Seeking advice for Koby (Koby has gone to the Bridge)

[annie]

I’m new to this forum, but I have been over on the diabetic forum. I’ll try to be brief in giving everyone the basics so far.

Koby is 14 yrs. old, part terrier. My husband and I adopted him from our local shelter when he was 2. Turned out to be the greatest!

On 3/20 Koby went in for a dental cleaning and 1 extraction. Pre-test showed liver enzymes high and BG at 202. He was put on Marin for the liver, to be rechecked in 30 days.

On 4/23 Koby’s liver enzymes were down, BG at 491. The vet talked of diabetes on the phone, we consulted with the vet on 4/25. We had many questions and fears. The vet answered every question we had. He wanted to eliminate other possible causes of the high BG.

On 4/26 Koby was in and out 4 times for testing. We preferred to bring him home between tests as he does not do well in a cage. When we picked him up after his last test, the vet said he tested positive for Cushings and put him on Vetoryl, 60 mg, for 2 weeks. Cushings might possibly be causing the high BG. Koby was given his first dose of Vetoryl at 5:30 pm with food.

On 4/27 Koby had his second dose of Vetoryl at 5:30 pm with food. The following morning at 4:30 am Koby vomited. At 7:15 am loose stool. I called the vet at 7:40. My regular vet was not in. Vomit again at 7:50 am. The office called me back at 8:24, vet there at the time said to skip the next dose and start a bland diet, then continue dosage today, 4/29. Koby just didn’t look good, sluggish. I decided to take him in. The new vet said the side effects are common, just stick to the bland diet and 2 nausea pills he gave for Koby.

So a bland diet of rice and hamburg or rice and boiled chicken, which Koby ate ok. No more vomitting. But all day Saturday and Sunday he had no energy, sleeping a lot. I started him back on his regular food today and he seems a little better. Moving around more but still not his usual self.

I do not plan to give him the Vetoryl today. Maybe the dosage was too high for him to tolerate?
He weighs about 38 lbs. I will talk with my regular vet tomorrow and will try to get copies of all tests and results. It’s all so confusing and overwhelming, Cushings and most likely diabetes.

I would appreciate any input, especially regarding the Vetoryl.

Thanks for reading,
Annie

[lulusmom]

Hi Annie and welcome to you and Koby.

I'm happy to hear that you will be getting copies of all testing done by your vet. Cushing's is not easy to diagnose and in a dog with diabetes, it's near impossible until you get the diabetes under control. Both cushing's and diabetes share common symptoms as well as bloodwork abnormalities so it's very difficult to distinguish one from the other. What symptoms did Koby have that lead your vet to believe cushing's was involved? Here's is an excerpt from Dr. Mark Peterson's blog regarding the difficulty in diagnosing cushing's. Dr. Peterson is a renown endocrine expert, widely published.


Both dogs with Cushing's and diabetes will show signs of PU/PD, have hepatomegaly, and have high serum alkaline phosphatase activity. So we have to start looking at other signs, generally those of the skin or hair-coat, to really know if hyperadrenocorticism is also contributing to the signs seen in your dog with diabetes.

This can be a difficult diagnostic challenge (ie, making the correct diagnosis of concurrent Cushing's syndrome in a diabetic dog). But in my mind, it is almost always better to err on the side of not over-diagnosing Cushing's syndrome than it is to make a false diagnosis of the disease when it really isn't there!

The product information for Vetoryl, recommends starting dose at 1mg to 3mg per pound and while not yet published, Dechra recommends that you start at the low end of the range. In Koby's case, that would be 38mg which you could either round down to 30mg or up to 40mg. 60mg could very well be way too much for Koby. If it were me, I would 1) make sure adequate testing was done to make absolutely certain that a correct diagnosis was made and 2) if I was sure of the diagnosis, I would absolutely not start him back on the 60mg. Do you have 60mg capsules or 30mg? If you have the 30mg capsules, I'd start with that. If not, I'd try to have the 60mg capsules repackaged into 30mg capsules by a compounding pharmacy.

I'm sorry for the reasons that brought you here but I'm glad you found us. We're here to help you and Koby in any way we can. The more information you can provide, the better the feedback we can share.

Glynda

[frijole]

Hi Annie. I am Kim and I'm the one that posted over on the diabetes forum. As I mentioned over there - cushings does not elevate glucose. If you are dealing with diabetes we OFTEN see dogs that get misdiagnosed as also having cushings.

As I mentioned previously I don't understand why your vet isn't treating the diabetes first. I would insist on treating the diabetes and would hold off any further testing for cushings and the trilostane as chances are good that your dog doesn't have cushings.

Can you share with us why you weren't told to treat the diabetes? Thanks!!! Kim

[annie]

I think my regular vet is trying to determine if Cushings is causing the high glusose before he proceeds. After the vet mentioned Cushings I did a lot of searching on the subject and remember reading that high cortisol levels can cause the glucose to go up also. My understanding is he's trying to rule out other possible causes of the high glucose. How does a vet tell if it's strictly a Cushings problem or diabetes or both. Koby does have a fat belly, and the other vet mentioned saturday an enlarged liver will cause that. I don't think an ultra sound was done or our bill would be twice as much. Koby's high liver enzymes were seen on his pre-test for dental work.

