Nigel - Need help with mitotane re-induction and diabetes

[Nigel's Mom]

Hi everyone, I am so pleased to have these sits to discuss issues on. Hope I am doing this right. My Yorkie, Nigel was diagnosed with diabetes in May 2012, have been struggling to regulate him ever since, jumps all over the place with his BG, anywhere from 8 - 26 in a 4 hour period, originally was running 32+ so is a big improvement but couldn't get him to hold any low numbers. They did a LDDST test yesterday and came back he also has Cushings. The vet has. Insulted with a specialist and they prescribed Micotane 1ml twice daily and lowered his insulin from 5 to 4 units twice daily. I am to watch for any changes and contact him if he has any eating changes, vomits, get loose stool, mood change etc. I would like to know if anyone else has use this drug and what the outcomes have been, also if anyone has any tips or other things to watch for. I am running a spreadsheet to track doses, food, BG's and notes.

[Harley PoMMom]

Hi and welcome to you and Nigel,

So sorry for the reasons that brought you here but glad you found us.

We have a sister site that deals with canine diabetes, they are very knowledgeable and have a wealth of information regarding canine diabetes, I do hope you join there also, here is a link to the canine diabetes forum: http://www.k9diabetes.com/forum/

Cushing's is one of the most difficult endocrine diseases to get a confirmed diagnosis for because other non-adrenal illnesses share some of the same symptoms and not one test is 100% accurate at diagnosing Cushing's.

Also, the tests for Cushing's can create false positive results when a dog has other health issues, such as uncontrolled diabetes.

I was wondering if you could tell us more about Nigel such as his weight and clinical symptoms. Is Nigel on any other herbs/medicines/supplements? What is the dose of Mitotane that the vet rx'd?

Please know we will help in any way we can so do not hesitate to ask any and all questions.

Love and hugs,
Lori

[Nigel's Mom]

Thanks Lori, Nigel is almost 12 lbs, he is presently been on Caninsulin 5 units twice daily. Has been on insulin since about May 2012. The Vet suspected cushings since shortly after diagnosed with diabetes, have been trying to get it regulated, almost achieved it a couple of times and then BG's would go off the chart all off a sudden, either up or down, no obvious reason, I do my own curves and e-mail them to my vet, I document all food, changes, stressors etc. Finally decided had to do the test for cushings, his results for ACTH Stim was 642. The vet prescribed Mitotane, 1 ml twice a day. It is liquid suspension chicken flavour, I am to start him in the morning for 8 days and then have to do another test, as long as he does not have any complications with it, then I need to call him right away to review. We are also lowering his insulin to 4 units twice a day. He is on Medi-cam diabetic dry with a teaspoon of Hills wet, i also add some veggie, beans, broccoli , or something like that and a pinch of cheddar cheese. I am very worried about starting the Mitotane as I work daily Mon/Fri, I leave at 7:30 am and come home for lunch, then go back from 1:00 to 4:30 so he is alone for a big part of the day. I am so afraid something will happen when I am at work.

[Harley PoMMom]

Unless Nigel is demonstrating strong and obvious signs of Cushing's, I believe that the Cushing's diagnosis should be put on the back burner for now. Although I am no expert concerning canine diabetes, I think, sometimes, it can take a while to get the diabetes under control. Could you tell us what symptoms Nigel is showing?

I am including a link to a blog by Dr. Peterson, who is a renown Cushing's expert, which he responds to a vet about a dog with diabetes and is suspected of having Cushing's: Q & A: Diagnosing Cushing's Disease in Dogs with Diabetes Mellitus (http://endocrinevet.blogspot.com/2012/01/q-diagnosing-cushings-disease-in-dogs.html?utm_source=dlvr.it&utm_medium=facebook)

An excerpt from Dr. Peterson's blog:
The problem with diabetic dogs is that it's very difficult to make a diagnosis of Cushing's with certainty unless we see cutaneous changes. PU/PD, polyphagia, and high liver values all could be secondary to the diabetes. False-positive test results on a LDDST are very common in dogs with nonadrenal illness, such as diabetes (1-3).

Does he have any cutaneous signs (hair loss, etc)? His insulin dose isn't high enough to say that he has insulin resistance. I'd recommend that you continue to monitor Rex closely an slowly raise his NPH dose to see if that helps control his signs. Because it can be very difficult to be sure in these diabetic dogs, sometimes observation and monitoring is the best course.

