Totally freaked out

[Sunripenedsmile]

Hi everyone I'm new but have reading through several posts. My Sidney (11 years old 16lbs, Maltese/Lhasa mix) was recently diagnosed with Diabetes (Monday, April 3, 2017). With some research (low dose Dex test and ultrasound) we figured out she has pituitary gland driven Cushing's. My normally peppy sweet girl has been sleepy and sad. I have been giving her 3.5u of insulin twice a day since her diagnosis and 5mg of vetoryl since Sunday, April 9, 2017. She's had a couple of good days, normal energetic. Today she is very lethargic, hard to get her to anything. I am super worried but I know this is a process. I just wanted to introduce myself. Any help or advice would be greatly appreciated.

[Squirt's Mom]

Hi and welcome!

First thing - STOP the Vetoryl immediately. Is she eating? Does she have loose stools or diarrhea? Is she nauseated or has she vomited? If you answer yes to any of these, get her to the vet ASAP for an ACTH to be sure her cortisol has not dropped too low. That is a life threatening situation so do not hesitate to get her to the vet if you think this is a possibility.

Second, a cush savvy vet will not try to diagnose Cushing's and Diabetes at the same time. That is not wise since they share many of the same signs AND the stress of diabetes can cause the cortisol to rise naturally causing false positives on the testing. So if I were you I would ignore the diagnosis of Cushing's for now and focus solely on getting the BG under control. Toward that end, please go now to our sister site and register with them so you can start talking to them... the are the experts on canine diabetes. The website is - http://www.k9diabetes.com/forum/

So three things - STOP the Vetoryl; get her to the vet asap if you think the cortisol may be too low; register at K9Diabetes.

Then you can come back and chat with us any time - diabetes MUST be your first focus; the Cushing', if in fact it IS in play, can wait and we will be here.

I would like to hear back on how your baby is doing when you can, tho. ;)

Hugs,
Leslie and the gang

[Sunripenedsmile]

We got up this morning for her AM insulin, she ate and got her shot and Vetoryl. Since then she's been very sleepy, good water intake but not too much, not vomiting and no diarrhea. I am going to get her into the vet today. I did go to two different vets who advised me that without getting the Cushing's under control we couldn't get the diabetes under control. Her cortisol levels on April 7 were as follows:
Initial blood test -
The complete blood count has a normal WBC count of 7,300 (optimally between 5,000 and 8,000), The HCT
is 54.6%. The percentage of Eosinophils is 8% and above the optimal percentage of 2-3 %.
The chemistry shows a Glucose High 447 (74-145), SGPT High 224 (14-151) a liver enzyme, Alk Phos High
2267 (13-289) a bile duct enzyme, Cholesterol High 457 (98-300) can be elevated due to low thyroid (low
thyroid hormone function due to Cushing's Disease) or diet, Albumin High 4.4 (2.6-4.0) due to dehydration,
Potassium High 5.8 (3.4-5.6) due to dehydration. Chloride Low 97 (100-121). GGT High 36 (3-19) a liver
enzyme.

Low Dose Dexamethasone test -
Baseline Cortisone 4.8 (1.0-5.0)
4 hour Post Cortisol 3.4
8 hour Post Cortisol 7.1

Taking her to the vet now....

[Harley PoMMom]

Welcome to you and Sidney! !

Leslie is spot on, the diabetes should be the priority, diagnosing Cushing's when diabetes is not controlled can cause false positive results for Cushing's.

I'm including this article from Dr Mark Peterson's blog (Dr Peterson is a renown and very well published veterinary endocrinologist) titled: Q & A: Diagnosing Cushing's Disease in Dogs with Diabetes Mellitus, http://www.endocrinevet.info/2012/01/q-diagnosing-cushings-disease-in-dogs.html An excerpt from this article:


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.

More than likely your vet is familiar with Dr. Peterson's name so I'd print this out and discuss it with the vet.

If you have any questions do not hesitate to ask them and know that we will help in any way we can.

Hugs, Lori

P.S. I have manually approved your membership so now all your posts will be seen right away and please disregard the validation email that was sent to you from k9cushings. ;)

[Sunripenedsmile]

We are going to stop the treatment of Cushing's at this time. Our vet is convinced that she has Cushing's but I am feeling like the vetoryl is doing more harm than good at this time. My plan is to continue this next week with 3.5u insulin shots 2x daily and do a glucose curve next Saturday. I truly appreciate all your responses and the article was really helpful. It is hard when you're being told something by a professional and you just want to believe them but you feel like something isn't right...

[Sunripenedsmile]

Does anyone have an opinion on getting the high dose Dex test done??

[labblab]

Hello and welcome from me, too! When you say you are stopping the Vetoryl, I hope you are talking with your vet prior to actually making the change. I am not saying that it's a bad decision to hold off on Cushing's treatment right now, but Sidney's insulin dosage may also need to be changed if the Vetoryl is discontinued and cortisol levels start to increase again. So I think you need to let your vet know what you are planning to do.

As far as the HDDS test, I would hold off on it myself. That test can only be accurately interpreted if you feel confident that the general Cushing's diagnosis is correct in the first place. I forget the specifics of that test, but both a normal dog and a dog with one form of Cushing's will exhibit the same type of result. So you don't want to administer that test until you have firm reason to believe that the dog does have Cushing's in some form.

And actually, the ultrasound ought to have eliminated the need for the HDDS, anyway. If Sidney suffers from an adrenal tumor, that abnormality ought to have been seen on the ultrasound.

Marianne

[Sunripenedsmile]

They diagnosed her with the pituitary form of Cushing's based on the ultrasound and high cortisol levels in her Low Dose Dex Test.i spoke with my vet today and I just feel like she is not being proactive on Sidney's behalf. She wants to administer the insulin and Vetoryl for 2 weeks before we test again and said that will give us a better idea.

