New to site Pepper Cushings and Diabetes (6.5 y/o miniature schnauzer)

[Babysam52083]

Hello All,
Pepper is a 6.5 y/o 20.5 lb miniature schnauzer. The last 4 months have been quite a rollercoaster ride for my little guy. He was initially dxd with Cushings via low dose dexamethasone suppression in late september. His alk phos when he first started exhibiting symptoms was only 220. He was drinking and eating excessivley. He was panting and peeing all the time. It took us about a month to get him diagnosed. He was started on on Lysodren, and is currently taking 1000mg/weekly. We split his dose so that he is taking 500mg on fridays and 500mg on tuesdays. Our vet has been monitoring his alk phos levels each month, and the were continuing to come down until last week. I took him in for his monthly check and his alk phos had gone from 433 to 543. He had also lost 4-5lbs in two weeks. The vet said not to worry and put him on hills l/d to help with his cushings.

That's when thing went really bad. 3 days after our lab check Pepper began peeing all over the floor ever 20 minutes. He even peed in his crate (which he never ever does). Finally at 3:30 am my husband and I made the executive decision to take our son to the emergency vet. His glucose was 590!!! He had a myriad of tests including an ACTH stim which revealed cortisol levels at 5.0 and 5.3. He spent 3 days in patient and just came home yesterday. He is currently still on his 1000 mg of lysodren, and was discharged on 4 units bid of humulin. He now eats Hills w/d 1/3 of a can bid with 2gm of fish oil divided BID.

This is all so confusing. I've read that a lot of people have had issues with hills w/d. However, he can't have high fiber due to his cushings, but can't have low fiber due to his diabetes. I dont know what treats to use...so he's been eating getting cucumbers and green peppers for treats.

I'm also really worried about the use of lysodren, but he seems to be tolerating it well. It does make him sleepy when he first takes it, but he bounces right back. Any information you could provide would be greatly appreciated. I'm already a member for the k9diabetes forum as well so you can find me there too...

Thank you so much,
Sam and Pepper

[Franklin'sMum]

Hi Sam,

You beat me to it, I was going to suggest k9diabetes :). I'm not familiar with most of the Hills foods, so I'll leave that alone. When you say that Pepper can't have high fibre due to his cushings, do you mean that if he has high fibre and his stools become soft, you wouldn't be able to tell if it was Lysodren related or fibre related?
Is the hills w/d for diabetes? I'm thinking of the carbohydrate level.

I get a bit dippy with a lack of sleep, so bear with me please. Pepper had cushings, was already on treatment when he went to the e.r, yes? Was diabetes already diagnosed before then, or was that diagnosed during the hospital stay?
Was a urine test performed to check for a urinary tract infection?

Jane, Franklin and Angel Bailey xxx

[caroleh]

This is Carole and I just wanted to ask you if your Pepper was tested for pancreatitis. I just lost my Schnauzer who was 10 years old. He had been treated for seizures since we rescued him and then was diagnosed with Cushings, diabetes and pancreatitis. Unfortunately we had several inept vets who didn't have a clue and we lost our precious Fritz.

Please Sam, no matter what find a vet that knows about Cushings and knows what they are talking about. It will save you a lot of heartache. Good luck to your sweet Pepper. I honestly don't think there is anything like a Schnauzer.

Carole

[frijole]

Hi - mom to two schnauzers that have had cushings and my family has 3 with diabetes. Very common.

I'm not going to mince words because you obviously have a very sick little dog and I want to make sure you have the best possible outcome.

Are you SURE your vet is measuring the alk phos monthly since starting lysodren? The test you need done is the acth test which measures cortisol. Please, it is important that you find out if you have done this test. Also the results (there are two numbers on it).

Please also tell me how your vet came up with that lysodren dosing? 1000 mgs for a 20 lbs dog is way too much to start out. A 20 lb dog should be at no more than 500 mgs a week. (This is following vet protocol not my opinion) Plus your dog has lost 4 lbs and that means you are now giving almost THREE times the MAX level.