We define insulin resistance as doses greater than 2.2 U/kg/injection to control hyperglycemia (4), so we aren't even close to the doses required to diagnose resistance.

And yes, diabetic dogs can get marked hepatomegaly secondary to fat accumulation in the liver. That can lead to a mild-moderate "pot bellied" appearance.

Because it can be very difficult to make a diagnosis of Cushing's syndrome in dogs with diabetes, observation and monitoring is the best course in many of these patients. If Cushing's disease is present, it will be progressive and other signs will develop to make the diagnosis easier to confirm.

I am sure other members that are more knowledgeable about diabetes will be along shortly and can give you more insight.

Also, here is a link from our Resource Thread with info about Lysodren/Mitotane: Lysodren loading Instructions and related tips. (http://www.k9cushings.com/forum/showthread.php?t=181)

Could you clarify the liquid suspension, you should be able to find the actual mg on the bottle. 1 ml or syringe full of medication should equal the mg on the bottle...Thanks!

The results of Nigel's ACTH stim test that you mentioned, is that a post stim of 642 with the units of measurements in nmol/L ? If so, that converts to 23 ug/dl, ug/dl are the units we are used to seeing, which to me isn't that elevated.

I realize that this is so confusing and scary but know we will help you every step of the way.

Love and hugs,
Lori

[molly muffin]

Hello and welcome.

I'll let those who have some experience with diabetes and cushings answer the technical questions and just send you a warm welcome. I full encourage the joining of our sister diabetes site as there are dogs there that have both diabetes and cushings. Everything that I have read on the forums suggest that it is most important to get the diabetes stabilized prior to starting the cushings treatment.

I know it can be so scary when you are first starting down this road, but it might be better to start him (whenever you do) prior to a weekend when you can be home to keep an eye on him, especially with the diabetes issue too.

hugs,
Sharlene and molly muffin

[Nigel's Mom]

Hi, Nigel is actually 13.4 lbs or 6.80 kg, he has a pot belly which is quite pronounced when he is laying down, his skin is dry and tight,he is also having problems with his back legs, will suddenly limp or stumble after he has been laying down, was one leg now is both. he has been on 5 units insulin twice a day which is 10 units a day, and he is still reading consistently high, 25.6 this morning, I don't know what the ATCH Stim is for nmol/L? Just says beside it Cush selected. I know my vet did consult with a specialist in cushings. Another issue is the pd/pu cleared when first put on insulin, never cleared up completely but is back with a vengeance, he is hogging his food and looking for more which he has never done before. Also his curves which I do regularly are not good, he is high and after insulin will drop maybe 10, (ie:23-13) then proceeds to raise again within three hours, then will drop again a few points, curves look like pokes up/down/up/down, has never stayed level or under 7 for a period of time. He had a crash last week went down to 2.8 and had difficulty bring him back up, used food as did not want him to rise too fast, over a couple of hours he rose to 7.4, then an hour later he was 15.9 , just totally irrational. I know a lot of the symptoms are the same but he is getting worse the longer we go and adding some of the other signs, ie:pot belly, legs, skin. He said after he discussed with the specialist, although his signs of cushings are not extreme they felt they should start treatment due to his lack of response from the insulin and we are on the high end for the insulin not much more movement for that, seems the higher we go with insulin the higher his average BG gets. I just pray I am doing the right thing with him.

[Nigel's Mom]

Sorry, also, your question on the Mitotane suspension, he is to take 1ml twice daily, the bottle says 125mg/ml.

[lulusmom]

Hi Nigel's Mom

Lori has asked some very good questions and referred you to some good information so I'll keep my questions to a minimum for the moment. To make it easier for you to respond I've listed my comments and questions below:

1. Does Nigel have any symptoms associated with cushing's or did your vet pursue a cushing's diagnosis based solely on the fact that you could not get Nigel's diabetes regulated? If he has symptoms, what are they?

2. Your vet has prescribed a compounded liquid form of Mitotane and 1 ml is the syringe measurement, not the mg dose. For instance, if Nigel is getting 100mg twice a day, one syringe would equal 100mg. If he were getting 50 mg twice a day, you would give him .50 ml (1/2) of the syringe. Please check the bottle to see if the actual mg is listed. If not, can you please get that information from your vet?