[labblab]

If the ultrasound was consistent with pituitary Cushing's, then there really would be no value to the HDDS. The purpose of that test is solely to differentiate between adrenal and pituitary Cushing's; it cannot diagnose Cushing's itself. The only general diagnostic alternative to the LDDS is the ACTH stimulation test (which is also used to monitor trilostane treatment after the medication has been started).

Thank you for posting those abnormal lab values. Out of curiosity, does Sidney exhibit any skin or coat issues? Per that article by Dr. Peterson, those types of overt symptoms can give greater support to the accuracy of a Cushing's diagnosis in a diabetic dog.

Marianne

[Sunripenedsmile]

She has no other symptoms outside of excessive thirst and excessive urinating. So, no pot belly, no skin issues and no hair loss.
I truly appreciate all your help, in speaking with the Dr. Further we are going to stay the course with the vetoryl and insulin and do testing soon to see how her levels are. My Dr. believes Sidney is very sick and wants me to trust this course of action.

[Budsters Mom]

FYI - Excessive thirst and excessive urination are also symptoms of uncontrolled diabetes. It is really hard to tell if these symptoms are actually Cushings related.

Kathy


She has no other symptoms outside of excessive thirst and excessive urinating.

[Squirt's Mom]

Have you joined K9Diabetes and discussed this with them?

[westcoastflea1]

what kind of dog food are you feeding? anything with grain will cause a rise in glucose you could try merrick all meat canned food low fat high protein to help with muscle wasting and to keep ligaments etc healthy which is important in cushings dogs

[molly muffin]

Hello from me too. Just wanted to also say that when you have a dog with both diabetes and cushings, then the recommendation from Dr. Peterson is to do twice a day vetroyl. You can get a compounded low dose vetroyl, maybe 3 mg twice a day to try and keep the cortisol at optimal levels through out the day instead of once a day dosing. So that is something to look into also. Getting the BG down is paramount and will be of help likely with liver enzymes too.
You said they did an ultrasound? Did they say how the gall blader and liver looked? If not ask them to review that. Just make sure there is no gall blader sludge that could cause the ALKP to go super high like that.

[Sunripenedsmile]

Thank you all for your input. I am currently working with the extremely helpful members of k9 diabetes as well. We haven't changed her food yet, she's eating Simply Nourish​ 1/2 c twice daily. We are trying to get her BG under control still and have recently increased her to 5u twice daily. I am going to do another curve in a week. The results of the ultrasound showed some live and kidney enlargement but nothing major. Everything else looks good. I will.contact my Dr about possibly going to twice daily for the vetoryl. Should I get a blood test to see if her cortisol levels have decreased?

[molly muffin]

is she still off of vetroyl?

I personally would get an ACTH to see what her levels are at now? If she is on vetroyl then she should be getting regular monitoring ACTH test.

You are looking at a spit dosage for the vetroyl. So, if on 10mg once a day you'd go to 5mg am and pm. This keeps the cortisol levels at a more even level throughout the day, which helps with diabetic control.

[Sunripenedsmile]

She is on vetoryl 5mg once daily. I never took her off vetoryl as it was not suggested by the three vets that I have seen. So, we kept her on the low dose. At 15lbs she could be up to 15mg a day. I don't know anymore...I am going to schedule her for a the ACTH test.

[molly muffin]

Well it depends on what her ACTH is, but you could also do 5mg am and pm or if she is controlled on 5mg, then 3mg am/2mg pm (compounded trilostane)

As an example. Let us know what the ACTH shows. For good control you are looking for a ACTH post result of say 2.0 - 5.0ug (it can go up to 9.0ug post IF her symptoms are controlled and you have control of her diabetes)

[Sunripenedsmile]

We are officially going to be switching Sidney to Lysodren after her most recent lab results. I am feeling extremely nervous about it. Can anyone give me some advice? Or positive stories?

[lulusmom]

I have taken the liberty of merging your last post with your original thread so that we have all of Sidney's info in one place.

I am just now reading your thread and have read both of your threads at k9diabetes and there are a lot of missing pieces to Sidney's puzzle. Others have already mentioned that testing for cushing's while bg is uncontrolled is not recommended as a false positive results, especially the LDDS test, are likely. With Sidney's only symptom being excessive drinking and peeing, my concern about the cushing's diagnosis increases as this symptom is definitely associated with both diabetes and cushing's. You mentioned that an abdominal ultrasound showed an enlarged liver and kidney. Diabetes can cause an enlarged liver so I am wondering what the adrenal glands looked like. Were they normal or both enlarged?

To update members here, according to your thread on k9diabetes, the insulin your vet prescribed is Prozinc. K9d member Mike Murphy shared some very important information about that insulin on Dr. Mark Peterson's Endocrine Vet Blog Spot, which I hope you saw. I would agree with Mike that based on Dr. Peterson's comment below, the struggle you are having gaining control is because "the Prozinc may be taking too long to start working and then it is not lasting long enough." Did you talk to your vet about changing insulin?



"Protamine zinc insulin (Prozinc) is not generally recommended as a first choice therapy for diabetic dogs as it has a less predictable action with a slower onset than Lente (like Vetsulin) insulin or the 70% or 100% NPH (like Novolin N) preparations."

If your vet is following proper Vetoryl protocol, Sydney should have had two acth stimulation tests and it would help us greatly if you could post the results of those tests? Did you give the Vetoryl with a meal 3 to 5 hours before the acth stimulation tests were done? Is Sydney on once a day or twice a day dosing? If Sydney truly does have cushing's, she should be on twice daily dosing to make sure that her cortisol is being controlled throughout the day. Have you discontinued the Vetoryl? What is happening at this point in time that your vet wants to change Sydney from Vetoryl to Lysodren? Has she decided Sydney is insulin resistant, which I believe may be way too premature at this point, or do the results of the acth stimulation tests show that Vetoryl is not having any impact on lowering cortisol?