Regarding the Vetoryl, they are 60mg in 1 gel capsule. Instructions on the box say not to try and divide. So I may be stuck with these for now. Yes, very expensive.

I forgot to mention here, when the tests were done on 4/26 Koby's glucose dropped to 291. Reason unknown. Hopefully tomorrow there will be a more positive outlook both from the vet and myself.

I won't hesitate to check around for another vet if need be. I'm also keeping a daily journal on Koby and his progress. I'll post when I get more results.

Thanks again for all the support,
Annie

[annie]

Forgot to mention, the vet said Koby has pituitary related Cushings. More reading for me to do.

Annie

[frijole]

Forgot to mention, the vet said Koby has pituitary related Cushings. More reading for me to do.

Annie

Annie, You mentioned lots of tests were done. It would be helpful to get the results of the tests and the names of them as well. If your vet is saying pituitary I assume he did an 8 hr blood draw test called the LDDS test (low dose dex suppression)

Could you share the blood panel results as well for anything that was high or low? (example the liver enzymes, glucose etc)

As Glynda mentioned, the 60 mg dosage is too high for your dog's weight. I'm glad you are not giving any more trilostane. I would ask the vet to take it back - you can't use that high of a dosage. That could also be why your dog vomited.

Good luck tomorrow! Kim

[annie]

Yes, I remember the vet saying last thursday that a 4 hr. test was not conclusive, so he did an 8 hr.

Just from the receipt I have, it shows these tests were done:
4/23 blood glucose I believe that one was 491.
4/26 blood glucose This one may have been 291.
urinalysis w/exam of sediment
acth cortisol sttimulation test
cortisol assay small animal

Hope to get more information on results tomorrow.

Thanks,
Annie

[lulusmom]

Hi again.

If you did not have an abdominal ultrasound done and your vet already knows that it's pituitary dependent cushing's, then I would have to assume that he did a low dose dexamethasone suppression test. Unfortunately, this test is likely to yield a false positive result if a dog has diabetes. Unless Koby has more than a pot belly and elevated liver enzymes, a confirmed diagnosis cannot be made.

I read your thread on k9diabetes and would like to recap things to make sure I have a good understanding of the progression of things. Koby went in for a dental procedure, the vet did a blood chemistry and found elevated liver enzymes and BG. BG was 202 at that time. Follow up bloodwork was done 30 days later and liver enzymes had improved but BG was now 491. Note: It is highly unusual for liver enzymes to improve without cushing's treatment. Three days later more bloodwork was done and BG had dropped to 291. No insulin has ever been given.

Based on everything you have told us, it would appear that your vet based his diagnosis of cushing's on 1) a positive LDDS, which is likely to be a false positive in the face of diabetes; 2) Elevated liver enzymes which can be attributed to diabetes; 3) big belly which is also possible with diabetes and 4) absent of any common symptoms associated with cushing's such as huge appetite, excessive drinking and peeing (also common in diabetes), panting, loss or thinning of coat and thin skin which easily bruises. Did Koby have any of these symptoms when he went to the vet for his dental appointment?

I am providing you with a link below to Dr. Mark Peterson's blog where he answers a vet's question about a diabetic dog suspected of having cushing's.

http://endocrinevet.blogspot.com/2012/01/q-diagnosing-cushings-disease-in-dogs.html

Glynda

[marie adams]

Welcome Annie and Koby,

I am so sorry for all of Koby's problems.

You are definitely in good hands here. I know Glynda and Kim are helping you sort things out. There is so much information out there and you hope in your heart you have found what is ailing Koby. It is so confusing and stressful.

The experts will help you get to the bottom of the puzzle once you post the actual numbers.

It is not uncommon for vets not to know as much about Cushing's and that is why when I started the journey everyone here helped me get My Maddie through her first loading and how to handle everything afterwards.:)

Take care you will find answers....:)

[Somesie]

Annie, I am sure it feels counterintuitive, but I would urge you to trust the folks on this forum, up to and including finding a new vet or specialist, if necessary. Our vet decisively stated that not only did Jordan have Cushing's, but that it was adrenal-dependent. Had I not been on this forum, with the help of Glynda, Kim, Marianne, Leslie,and others, we would have put him on Vetoryl (at a too-high dosage). Instead, I knew to question her and push for more testing, which uncovered that he does not have Cushing's, adrenal or otherwise. These drugs can be a huge value to dogs that truly need them, but they are powerful meds that ought not be taken lightly. If I were you, I would cease meds until I had more information. Good luck to you! Please keep us posted!

Jenn

[k9diabetes]

Hi Annie,

I'm going to cover here what I just posted at K9D, particularly regarding the question of high blood sugar and Cushing's disease.

