Pending Diagnosis

[SanD]

Hi all...so glad I found this site :) I have an Irish Wolfhound/German Shepherd Cross male dog, and he's 10 years old. He's not really been himself for a good while now, but kept getting told "it's his age" and "he's old for a big dog"
After repeated ear infections, treated with steroids for a month his water intake/output went through the roof.
He was tested for and subsiquently treated for Diabetes. However, despite raising his insulin his levels were still too high.
I did say to the vet at the start I suspected Cushing's but was told it was very doubtful as he'd only been on a short steroid dose etc etc...but I told them he has all the symptoms. I was told only an expensive blood test could confirm this and diabetes was much more common, hence his treatment for that.
So, after a month on insulin, and no improvement, more noticeable pot belly, the vet has agreed it looking like Cushing's!
The day of expensive blood tests is on Wednesday to confirm or disprove this.
My question is, if he is diagnosed with Cushing's the only treatment licensed in the UK is Vetoryl...due to his breed he is a big dog, so will probably require a larger dose...will the Vetoryl also treat the diabetes, or would he need to carry on with the Insulin too?
Sorry for waffling on a bit but I wanted to give a bit of background info too. Thankyou so much for any information you can give me

[Harley PoMMom]

Hi and welcome to you and your boy!

First thing I want to provide you with is a link to our sister site, k9diabetes (http://www.k9diabetes.com/forum/), they are a wonderful group of people who know their stuff regarding canine diabetes. I strongly recommend joining their forum too.

A dog being treated with steroids for a month can definitely display the same symptoms as a dog with the naturally-occurring Cushing's. This steroid induced Cushing's is known as Iatrogenic Cushing's and the only treatment needed is to slowly taper the steroid use.

Diagnosing Cushing's is difficult in itself and when diabetes is thrown in the mixture it makes it even more challenging. When a dog is diagnosed with diabetes it is important to get that blood sugar regulated before any tests for Cushing's are performed. Diagnosing Cushing's in an uncontrolled diabetic dog is next to impossible as diabetes can cause the same organ abnormalities on imaging, overlapping symptoms that are also associated with Cushing's and diabetes can cause false positives LDDS and ACTH stimulation test results. I'm providing a link below to Dr. Peterson's blog entitled Q & A: Diagnosing Cushing's Disease in Dogs with Diabetes Mellitus. http://www.endocrinevet.info/2012/01/q-diagnosing-cushings-disease-in-dogs.html It has some pertinent information so I do recommend that you read it.

It would be very helpful if you can give us as much information about your boy as possible, this will enable us to provide you with more meaningful feedback, so here are some questions that I have: How much does your boy weigh? Besides the diabetes does your boy have any other underlying diseases and if so what are they and what meds is he taking for it? Can you please get copies of all testing that was done by your vet and post the results here. With respect to the blood chemistry & complete blood count (CBC), we need only see the highs and lows, and please include the normal reference ranges. Was an urinalysis done, and if so, could you post those findings too?

As for the dose of Vetoryl, Dechra, the makers of Vetoryl, have since revised their starting dosing protocol and now recommend that treatment should be initiated at 1 mg per pound of a dog's weight. Here's the link to where this information can be found: http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf. On the forum I don't recall that the insulin treatment needed to be stopped in a diabetic dog when therapy for Cushing's was started.

Please know we are here to help in any way we can so do not hesitate to ask all the questions you want.

Hugs, Lori

[molly muffin]

Hello, I just want to say hello and welcome also. Lori has covered the basics, I just want to add in addition in response to your questions, no vetroyl does not treat diabetes, it is used to lower cortisol in the body.

If the steroids caused the cortisol to go up, then a test will show it is high whether or not it was caused by the meds or not.

So you might want to wait a bit before testing for that. They diagnosed the diabetes via a blood test for the glucose?

Are you doing curves and monitoring the glucose to see if he is resistant?

You would if he does indeed have cushings, need to treat both diseases, but often the symptoms are the same and if you can get the steroids stopped and get the glucose under control, then the excessive urination/drinking might diminish on it's own.

Welcome again to the forum.