To answer your latest question, I have treated two cushdogs with Lysodren and have done obsessive research on the drug over the last eleven years so I am intimately familiar with it. There is much to learn about the drug and we can definitely help you with that. Has your vet prescribed Lysodren yet and if so, what dose has she prescribed? Has she given you written instructions on the part you must play in the Lysodren loading phase so as to make sure Sydney does not get overdosed and become ill?

I apologize for so many questions but I am always greatly concerned about the welfare of any dog who is diagnosed with cushing's based on tests that were done when bg was out of control. I hope you aren't overwhelmed by me because I know you are already on the edge dealing with all of this. We are great hand holders and you will not find greater moral support; however, helping members learn is so very important and it's much easier for us to provide that help if we have all the facts.

Glynda

[Sunripenedsmile]

Wow!! Thank you for taking such an interest in my baby!! We haven't had any ACTH tests done just a new blood panel yesterday. Sidney was on 2.5 mg twice a day of vetoryl and we are up to 6u of insulin. I got vetsulin today and we will start that tomorrow.
My vet wants to switch us to Lysodren because of Sidney's lab results. She is now showing signs of fatty liver disease and the vet says it is because her Cushing's has not been controlled. It is her opinion and the opinion of two other vets that she has Cushing's driven diabetes and that we have to resolve the Cushing's before we will have proper insulin dosing.
She has prescribed Lysodren. Sidney will be one 160mg twice a day during induction and the. 160mg prn to keep her stable.
I think I touched on everything but I welcome any other questions,comments and help you may have.

[lulusmom]

I am deeply, deeply concerned with your vet's breach of Vetoryl treatment protocol and her reliance on blood chemistry to determine that Vetoryl is not effectively controlling cushing's. There is no way your vet can possibly know that Vetoryl is not effective without doing an acth stimulation test. Your vet should have also checked electrolytes as it is well known that Vetoryl can cause a reduction in aldosterone that can be life threatening.

You should never, ever switch to Lysodren without knowing for a fact that Vetoryl has not lowered cortisol adequately nor should you ever switch without going through a wash out period. If Sidney's cortisol is already too low and you start Lysodren loading, Sidney could experience adrenal toxicity landing her in the hospital or worse. You mentioned that you are giving 160 mg dose of Lysodren am and pm and that the pm dose is given to stabilize. That is not how Lysodren works. The goal is to give very large doses of Lysodren needed to kill off enough of the adrenal cortex tissue to decrease the flow of cortisol. The dose is split between am and pm not to stabilize but because the drug can cause GI disturbances so this reduces that likelihood. It has a cumulative effect so splitting the dose does not lessen the effectiveness of the drug. Because it's cumulative, you can't take back the pill once you've given it so your vet should have counseled you on the importance of monitoring Sydney for signs of loading. Did you receive that counseling and if so, what were you told? Here is another never, ever. You never load with Lysodren without several prednisone pills on hand in case of emergency. Do you have prednisone?

There often comes a point in time that some doggie patients will become complicated cases that are well above a general practitioners' level of education and experience to effectively diagnose and treat. We've seen this happen time and time again in dogs with concurrent diabetes and cushing's and to be perfectly honest, based on what you've shared with us, there are red flags with your vet's approach to treatment of both diseases and I fear for Sydney's welfare. Both of my cushdogs had concurrent diseases that weren't as complicated as Sydney's issues and my gp vets were ill equipped to handle their care. They were both diagnosed and treated by board certified internal medicine specialists until the day they passed. I highly recommend that you consider having Sidney examined by a specialist asap. Your vet should be happy to give you a referral. If you let us know what state and city your are in, members may be able to give you a reference. You can also search for specialists in your area at http://vetspecialists.com/

[Sunripenedsmile]

I am totally at a loss of what to do now. I think I didn't state clearly what I was doing. I am give 160 mg twice a day until the loading phase is over and then 160 prn (as needed) once she is past the loading phase. I did visit an internal medicine specialist when she had her ultrasound and that Dr. Said they were satisfied with the course of treatment through my vet. I am currently 30 miles outside of Milwaukee WI in a small town of East Troy. I do have Prednisone which was given to me with the script for Lysodren. My vet said she was much more.comfortable with Lysodren and has seen great results and made me feel confident we were headed in the right direction. She said day 3 of the loading phase I would reduce Sidney's insulin to 4u twice daily (from 6u twice daily) because Sidney's diabetes is dependent on her Cushing's.
Once again I am in a place where I am totally freaking out, I thought by seeing three Dr's I would be doing what is best for her but it sounds like I am still failing her. She has received one dose of 160mg Lysodren this morning.
Her original Alk phosphorus level was 2267 and now she is 762, to me that means she is getting better...

[Sunripenedsmile]

Initial blood test -
The complete blood count has a normal WBC count of 7,300 (optimally between 5,000 and 8,000), The HCT
is 54.6%. The percentage of Eosinophils is 8% and above the optimal percentage of 2-3 %.
The chemistry shows a Glucose High 447 (74-145), SGPT High 224 (14-151) a liver enzyme, Alk Phos High
2267 (13-289) a bile duct enzyme, Cholesterol High 457 (98-300) can be elevated due to low thyroid (low
thyroid hormone function due to Cushing's Disease) or diet, Albumin High 4.4 (2.6-4.0) due to dehydration,
Potassium High 5.8 (3.4-5.6) due to dehydration. Chloride Low 97 (100-121). GGT High 36 (3-19) a liver
enzyme.

Low Dose Dexamethasone test -
Baseline Cortisone 4.8 (1.0-5.0)
4 hour Post Cortisol 3.4
8 hour Post Cortisol 7.1


Updated blood test is as follows:
The complete blood count and differential are normal and there are no problems with this.
Her HCT is 51.2 % (33-58.7%) and the WBC count is 6,400 (4,000-18,200). Both are optimal.
The eosinophil count is 6%.

The chemistry is; Glucose High 485 (74-145), ALT(SGPT) is high 248 (14-151), AlkPhos High 762 (13-289),
Cholesterol High 447 (98-300), Sodium Low 137 (141-159), Chloride Low 99 (100-121), GGT High 28 (3-19).
Amylase Low 263 (268-1653).

