Kirby - Possible Cushing's, but now treating diabetes

[peony]

My dog Kirby is an eight year old schnoodle. He started drinking a lot more this summer. No other symptoms. He's had a few tests including an eight-hour test for Cushings, a sterile urine test (needle) and several blood tests. They say he has Cushings and recently they've added Diabetes but the most concerning is hypercalcemia. The high calcium level and the Cushings have opposite symptoms so it gets more confusing. According to several websites the number one cause of hypercalcemia in dogs is cancer. My vet told me one day to just make him as comfortable as I could (he mentioned the calcium as a marker for a tumor.) Another day he tells me we need x-rays, an ultrasound, additional tests for Cushings and insulin. Kirby has the extreme thirst and the ravenous appetite that you talk about. He is however losing weight rapidly. He has lost over a third of his body weight in six months. He has lost most of his muscles and struggles to move. He is skin and bones - it is heartbreaking. He is incontinent after years of being completely trained. I've spent $1,000 already and I don't know what to do. They did not give me copies of his blood work - just called me on the phone. He has never been sick before or taken any medication other than heart worm preventive medicine. Any advice would be appreciated. He sits by me all of the time now and I find myself in tears every day. I take him outside nearly every hour. I am at home and disabled.

[labblab]

Hello and welcome to you and Kirby, although I very sorry that he is doing so poorly right now. First of all, I must tell you that I am not a vet, so the things I am offering are just my personal thoughts. However, based on what you've written, it seems to be that if Kirby has now been diagnosed with diabetes needing insulin, that is your immediate concern over and above anything else. I know very little about hypercalcemia, other than the fact that it is indeed a significant worry, as well, especially depending upon how far outside of normal range his calcium value falls. But if Kirby's blood sugar is elevated to the point that your vet says he needs insulin, that needs to be attended to immediately or he may die. We have a sister site that is dedicated to diabetic dogs, and I encourage you to join them for their info and support.

http://www.k9diabetes.com/forum/

As you are already aware, Kirby's situation may be a tough one to unravel because some of his symptoms could be caused by any one of these three issues: diabetes, Cushing's and/or hypercalcemia. To further complicate things, the blood tests for Cushing's can return "false positives" if the dog is suffering from another illness that is having a significant effect on his system. So unfortunately, your vet may be correct that additional testing may be necessary to get to the bottom of things. In Kirby's case, it seems to me that an abdominal ultrasound might be especially helpful in order to look for the presence of any tumors and also to evaluate the status of his adrenal glands to see whether they are consistent with Cushing's.

But as I said above, to me, the first order of business would be to get started with the insulin if the vet says that Kirby needs it. I believe that can be an emergency situation. Also, it will help us a great deal if you will request copies of all his test results since the summer. That way, we can carefully help you to sort through the abnormal values. We surely understand why you are feeling so scared and worried, and we will do our best to help you make sense of things.

Marianne

[AvileeG]

I will heartily agree with the advice about getting Kirby on insulin ASAP if he is testing diabetic (which is a lot more definitive than the tests for Cushing's for sure!). They used to call diabetes "the starvation disease" back before they figured out how to replace insulin, because that is what happens -- with the body unable to use nutrients due to lack of insulin, diabetics will eat and eat and eat and keep losing weight. Our little Daphne went from a 12-pound dog to a 10-pound dog in a few months, just when her diabetes was first beginning to kick in (she had still tested pre-diabetic at the beginning of that time); it was so good to see her weight return once we got her stabilized on insulin! According to our doctor, diabetes can be a side effect of Cushing's -- or even incipient Cushing's, as Daphne's was at the time -- so it is not surprising they might think he has both.

Good luck and good wishes!

[peony]

Thanks for responding! I have felt so helpless with all of this.

I called the vets office today and asked for copies of Kirby's tests. I also have a call in to the vet to see if he should start insulin. He has been seeing this vet since he was a puppy. I also joined your sister site for diabetics as you suggested.

