Schnorkie diagnosed with Cushings/Diabetes

[Abby's Mom]

I am so glad that I have found this site, and while I have been reading for several weeks now, I have decided to join the forum and tell my story:

Abby (my buddy) is a 1/2 Yorkshire Terrier and 1/2 Schnauzer weighing at 27 lbs. I took her in due to increase thirst and urination, and she was first diagnosed as having diabetes on 5/13. Dr. put her on 10 units 1x a day of Humilin (after a 3 day stay at the hospital to regulate her), and told me to see him in a week. In the meantime I switched vets, and this vet was more concerned about her high liver functions that went un-noticed at the other vet. She tested the pancreas, and results were normal. We then scheduled an Ultra-Sound and she also had a Aspirate of the liver. Liver showed some thickening, but while there they found that both Glands were enlarged, and decided to test further for Cushings. Liver results came back normal. Meantime her Insulin changed from 10 units 1x a day to 5 units 2x a day. She then become normal for a few days - was taken off of insulin, but then glucose levels were high - went to 3 units 2 x a day. I also switched her to a raw diet at this time (results have been wonderful), as well as a low purine diet. Her pre ACTH test (she is now at 21 lbs) was at 26, and I believe the high range is at 22 for cortisol.

Signs of Cushings have been: Increase in food, Potbelly (not so much now, because she has lost weight), increase of thirst/urination (could be because of diabetes). There was some panting and looking for a cool place to lay, but since on insulin this has gone away as well. Coat is shining, no hair loss.

We are now in day 2 of Trilostane (20 mg) 1x a day, and Vet has suggested that we stop insulin. Her glucose has been running positive (I am only testing by those urine strips). My Vet believes that the Cushing is causing the Diabetes. Abby has been very lethargic lately, but this could be because her Glucose levels have not been regulated, and a few days ago her water consumption as increased once again.

From what I have read on these forms, the diabetes should be regulated before attempting any drug to control Cushings, but then diabetes can not be regulated until Cushings as been controlled.

She has had no stomach issues (vomiting or otherwise), even though we switched her diet. The more I read about the disease and the therapy the more I get scared and worried. Wondering if Trilostane is the right choice, or if enough tests have been done to determine the problem.

Thanks for all that you do.

Barb

[littleone1]

Hi Barb,

Corky and I want to welcome you and Abby.

I'm glad you decided to join us.

I don't have any experience in treating diabetes, but we do have members that are treating both diseases. Others will be along that have experience with both cushings and diabetes.

We do have a sister website , k9diabetes.com, that you might also want to join.

Corky has been taking Trilostane for 20+months now, and he hasn't had any problems with it.

I hope Abby will start improving with everything.

Terri

[Abby's Mom]

Thank you Terri, I will post on the sister site as well (I have been reading both). Just curious...were there any initial problems while Corky was adjusting to Trilostane?

[lulusmom]

Hi Barb and welcome to the forum.

Getting a handle on cushing's is difficult enough but throw in diabetes and you have a real job on your hands. It is very difficult to get a confirmed cushing's diagnosis with uncontrolled diabetes because 1) they have overlapping symptoms and 2) diabetes can cause false positive test results on diagnostics like the acth stim test. So I think getting the diabetes under control is the first order of business. If a dog does have cushing's, gaining the upperhand on diabetes is not easy and quite frankly, most gp vets don't have the knowledge or experience to successfully and safely treat a dog with both conditions.

I am concerned about Abby because unless your vet knows for sure that the cushing's is being adequately controlled and that the diabetes is a transient condition due to cushing's, it is very dangerous to stop the insulin. Most dogs on Trilostane do well on once daily dosing; however, an experienced vet will prescribe twice daily dosing for a dog with diabetes to insure adequate control throughout the day. Trilostane has a short half life so it starts to lose it's enzyme blocking abilities any time after 6 to 8 hours. For a dog who doesn't have diabetes, this usually isn't a problem but not so for a dog with diabetes.

