Nisaleta

[nisaleta]

Harley is a nine year old Jack Russell Terrier with diabetes and cushings. He seemed to respond pretty well to Trilostine the first couple of days but has lost his appetite. Is it okay to give him his medicine without his eating first?

Thanks!

[labblab]

Hello and welcome!

No, if Harley has lost his appetite you need to hold off on the trilostane for the time being and contact your vet to let him/her know. Sometimes loss of appetite can result simply as a side effect of beginning the drug and reacting to a lowered level of cortisol. However, it can also signal an actual overdosing of the medication and a cortisol level that has dropped too low. Since Harley is also diabetic, I know that food consumption is also important in terms of insulin dosing. So if he is not eating, it is best to hold off on any more trilostane until your vet has a chance to evaluate the problem.

Can you tell us more about Harley's health history, including how he came to be diagnosed with the diabetes as well as the Cushing's? Also, how much does he weigh and what dose of trilostane have you been giving him (and for exactly how many days?).

Thanks so much for this additional info,
Marianne

[lulusmom]

Hi and welcome to you and Harley

Marianne has provided you with some great information but I also wanted to mention that Trilostane can drop cortisol rapidly which can cause a myriad effect on a dog, especially a diabetic dog. This rapid drop can result in a dog feeling really crappy due to cortisol withdrawal; it can drop cortisol levels too low, which can be life threatening if not addressed immediately, and it can also throw a dog into a hypoglycemic episode as lowering cortisol can have a marked effect on insulin requirements. As not eating is a symptom of all of these issues, it is very important that you contact your vet and let him/her know what is going on.

It is extremely difficult to diagnose cushing's in a dog with uncontrolled diabetes, and in our experience, a good number of dogs are misdiagnosed. When was Harley diagnosed with diabetes and how long after that was he diagnosed with cushing's? Why did your vet pursue a cushing's diagnosis? Was it persistent symptoms and if so, which symptoms? Or was it due to an inability to get Harley's bg under control? What insulin dose was he on when your vet decided to test for cushing's?

It is recommended that diabetic dogs be on twice daily dosing of Trilostane so as to maintain constant control throughout the day. Is Harley on twice daily dosing? Marianne has already asked the reamainder of my questions so will look forward to your responses to both of us. The more information you can provide, the better handle we will have on Harley's case. That really helps us provide you with meaningful information as well as pertinent reference material that can help you gain a much better understanding and the complications that can accompany both canine diseases.

If you have not already joined our sister site, www.k9diabetes.com I highly recommend that you join there so that you have the best of both worlds.

Glynda

[nisaleta]

Hi Marianne and Glynda....thanks for your responses. I'll try to answer your questions as completely as possible.

We adopted Harley from the Bakersfield ASPCA when he was five years old; Harley had been found walking down a freeway and was taken there. We have had Harley for about 4 1/2 years..

Very little is known about his health during his first five years of life. Veterinarians suspect that he had distemper at one time due to pitting's in his teeth.

Something that we thought was unusual when we got Harley was that he had a bloated stomach. The veterinary office that we were using at the time did not think that to be abnormal. He was giving a thorough physical examination, including a test for diabetes, and nothing was found to be wrong. Since then Harley has had semi-annual examinations with no negative results

Last November Harley suddenly stopped eating and became lethargic. We took him to the veterinary office who could find nothing wrong with him. The veterinarian suggested leaving him overnight; I declined because they have no overnight staff.

The next day Harley seemed even worse. I took them back to the veterinary office and got a different vet; this vet disagreed with the diagnosis of the first vet and suggested we get him to a hospital immediately.

Harley was examined at the animal hospital and we were told that he had diabetes and pancreatitis and needed to get to a specialist immediately to have an ultra sound performed which they were unable to do. We took him to a more complete hospital in Ventura and the ultra sound was performed. Both diabetes and severe pancreatitis were confirmed and Harley was given about a 30% chance of survival. He remained in the hospital for about two weeks but would not eat and it was getting even more critical. Just as a trial suggested by the vet I took some food down to them and he ate out of my hand. The vets decided I should take him home and try to feed him there; if that didn't work the only option was surgery to implant a feeding tube. Fortunately it worked.

As you might suspect, we are no longer using the original veterinary office and the Bakersfield hospital took over his care. By this time Harley was emaciated; he was literally just skin and bones. Between November 2013 and January 2014 Harley seemed to improve, but did not gain weight or return to the way he was prior to the onset of illness.

