Elliot~Newly Diagnosed

[Emily]

Hello,
My dog, Elliot, was diagnosed with Diabetes in March 2013 and it has been a roller coaster ride since that time. He has been on 2 different insulins, multiple different foods and his BG levels continued to be all over the place (mostly very high).
He developed cataracts and lost his sight in August 2013.

We started with a new vet in early June. He started Elliot on Lopid for his high trigylceride level, but that did not have the desired effect. He didn't feel Elliot presented as a case of Cushings based solely on physical findings (i.e. no hair loss, pot belly or muscle weakening), but since other things weren't working he ran tests for Cushings last Thursday (LDDS) and they came back positive. I didn't get numerical values during our phone conversation and I wasn't really sure what questions to ask. Please let me know if there are certain things I should be asking when I speak to him. He is starting him on Lysodren 500mg tomorrow (daily pill for one week and then further testing). I'm just getting it from the local pharmacy, but I'm wondering where else I could it at a more cost effective price? I'm paying $130 for 25 pills....maybe that's normal?

Elliot's appetite, appearance and general personality have been great since his original diagnosis. I'm just wondering what to expect with this new diagnosis. I'm not as familiar with Cushings and don't want to read too much online and scare myself. :) I'm most apprehensive about the "loading phase". How closely does he need monitored? I check his BG levels frequently as it is. I'm a teacher on summer break so I am home, but I have family coming to stay with me in a couple days and we will be out of the house a lot. I'm wondering if I need to re-schedule so that I can be home to monitor him.
I'm looking forward to any insight you may offer. Thank you!!

Breed: Min. Schnauzer
Age: 10 years
Weight: 25 lbs. (down from 32 lbs. pre-Diabetes)
Insulin: 18 unites 2x/day Vetsulin
Diet: w/d Glucose Management 1 1/4 cup 2x/day with 2 Tbsp poached chicken breast and 1 Tbsp. soft Beneful dog food
Additional Medication: Tachrolimus and Prednisolone eye drops, Vitamin E, Fish Oil, B12 and Lopid for high trig levels

[lulusmom]

Hi Emily and welcome to you and Elliot.

I only have a minute right now but will be back later to share some thoughts and ask some questions. In the meantime, I am providing a link to a great article on Dr. Mark Peterson's blogs for veterinarians. It presents a case study of a dog with much of the same issues as Elliot. and Dr. Peterson discusses the difficulty in diagnosing cushing's in a dog with diabetes. Please take a look at it and I'll be back in a bit.

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

Glynda

[lulusmom]

Okay I'm back with more information from Dr. Mark Peterson as it relates to insulin resistance in Miniature Schnauzers with hypertriglyceridemia and it does sound as though Elliot definitely has hypertriglyceridemia. I am always concerned about a diagnosis of cushing's when testing is done when blood sugar is not controlled and the LDDS test is the chosen test. The LDDS is highly likely to yield a false positive results in the face of uncontrolled diabetes. I am even more concerned about a misdiagnosis if the dog is a Schnauzer with high triglycerides and doesn't present as a cushinoid dog. If Elliot were my dog, I would definitely question the diagnosis. I am providing a link to another Mark Peterson blog that is very informative. He mentions in that blog that in his experience, very few of the problematic diabetic Mini Schnauzers have cushing's and that cushing's is a very uncommon endocrine disorder in the miniature Schnauzer.

http://endocrinevet.blogspot.com/2012/11/association-of-hypertriglyceridemia.html

Given that Elliot is a difficult case for even the best specialist, you might want to consider a consult with an internal medicine specialist (IMS). Most require a referral and I'm sure your vet would be happy to give you one. If you don't know an IMS in your area you can search for one at www.acvim.org. You can also let us know what city and state you are in and perhaps members might provide you with some names. If a specialist is not an option, then I highly recommend that you not place blind faith in your vet and start asking questions. Print out Dr. Peterson's blogs and share them with your vet and tell him/her that you are very concerned about the cushing's diagnosis. Cushing's is probably the most misdiagnosed canine disease even in dogs who don't have the complications of uncontrolled diabetes and hypertriglyceridemia. Based on the information you provided so far, and the credible information from Dr. Peterson, the odds of a misdiagnosis in Elliot's case are high.