Kirby had lost about eight pounds when they diagnosed him with Cushings and high calcium levels. He wasn't diagnosed with Diabetes until follow up blood work for the calcium a month or so later. He has lost another four pounds since then. He started at 30 pounds and is now at 18 pounds. Up until the Diabetes diagnosis the vet wasn't recommending any treatment. It was after that that he started suggesting x-rays, ultra sound, etc. I want to do everything I can to help Kirby but I also don't want to torture him. He was very upset after having to spend a whole day at the vet fasting and in a cage for the Cushings test.

Thanks again for talking with me. It truly helps.

[peony]

I talked to my vet this morning. He doesn't like the idea of treating him for diabetes without doing other tests. He said he doesn't feel like insulin alone will help Kirby.

He wants him to come in for several all day tests. The previous all day test had Kirby upset for days. Kirby is never crated and gets very upset at being crated. I even found a groomer who doesn't crate him.

Do you think I am over-reacting at thinking I need to change vets?

[labblab]

No, I don't think you are over-reacting, because your vet's response is confusing me, too. I am especially confused about the diabetes. Unlike with Cushing's where there is no single definitive test, with diabetes either the blood glucose level is elevated or it is not. If it is elevated, this can be caused or worsened by various underlying conditions of which Cushing's is one. But if it is elevated highly enough, the dog will need insulin, at least temporarily, regardless of what all else may be going on. So if your vet is saying "no" to insulin, I can only assume that Kirby's glucose level is not actually high enough to be considered diabetic. Maybe it is running at, or just above, the high end of the normal range.

At this point, I am not saying your vet is wrong. I'm just confused by what he is recommending because I don't yet really know the specifics. This is where it will help us so much once you get those actual copies of Kirby's test results, so that we will know exactly which numbers are abnormal and by how much. Also, I would ask him to tell you exactly what additional tests he wants to perform. Aside from the 8-hour LDDS which Kirby has already had done, I'm not sure what else would be taking all day, on multiple days.

Once we know exactly what your vet has in mind, I think you will be better able to judge whether you want to seek a second opinion about all this.

Marianne

[Budsters Mom]

It is not only important that your vet is knowledgeable, it is equally important that you're comfortable with the vet you have chosen. Both diabetes and Cushing's can be hard to regulate and you need a vet on your side. You are a team. You are the most crucial member of that team. You need to feel comfortable and have open communication with that vet at all times. You are scared right now. It does get better once a diagnosis has been made and treatment is underway. Right now everything is so new. Discuss your concerns with your vet. If you're still not feeling a connection after that, you might want to look into getting another one. An IMS ( internal medicine specialist ) would be the best choice, but are pricey. Many of us have had our dogs evaluated through an IMS, then managed through our regular vets under their guidance. It's cheaper and the best of two worlds if you can do it. Basically, the IMS runs the case and calls the shots regarding treatment and the regular vet carries out the plan. They have to be willing to work together. Some really do care and will do this for free.

Hang in there,
Kathy

[peony]

Thanks for responding! I am heart-sick over this whole thing. It really helps to discuss it with someone.

I am taking Kirby this afternoon to have his glucose level tested. I've asked for copies of all of his tests. I only see a tech today and the vet will call me tomorrow.

[peony]

I want to cry every time I talk to Kirby's vet. I'm not sure if it's the bad news or his manner that upsets me more.

[LittleArfinAnnie]

Just wanted you to know that I'm thinking of you and Kirby today, hon.

I'm sitting by the phone now waiting for blood work results that will determine whether or not my 9 1/2 year old Dachshund, Annie, has diabetes in addition to the Cushing's Disease that has already been diagnosed.

Like you, I, too, have shed an abundance of tears today.

If it can provide you with even a heartbeat's worth of comfort, please know that you're not alone . . .

Catherine

[peony]

Thank you! I will be thinking about you and Annie too!

[peony]

I have Kirby's test results. the LDDS says:
Time 8:30 Cortisol Sample 6.4
Time 12:30 Cortisol <1.0 (result verified)
Time 4:30 Cortisol 1.4

The notes on the bottom are very confusing to me.

With the blood work do you want everything or just the ones that are high or low? I have 9/2/15 and 11/24/15. I won't have today's until Monday.