[SanD]

Hi...thankyou so much for your replies so far. My boy is called Max, and he's a big boy at 39 KG. He has no other health issues, and has never had to take any medication until the steroids for his ear infection. He's no longer taking the steroids, these were tapered off and ultimately stopped 2 months ago. For some time Max has drank lots of water, up to 5 litres daily, and there have been things like loss of muscle tone around his back end, and stiff joints, all things when I mentioned them were put down to an ageing dog. What set alarm bells off and made me go back to the vets was whilst he was on the steroids his drinking instantly went up to 10+ litres a day, he became incontinent, and we were up and down at night, all night with him. The steroids were as I said tapered off and eventually stopped, but the symptoms didn't. Even after a couple of weeks. This is when I went back to the vet again and said he wasn't getting better, and although I knew steroids took a while to get completely out of the system, I suspected Cushing's, the young vet I saw (not my usual vet) grinned and said "Oh, have you been searching the internet?" She said there was no way he could have got it so quickly, even though I told her I suspected he'd had it underlying a while. After this I have only taken Max to see his usual vet, and whilst he didn't think it was Cushing's at first, he suspects this now. He first did a urine analysis which showed glucose, and a blood test that showed sugar. Hence the diagnosis of diabetes, which he believes was sub-clinical, i.e. there, but not producing noticeable sypmtoms until the steroids. The vet did other blood tests, and his liver function did indicate Cushing's he said, but the steroids could give an "altered" reading too so he wanted to get them completely out of his system first.
At the vets yesterday he told me the sugar in his bloods was normal, but his urine was still showing glucose and it shouldn't be if the diabetes was the only problem. He then said he wanted to test for Cushing's, and to keep Max on 16 units of insulin twice a day. Up to now we had been increasing his insulin by 2 units every 3 days until he was stable, upto a limit of 20 units. Although he isn't stable, because his blood sugar is ok now he says any further increase would send him into a hypo so we need to find out what the other problem is, and as he is now suspecting Cushing's, hence the blood tests tomorrow.

I've read Cushing's can bring about Diabetes, but was wondering, is the Diabetes a symptom of Cushings, and therefore would it then "go" if the Cushing's was brought under control, or is the Diabetes an illness caused by Cushing's, and therefore will not disappear with treatment of the Cushing's and will need to be treated seperately.
I realise the Cushing's medication isn't for diabetes,but was thinking diabetes is a result of Cushing's it may cease to be a problem after.
I hope some of this helps, and again, thankyou so much for accepting me into your group, it's a big help to know there is somewhere I can turn for advise from people who've been where I am with Max.
Sandra.xx

[Harley PoMMom]

From Dr. Peterson's blog (in which I provided a link to :))

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.


So as far as Max's insulin dose, it doesn't seem that he is at the maximum that he can take.

Dr Peterson is a renown Cushing's expert and is also a contributor to Dechra's continuing education site, so I do highly recommend that you read that article on his blog: http://www.endocrinevet.info/2012/01/q-diagnosing-cushings-disease-in-dogs.html

[labblab]

I've read Cushing's can bring about Diabetes, but was wondering, is the Diabetes a symptom of Cushings, and therefore would it then "go" if the Cushing's was brought under control, or is the Diabetes an illness caused by Cushing's, and therefore will not disappear with treatment of the Cushing's and will need to be treated seperately.
I realise the Cushing's medication isn't for diabetes,but was thinking diabetes is a result of Cushing's it may cease to be a problem after.
Hello and welcome from me, too. I think you've asked some very interesting questions. From our experience here, we know about many dogs who have been diagnosed with both diseases, and there often seems to be a bit of a "chicken or the egg" question in terms of the relationship. To date, I can't remember anybody who has been able to completely stop diabetic treatment once cortisol levels come under adequate control. But based on "human" experience, it may not be impossible. Here is a link to some associated research based on human Cushing's/diabetic patients:

http://www.ncbi.nlm.nih.gov/pubmed/20829624

Here's part of what they have to say:


Active Cushing's syndrome is associated with insulin resistance induced by the high and prolonged circulating level of glucocorticoids. In endogenous Cushing's syndrome the overall incidence of diabetes mellitus and insulin resistance is very likely to be under-reported as not all patients are actively investigated with glucose tolerance tests...

... in the acute setting insulin therapy is frequently needed. Definitive management directed against source driving Cushing's syndrome is often highly effective at either reducing the severity of diabetes, or allowing its complete resolution. Patients experiencing diabetes mellitus in the context of exogenously administered glucocorticoids may well require insulin therapy for the period that the high levels of steroids are being administered. Despite resolution of Cushing's syndrome after definitive treatment patients may continue to exhibit insulin resistance. This and other cardiovascular risk factors require ongoing and long-term attention.

So apparently at least with humans, effective Cushing's treatment can sometimes eliminate the need for insulin. But of course, this would only be the case when the diabetes has arisen as a result of the elevated cortisol. If the diabetes occurs independently, lowering the cortisol should aid with diabetic management but it will not eliminate diabetes as a disease process.

Marianne