is pretty determined to have a set date of assuming we're loaded and running the ACTH stim test, as opposed to the change in appetite, reduction in water intake that many go by. I'm just wondering what other changes anyone who has used lysodren saw, and if sleep changes (especially going from not much at one time, to hours at a time) seemed to play a factor in when you felt your pet was loaded. Thanks!

PS Yup, the lack of sleep and stress finally got to me...home sick today! Then again, everyone at work has had the creeping cruds lately, so it might just be a coincidence.

Laura

[Rudy's Mom]

Update: Rudy started hacking, then acting like he needed to vomit (licking lips, body heaving), let him outside, just the actions continued, but no vomiting, he started eating some clover, just as I was getting him to stop, up came the food from 4 hours ago. Poor guy. Puked a couple more times, now is inside the house, but licking his lips like crazy, and doing some gulping sounds, and acting like he's chomping on something, thereby making his teeth clang.

This seals the deal for me: I'm not giving the lysodren tonight, am assuming he's loaded, will take him to work with me tomorrow for the ACTH stim test, which means I'd better get healthy pronto. Will also try to reach his primary vet. BG 7:35am=358 (pre-food/insulin/lysodren), 10:30am=435, noon=342 (post-vomiting)

Laura

[lulusmom]

Laura, you made a good call to stop the Lysodren. Be sure to keep your eye on him today and if he gets any sicker, you should get him to the vet sooner than tomorrow. It is possible that Rudy is having GI issues rather than low cortisol as GI problems are the number one side effect listed. However, it is also possible that Rudy's cortisol is too low and since Lysodren has a cumulative effect, he could very well get worse over the next 24 hours or so. Did your vet give you prednisone?

Glynda

[Rudy's Mom]

Lab results:

11/2/10 ACTH
PRE-ACTH CORTISOL 3.5
POST-ACTH CORTISOL 31.2

ACTH Reference Range:
Canine: Feline
2 - 6 0.5 - 5 Pre-ACTH (resting) cortisol
6 - 18 5 - 15 Post-ACTH cortisol
18 - 22 15 - 19 Equivocal post-ACTH cortisol
>22 >19 Post-ACTH cortisol consistent with
hyperadrenocorticism
<2 <0.5 Post-ACTH cortisol consistent with
hypoadrenocorticism
1 - 5 n/a Desired pre- and post-ACTH cortisol on
lysodren therapy

10/27/10 URINE CORTISOL/CREATININE
URINE CORTISOL 45.6
URINE CREATININE 232.9
URINE CORTISOL/CREAT RATIO 61

<34 Hyperadrenocorticism is highly unlikely and investigation of
other causes of the dog's clinical signs is recommended.

>or= 34 Hyperadrenocorticism is possible; however a urine sample
collected from a stressed dog or dog with nonadrenal illness
can have an increased ratio. The urinary cortisol:creatinine
ratio is not a specific test for hyperadrenocorticism, and
should not be considered a sole diagnostic test for this
condition. Additional testing using either a low-dose
dexamethasone suppression test or ACTH stimulation test is
recommended for further identification of
hyperadrenocorticism.

***And here are results from when he was first diagnosed with Cushing's, we started Trilostane, had bad reaction, found out from Idexx specialist that diabetic dogs who aren't well-regulated may test false-positive, so stopped treatment.***

7/11/08 DEXAMETHASONE SUPPRESSION
PRE DEXAMETHASONE 4.0
POST 4 HR DEX 0.3
POST 8 HR DEX 1.7

7/9/08 URINE CORTISOL/CREATININE
URINE CORTISOL 2.7
URINE CREATININE 60.9
URINE CORTISOL/CREAT RATIO 14

[Rudy's Mom]

Laura, you made a good call to stop the Lysodren. Be sure to keep your eye on him today and if he gets any sicker, you should get him to the vet sooner than tomorrow. It is possible that Rudy is having GI issues rather than low cortisol as GI problems are the number one side effect listed. However, it is also possible that Rudy's cortisol is too low and since Lysodren has a cumulative effect, he could very well get worse over the next 24 hours or so. Did your vet give you prednisone?