I have posted on the diabetes board already but his blood glucose today was 421. It was 405 on 11/24 and 109 on 9/2. He was already very thirsty and had lost weight when he had blood work in September (normal I believe.)

It makes sense to me now that the diabetes has been brought on by something else. I guess that is why the vet doesn't think treating the diabetes alone will help. The tests are another LDDS and all day monitoring of his glucose levels (he indicated this would need to be done more than once.)

If you could explain the LDDS numbers and let me know what numbers you want from the blood tests I would really appreciate it.

Kara

[labblab]

Hi Kara, thanks for getting back with us so promptly! As far as Kirby's test results, all we need are the values that are either too high or too low, along with the "normal" range for that particular value.

As far as his LDDS test, it is the 8-hour value that determines whether or not the result is consistent with Cushing's. Can you double-check his test to make sure, but I'm guessing that 1.4 ug/dL is probably right at the "cut-off" between a normal result and an elevated result (for most labs, it is either 1.4 or 1.5). If that is the case, Kirby's LDDS would have been borderline for Cushing's. However, here is the thing about the LDDS test -- of the two diagnostic blood tests for Cushing's, it is the one that is most likely to return a "false positive" if there is another illness going on. So uncontrolled diabetes could actually end up falsely elevating this Cushing's test. If your vet is wanting to repeat a Cushing's test, it would probably be better to switch to the ACTH stimulation test rather than repeat a LDDS, because the ACTH is less prone to "false positives." I know I am making this sound very complicated, and I will come back later and try to explain this all more clearly.

But this is the most important thing. If Kirby's glucose today was clear up to 421, I don't understand why your vet isn't starting him on insulin, immediately. Once again, as far as I understand things, it really doesn't matter whether the diabetes is the chicken or the egg here. Kirby's glucose level is way high and needs to be attended to, regardless of anything else that is going on. If Kirby does have Cushing's, too, his insulin needs may end up decreasing once the Cushing's is effectively treated as well. But the elevated glucose is the top priority and I don't understand why your vet is dilly-dallying with this. What are the folks telling you about this on the diabetes forum?

Marianne

[peony]

Hi Marianne. Thanks for getting back to me so quickly.

The 1.4 ug/dl is the cut off on my report. I could find that but I don't understand the rest of the comments. When Kirby had the Cushings test his glucose wasn't elevated. It wasn't until 3 months later that it showed up.

I have a gut feeling my vet thinks it's cancer and just isn't saying it. I am going to push for insulin tomorrow and will buy by own kit. I checked my Mom's glucose so I have a good idea how to do it. I just have to figure out the best place to do it. I've watched some videos on the diabetes forum. Thanks so much for sending me there.

Thanks, Kara

[peony]

Blood work 9/2/15
Total Protein 7.6 HIGH Range 5.0-7.4 g/dL
Alk Phosphatase 327 HIGH Range 5/131 U/L
Calcium 12.3 HIGH Range 8.9-11.4 mg/dL
These were the ONLY values out of Range on 9/2/15

Blood work 11/24/15
Alk Phosphatase 183 HIGH Range 5/131 U/L
Total Bilirubin 0.5 HIGH Range 0.1-0.3 mg/dL
Glucose 405 HIGH Range 70-138 mg/dL
Calcium 11.7 HIGH Range 8.9-11.4 mg/dL
Sodium 134 LOW Range 139-154 mEq/L
Chloride 96 LOW Range 102-120 mEq/L
Cholesterol 364 HIGH Range 92-324 mg/dL
Triglycerides 2073 HIGH Range 29-291 mg/dL
result verified
PrecisionPSL 751 HIGH Range 24-140 U/L
PrecisionPSL with a result >216 is supportive of, but not definitive
for, a diagnosis of pancreatitis
CBC
MCHC 38.3 HIGH Range 30-38
The vet didn't mention pancreatitis to me.

He appears to be much sicker in November than September. He had the LDDS done in July.