Is your vet an internal medicine specialist (IMS)? If not, I would highly recommend that you get a referral to one. I have two cushdogs, both with multiple conditions and they treat exclusively with an IMS. I am surrounded by general practitioners in my neighborhood and unfortunately, none of them have the experience necessary to treat my dogs. I therefore drive 50 miles in traffic to get them the best care possible. If you don't know of any specialists in your area, you can try to locate one using the link I have provided below. You can also let us know what city you are near and perhaps a member may be able to provide you with a name.

http://www.k9cushings.com/forum/showthread.php?t=182

Like Terri, I would highly recommend that you join our sister site, www.k9diabetes.com. Like here, there is a wealth of information there with very experienced people who will take your hand and guide you, support you and educate you. Because I am so concerned about the diabetes, I am going to postpone launching into the usual 20 questions we normally ask until you have had an opportunity to join the diabetes forum and receive their feedback.

Glynda

[Abby's Mom]

Thank you so much Glynda. I live near Raleigh, and there is a Vet School that is part of NC State. In fact, I am told that my Vet's office can work closely with them. I will suggest this to my Vet on Monday (she appears to be out of the country until the 19th). In the meantime, I have not stopped giving the insulin. However, her levels are still high, based upon the urine samples, so she is obviously not regulated.

Thanks again, and I am so glad that I found this site, and all of you.

Barb

[lulusmom]

Hi Barb,

Whew, I'm really happy to hear that you have continued with the insulin. I haven't checked in at k9diabetes but hope you've joined and have already received some sage advice. I am also very happy to hear that you are receptive to a consult with a specialist.

It's been one long and ugly day for me so I am gonna call it a night but will be checking in from time to time to see how Abby is doing.

Glynda

[Harley PoMMom]

Hi Barb and welcome to you and Abby!



We are now in day 2 of Trilostane (20 mg) 1x a day, and Vet has suggested that we stop insulin.

Barb

This study might be worth mentioning to your vet: Retrospective evaluation of the effect of trilostane on insulin requirement and fructosamine concentration in eight diabetic dogs with hyperadrenocorticism. (http://onlinelibrary.wiley.com/doi/10.1111/j.1748-5827.2010.01005.x/abstract;jsessionid=975F587BCB9104351651A2FD69E53A F9.d01t04)

An excerpt from this study:
Clinical Significance: Insulin requirements and fructosamine concentrations do not consistently reduce during trilostane treatment for HAC. Prospective studies are required to provide recommendations regarding reductions in insulin doses with trilostane treatment.

Please know we will help you and Abby in any way we can.

Love and hugs,
Lori

[Abby's Mom]

Hi y'all. Thought I would post an update on my Abby girl!

I have been busy over on the K9Diabetes site, and I have gotten wonderful information. I am home monitoring the BG levels, and all symptoms have gone away when I can get those BG levels down.

Spoke with my Doctor, and she was stating that 20mg is low for a start, but I have suggested using 10 mg in the am and then 10 mg in the evening. She seems to think that the Trilostane will help the diabetes, stated that she had several dogs with 1x a day, but found that none of them have diabetes.

I have also suggested the full adrenal panel prior to continuing with any therapy drug and have directed her to Dr. Jack Oliver.... (in attempting to look for more information on the panel to share with my vet, I found that he passed away a few weeks ago.. he will be sadly missed.)

Glynda you mentioned that the diabetes can give false positives to the ACTH stim test? We also had an ultra sound done, and they stated that both adrenal glands were swollen. Would this be enough tests to conclude that she has Cushings?

The more I read, the more I doubt her Cushing's diagnoses. When her BG levels are normal, she has no other symptoms. Her liver functions were high, but I understand they could be high if BG levels are high as well. Vet stated that she should be on medication as soon as possible, and not wait until she has the 'advanced' signs of Cushings. From what I read on this forum, we have some 'wiggle' room and really do not need to treat Cushings right away.

I have an appointment on Thursday, so will mention the IMS at this time to the vet, but I want to also be sure that we have a conclusive diagnosis, so perhaps the IMS can help here as well.

Lori that study is quick interesting. I will be passing this along as well.

Thanks everyone!!