In January 2014 Harley had another major pancreatitis attack. Once again the Bakersfield hospital referred us to the larger and better equipped hospital where another ultrasound was performed. Once again, pancreatitis and diabetes were confirmed. He stayed in the hospital for about a week and was then transferred back to the Bakersfield hospital where he stayed another two weeks. During that time he was also tested for Cushing's disease; the test was negative.

Harley continued to be emaciated and lethargic. He had regular glucose curves performed and his readings were in the 200's. Suddenly they jumped into the 500 area and the vet said he was "insulin resistant" and needed to return to the larger hospital.

At this point I decided to get a second opinion. I checked our local "best listings" and made an appointment with the highest-ranking veterinarian. He did a glucose curve and his reading indicated that Harley's glucose level was in the 200's area. I have remained with this vet since then and Harley has gained his weight back and has vastly improved. The vet believes, however, that Harley will probably remain with glucose in the 200's area because of his age and history. In addition, this new vet stated that the Bakersfield hospital and the Ventura hospital were in error respecting the type of insulin (they had him on Petsulin; he put him on Humulin), syringes, and dosage.

About two months ago Harley began staggering and falling down. Our new vet suggested another Cushing's test which came back positive. He also found that Harley has a minor liver problem. The vet delayed Cushing's medication, first wanting to see if proper insulin administration would solve the problem. When that didn't happen he put Harley on trilostane.

Harley has only been on the medication for nine days. After the first couple of days Harley became alert and more active. His appetite improved and he even started to play again. As a general rule by the time his insulin wears off he becomes lethargic and somewhat unsteady but shortly after receiving insulin he recovers. This morning, for the first time since starting the Cushing medication, he did not finish his meal. He is very lethargic and unsteady. If I move toward the front door he will run to it to take a walk but appears unable to complete it.

Harley now takes five units of Humulin insulin twice a day. In addition, it takes one30 MG trilostane capsule every morning.

There was a slight interruption of my recording. Harley had his medication this morning at 5:30 AM. It is now just after 12:30 PM and Harley has gotten up and is showing interest in his food. I should mention that even when he wasn't interested in his breakfast this morning he was happy to take a little no-fat broasted turkey.

There was another interruption in my reporting. All of a sudden Harley became very energetic and insisted on being let out and to the patio where he is currently running around as though is not sick at all.

Third interruption; Harley came in from the patio and, although more energetic than he was earlier, appears tired. He is at this moment reconsidering his breakfast.

I welcome input from anyone that can make any sense of this and am posting it before Harley goes in yet another direction.

[molly muffin]

Hello and welcome to the forum. Glynda and Marianne have covered all the major things.

I don't see where you mention what Harley's weight is? Starting dosage of trilostane should be 1 mg/l lb and Dr. Peterson, who is world known in the area of small animal cushings, suggest that best results for a dog with diabetes and cushings is a split dose, where instead of say 30mg once a day, 15 mg am and pm would be given, so that the cortisol levels stay more stable and this helps with the diabetes.

When is your ACTH follow up test scheduled? That would be a good point to switch him to twice a day dosing, especially when you see where the values are currently at for cortisol.

This is the link to Dr. Petersons blog about the subject, which you might want to print off and give to your vet for follow up reading.

http://endocrinevet.blogspot.ca/2012/12/low-dose-twice-daily-trilostane.html


In diabetic dogs with concurrent Cushing’s disease, twice-daily administration is essential in avoiding large fluctuations in serum cortisol concentrations during the day (1,2). With once-daily trilostane administration, adequate diabetic control will be next to impossible in many dogs with concurrent Cushing's syndrome.

I'm glad to hear that he is eating and playing, but due worry a bit about the cortisol going low, if he is under 30lbs.

Sharlene and molly muffin

[nisaleta]

I cannot thank you enough for your response. Harley is 18 ½ pounds......and I'm beginning to think that we don't have any vets in Bakersfield that know what they're doing.

[molly muffin]

When is your ACTH appt? Usually they will do it at 12 - 14 days into treatment, but I'd go ahead and get it done now.

I'm thinking the dosage that would work would be something like 10mg am and 10mg pm, at most but if the cortisol has dropped too low already, then that would need to be addressed. I would get an ACTH done as soon as possible. Remember it is done after the morning dose at 4 - 6 hours.

Well, you know vets often follow the inserts and in this case, the insert hasn't been changes, yet there have been follow up studies done showing that is is safer to start lower or at the low end of what the insert states.

Now, University of Davis in California, is a top Vet school and has another one of the best vets, Dr. Feldman. Actually they have a wonderful staff that deal with cushings, if you run into any problems with your vet.

Another good one in LA area is Dr. Bruyette. So there are options and they will all work with your local vet from what I understand.

Sharlene and molly muffin