I am so sorry for the reasons that brought you here but I'm glad you found us. We're here to help you be the best advocate you can be for Elliot. There are lots of folks here to hold your hand, help educate you and be your sounding board when you want to vent. We have a sister site, www.k9diabetes.com and I urge you to join there as well so that you can have the best of both worlds.

Glynda

P.S. I love the name Elliot. It reminds me of ET. :D

[Emily]

Thank you for this information. I had actually read this information previously when Elliot was found to have high trig levels last summer.
He has been taking Lopid for high trig for about a month with no improvement.
What else is to be done? If we can't get his trig levels down then the diabetes remains uncontrolled. How can Cushings be confirmed or ruled out when the diabetes is uncontrolled? Is there another test that is preferred in this type of situation?
I will pose these questions to my vet before starting any new medication tomorrow, but, to be honest, I am at my wits end with all of this. Nothing has worked and something has to change.
Thank you, also, for recommending K9diabetes.com. I found this forum last summer and they have been very helpful throughout the past year.
Thanks again!

[Emily]

I spent hours last night reading about Cushings diagnostics and, while there is mention of false positives for dogs with diabetes, there is mention that Cushings can "cause" diabetes. Could that be the case with Elliot? Cushings came first, but wasn't diagnosed until the diabetes symptoms presented themselves?

I have a call into the vet to ask additional questions before filling the prescription for Lysodren. The reading I did regarding the loading phase was intimidating. He is scheduled to have a follow up test next Tuesday, but it seems every dog is different. How do I know if he is "loaded" sooner than Tuesday? I don't want to accidentally over medicate him.

In a lot of my readings I saw that life expectancy after this diagnosis was approximately a year to a year and a half. Can anyone speak to their experience or knowledge about this?

Can you tell I'm freaking out a bit??? Thanks for any information you can provide.

[Jenny & Judi in MN]

A receptionist at my vet's office had a dog live for well over 8 years with cushings. My Jenny was diagnosed in 2011. Ignore that stuff

[Emily]

I spoke with my vet this morning and brought up the concerns Glynda mentioned. I really like him. He was very understanding of my concerns. He said he was going to call me this morning and tell me to hold off on picking up the medication anyway. He wanted to wait for the additional test results and is researching a cheaper source for the medication. My pharmacy is charging $130 for 25 Lysodren 500mg. Does that sound comparable to what others have paid?

He said that he did 3 separate tests for Cushings. The LDDS came back first and indicated Cushings. He acknowledged that although this test is the most sensitive, it also has a higher incidence of false positives. He suggested waiting for the results of the other 2 tests before making further decisions. He is expecting those results either today or tomorrow.

I brought up the fact that he wasn't regulated on insulin, has high trig levels etc. Could it be insulin resistance and not Cushings? He acknowledged all of those concerns as valid, but thought we should wait for the final test results before making any further decisions.

Regarding medication....I see that Lysodren is the most commonly prescribed. I read of other medications...are they not as effective?
It also seemed that many dogs experienced over medication with Lysodren. How can that be avoided? What are the signs?

I am feeling a bit calmer knowing that more information is coming to help me to make my decision. I just don't want to make a mistake.

[labblab]

Hi Emily,

Welcome from me, too! Glynda has done a wonderful job of laying out some of the possible issues related to Elliot's diagnosis, and I'm really glad you are having the opportunity to talk things over in greater detail with your vet before beginning treatment. In response to your questions, here are a couple of thoughts that I can add.

I am hopeful that one of the other diagnostic tests performed by your vet was an ACTH stimulation test. Along with the LDDS, it is the other main diagnostic blood test for Cushing's. Both tests have strengths and weaknesses. As you already know, the LDDS does a better job of identifying Cushing's in dogs who truly have the disease, but it also has a higher rate of "false positives" for dogs who are actually suffering from other illnesses. The reverse is true for the ACTH: it is more likely to return a "false negative" even when a dog has Cushing's, but a "positive" on the test is less likely to be skewed by a nonadrenal illness. It can still happen, but it is a more specific test for Cushing's than is the LDDS. Plus, for dogs who are going to move forward with treatment, the ACTH supplies a very helpful baseline measure of pre-treatment cortisol reserves. This info can aid in evaluating the effectiveness of medication in lowering circulating cortisol levels, because all subsequent monitoring of drug treatment will be performed via periodic repeat administrations of the ACTH. So I am hoping this is one of the other tests your vet has performed.