[molly muffin]

I am surprised too that none of the vets recommended an ACTH test at any point, either during vetroyl treatment or before starting lysodren to know what her actual cortisol values are at.
Did I get that correct or am I mistaken in that assumption?

We have seen dogs here on the forum with both diabetes and cushings, treated with vetroyl, still have out of range blood work (liver enzymes, etc) and BG and have controlled cotrisol levels, so that is not true that BG will be controlled if cortisol is controlled necessarily.

I am going to give you the link to our lysodren information. Read this carefully, print it out, etc, http://www.k9cushings.com/forum/showthread.php?t=181

If you notice her not eating, even not eating the same as she normally does then she could be loaded and you'd need to schedule an ACTH test.

Lysodren isn't forgiving with any Over loading, since it isn't a take back kind of drug, you don't want the cortex to erode too much.

I have plenty of concerns about not following any type of normal protocols with the vetroyl and the lysodren switch, so I am hoping that perhaps some information was lost along the way?

When was the lab work done that you just posted?

[Harley PoMMom]

I, too, am quite concerned with the vet's course of action with Sidney. This is probably a moot point now since the Lysodren has been started but I'm providing excerpts from 2 veterinarians that specialize in endocrinology regarding Vetoryl treatment in a dog with diabetes that has Cushing's:

1) Rhett Nichols, DVM, Diplomate ACVIM: Internal Medicine:
Once-daily or twice-daily trilostane: and the winner is?

Until it is proven whether SID or BID treatment is better, we prefer to start with a twice-daily regimen, if feasible from a compliance and cost perspective and the owner agrees.

Why? Controlling cortisol concentrations as much as possible throughout the day seems to make the most sense. For example, in diabetic dogs with concurrent HAC, twice-daily administration of trilostane is essential in avoiding large fluctuations in serum cortisol concentrations during the day. With once-daily trilostane administration, adequate diabetic control is often difficult at best in dogs with concurrent HAC.

https://s3.amazonaws.com/media.guidebook.com/upload/9agrckHp8BOH3jb2YeR3E2G2FJxtwL4RU2ncqtqb/dbbce06a-b8c2-11e5-8abb-0e091904946b.pdf

2) Dr. Mark E. Peterson, who is a world-renowned veterinarian specializing in endocrinology (hormonal disorders).


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.

https://endocrinevet.blogspot.com/2012/12/low-dose-twice-daily-trilostane.html

As you can see both of these veterinarians are saying pretty much the same thing, with a diabetic dog Vetoryl needs to be dosed twice a day. And since this protocol was not followed the chances were next to nil in getting that diabetes under some kind of control with Vetoryl .

Regarding the fatty liver, dog's with diabetes are very prone to that too, quoting Dr Peterson:
...diabetic dogs can get marked hepatomegaly secondary to fat accumulation in the liver. That can lead to a mild-moderate "pot bellied" appearance.

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

I realize this is overwhelming and I am so sorry for that, it's just that I am worried about your girl as I know you are too. Your love and devotion to Sidney is very obvious to all of us.

The link that Sharlene posted to you has invaluable information about Lysodren so please do read it and if you have any questions do not hesitate to ask them.

Lori

[Sunripenedsmile]

You are correct that she has not received a ACTH test. Just the low dose Dex test. Her last set of labs were taken on May 9th. I just want to be doing what is right for her but I doesn't seem my vet is on the same page as anyone​ when it comes to this treatment. I have never thought of her as a bad vet and she has seen me through many issues with my other dog. Day 2 of "loading" has gone well, her appetite is still crazy. I have read pages and pages of information but more is welcome as always. Just trying to do what is best for my little girl... We did split her 5mg Vetoryl to 2.5 twice daily, so she was taking that properly after her first week of taking it. Ugh. Another sleepless night ahead. I called my vet today to give a report. I'm going to do a curve tomorrow to see how she is doing BG wise. Thank you so much for all your help and advice.

[labblab]

Hello again from me. Gosh, I have to agree with the other folks that I am stunned that no monitoring ACTH testing has been performed in conjunction with Sydney's treatment and that this shift to Lysodren has taken place without any quantifiable knowledge re: the status of her adrenal function and cortisol level. Have you specifically asked your vet why she has not performed any ACTH testing thus far? What explanation has she given?

Of equal importance -- at this point actually more important -- what is the exact monitoring and testing plan now that the Lysodren has been started? For safety's sake, you absolutely cannot proceed unless your vet plans to perform an ACTH just as soon as you first notice observable signs that loading has been achieved. Can you tell us the exact instructions you've been given in conjunction with this switch to Lysodren?

Marianne

[Sunripenedsmile]

My Dr. does not believe she needed that monitoring. She said the labs we have done this far have given her enough information to make the decision to start this course of treatment. I could demand one and maybe that is what I should do. I live in a very rural area and have always felt lucky to have such an amazing vet near by, as I said I have never doubted her abilities until now.

The course of action is for her to have a vet visit as soon as the loading stage has completed. We are going on lack.of appetite rather than water consumption because of the diabetes complication. Once we have that visit we will talk about the next steps. What we discussed is that some dogs need upkeep medication (in her case 160mg) once a week, sometimes twice a week and she has seen many cases where upkeep is done every two weeks. She told me each dog is different and we will figure out Sidney's balance. So the plan is 160mg of Lysodren twice daily until loss of appetite and then a vet visit to determine how often we will be giving her upkeep dosage.

[labblab]

OK, this is seriously wrong now. :( :( :( :(

I truly do not believe there is any safe way for Lysodren treatment to proceed in the absence of ACTH monitoring testing, and I am dumbfounded that your vet would consider doing so. I can easily understand that the options in your immediate area may be very limited, but if you are within 30 miles of Milwaukee, there have to be a number of vets available to you there. You mention consulting with a specialist at the time of Sidney's ultrasound-- have you spoken with that specialist ever again? If not, now would be the time to do so! You need to let somebody know that your vet intends to treat Sydney with Lysodren without the benefit of any direct monitoring of adrenal function. I am so sorry, but this is absolutely nuts -- and frightening!