Glynda

Hi Glynda,

Thanks for the response. Rudy's calmed down, but was still doing the lip licking, and teeth chomping for some time, probably all of it lasted about 45 minutes. He's had some GI issues before, so this all looked familiar, but nothing that's happened since on the lysodren, so didn't want to take any chances. I've got a call into his doc, but haven't heard back yet. Since Rudy's okay right now I'm not overly concerned, otherwise I'd be hauling my sick fanny down to work with Rudy to have him checked out. Mind you, should anything change in the next few hours, down to work we'll go. Those long stretches of sleep really were setting off light bulbs for me, and this vomiting episode confirmed it. He hasn't been drinking much water today, either, although his "keen interest" (how's that for being a nice mom? ;)) in food hasn't abated much. I really think this is Rudy saying, "Whoah, Nelly, we're done with this loading phase!" Will definitely have the ACTH done tomorrow.

Again, thanks, Glynda...LOVE the Lulu picture. :)

Laura

[lulusmom]

***And here are results from when he was first diagnosed with Cushing's, we started Trilostane, had bad reaction, found out from Idexx specialist that diabetic dogs who aren't well-regulated may test false-positive, so stopped treatment.***

7/11/08 DEXAMETHASONE SUPPRESSION
PRE DEXAMETHASONE 4.0
POST 4 HR DEX 0.3
POST 8 HR DEX 1.7

7/9/08 URINE CORTISOL/CREATININE
URINE CORTISOL 2.7
URINE CREATININE 60.9
URINE CORTISOL/CREAT RATIO 14

Considering the UCCR was normal, I am curious as to why a cushing's diagnosis was pursued via an LDDS test. With a normal UCCR, one would automatically question whether the LDDS test result, done just two days later, was a false postive.

Glynda

P.S. Lulu thanks you for the compliment.

[Rudy's Mom]

Stopping the lysodren WAS the right thing to do! :) I was getting "the feeling" something was up when Rudy started sleeping more (usually non-stop panting ;)), then when Rudy puked yesterday it was pretty much driven home. Took him in for an ACTH test and got this just as I was leaving work.

ACTH STIMULATION
PRE-ACTH CORTISOL 1.9 ug/dL
POST-ACTH CORTISOL 1.8 ug/dL

Rudy's doctor is thinking 1-2 pills a week for maintenance, but maybe even less. He's talking about maybe starting maintenance on Sunday and I'm wondering what you all think. His doctor hasn't had a Cushing's case in several years, so the more info the better. Thank you!

Laura

PS His blood glucose was: 372 @ 6:45am, 275 @ 11:45am, 324 @ 2:40pm.

[frijole]

I am a bit surprised your vet isn't sure about the maintenance dose and like you said, he hasn't had any cases in a while. Protocol is that the maintenance dosage is the same as what you were giving during loading - but instead of giving it daily, you give it weekly. There is a HUGE difference between one pill and two!

What dosage did you give Rudy daily during the load?

Most vets wait ONE WEEK from the last pill given before starting the maintenance dosage. Remember lysodren continues to work for a few days after giving it. You don't want to go lower than where you are so I would wait one week before starting anything. (one week from the last pill you gave)

Glad you posted and congrats. Kim

[lulusmom]

Hi Laura,

I think Rudy's last dose was yesterday morning right? If so, those low numbers could go even lower. I think I mentioned Lysodren's cumulative effect and even though you stopped the dose, it will continue to erode the adrenal cortex for 48 hours and maybe longer. Keep a close eye on him and I hope you have prednisone on hand.

I'm an insurance professional so my feedback is based solely on my experience with Lysodren, 5+ years of obsessive research and my observations of many Lysodren case studies here. Based on all of that, I am of the opinion that neither the timing for starting maintenance or the weekly dosing your vet has presribed is appropriate for a dog with uncomfortable low numbers after loading in on 46.6 mg/kg in only 4 1/2 days. Dogs who load in 7 to 8 days at 50 mg/kg and have a post stim numbers, 48 hours after the last dose, of 2 to 3 ug/dl, usually start a maintenance dose equal to the daily loading dose one week after the last loading dose. With Rudy's number being low 24 hours after the last dose, I would expect those numbers to be lower today.

Dr. Edward Feldman at UC Davis lectured that he prescribes 50 mg/kg loading dose for his patients and if the dog has a post stim equal or less than 1.5 ug/dl after 5 to 7 days of loading, he waits two weeks and starts the dog on a weekly dose of 25 mg/kg. In Rudy's case, that would be a bit over 670mg, which doesn't make for easy pill splitting. It may be safe to kick it up to 750mg, split into three doses of 250mg. i.e. 1/2 pill (250mg) on Mon, Wed and Fri.

My old gp vet had an internal medicine specialist she could call if she was ever unsure of anything, whether it be dosing, timelines, symptoms, etc. Since your vet has had limited experience with cushing's, you may want to suggest that he consider discussing an appropriate maintenance dose and timeline with a specialist. Skill at assessing an acth stim test based on a whole lot of factors, and the law of averages, is acquired through experience and even the most experienced specialists in endocrinology don't always get it right.