[lulusmom]

Any chronic illness, and most certainly diabetes mellitus, can cause false positive acth and LDDS results and even enlarged adrenal glands. You mentioned that you would like to have a UTK adrenal panel done before starting Trilsotane treatment. Dr. Oliver's passing was a huge blow to all of us but his work is being carried on by his colleagues at UTK so anyone can still request an adrenal panel. However, in my opinion, I think it is more important to have Abby seen by an internal medicine specialist and let him/her confirm the cushing's diagnosis. I must admit that it is really odd that 1) you are getting the diabetes under control without cushing's treatment and 2) Abby has no symptoms associated with cushing's now. Red flags are going up for me.

As regards the enlarged adrenal glands, please take a look at Dr. Mark Peterson's blog where he answers a vet's question regarding a dog, only 11 months old, with chronic illness who was diagnosed with atypical cushing's. Excerpt from that blog sums things up for me:


In any dog with chronic nonadrenal disease, the finding of enlarged adrenal glands with abdominal ultrasonography is not an uncommon finding due to the chronic stress of illness.

This finding of "big adrenals" can never be used to confirm a diagnosis of Cushing's syndrome — be it typical or atypical hyperadrenocorticism.

Diagnosis must be based on a combination of the typical clinical features of Cushing's disease together with results of standard pituitary function testing (i.e., low-dose dexamethasone suppression and ACTH stimulation testing).

http://endocrinevet.blogspot.com/2011/05/q-atypical-cushings-disease-in-11-month.html

The adrenal panel is one of many diagnostic tests that a vet can do in an attempt to confirm a diagnosis. UTK can only advise if there is increased adrenal activity and recommend treatment; however, neither should be interpreted as a diagnosis. The UTK panel is only one component that is looked at for purposes of diagnosing a dog with typical or atypical cushing and in the absence of symptoms, non adrenal illness becomes a likely suspect.

Glynda

[Abby's Mom]

Thank you so much Glynda for your insight. You are confirming my suspicion that she may not have Cushings, or at least be cautious in treating cushings at this stage, and my postings in the sister site K9Diabetes have also suggested the same.

Thanks!

[Abby's Mom]

I stayed up last night prior to my vet's visit this morning, and came back with a wealth of information. I have asked her to postpone any further Cushing's testing on Abby until we have her BG under control. She does not appear to be resistant to the insulin and we are seeing some good numbers since I have been home testing, so that is a good sign. She started out weighing in about 27 lbs, but she is now at 19.6 -no longer an extended tummy, no clinical signs of cushings in any way, including thirst, hunger, coat, skin, weakness in legs..

However, I did want to share some of her test results that she had back on 5/19 and her test results from her ACTH test on 6/4 and get you input.

5/26 Results: Ranges:
ALK: 2631 10 - 150 H
ALT 426 5 - 107 H
AST 56 5 -55 H
CK 303 10-200 H
CHOLESTEROL 401 112 - 328 H
GLUCOSE 383 60-125 H
CHLORIDE 101 105 - 115 Low
POTASSIUM 5.1 Normal
SODIUM 140 141 - 156 Low

Urine Test done on 5/19/2011:

Method: Free Catch
Specific Gravity 1.025


T4 1.6 Reference Range: 1.0-4.0 Normal

Abby's ACTH Stimulation test, done on 6/4/2011

PRE-ACTH CORTISOL: 4.1
POST-ACTH CORTISOL: 26

The reference range appears as:

2-6: Pre_Acth (resting cortisol) normal range
over >22 they are stating is Post_ACTH cortisol consistent with hyperadrenocorticism.

When we have the diabetes under control, we will continue to test for Cushings, but at this time I will be going to an IMS.

[Abby's Mom]

Thought I would give an update on Abby:

I have asked the vet to put off any further testing on Abby till we get her diabetes under control. In addition, since she has lost about 9 lbs, she no longer has a pot belly, panting has completely diminished, her water intake is normal. In other words she has no symptoms.

Vet still wants to continue with Trilostane, and I have asked her that even if she has cushings, and it is a slow progression of a disease, why rush it. Also, how would I know that the drug is working, as she has no symptoms.