As far as Cushing's medication, trilostane (brandname: Vetoryl) is now prescribed more widely worldwide than is Lysodren. Even here in the U.S., our experience on the forum is that the majority of new cases are being treated with trilostane. This does not mean that it is necessarily a better choice, and we are definitely aware of vets who still prefer Lysodren due to their personal experience with the drug. Unlike Lysodren, there is no differentiation between a loading and maintenance dosing period for trilostane. The drug must be given daily for the life of the dog. And in some cases, including for management of diabetic dogs, the dosing preference is twice daily rather than only once daily. There is a general perception reflected in a lot of the literature that trilostane is associated with fewer adverse events and major side effects than Lysodren, and I suspect that accounts for its popularity. However, our experience here is that both drugs can work very well, but both drugs carry risks for the same types of side effects. So proper monitoring is equally critical for both drugs.

I honestly do not know whether endocrinology experts currently favor one drug over the other in terms of managing Cushing's in a dog who also suffers from diabetes. Perhaps that is info that Glynda may know. However, prior to FDA approval of trilostane here in the U.S. within the last decade, Lysodren obviously was used to treat virtually all dogs with Cushing's, including those with diabetes. So there is a history of experience with that drug combination even though it may be less commonly prescribed now.

One last thing...you may already have seen and read through this, but here is a link re: Lysodren loading instructions that we maintain in our Resources section. It contains very specific instructions, including the signs that you will need to watch for if, indeed, you do proceed with loading Elliot.

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

Once again, welcome, and I'll be very anxious to read how things develop for you two!

Marianne

[Emily]

Thank you, Marianne. I've been reading articles about both medications. I would imagine the Lysodren is more cost effective since it is administered less often than the other. I don't want to make health decisions based solely on the financial aspect, but treating his diabetes alone is costly. I want to make sure I am making financially responsible decisions along the way so that I can comfortably afford his care in the long term.

I read the thread regarding the loading phase. It seems that monitoring of water consumption is important. I have another dog in the home, so how have others addressed this situation? Should I only make water available at intervals throughout the day so I can appropriately monitor and measure his consumption? I don't want him (or my other dog) to be thirsty.

Thanks again!

[labblab]

We surely understand the cost issue!!!! I used trilostane rather than Lysodren to treat my dog, so I'm not really familiar with the cost of Lysodren. My understanding is that the per-pill cost of Lysodren is higher, but yes you are right, the dosing frequency is a lot less often. One wild-card with trilostane is that dogs can end up requiring widely varying dosage amounts. Initial dosing is based on weight, but dogs of the same weight can end up requiring very different doses due to individual differences in how the drug is metabolized. Glynda has used both drugs, so again, she may be a good source of info re: relative costs.

In terms of water, you need to leave water available at all times. But for several days prior to loading, measure the total daily water amount that you put out very carefully, and hopefully it will remain relatively constant Once you begin the loading process, you have to assume that the water consumed by your other dog will remain unchanged. So if there is a decrease in the total, Elliot will be the dog who is responsible. This is not perfect, but it is the best you can do in a multi-dog household. There may also be other behavioral cues that you will notice in that regard. For instance, if Elliot currently stops by the water bowl and guzzles every time he passes in that vicinity and that changes -- he walks on by or doesn't drink as long -- those can be visual signals that something has altered for him.

Marianne

[lulusmom]

Hi Emily,

Did you print out Dr. Peterson's blogs and give them to your vet? If not, please send them to him. I just read your entire thread on k9diabetes and you and Elliot have been on a wild ride in the last year. Nothing that I read there improved my comfort level with the cushing's diagnosis. You mentioned that your vet did two more tests for cushing's. I'm very interested to know which tests those are because if they were done while blood glucose was not controlled, those tests are likely to yield false positive results as well.