I am surprised there hasn't been vomit and diarrhea (signs of too much lysodren)

Cushings dogs, especially schnauzers cannot tolerate much fat so the only special diet you would need is a low fat diet. W/D looks like it is a weight loss thing and to be frank.. it is a revenue stream for vets.

I am wondering how much experience your vet has with cushings- if you haven't had an acth test done yet I would take Pepper and run, not walk, with my records to a vet that has more experience.

With all this going on, if there is an internal med specialist in your area I highly recommend going that route. They are used to dealing with these complex diseases. Please correct me if I have read anything wrong. Kim

[mytil]

Hi Sam,

Welcome from me too. I know there are a lot here who are dealing with Cushing's and Diabetes and with this combination find it a bit difficult to keep both regulated; but many are doing well with it.

I do not have direct experience in dealing with both so I know others will chime in shortly too.

There is one thing I would like to ask - has a UTI (urinary tract infection) been ruled out?

Terry

[Babysam52083]

To my fellow dog lovers,

Needless to say my husband and I are in the process of looking for another vet. It's really heartbreaking b/c the vet we were taking him to was supposed to be one of the best in the area.

Pepper was first diagnosed with his cushings via LDDS. No ACTH was done by our primary care vet. He had a loading dose of lysodren with prednisone the first week, and then was put on 500mg weekly. He was just increased prior to his hospital stay. Alk phos' were used to monitor his cushings to see if they were improving...again no repeat ACTH was done!!!!

However, when he was admitted at Avets in monroeville (the most amazing vet hospital I have ever seen) He had an ACTH level which showed 5.0 and 5.3. He was tested for UTI via UA and C&S. NO UTI thank goodness. They do have an internal medicine specialists who consulted with the critical care vet that was seeing him. She did advise for him to stay on Lysodren at 1000mg weekly. He has a follow up with her scheduled for 2/9/2011. She wants to see him every 3-6 months which is perfectly fine with me. I would build her a guest house at my house if i thought she would come.

I don't know what to do about his lysodren though...the internal medicine specialist said to def. leave him on it in her discharge instructions. If the cushings gets out of control, then his diabetes worsens due to the overproduction of the glucocorticoids. This is so frustrating and there is so much conflicting information. Does anyone else have an opinion on Lysodren

[frijole]

You said that you increased the lysodren prior to going into the hospital. In my mind that means you were on the proper dose of 500 mgs and that is how you lowered the cortisol to the 5.3 level. (that is a good number)

My guess is that with everything going on the specialist that said leave it alone did not know the change to 1000 mgs was recent.

I noticed you only mentioned weekly amounts - did you ever do daily dosing? This is called loading and is how cortisol is lowered prior to going weekly.

Please don't do anything without consulting the specialist you mentioned. But please write down for this specialist (and post here please) exactly when you started giving lysodren, how much, how often and exactly when you made changes and how much etc.

I think that if the specialist sees the history they will realize that protocol wasn't followed and perhaps take a look as to whether or not your dog even has cushings. (cushings and diabetes often have the same symptoms)

Another thing you could do is go to your original vets office and ask for copies of every single test - including the ldds test that diagnosed cushings.

Just so you know - for now I would keep everything the same because your dog has diabetes but I would waste no time in getting back to the specialist with how your cushings was diagnosed, the fact there were no tests to measure cortisol etc... They need the big picture asap. It will help them help Pepper.

Here is a link to our important info section. You can find info on diagnosing, testing, and lysodren dosing... it will support what I have told you. Big hugs, Kim

http://www.k9cushings.com/forum/forumdisplay.php?f=10

[lulusmom]

Hi Sam and welcome to the forum.

I don't have a lot of time but wanted to welcome you and let you know that my two wee ones are treating with Lysodren and because their cortisol had crept up in the two years after loading, both are taking maintenance doses much higher than the max loading dose of 50mg per kg. Lulu, my littlest one (4.5 lbs), is getting 60mg four times a week which equates to 109 mg per kg. That's even more than Pepper's 100 mg per kg.

I also have the same questions Kim has asked so will look forward to your responses.