One of our staffers lives in the Milwaukee area, and I'll see if she might have some vet suggestions for you.

Marianne

[molly muffin]

WOW. Let me just express my shock that Any vet would not think a monitoring ACTH test is needed when a load while on lysodren is even suspected. I've Never in all my years dealing with cushings, specialist, vets, etc, heard any of them say such a thing.

Let me explain why that is such a shock and worrisome to all of us.

Lysodren erodes the outer cortex of the adrenal gland so that it cannot produce as much cortisol. However, cortisol is needed to live. Period. So if you erode too much, then you risk and it happens, going into Addisons. If that happens the adrenal glands do not produce Any cortisol and the elctrolytes are considerable out of whack, sodium and potassium being the main two, and both need to be in harmony for life. So that has to be rectified and supplemental steroid (which mimics cortisol) introduced.

These issues have to be introduced as soon as possible in this situation and is considered an emergency.

So that is why no vet i've ever heard of plays around with lysodren without acth test to monitor the cortisol and use that to gauge how much of the cortex is being eroded.

Once you go too far, there is no going back, the adrenal glands are done. It's a drug that works but only with a vet who is quite knowledgeable and experienced in it's use.

So, yes we are concerned. I think that if you continue on this road, that you have to at the very list, demand your vet perform an ACTH when loading is suspected and an electrolyte test. You are well within your rights as Sandy's caregiver to require that they do this and if they refuse for any reason, then I'd not just walk, but run out the door to a vet who has experience with lysodren. In fact, it might be worth it to call some vets, specialist to see who has experience with lysodren and the protocols surrouding it's use and have they been successful. Just so you have an alternative. Its just a few phone calls and if not needed, great, but if you do need it, then you'll know where to go.

[Squirt's Mom]

I was the one who first posted to you and I said then to stop the Vetoryl...that no vet who knows Cushing's would try to diagnose both Cushing's AND diabetes at the same time. Nearly every post since then has told you the same thing in one way or the other. We are not vets, no, we are not. BUT we have **lived** with canine Cushing's day in and day out for years....not many vets can claim that. We do know what we are talking about and we tell you these things in an all-out effort to help you and your baby have the best life possible with your new norm, to maybe even save her life.

Cushing's is very very rarely immediately life-threatening. So it can wait EVEN IF the diagnosis is correct, which is still not clear to most of us.

Diabetes **IS** immediately life-threatening and because of that fact it should be your only focus for right now. The ONLY one. :)

After you have spent some time (probably months) working on the blood sugar, using the correct insulin ;) , with no good control maintained...then, THEN, you might want to revisit Cushing's. But not before.

I join the others in expressing my deep concern in your vet's ability to deal with Sidney. So far, there are red flags all over the field of Sidney's treatment track. ;) You simply must educate yourself and do so quickly so you will have a better idea of when this vet is going way off track and you can call them back. You have to do this - Sidney cannot speak, she has to count on you to speak for her. So you have to educate yourself. And while you are learning, look for another vet if this one will not listen to you and work with you for Sidney's best results. Start your education at K9Diabetes. ;)

We are worried about Sidney so we share our knowledge and experiences with you. We also care about you so we try to teach when we can so you don't look back one day and say "...if I'd only known..." We try to make sure you know. What you do with that is of course up to you but I hope you will listen and trust us as well as those at K9Diabetes to guide you and Sidney to the very best of our abilities. We do care plus we have some gurus here and I mean true gurus. Glynda and Marianne are two of those gurus who have been talking to you earnestly. Please listen.....

Hugs,
Leslie and the gang

[Sunripenedsmile]

Thank you all so much. You're so helpful.i have been reading endlessly the paperwork my vet has given me and every article on the internet I can find. I have a phone call in to.my vet clinic for an ACTH test to get scheduled asap. She should be calling me back. I have also called the big clinic where we got her ultrasound (and hour and a half away) and they can do it any time (they have 24 hour care). Today she has been good but her sugar is in the 500s all day (she is off Prozinc and on vetsulin now). We went for a big walk and she was running all over chasing the geese around. She seems happy when she is outside playing and when she is eating. But when we are home she seems like she doesn't feel good. She has had 5 doses of Lysodren at this time so 2.5 days worth. I have also told the big clinic that she could become "loaded" this weekend when my vet is closed and they are prepared for me to come in if that is the case. I am not sure why both the big clinic and my vet have only used the low dose Dex test as her baseline and we have had no cortisol testing since. When I hear back from my vet I will post an update. I am going to fight for my little girl! Thank you for making me feel confident in these demands.

[Squirt's Mom]

It's tough to stand up to a professional but we have to remember they are human too and as such not infallible. The key is...do they know that?! :D

Most vets seem willing to work with proactive pet parents. The ones who puff out their chests and start telling us how much they know and how little we know are the dangerous ones. We need vets who are willing to listen and to learn...to work with us. ;)

You can do it!

[molly muffin]

You can do this!!

Don't just rely on food, I know that water is a symptom with diabetes also, but drinking less water, stopping instead of gobbling their food, all can be a sign of a load having taken. So keep an eye on her.

[labblab]

Just wanted to check in again in order to see how you guys are doing! I surely hope that everything is OK, and I am really anxious to see an update when you are able to post again.

Marianne

[Sunripenedsmile]

Sorry I haven't been posting did an ACTH pre 7 post 21. Not thrilled. We are on day 11 of Lysodren and she is still eating, and drinking like crazy. Loading with 160mg twice a day she is a 14 lb dog. Her sugar numbers are still incredibly high and I have been quiet because basically I feel such defeat. We are chugging along. I don't think vetsulin is working I'm hoping to switch her to humulin once she is loaded....she feels like crap and I feel like crap.