While I haven't had a dog with Cushing's, I have hung around the Cushing's forum and we have a number of members here whose dogs have both so I have picked up a fair amount about the issues diagnosing Cushing's vs. Diabetes vs. both.

I can tell you that while it's technically possible for Cushing's to raise blood sugar in a dog who does not have diabetes, it is rare and it also usually creates only a mild increase in blood sugar.

So when I see a dog whose blood sugar is sustained over 200, I'd bet a million dollars (if I had it! http://www.k9diabetes.com/forum/images/smilies/redface.gif) that the dog absolutely has primary diabetes.

And thus should be started immediately on insulin.

And frankly, I'd rather have a dog with primary diabetes than with Cushing's disease because Cushing's is a lot more expensive to monitor and treat and often requires an internal medicine specialist to diagnose and treat it properly.

So I am EXTREMELY concerned that your dog has not yet been started on insulin. Untreated diabetes can be fatal quickly if the dog develops ketones while untreated Cushing's disease is fatal only after long periods of time without treatment.

Please demand that your dog's diabetes be treated and the concern about Cushing's disease be put on a back burner until you see how Koby does on insulin.

It is very dangerous to give a dog these very serious medications when they quite possibly do not have the disease.

The vomiting Koby experienced could come from the cortisol level being taken too low by treatment for a disease he doesn't have.

This is an all too common but very serious problem - vets jumping to Cushing's diagnoses in dogs who just have plain old diabetes. I'm very worried about Koby's health...

Natalie

[annie]

Sorry I was so long in getting back. Took Koby to the vet yesterday for another glucose test. He was feeling much better, moving around more but BG was 489. He was given insulin right then and seems ok so far. Took him back this morn for another test and BG was down to 179. I am taking him back later for another check.

I do have his previous test resuts, but my scanner is not working good to copy them. What specific results do you need and I can pass them on. It would take quite a while to type it all. Cushings is still part of his diagnosis.

I will know more later and hope to get back here.

Thanks for all the advice,
Annie

[annie]

Just a quick update. Koby is now at the Bridge. Can't really talk about it now. We miss him terribly already. Life will never be the same.

Annie

[mytil]

Oh Annie,

I am so very, very sorry.

I have just added your boy to our very special remembrance list http://www.k9cushings.com/forum/showthread.php?t=3918 - we will remember him always.

Please do stay with us - we are all here to lean on.
((((hugs))))
Terry

[Bo's Mom]

Annie,
I am so sorry to hear about Koby. Please know that everyone here is with you in whatever you may need. Hugs and prayers to you and your family.

[addy]

I am so very sorry to hear this. Please know we are here for you if you need to talk or whatever you may need.

Rest in peace, Koby.

love,
addy

[jmac]

I am so sorry to hear you lost your Koby. I hope some memories will bring you comfort.

Julie & Hannah

[Rosierod]

Hi My dog Gizmo 12yrs old a llasha was diagnose with cushing about 3yrs ago. he also had the high liver values also for about 2yrs prior to this. he is about 19lbs & has been on vetoryl 90mg daily 60 in the morning & 30 in the evenings, for about the same amount of time. Very expensive but gotta do what we can for our furbbies. He has always tolerated it well didn't have any vomiting or loss of appetite.
Hope ur baby feels better soon.
Rosie

[Rosierod]

So sorry didn't realized he past...what happened if you don't mind sharing...My prayers r with u & ur family.
Rosie

[frijole]

Dear Annie, I am so very sorry. Know Koby is free of all pain and now lives deep within your heart. I lost my baby just a couple months ago and I know it is hard. May the wonderful memories sustain you as you heal. We are here when you feel like talking. Hugs, Kim

[Cyn719]

Annie

so very sorry for the lost of Koby. Losing your baby is so hard...but take comfort in knowing what a wonderful life you gave him..you loved him so much and he loved you right back. Hold on to the beautiful memories forever.....

Sending you lots of love hugs strength support and prayers

Godspeed Koby

Love

Cindy xoxoxo

[nikethelab]

I am so very sorry about your loss. Our pets are our children and are so wonderful. I am sure you had many terrific years with Koby and the little angel is watching over you from heaven.

[CJandTucker]

My heart aches for you and your loss of Koby. You will always have Koby with you in your heart.

[annie]

I just want to thank everyone for their kindness and understanding.
I hope to move over to the memory forum soon, but it is still so,so hard to talk about. The ache won't stop and the tears keep flowing. He is just missed so much.

Annie

[Jenny & Judi in MN]

Annie, I have sure been thinking about you and Koby lately. I hope when you can you will tell us more about him. hugs, Judi

[addy]

Oh Annie, it is heartbreaking and people say the the pain is so bad because the joy was so great.

We understand you cant talk about it now. We are always here for you and one day when the pain is not so fresh and new, when the heartache is not so deep, we would like to hear more about Koby.

Sending love and hugs,
addy