Glynda

[Squirt's Mom]

Hi Sam and welcome to you and Pepper! :)

As Kim and Glynda have noted, some things need clearing up. A few red flags went up for me with the mention of using pred along with Lyso - poor protocol; the lack of more thorough testing; the emphasis on the liver values VS cortisol; the increased dose with no follow up monitoring.

Another note - dietary fiber is not a nutrient that should be limited in cush pups but rather fats as cush pups are prone to pancreatitis. So don't be overly concerned about fibers, especially since he is diabetic.

Many good vets just aren't up on Cushing's and several of us have had to change vets or, if we were lucky, we got to educate our vets - we learn together. So you may find that your current vet is willing to listen to you, talk with you and experts in the field of Cushing's, and work with you.

You and Pepper are not alone. You have the best of both worlds when it come to Cushing's and Diabetes - two great families who will walk every step of this journey with you. Never hesitate to ask questions or just vent if you need - someone is here 24/7.

Hang in there!
Hugs,
Leslie and the girls - always

[Babysam52083]

Kim,
Pepper did have a loading dose of Lysodren done at the end of November which is when we finally got his diagnosis of Cushings. He was placed on prednisone with this loading dose for fear that they would drop his glucocorticoids too fast. His alk phos at that point was only in the high 200's. He received 1/4 tablet daily x 7 days. When he went in after that first week of treatement his alk phos had gone to 993.Then he went to 3/4 tablet daily for the rest of November. Repeat alk phos on Dec 22 was 443. In December he was increased to 1 500mg tablet daily. Then January 22nd he was increased to 2 tablets b/c his alk phos went up to 553. (I now know that this increase was most likely due to his new onset of diabetes). Below you will find his test results from his inpatient stay at AVETS in Monroeville PA (they are my new best friends)

January 26th
alk phos 204
bun 19
Ca 10.9
creat 0.7
Glucose 590
Alt 52
HCO3 18.4
ph 7.35
CO2 36
An Gap 27.8
tCO2 19.5
Na161
K 5.6
Cl 121

January 27
alk phos 167
alt 42
AST 28
CK 131
GGT 7
albumin 3.1
total protein 7.3
globulin 4.2
toatl bili 0
direct bili 0
indirect bili 0
BUN 15
creat 0.6
cholesterol 339 --> he's now on fish oil 2 gm divided bid
triglycerides 2600
glucose 433
Ca 9
Phosphorus 4.4
TCO2 (bicarb) 4.4
Cl 106
K 4.5
Na 141
A/G ration 0.7
B/C ration 25
NA/k ratio 31
Hemolysis index 2
lipemia index 3
Anion gap 19
WBC 11.0
RBC 6.18
Hgb 17.5
Hct 46
Neutrophil 80 --> left shift secondary to stress (per critical care vet) no bands :)
Platelet 392
Acth Pre 5.0 --> Post 5.3 (interpreted and reviewed by internist)

The internist made a remark that maintenance dose is 100-200mg/kg per week (this is not what I found online)

that's what I have from his discharge instructions. I did contact our primary care vet who said to only give him 500 mg of lysodren this week. Then decrease to 3/4 of a 500mg tablet next week. I have a call in to Dr. O'Keefe who is the internist who is seeing our little guy on 2/9/2011. She also saw him in the hospital. That was the earlies I could get him in. He is to have a glucose curve done this Friday 2/4/2011 at our primary care vet. The doctor that got all of his discharge info and advised not to give the 1000mg of Lysodren is not the vet that increased his lysodren dose, missed that the 4lb weight loss and elevated alk phos. She seems to be up on her game. Any additional information you could provide would be greatly appreciated. I am truly blessed to have found this forum


Thank-you from the bottom of our hearts,
Sam and Pepper

[Squirt's Mom]

Hi Sam,

Thanks for providing the extra info from the CBCs. If you would post the normal ranges for those value that would help us a great deal. Different labs use different norms so we like to see the norms to know what we are looking at.

Do you have the results from the ACTH or other cush specific tests done? LDDS, HDDS, UC:CR or ultrasound? Those would be especially beneficial for us to see as they tell more of the complete story concerning Cushing's.