[labblab]

I am so sorry that things are not settling down for you two! We have another new member right now whose dog is also being very slow to respond to Lysodren, and she is feeling quite downhearted, too. :o

Can you tell us at what stage of the loading was that ACTH performed? How many more days have since passed by?

Marianne

[Sunripenedsmile]

ACTH was done day 9 after her first dose for the day. She has just completed day 13. She had a few good hours this afternoon. She didn't drink as much water last night which felt good. This morning I moved her food bowl because I had spiked food and she was even a little aggressive (she's always been a tiny bit food aggressive-nothing new there)so I know her appetite is still way up. This evening she is back on the couch feeling yucky. Another ACTH is scheduled for Wednesday.

[molly muffin]

Gads, I am stumped as to why a load would be taking this long. It seems bizarre to still have a post of 21 on that load after 13 days.

Has your vet said why this seems to be a prolonged event? I'm curious about that. I hope some of the ones who have used lysodren and gone through the load themselves can pop in and give their thoughts.

[Sunripenedsmile]

Sidney loaded tonight!!! I am so happy to announce this. I fed her her dinner and she ate about half took a drink and walked away!!! She has never done that in her life. So 13.5 days in and she's loaded. Now on to maintenance​ dosing and working on getting her blood sugar in check. Hooray!!!

[labblab]

That is great news!! However, you're not going to like hearing me say this, but you really need another ACTH right now in order to document the actual cortisol level. The result can affect how quickly you launch into maintenance dosing (if her cortisol has gone really low, you may need a break before starting maintenance) and also the exact dose that you'll be using...

Marianne

[Sunripenedsmile]

I love you saying that! I have one scheduled for tomorrow morning! Woohoo.

[Joan2517]

Woohoo is right!

[Harley PoMMom]

Congratulations on Sidney's load!!! Man, I know how nervous you must have been feeling during the induction phase, but now that's over with!!! YAA!!!

Hugs, Lori

[Sunripenedsmile]

So, bad news my vet clinic had an emergency this morning and I was unable to get Sidney's ACTH test done with work this afternoon. However, we should be good tomorrow morning if we have 48 hours. Her load occurred officially 5pm on Tuesday. She felt good, slept through the night without getting up for water. This morning she ate but at a slower pace and didn't drink a bunch of water afterward. I am feeling great. We have also lowered her insulin (I may have said this) to 4u 2x a day as she was experiencing the somogyi effect with 6u 2x a day. We have not performed a curve for her yet but I am planning on doing one Saturday. Thank you, thank you, thank you, for all your support, it means more than I can express. I know we are not out of the woods yet but, the fact that she finally loaded and seems to be feeling good is soo soo positive to me and for her <3

[Joan2517]

So happy that you're happy....happy is such a great feeling!

[Sunripenedsmile]

Edit: I thought I had posted this...on Thursday May 18th, I had taken her into the vet for an ACTH test and to see if we get get something to help with the gas she was experiencing from the Lysodren. We got some x-rays because she seemed like she was in some pain. We found out she has IVDD and Spondylosis of her T13 L1. After feeling completely defeated, as we have been through so much. I went on a mission to find something to help with the pain - since she can not take steroids due to the Cushings. So, we will be getting a Wiggleless brace and see how she does with it. I am hopeful it will help with the pain and spasms she is feeling and also hopeful that as she rebuilds muscle once she is regulated that she will start to feel better. Right now she is having some major back leg weakness. Thank you for listening!

[molly muffin]

Oh now, how horrible for something else to happen and something that will cause pain. What about some mild pain medication like tramadol to help also?

[Sunripenedsmile]

Sidney is slowly resolving her diabetes since we have gotten her Cushing's under control. She had the lowest readings yet this last Saturday (in the 200 and 300). She is needing her upkeep dose about every 5 days and we are giving her 160mg once a day on those days. I have been using water intake and appetite. Though I know this has not worked for everyone it seems that Sidney fits into these parameters very well. Once she loaded (14 days) her first upkeep dose came after 8 days and her second came after 5 days. With both upkeep dosages I noticed her increased appetite and water intake and immediately got her tests, and her levels had started to rise. I am considering either just doing a twice a week dose or sticking with the 5 day dosing - I think I will figure this out over time. From now on I intend to just use those physical markers as prompts for her upkeep dosing. Her energy is slowly coming back and even if she does not fully resolve her diabetes the lower numbers are highly encouraging. Thank you all for your help.

[molly muffin]

I've very glad to hear that Sidney's diabetes is doing better.

Breaking down how you give you the maintenance dose, I believe is up to the owner. You give what works for you and Sidney and can break it into however many days you need to. Some do once a week, some do 3 times a week, some do more, the key is that you have a maintenance dose of a set amount for the week and how you give it is whatever works.

[Sunripenedsmile]

So we've moved to twice a week, my question is for Lysodren users do your pup's feel awful the day of maintenance post Lysodren. Sidney has been feeling great the two days in between treatments but the day of then I give her the Lysodren she feels cruddy .

[Squirt's Mom]

My Trink sleeps a bit more on her Lyso days and her stools are a bit looser....but she is an odd case there. She has some digestive issues and her feces is usually very hard so her "loose" stools would be more akin to normal stools in another dog. Most days I have to assist in cleaning out her bowels - on the Lyso days I don't. ;) Other than that there are no changes with her. Her does is very low tho.

[Sunripenedsmile]

She seems to be a bit wobbly on Lysodren days, like back end/ back leg weakness...any thoughts?

[molly muffin]

When do they plan to retest ACTH to see where her levels are on the maintenance dose?

If she is worse on maintenance days then it could just be the lyso itself causing upset?

Did they mention giving pepcid to try and calm any nauseousness? Not that it would cause her legs to be weak, stomach wouldn't do that but maybe feeling awful and sick to her stomach would cause that

[Sunripenedsmile]

She's getting retested in Thursday. She suddenly stopped having much of an appetite... ughhh. We will see where she is tonight.