3. Did your vet tell you that you must monitor Nigel carefully and did he tell you what you should be looking for in determining if Nigel is loaded? i.e., if Nigel has a voracious appetite, any change in his eating habit, even the slightest nuance such as looking up at you before cleaning his bowl, could indicate that he is loaded. At that point dosing should stop and not be resumed until an acth stimulation test has been done. Since the drug has a cumulative effect, the optimum time to do the acth stim test is 48 hours after the last dose.

4. Did your vet give you prednisone to use in the event Nigel's cortisol goes too low and he gets sick? Did he instruct you on what to do and where to go if this should happen when his office is closed?

5. I would agree with Lori that if the acth stim test was the only diagnostics done, I would be very worried about a misdiagnosis as 642 nmol is barely over borderline which could be attributed to the diabetes. Were there any other tests done to confirm a cushing's diagnosis?

6. Did your vet do a urine culture to make sure Nigel doesn't have an active urinary tract infection? Any active infection can cause a problem.

I would like to second Lori's suggestion that you join our sister site www.k9diabetes.com. You would definitely have the best of both the canine diabetes and cushing's worlds. We'll all do whatever we can to get you and Nigel on the right track.

Glynda

P.S. Just saw that you answered the question about the dose. 125mg twice a day sounds about right for a 12 pound dog.

[Nigel's Mom]

Thanks so much, after reading the questions and information given i have decided to wait, however I did give him his first dose this am, will that effect him. The vet did not mention what to look for was to give this to him for eight days and then do another ACTH test. Did not give me any prednisone, did not even mention it. Although Nigel does have a lot of the cushings symptoms they are also for diabetes, he does still have some room for upping his insulin, also on my diabetes site someone suggested possibly changing types of insulin from Caninsulin to Novilin or Humulin n or np? I did mention the issues with the Caninsulin or Vestilin (US) and he assured me that the Caninsulin is safe. Nigel has a pot belly but not like I see in pictures, I tried to take a picture (not the best) and put it in my album if you want to see it, his hair is thin on his lower sides/belly but always has been, no bald spots but one which was from a bad injection when he was two. He is drinking lots and urinating of course, however if he is drinking or eating and a noise happens he is quickly distracted and runs to see what it is barking the whole way. I am just beside myself, my stomach is in knots, I just don't feel I can do this and keep my sanity. Is it ok I already gave him a dose, if I just don't give him anymore and talk with the vet again?

[frijole]

Hello! Yes it is ok that you gave one dose and stopped. Hang in there! Kim

[Jenny & Judi in MN]

hang in there, it does get better. My Jenny was diagnosed with diabetes in May 2011 and Cushings in July 2011. She had probably had Cushings since January but my primary vet didn't even mention it till I brought it up.

All the cushings meds do is alleviate the symptoms so those meds aren't as much of a panic. Jenny uses NPH insulin, at the time weighed 8 pounds and was up to 7 units twice a day until we got her cushings under control. The higher cortisol levels definitely make them need more insulin sometimes.

Over on the K9 diabetes forum, people have had some luck trying different types of insulin. We entered the diabetes world after Caninsulin was no longer available in the US but I thought some folks had a harder time regulating using that than the NPH or one of the others.

Everyone here urged me to see a specialist regarding treating the 2 issues and I didn't because I had faith in my 2nd vet who has treated a lot of dogs with both. We used lysodren but overdosed Jenny who now has very low cortisol and is currently drug free regarding her cushings while her cortisol levels slowly come back up. So, if you haven't seen a specialist you really might want to.

The specialist I did eventually see said that he would have put Jenny on Vetoryl if she was new to him so I don't see that as a problem if Nigel really has cushings.

Are you on the diabetes forum? I've lost track, I'm sorry I think you are.

Hang in there, try not to be overwhelmed. If your dog is happy, focus on that! the fact that you are testing is huge!!

Judi

[Nigel's Mom]

Thanks so much, when I saw that I should have prednisone and to watch for being able to distract Nigel from water or food would indicate he is loaded, well I was not given prednisone and I have always been able to distract him from food or water just by calling his name. He has already gotten a very loose stool, I am thinking from the Mitotane as he has never had an issue in this department.
Thanks again will post what happens after I speak to his Vet again.

[frijole]

Thanks so much, when I saw that I should have prednisone and to watch for being able to distract Nigel from water or food would indicate he is loaded, well I was not given prednisone and I have always been able to distract him from food or water just by calling his name. He has already gotten a very loose stool, I am thinking from the Mitotane as he has never had an issue in this department.
Thanks again will post what happens after I speak to his Vet again.