Glynda

[Rudy's Mom]

Kim & Glynda, thank you SO MUCH for taking the time to respond. I know Rudy's vet has his best interest at heart, but there's nothing like the information/feedback from those who deal with this ON A DAILY BASIS! Your knowledge is crucial to the decisions I ultimately make with Rudy's care. We are our pet's advocate and I've learned to gather all the information I can and make a decision based on what I feel is best for Rudy, based on that info. I most definitely want to err on the side of safety with Rudy, and I can tell he's still not himself...although who knows exactly WHAT normal is for Rudy, ya know? :) Obviously there will be changes with him, but my gut tells me things are obviously still going on with him, despite having given the last dose Tuesday morning, now being 48 hours later. I'm definitely going to discuss the valuable information you've all given me with his doctor, and am obviously leaning toward the "less is more, and waiting a week" approach. Please keep Rude Dog in your thoughts. Thank you. :)

Laura...and Rudy :)

[lulusmom]

Hi Laura,

Nobody knows our furbuts like us moms and dads so if you think something is still going on with Rudy, go with your gut. Rudy has two very serious, life long endocrine disorders, neither of which is a snap to control. My two cushdogs have additional conditions but not diabetes; however, I do know that uncontrolled cushing's can make it very difficult to get diabetes regulated. Do you think it might be possible that your vet feels an urgency to start maintenance sooner than later as to not lose any ground?

As I mentioned before, even the most experienced endocrinologists don't have an easy time of getting these two diseases under control without glitches....and Rudy has glitches. His loading was very short and his acth stim was done 24 hours ahead of optimum time, meaning the already low results were probably overstated. With Rudy still acting not himself, it is possible that Rudy's cortisol levels dropped to 1 or below. That is dangerously low and I believe that to contemplate starting maintenance in a week may not be wise without doing another stim test first. However, I will tell you that some of us have dogs that defy logic. My second cushdog never showed me a sign of loading after 8 or 9 days and his first post stim number was .7. That was scarey. I'm trying to remember but I think we waited two weeks to start maintenance which proved to be too long as a stim 30 days later showed cortisol too high. Doh! What's a person to do besides rip out what little hair that's left. :D

As I mentioned previously, my two cushdogs have other conditions that go hand in hand with cushing's but luckily, neither has diabetes mellitus. One has diabetes insipidus but all that's required for that problem is keeping buckets of water down and piddle pads to catch the lakes of pee. Because my dogs have endocrine disorders that gp vet are not formally educated to diagnose and treat, I drive 50 miles to their internal medicine specialist. Please keep the possibility of consulting with a specialist in the back of your mind but for sure, please seriously consider respectfully requesting your vet to discuss Rudy's treatment history with a specialist to get his/her advice on whether another stim test should be done before starting maintenance and/or when to start maintenance and at what dose.

I've learned over the years that with lysodren, more or less can be good or bad, and less is definitely not always more, depending on the situation. A loading dose that is too small can drag out loading and cost you a fortune in stim tests and drugs and even the smallest maintenance dose can be enough to throw a dog into an addisonian crisis if the adrenals are producing too little cortisol already. Believe me, nothing about cushing's or lysodren is vanilla. That's why it's the most difficult canine disease to diagnose and treat and that's why I'm almost bald and walk around in a daze most of the time. :p;):p

Glynda

[frijole]

Wow... I forgot you were dealing with diabetes too. You are doing fantastic! Are there any specialists where you live? If I had the 2 diseases I would need some help no doubt. ;) So glad you checked and Glynda is right - that was a fast load... HOLD off for at least a couple weeks and you should be able to tell by how Rudy is acting.

Keep posting us the updates and we'll keep an eye out for them. Kim

[Rudy's Mom]

Hi, sooooo sorry for not updating, and unfortunately just have a brief moment right now...home for quick lunch break. For the first time in MONTHS Rudy actually brought me a toy and was in his "wanna play, wanna play, booty up in the air, paws down on the ground" stance....and it was HEAVEN! :) Stopped the lysodren when he vomited about 8 days ago, posted the ACTH stim test results, am now taking him back to work for me to have his electrolytes checked because we're planning on starting him on his maintenance dose. Will post the results as soon as we get them.

I'm sure you all know, having been down this road yourselves, having the feedback and support from others who are going through this or have been through this, is an ABSOLUTE lifesaver...THANK YOU! :)

Laura & Rudy