A very small percentage of dogs with cushing's develop diabetes mellitus and based on what I read on the diabetes forum, I'd say no. if cushing's came first for Elliot, you would have seen symptoms associated with cushing's and those symptoms most certainly would have progressed in well over a year. I also don't think you would have achieved the good curves you posted on k9d in the early days of diabetes treatment.

Vetoryl (Trilostane) is the most prescribed drug for cushing's, not Lysodren. Most specialists prescribe twice daily dosing of Vetoryl for dogs with diabetes; however, Lysodren is as effective.

Does Elliot have pu/pd (excessive drinking and peeing with diluted urine and low specific gravity)? This is common in dogs with diabetes and cushing's so unless the diabetes is well controlled, there is no way to determine if cushing's is the causative factor for pu/pd. Does Elliot have a voracious appetite? Dogs with cushings are ravenous, foraging for food, licking their bowls clean and looking for more. According to what I read on the diabetes forum, I'd say Elliot's appetite was normal except in those times when bg was very high. There are two signs that you look for when loading with Lysodren, a decrease in appetite and a decrease in water intake. The appetite is a much better gauge as some dogs don't see a resolution of pu/pd until after loading. If Elliot has neither symptom, then there is no way for you to even determine the end point of loading and the risk of overdosing is great. What information did your vet provide you about Lysodren and what instructions were you given? The fact that you are asking us what signs to look for in an overdose tells me that your vet failed to provide proper instructions so I am very glad to hear that the vet has taken cushing's treatment off the table for the time being.

Can you please round up the most recent testing that was done, including blood chemistry, complete blood count, any urinalysis, the LDDS test and post the results here? With respect to the blood chemistry and complete blood count, we only need to see the highs and lows and please include the normal reference ranges. Elliot's breed and high blood lipids makes him a difficult case and it just seems to me that your vet is looking for a reason to explain the inability to get the diabetes under control. While you are close to an insulin dose that would deem Elliot as insulin resistant, according to Dr. Peterson you are not there yet. Elliot is currently on 18units per injection, which is less than 2units per kg of weight indicated in Dr. Peterson's blog. What I don't know is whether that max dose applies to dogs with chronically elevated triglycerides. That would be a good question for the folks on the diabetes forum as I'm sure they have had members with Mini Schnauzers who were a devil to get regulated on an appropriate dose of insulin. I'll also see if I can find anything on the subject.

Glynda

P.S. Here is another link to information you may want to share with your vet regarding the double edge sword of high bg and high triglycerides. Quote from article...."It is possible then, the authors hypothesize, that insulin resistance may further elevate triglyceride concentrations in miniature schnauzers with primary hypertriglyceridemia and, ultimately, increase the severity of both conditions in these patients." Sorry for inundating you with information but I want to make sure that your vet has taken absolutely everything into consideration. http://veterinarymedicine.dvm360.com/vetmed/Medicine/Hot-Literature-Hypertriglyceridemia-and-insulin-re/ArticleStandard/Article/detail/723968

[Emily]

When the other 2 tests come back I will ask the office to email the reports to me.

Elliot's water consumption is elevated compared to Sasha (my other dog) but he isn't at the water bowl constantly. I have a large bowl and they don't even empty it over the course of a day. (An empty water bowl was what initially clued me in that something was going on.) If he starts this new medication, I will have to do some measuring so that I have baseline information. He does urinate more frequently than Sasha and goes for a long amount of time and his urine appears diluted. I have a doggie door so I don't monitor him. I mostly notice this on our walks. He has never had an accident in the house.

I forgot to mention that he does have muscle loss on his shoulders and I've noticed some tremors in his legs recently. I started the B12 about 6 weeks ago to help in this area.

I know I'm preaching to the choir, but I am so tired of this. I just want to know what is wrong with Elliot and make it better.
This is emotionally draining:(

[lulusmom]

It does not sound as though Elliot has pu/pd. Your vet could have verified this via a urinalysis which includes urine specific gravity. If urine is diluted, a culture and sensitivity should be ordered to rule out urinary infection and/or identify bacteria present. Has your vet done a urinalysis?

With respect to loss of muscle and tremors in legs, this can be attributed to diabetic neuropathy due to chronic elevations in blood glucose.