Hugs,
Leslie and the girls - always

[lulusmom]

Hi Sam,

Please see my comments in blue below:


Kim,
Pepper did have a loading dose of Lysodren done at the end of November which is when we finally got his diagnosis of Cushings. He was placed on prednisone with this loading dose for fear that they would drop his glucocorticoids too fast. His alk phos at that point was only in the high 200's. He received 1/4 tablet daily x 7 days. When he went in after that first week of treatement his alk phos had gone to 993.Then he went to 3/4 tablet daily for the rest of November. Repeat alk phos on Dec 22 was 443. In December he was increased to 1 500mg tablet daily. Then January 22nd he was increased to 2 tablets b/c his alk phos went up to 553. (I now know that this increase was most likely due to his new onset of diabetes).

I am dumbfounded that your vet was using liver values to monitor treatment. :confused: This is unorthodox, inappropriate and could be extremely dangerous, especially if Pepper is like a good number of dogs whose Alk Phos never returns to normal. The acth stimulation test is the only test used to monitor treatment. This is a huge red flag that your vet has very little experience with cushing's.

The internist made a remark that maintenance dose is 100-200mg/kg per week (this is not what I found online)

I'm going to give your internist the benefit of the doubt and say that she was making reference to Pepper's current maintenance dose. If she was not and actually thinks the recommended starting maintenance dose is 100mg - 200mg, I'd find another specialist. Adrenal tumors are resistant to Lysodren so those dogs may end up with maintenance doses that high but most dogs with pituitary based disease are on maintenance doses between 25mg - 50mg per kg.

that's what I have from his discharge instructions. I did contact our primary care vet who said to only give him 500 mg of lysodren this week. Then decrease to 3/4 of a 500mg tablet next week.

I have a call in to Dr. O'Keefe who is the internist who is seeing our little guy on 2/9/2011. She also saw him in the hospital. That was the earlies I could get him in. He is to have a glucose curve done this Friday 2/4/2011 at our primary care vet. The doctor that got all of his discharge info and advised not to give the 1000mg of Lysodren is not the vet that increased his lysodren dose, missed that the 4lb weight loss and elevated alk phos. She seems to be up on her game. Any additional information you could provide would be greatly appreciated. I am truly blessed to have found this forum

If Pepper is getting 1000mg per week and his post stim is still a bit above the recommended therapeutic range of 1 - 5 ug/dl, why is the vet suggesting you lower the dose? Is Pepper showing signs that his cortisol is too low such as not wanting to eat, diarrhea, vomiting, lethargic? If none of those are evident and Pepper is acting normal, I'm not sure I'd reduce the dose because to do so could mean you lose the erosion of the adrenals that was accomplished during loading and quite possibily you'll lose control of the diabetes as well. You would definitely have to reload.

[frijole]

Glynda, I'm kind of hurried at work and I will post what I THINK she is saying and if I am wrong she can clarify...

I think the dog loaded at 500 mgs and the xxxx vet decided to increase it to lower the alk phos... no acth test was done until the poor babe was in the ER room with a vet with a clue.

So I think that the right dose is 500 mgs. I don't think there was a long load process. I think they are recommending going back to 500 mgs to be safe.

Kim

[lulusmom]

Kim, I think I had it right. Sam actually said that the gp vet was using the alk phos to monitor treatment and that the specialist wanted Pepper to stay on the currrent 1000mg dosing. See post below. I do have another question though. How long was Pepper on the 1000mg before he was seen by the specialist?


No ACTH was done by our primary care vet. He had a loading dose of lysodren with prednisone the first week, and then was put on 500mg weekly. He was just increased prior to his hospital stay. Alk phos' were used to monitor his cushings to see if they were improving...again no repeat ACTH was done!!!!However, when he was admitted at Avets in monroeville (the most amazing vet hospital I have ever seen) He had an ACTH level which showed 5.0 and 5.3. He was tested for UTI via UA and C&S. NO UTI thank goodness. They do have an internal medicine specialists who consulted with the critical care vet that was seeing him. She did advise for him to stay on Lysodren at 1000mg weekly. He has a follow up with her scheduled for 2/9/2011. She wants to see him every 3-6 months which is perfectly fine with me. I would build her a guest house at my house if i thought she would come.