I will ask for another blood test in a few months to see how her elevated liver functions are, but she does not appear to be insulin resistance, and I believe we are almost where we need to be with her insulin amounts/injections.

I will keep you posted.

[Jenny & Judi in MN]

You are being so smart! Her liver phosphate and other #'s definitely mirror Jenny's. Except Jenny has a huge pot belly, bad skin and a huge appetite.

I'm glad her BG is reacting to the insulin, that is the most important thing I think.

Sounds like Abby and her mom are on the right track. Judi

[Abby's Mom]

Thanks Judi. I know, isn't is scary that Jenny and Abby have similar readings!!

[Abby's Mom]

Thought I would give an update -
Abby was seen as an emergency last night for dehydration, and what I thought may be some blockage. They did an xray and there were no blockages, but she has a lot of air pockets in her stomach. She is bound up, and even though they have given her two enemas, she has not been able to relieve herself (due to the dehydration). She vomited last evening (which was dinner from 24 hrs ago). She has been not on any medication, other than one pill of clavamox, but that was given AFTER her symptons, as her vet (morning visit) stated that she had a UTI.

The good new is that there is an IMS located at this vet. They want me to come in and talk with him, as they feel that Cushings may be involved:confused:

Abby had some blood work done yesterday,

ALB (normal) 3.4
ALKP (high) 769 Range: 23-212
ALT (high) 173 Range: 10-100

Everything else is normal. From what her numbers were in the beginning of May, this is tremendous improvement. In addition, I have been able to get her BG levels in the 100-200 range, certainly within normal. No other symptoms. No potbelly, no increase urination, no increase of thirst, no hair issues..... No symptoms {period}

I am just so confused at this point, as I would think that these are clear indicators that Cushings may not be involved. I will speak with the IMS and see what they say.

[Squirt's Mom]

Hi Barb,

Do let us know what his thinking is as those are not typical signs of Cushing's.

Plain pumpkin can be used to help with both constipation and loose stools but I am not sure how that would work with the diabetes so I leave such tips up the those with experience. :o

I hope Abby is feeling better soon and glad she is home in your loving arms.

Hugs,
Leslie and the gang

[Abby's Mom]

Thanks Leslie....
I just spoke with my Vet #3 (can't believe that I have gone through so many in 3 three months), and she had more information that I from the Emergency Vet. Stated that Abby has mineral deposits in her colon, causing her not to go, and she stopped eating and drinking.

She is still at the Emergency vet, but my Vet #3 (her normal Vet) did not want to go down the Cushing road just yet. Agreed with me that her BG levels would not be controlled, and she did not see any clinical signs of her being a Cushnoid dog. More of a wait and see. Will monitor her liver functions again to see if they continue to improve. I would suspect a rise in liver functions if Cushings was the problem.

Not sure what I would so without this forum. Thank you for listening.

[jmac]

Sorry to hear you are having such a confusing time. I don't have much advice to offer you, but I would agree that her liver values would probably be much higher with Cushing's. I hope you'll be able to get some helpful information and that your pup is feeling better soon. I agree that without this forum, it would be so much more difficult to go down this road. There are so many caring, helpful people here. Hoping you'll get some answers soon.

Julie & Hannah

[lulusmom]

How is Abby doing today?

[BestBuddy]

Hi Barb,

My Buddy had been diabetic for many years before cushings raised it's ugly head. We started testing for cushings because of the hair loss,increased water intake and excessive peeing and the fact that he had been a very well controlled diabetic and all of a sudden we were getting high BG readings all over the place and nothing else had changed.

Our experience makes me believe if you have got good diabetic control then cushings isn't something to consider. Diabetes is a disease that comes on quick and needs immediate attention where I believe cushings is a slow progressing disease which gives you time to sum up all the issues and tests before treating.

Good luck

Jenny

[Abby's Mom]

Thanks everyone for your concerns.

Abby is home. On Wednesday evening, as she was not getting any better, I removed her from the Vet Hospital. I asked for a stool softner. I force feed her water 1/3 cup every hour Thursday, and finger fed her Baby Food. About Thursday at 10:00 p.m. she finally passed whatever (it was look like normal stool to me), and she began eating on Friday morning. What a relief.