[molly muffin]

Only no appetite on days of her maintenance dose or no appetite any time?

[Sunripenedsmile]

Less of an appetite in general. She's feeling okay...but truly not eating well.

[molly muffin]

Did you have a retest done this past thursday? When do they expect results if so?

It is hard when they don't feel well and you know they don't. :(

[Sunripenedsmile]

She stopped eating complete and is having terrible tremors. Please pray we are on our way to the vet now. ACTH was normal last testing round.

[molly muffin]

Oh no!!! Do let us know what the vet says. Crossing fingers, and sending all our best that this is something she can over come.

Let us know how she is doing!

[Joan2517]

Hoping everything is okay...the poor girl...

[molly muffin]

Checking in this morning and hoping to hear some good news.

[Sunripenedsmile]

Liver and kidney functions are normal, she is not Addisonian, she has been put on Gabapentin in conjunction with her rimadyl. Praying she starts to eat or drink. The Dr has no idea what could be going on. She has consumed very little since Sunday evening. Other than the tremors and not eating/drinking she is acting pretty okay. She's responsive and active.

[Harley PoMMom]

Her potassium and sodium were normal, right? Did the vet say to stop the Lysodren until her appetite has picked up?

[Sunripenedsmile]

Yes we are off Lysodren, she has pancreatitis. She is so so sick. She has to be off her NSAID for 24 hours before they can treat her parents. Pray pray pray pray pray please!

[molly muffin]

Oh no. She'll be in pain so glad you have some pain killers When she will eat only bland small meals. Mushy boiled chicken and rice. Let us know how she is doing.

[Joan2517]

Poor baby, hope she feels better soon.

[Harley PoMMom]

Pancreatitis can be a bugger to get under control. It can also be very painful so getting some pain meds in her may help, my Harley took tramadol for his pancreatitis.

A bland diet is usually recommended until the pancreatitis has subsided; such as very mushy rice with some fat-free skinless chicken breast, small amounts of this fed throughout the day.

Keeping you both in my thoughts and prayers.

Hugs, Lori

[Sunripenedsmile]

She won't even look at food or water....I've been giving her Pedialyte every few hours...I feel like she is wasting away, she's in so much pain. We were prescribed a new medication called gabapentin which essentially enhances the pain meds she's on. I shouldn't have said pancreatitis so quickly, that was the initial diagnosis and now they are leaning toward an ulcer of some kind. The not eating at drinking at all is killing me...I feel so helpless.

[labblab]

Was her cortisol level actually checked by the vet? Her electrolytes (sodium and potassium) are only half of the picture in terms of Addisonian worries...

Marianne

[Sunripenedsmile]

She had another blood draw today....we will see...I'm.so upset she seems terrible I'm so afraid she is going to die. I've been to 2 ERs and my regular vet.

[labblab]

I surely understand why you're so worried. Please ask the vet for a specific number re: the cortisol level, though, so you can share it with us. For any dog who has been treated with Lysodren and is ill, it is extremely important to know the exact status of the cortisol level.

Marianne

[Sunripenedsmile]

Sidney was diagnosed with atypical/hidden/silent Addison's. She is recovering slowly but it has been a process. Thank your for the support you all have given me. Her tests both electrolyte and stim came back normal but she was showing signs of Addison's. We have begun treatment for Addison's and she is improving, eating, drinking and wagging her tail. She is certainly still sick but improving daily.

[Joan2517]

Awww, poor Sydney...praying that she continues to improve.

[Harley PoMMom]

Could you please get those ACTH stim results and post them here?

Lori

[Sunripenedsmile]

Test results are
7/17 pre test 5 post test 5.5
7 /19 pre test 3 post test 3.5

These were done at 2 different clinics.

Her appetite has increased substantially as of today. She ate 3/4 of a cup and was happy to see me when I got home. I can't even fathom how close we were to losing our little girl. I know she is not out of the woods yet, this has been incredibly hard on her body.

[molly muffin]

It's good to hear that her appetite is better. I'm thinking the pancreatis might be getting better. The post cortisol results are not reflective of Addisons, but are actually where they should be on the 7/19 test.

you want between a 2 - 5 post results on the ACTH when using lysodren.

Hoping she continues to improve each day

[Sunripenedsmile]

Yes they were both right around where they needed to be yet she was dying in front of me. Prednisone has been curative and she is on the mend. We will have to start over with Lysodren but now I am totally scared to do so.

[Harley PoMMom]

Although her ACTH stimulation results are within the therapeutic ranges for Lysodren it could be that Sydney needs her cortisol to run a bit higher. I believe that ACTH numbers are not the only way to judge how a dog's treatment is working, how the dog feels and acts are just as important.

Lori

[Sunripenedsmile]

Sidney has been on Prednisone for 3 weeks. Her appetite has come and gone and it's been hard to stabilize her. She's been feeling okay, wagging her tail and meeting me at the door but any time I think can lower her pred she stops eating all together and we start over. I think she may be permanently Addisonian. She feels better than she did as a Cushinoid dog but the pred comes with a host of different issues.

[Harley PoMMom]

Were her electrolytes checked recently?

[molly muffin]

When do you do the follow up ACTH test to see how she is doing? You might ask them to do an electrolyte test at the same time just to be sure of how she is overall.

[Sunripenedsmile]

She's drinking soo much water. Ugh. I'm worried about her kidney function now just because of how much she is drinking. Her food intake is still up and down. I called the vet today and talked to her about when we should retest. We do a lot of observation based assessment which has served us well as her ACTH tests and electrolyte tests have been fine. Next week Tuesday I have an appointment for a full blood panel, and a ACTH. We will be looking for her to be in the 7 - 9 range since she seems to function best a little above average.

[molly muffin]

I remember being told that not all PU/PD issues resolve in all dogs. Usually this resolves, but there will always be the dog that it doesn't resolve in. So that is a possibility too unfortunately.