[molly muffin]

It certainly does look like diabetes, and I'd think the vet would want to get him started on insulin right away. I'm not so sure if cushings is a culprit also, but I'd treat the insulin issue first personally, based on the LDDS test being on the borderline and see if you can't get that under control. It might make a world of difference. My dogs calcium has been up and down and if it where me, I'd treat the diabetes and get that controlled, then redo blood work to see where they end up at as the diabetes could be affecting other things too. That looks to me like the primary issue though based on this blood work.

[peony]

Thanks Sharlene. The vet said if the glucose tested high today he would give me a script for insulin. I've already talked to my pharmacist and have decided to give it a try.

[molly muffin]

Let us know what today shows. It can take some tweaking with the insulin, so stay in touch with the diabetes site, as they can really help with that!

[labblab]

For any of our folks who are also experienced with diabetes, can you please "identify" yourselves here this morning? ;)

Kirby's mom has started him off on insulin with the help of the great folks on the k9diabetes forum, but their database is out of commission this morning so she has no way to contact them right at the moment. :(

Thanks in advance for any help you can give us!
Marianne

P.S. Kirby's mom, I've changed the title of your thread so that it will more likely catch the eye of our diabetes experts.

[peony]

I saw the new vet today and she believes Kirby has Cushings induced diabetes. I brought her all the tests from the previous vet. She is agreeable to treating the diabetes, she just said it can be hard to regulate in a dog with Cushings.

BTW I really like the new vet! We were there for an hour and a half. Once I get Kirby's glucose somewhat regulated I'll be back here with questions. :-)

[Wally P's Mom]

Hello:

I have been in your shoes. My Fritz was a diabetic/Cushnoid turned Addisons dog.

The diabetes with insulin will be better controlled once the Cushings is under control.

It is a roller coaster of a ride, but once your dog gets under control in all phases, the effects of diabetes is slowed down. My Fritz lost his vision much later in his illness then we were told.

Fritz was 16.5 years old when he passed away.

Patience and perseverance is the key.

Marge

[peony]

Hello:

I have been in your shoes. My Fritz was a diabetic/Cushnoid turned Addisons dog.

The diabetes with insulin will be better controlled once the Cushings is under control.

It is a roller coaster of a ride, but once your dog gets under control in all phases, the effects of diabetes is slowed down. My Fritz lost his vision much later in his illness then we were told.

Fritz was 16.5 years old when he passed away.


Patience and perseverance is the key.

Marge

Thank you for responding! How did they get the Cushings under control?

[molly muffin]

It is certainly possible that it is cushings caused diabetes.

Usually you try to get the diabetes controlled first. If Kirby does not get control, then you'd move to adding in cushings meds (twice a day based on weight, divided)

Sounds like you have found yourself a good vet. It helps to have one who is well versed in both diseases and that you can work with.

Let us know how it goes.

[peony]

Thank you!

He didn't show any sign of diabetes until Nov and had been losing muscle and drinking excessively since March or April. I knew in my heart it probably wasn't diabetes alone. We'll keep taking it one day at a time.

[Wally P's Mom]

Thank you for responding! How did they get the Cushings under control?


We did things the old fashioned way and followed the lysodren protocol as prescribed by his vet. Never did anything without his vet knowing it.Loaded and recheck the ACTH, and kept loading til his ACTH indicated he was loaded.

Then we went "the other" way and became Addisons.

Please invest in 3 things, a canine glucose meter and test strips, a good calendar with lots of room to write, and a kitchen scale.

We weighed all of his food, water and religiously checked his BG twice a day, and documented how much insulin we gave. Our vet was awesome and we checked in with her a minimum of twice a day via email. More if needed. Based upon his behavior and water consumption, I knew before the vets did that he went the other way.
Good record keeping.

It's scary. But patience and perseverance got us through it.

Do a search for Fritz and my name, read our story. It does have a sad ending, but the time we had together was very good. It was always hard to share the good, I never wanted to jinx things.

I never left the group after his Addisons diagnosis because these people are family. If you haven't learned that by now, you will.

Marge and her Angels, Fritz and Wally P, and to come home Chewy (puppy)