I have been able to get her weight back on, and she is back to normal. Now her BG levels have been low (normal range), even with a UTI.

I'm not sure what the problem was other than perhaps an upset stomach, constipation. Pumpkin does work (even for a diabetic), and I have been giving her some of this throughout her diet. But she wanted no part of it of course when she would not eat.

So, we are back to normal, but they (the IMS at the Vet Hosp) is pushing the Cushings. The IMS there is convinced from her readings (her ACTH test back in May) that she has Cushings and wants to start her on Trilostane. Stated that I wanted to we could give her a ACTH test again, but I am holding firm, and stating that as long as I can maintain her diabetes, I will not think about the Cushings, unless I see other clinical signs. I also asked him about the control I have with Diabetes, and he did state that this was abnormal, but we should still pursue the Cushings.

Did I tell you that her Liver functions went down, from her initial readings by taking Milk Thistle. I also mentioned this too him, and he stated that it was artificially lowered because of the Milk Thistle. One of the Dr's at the Vet Hospital told me I would not have to work so hard in getting Abby regulated.... I wonder what she mean't by that..... that I home test? I am total frustrated!!

In addition, I did some research and wanted to know if anyone uses the following product from Standard Process:

http://www.standardprocess.com/display/VeterinaryCatalog.spi?ID=336

I have used their 'human' products, and I highly recommend them.

[Abby's Mom]

It has been almost 1 year since my Abby was Diagnosed with Diabetes, starting insulin dose at 5 units, and then shortly after with Cushings.

The Cushings diagnoses came a few weeks after the diabetes diagnosis, because her liver functions where high. Those were the only symptoms that she had at that time, as we were getting her Blood glucose levels down with less than her starting dose (due to a honeymoon period). So, the urination, the pot belly, due to a ravenous appetite all were going away.

My vet started her on Trilostane, and wanted me to stop giving her insulin. She was convinved that the diabetes was induced by Cushings. After 1 day of dosing, and these wonderful people on this forum (thank you Glynda) , I stopped and decided to treat the Diabetes only, with much push back from my vet. I had already join the K9 Diabetes forum... another group of wonderful people.

Abby is now on a 5.5 units (not a large dose for her size), no excessive drinking, slim and trim at 18 lbs (no excessive hunger), no hair loss, no weakness in the legs, in other words, no symptoms of Cushings. She is a healthy and happy dog, that loves to walk and still chase squirrels.. (without any excessive panting)

If this can help some folks that are experiencing the diagnoses of both Diabetes and Cushings at the same time, I would recommend to treat only Diabetes first. It will be become evident, soon enough if Cushings is suspected, and both the K9 Diabetes and K9 Cushings support groups will help you through it all.

Thank you all from the bottom of my heart.

Hugs,
Barb and Abby

[frijole]

You couldn't have chimed in at a better time. The last few days it seems like we are really getting hit with alot of cases just like yours and it is really difficult to convince total strangers (new members) that their vet might be wrong. Thanks for sharing this information. I hope that it serves as proof that many are way too quick to diagnose cushings when in fact it is strictly diabetes.

Kim

[Jenny & Judi in MN]

Abby is so lucky she has you!

[Abby's Mom]

Abby is so lucky she has you!

And Jenny you. We have been together from the beginning. Is it only approaching 1 year!!

[Abby's Mom]

You couldn't have chimed in at a better time. The last few days it seems like we are really getting hit with alot of cases just like yours and it is really difficult to convince total strangers (new members) that their vet might be wrong. Thanks for sharing this information. I hope that it serves as proof that many are way too quick to diagnose cushings when in fact it is strictly diabetes.

Kim

Kim,

I have seen some of the postings on the K9 Diabetes forum, and I was there about 1 year ago. I remember how I felt.. 'What, challenge my vet... one who knows more than I do?" But I think what I have learned through both the K9 forums, is to ask tough questions, and it is your decision at the end of the day. Be an advocate for your best friend.