There is no doubt that you are beyond frustrated and I know that you'd give anything to get Elliot regulated so that you can both catch a much needed break. I am doing everything I can to arm you with knowledge so that if getting your boy under the care and guidance of an experience internal medicine specialist is not an option, you can be Elliot's educated voice. It is possible that Elliot could have cushing's but you now have three pieces of very credible evidence that would indicate that there is very real evidence that Elliot's problems are more likely to be related to the extremely high triglycerides. Ask your vet how many dogs he has treated for primary hypertriglyceridemia and if any of them had concurrent diabetes and/or cushing's and what were the outcomes of those cases. Ask him what the red flags were for him to decide to test for cushing's, aside from the insulin resistance. That question is key because all of your vets have said Elliot does not present as a dog with cushing's. If it were me, I'd also ask him why you had to pay for the LDDS test when he admitted that he knew that it is more likely than any other cushing's test to yield a false positive result. A dog with uncontrolled diabetes is at the top of the list of conditions that you can almost rest assured to get a false positive result.

We have a member here, Louise, whose pup had hypertriglyceridemia and was misdiagnosed with cushing's. He did not have diabetes however. She rarely checks in here anymore but I'm going to try to see if I can contact her so she can share her experience. Her dog, Munchie, was seen by many specialists, last being an extension of UC Davis in San Diego. I am also aware of another member on the k9diabetes forum whose dog, Bogie, had diabetes and his vet was convinced he had cushing's. I believe Dawn, his mom, was not convinced and may have had him seen by an internal medicine specialist who ruled out cushing's. My memory is horrible so if Dawn is still an active member, you may want to pick her brain too. I believe her user name is Bogiesmom.

Glynda

[Emily]

I've communicated with Dawn (Bogie's mom) in the past regarding diet and insulin. She was very helpful.

I didn't ask questions about what test or why. I should have educated myself more. I would imagine he ordered 3 separate tests in hopes of solidifying a diagnosis. I will ask about the urinalysis.

We just recently increased his Lopid (for high trig) and it makes sense to me to see how that progresses before adding something else. I plan to discuss this with him further. This is the 3rd vet in a year and he has been the most attentive and invested in figuring out what is wrong with Elliot. He calls every other day to check up on Elliot.....so I would like to keep the relationship open and positive since he seems willing to listen to my concerns.

I will again when I have concrete testing information to share. I truly appreciate your insight and guidance. Thank you.

[molly muffin]

Hello, I want to pop in and welcome you to the forum. :) I didn't really want to interrupt the flow that you have going with Glynda and Marianne, both a wealth of knowledge.

It really does sound like your vet is trying to cover all the basis and there is certainly nothing easy or straight forward when you combine diabetes and possible cushings. So, I'm glad your vet is trying to cover all basis and testing to see if this is the right path or not.
Don't beat yourself up. All one can do is try to get as much knowledge as you can, so you make a good team with your vet and if needed an IMS.
I think you are doing an excellent job. I would get copies of all your test that have been done, so you have your own file at home. It's invaluable when you are going back and forth with dosages and trying to get cause and effect information.

Again, welcome.
Sharlene and molly muffin

[Emily]

I am ecstatic to report that Elliot's initial Cushings diagnosis was indeed a false positive!!! The additional tests returned on Friday all showing no indications of the disease!
In addition, the increase in his triglyceride medication must have finally kicked in because his blood sugar levels have been below 200 for the past 3 days. These are the lowest numbers we have seen by far for the past year.
I can't say thank you enough for you support and sharing of knowledge over the past week. It truly made a difficult time a bit more manageable.
Best of luck to all of you, and your pups, as you continue your journey.
God Bless!!

Emily & Elliot

[labblab]

This is great news, and three cheers for Glynda and her great advice regarding the triglycerides!!! :p :p :p

Even if Cushing's is out of the picture, we'll still always love to have you stop by to give us updates. We want to know how you guys are doing, plus your experience can help us be better guides to others who may come to us with similar issues and worries. ;) :)

Marianne

[molly muffin]

Excellent news! Good catch by glynda there.

Sharlene and Molly muffin