[Sunripenedsmile]

We now have a full fledged Addison's dog. She isn't doing the best but we are working on a plan that works for her. The diabetes is the biggest complication as we need to give her steroids for the Addison's but that drives up her sugar. We've been told by 3 different vets that it may be time to consider putting her down. I am devastated. Currently, she is eating well and perks up when I talk to her. She still takes herself out to pee and trots around outside. I'm not ready to let her go yet and I'm still semi-optimistic we will find something that works. Thank you for all your help. I am sorry for not posting more we have had a terribly hard time the last few weeks.

[Squirt's Mom]

Could you please post the results that the vet used to determine Addison's? How long had she been off the steroids when that ACTH was performed?

There are some Addison's groups online you can check out, too. Some links for you -

http://www.addisondogs.com/support/

https://groups.yahoo.com/neo/groups/k9Addisons/info

https://groups.yahoo.com/neo/groups/AddisonDogs_/info

I personally prefer online forums like ours and those listed above VS a Facebook group. Online forums are better monitored for inaccurate info and info that is purely opinion. Facebook groups get so very large it is almost impossible to monitor them 24/7 so too often LOTS of incorrect info gets bandied about in many of those settings. But here is the FB Addison's group -

https://www.facebook.com/addisondogs/

https://www.facebook.com/groups/2347518387/

Also, be sure to check in with our sister site, K9Diabetes and let them know about this development to see what they have to say. ;)

Hang in there!
Hugs
Leslie

[Harley PoMMom]

Oh my, I am so sorry that you are having these issues with Sidney. I found this article on Dr. Peterson's blog titled: "Managing Addison's Dogs with Concurrent, Uncontrolled Diabetes" I hope it helps, here's the link: https://animalendocrine.blogspot.com/2014/02/managing-addisons-dogs-with-concurrent.html

The article is very informative and one of the things that I found interesting that he said was:
Unfortunately, many dogs with Addison's disease are treated with too much glucocorticoid. Remember that our goal with glucocorticoid supplementation is to provide the same amount of steroid that the dogs would normally produce if their adrenals had not failed.

For dogs, the daily glucocorticoid maintenance dose for prednisone is only 0.1-0.2 mg/kg/day (3), so that calculates out to only 0.5-1.0 mg per day for Scooter, quite a bit lower that what you are currently giving (2.5 mg per day). That would certainly be enough to cause an increased thirst by itself, but would also contribute to glucocorticoid-induced insulin resistance, making the diabetes uncontrollable despite the higher insulin doses.

Therefore, we should try to lower the prednisone dosage first down to 1.0 mg once daily (or divided). If he is doing well clinically (i.e., normal appetite and no vomiting), then the dose can be lowered even further, down to 0.5 mg per day. Prednisone or prednisolone are available in 1-mg tablets, as well as an oral solution, making it possible to administer these smaller dosages (6,7). Now, this dog weighs 11 pounds and is getting 2.5 mg of fludrocortisone (Florinef) twice day along with 1.25 mg of prednisone twice daily, so his case could be totally different that Sidney's. Man, it seems to be quite the balancing act to get everything under control and I sympathize with you.

I hope you can find something in the article that helps with Sidney.

Hugs, Lori

[Sunripenedsmile]

I am going to go through the paperwork and find the results. It was an electrolyte imbalance along with a failed Dex test for sure. She has seen two vets and is going to an internal medicine Specialist on the 29th. She received a percorten injection on Saturday and has been on Dexamethasone since then as well. Her overall behavior is much better and she is eating like a champ. Her diabetes is out.of control and i.am sure we have to winnow down the amount of steroid she is receiving. The percorten is a shot that lasts 25 days and keeps her electrolytes in balance (sodium especially). She is drinking a terrible lot of water which makes me concerned for her kidneys. I will find her test results and post them. Thank you thank you thank you for the article about Addison's it cements my thought that she is getting too much Dexamethasone (.75 once a day)

[molly muffin]

I think maybe lower the steroid and you might get better control of the diabetes.

This is a really fine line balancing act it seems. If you can find that sweet dose for both hopefully things will be much better. Hoping the IMS can shed some light on this too

[Sunripenedsmile]

She is fully Addisonian, and went blind overnight due to uncontrolled diabetes while I was out of town last week. I feel defeated and like a bad mom. I know I am more devasted than she. We are beginning some mapping exercises tonight and working through this next obstacle. Keep us in your thoughts. Thank you.

[Squirt's Mom]

I am so sorry to hear about your sweet girl's changes. I know they are hard on you both but I also know you will do all you can to make things as easy for her as you can. Often dogs adjust to being blind much better than we do. ;) I've have several blind babies and they can truly amaze you! Please keep in touch and let us know how ya'll are doing.

[DoxieMama]

You are NOT a bad mom.

Read that again, until you believe it. Whenever you doubt yourself, repeat it again.

Your little girl loves you unconditionally.

Hang in there!
Shana

[Joan2517]

They adjust to being blind and deaf much better that we do. I cried for a week when I realized Lena was deaf, but we found ways to make it work...and you will too.

[molly muffin]

Oh my gosh! I am sure that was a huge shock. Remember though, blindness is one of those things that seems to bother us humans more than our pups. Once they figure out where everything is, they manage to do very well with the powerful senses they have other than sight. Just remember not to move things around at all. Rugs can give them a guide of what is where, (texture being the key there).

I know that you will do very well with the mapping and once you see that she can adapt then you will I hope feel better.

[Sunripenedsmile]

Thank you everyone. I am just still in shock. I needed to hear from you all that blind babies do well. Thank you again!

[molly muffin]

I found two facebook blind dog support groups. I was a member of one of them and I can tell you that they have some great ideas and are supportive of the situation many people are in with trying to figure out how best to help their blind furbabies.

https://www.facebook.com/groups/BlindDogs/?ref=br_rs

https://www.facebook.com/groups/126150894067756/?ref=br_rs

I would highly recommend popping over and joining up with one or actually both groups.

[Sunripenedsmile]

Wow. Thanks I have joined both of them. <3