Please stop giving lysodren. If you are seeing diarrhea it is a sign of overdose/too much. It continues to work for 2 days after the last dose so you could see vomit as well as diarrhea. This is what prednisone is for. Call your vet tomorrow and report this and DEMAND - don't ask - that you get prednisone first thing.

Here are instructions that you should have gotten from your vet. It explains how the drug works and what you should look for. Repeat NO MORE LYSODREN ok? If you have any questions just ask! Hugs, Kim

http://www.k9cushings.com/forum/showthread.php?t=181

[Squirt's Mom]

Hi and a belated welcome!

How is Nigel this morning? Still having diarrhea? Did he ever vomit or seen nauseated?

Do call the vet this morning and get some pred...and do NOT give any more Lysodren for now.

Let us hear from you when you can.

Hugs,
Leslie and the gang

[molly muffin]

How is Nigel?

hugs,
Sharlene

[Nigel's Mom]

Well I know it has been quite some time since I was on the forum, we did go ahead and load Nigel for Mitotane and he has been on it since, was doing quite well, tests every two months, then had one two months ago and his cortisol was up so we increased his dose which he has been taking every five days last week he had a ACTH test which came back elevated and the vet has been consulting with some specialists, he called me today and they believe Nigel has developed a tolerance for the Mitotane. Said his level was high in initial blood test and higher after the final test, said he is producing too much cortisol and they want to redo the induction phase for 7 days and then re test. I will get the actual numbers from his tests to post. Just wondering if any others have had to redo the induction. His Blood Glucose is still not consistent varies from average of 10 to 15 , periodic of 20+. He is presently on 5 units twice a day os Caninsulin.

[Nigel's Mom]

Nigel has been on 125mg/ml Mitotane for the past 8-9 months we test every two months with ACTH, two months ago we had to increase his dose (every 5 days) from 1ml to 1.25ml, had a test last week and his pre test was high and his post test was higher, I am getting the actual numbers from the vet, however, he consulted with specialists and they want to re-do the induction phase again as they feel he has become tolerant of the Mitotane. Has anyone every had to do a re-induction phase?

Moderator's Note: I have merged your latest update on Nigel into Nigel's original thread. We, normally, like to keep all posts on a pup in a single thread as it makes it easier for other members to refer back to the pup's history, if needed.

[addy]

It is not unusual to have to reload a Cush pup when treating with Mitotane/Lysodren-I'm sure our Lyso users will stop by to explain the reload



Relapses are common during maintenance mitotane administration, occurring in about half of dogs during the first year of treatment. Because of repeated relapse, maintenance dosages as high as 300 mg/kg/week may be necessary to control signs of hyperadrenocorticism in some dogs. Several factors may contribute to relapse in these dogs. One important factor under control
of the clinician is the administration of an initial weekly maintenance dosage of at least 50 mg/kg. Less than 25% of dogs can be maintained long-term with less than 50 mg/kg/week, and
very few with less than 40 mg/kg/week.-

reference-Dr. Mark Peterson

[Simba's Mom]

Hello and welcome to you and Nigel, you have found an awesome place for information and encouragement...settle in and read some threads, knowledge is power and we all need that for our furbabies!!

[Nigel's Mom]

Nigel went back in induction for Mitotane yesterday, 1ml every twelve hours this morning he was 9.9 bg gave his food and Mitotane then insulin 5 units Caninsulin. At 5:30 before food he was 9.9 by 7:30 he went down to 8.7 bg, by 8:30 he was at 6.3 bg, at 9:00 he was still 6.3 bg, I think I have to lower the insulin, does anyone know how much to lower it?

[labblab]

Nigel went back in induction for Mitotane yesterday, 1ml every twelve hours this morning he was 9.9 bg gave his food and Mitotane then insulin 5 units Caninsulin. At 5:30 before food he was 9.9 by 7:30 he went down to 8.7 bg, by 8:30 he was at 6.3 bg, at 9:00 he was still 6.3 bg, I think I have to lower the insulin, does anyone know how much to lower it?

If you are not already a member, I think it would help you a lot to join our sister forum that specializes in diabetes:

http://www.k9diabetes.com/forum/forumdisplay.php?f=2

They can give you really informed guidance re: insulin, and do have members who are handling both diabetes and Cushing's. Wishing you all the best of luck with Nigel's mitotane reinduction.

Marianne

P.S. I've taken the liberty of revising your thread title to reflect what you're dealing with -- I hope that's OK.