jeskel
05-11-2018, 07:20 PM
Hi Everyone,
I first posted over on K9 Diabetes, but I am leaning towards Cushing's being the key to determining whether Diabetes plays into symptoms. Kelsey is 13.5 and a Vizsla. She has had Cushing's symptoms for a long time (since age of 7), but they have been relatively stable, so they opted against doing formal diagnostics and treating, but she has been treated for Thyroid with Levothyroxine and has been pretty stable on that since 2015.
Her "crash" came about in early March 2018. Started with vomiting, diarrhea, 20 pound weight loss in a week, no longer eating, and was drinking water like no tomorrow with accidents to go along with the excess water intake...she was brought to the clinical for full blood tests that showed most notably a spike in glucose (over 680 mg/dl). Her BUN was elevated in the mid-30's mg/dl, and her ALK PHOS was reading out at 1649U/L. PHOS and Potassium were only slightly elevated. There was nothing considerably concerning on her hematology panel. Her UA showed ketones (15mg/dL) and Glucose (1000mg/dl). She was hospitalized for two days with initiation of long acting insulin along with bolus insulin to get her glucose back down and get her back to eating again.
Since the initial hospitalization, I have been struggling with getting a glucose curve anywhere near normal range, and after 3 consecutive insulin increases, ACTH and Low Dex Tests were done. As with everything, her results were borderline, but that in combination with years of clinical symptoms lead to the decision to try trilostane treatment (30mg morning / 10mg evening) to see if that would give us any improvement on glucose levels. Her results for her Low Dose Dex and ACTH tests are below, but I'm looking for feedback on anyone else with a similarly complex case on next steps...we are two months into this and while she is doing much better based on observation, her glucose is still severely out of control. I feel like her ACTH results are telling us to reduce her trilostane dose to avoid pushing her to Addison's, but initiating trilostane yielded the first glucose reading down in the 100's! Her weight is stable (within 2 pounds of her hospitalization weight)...
Diagnostic Low Dose Dex:
Cortisol Pre-Dex 2.1ug/dl
Cortisol 4 Hour Post-Dex 0.8ug/dl
Cortisol 8 Hour Post-Dex 1.5ug/dl
Diagnostic ACTH
Cortisol Pre-ACTH 2.4ug/dl
Cortisol Post-ACTH 21.3ug/dl
Post Trilostane ACTH
Cortisol Pre-ACTH 0.9ug/dl
Cortisol Post-ACTH 5.8ug/dl
Post Trilostane ACTH Re-Test
Cortisol Pre-ACTH <0.2ug/dl
Cortisol Post-ACTH 7.0ug/dl
Posts from K9 Diabetes for Reference:
I am struggling with insulin regulation in a newly diagnosed canine diabetic. Diagnosis was in March, insulin doses (U-100) started at 12 units 2x/day dosing, now up to 19 units 2x/day. I am doing curve testing using alpha track 2 at home, but I am seeing insulin duration of action as short as 2-3 hours, with the longest being 5 hours post dose before glucose spikes again.
When we first started out post hospitalization, curve started at mid 600 (pre-dose / 8 am), and dropped to mid 300 by noon, then spiked back to values between mid 500's and 700 for remainder of day. With the first dose increase, the curve started at mid 400 pre-dose, dropped to upper 300 at 10 am, and started increasing at noon with values ranging from mid 400's to mid 500's for remainder of day. With second dose increase, the curve started at upper 300 pre-dose, dropped to mid 200 at 10 am, and started increasing at noon with values ranging from mid 300's to mid 500's for remainder of day. Finally, the most recent increase resulted in 10-noon values that were in the 100's (most stable and favorable low I have seen), increasing to over 200 at 1 pm, and then spiking to 400's, and finally over 700 by the final read (just prior to evening insulin dose).
It seems we are making progress, but the glucose readings seems to be extremely dynamic and the insulin only seems to sustain a response for 3-4 hours at the most. I am under the impression the duration of action should be longer than 3-4 hours on 2x/day dosing. If the most recent numbers indicate we are in the 100's, why is the insulin wearing off and resulting in extremely high numbers the rest of the day?
Dog (13yo / 50+lbs) is being treated for thyroid (long term stable) and Cushing's (started treating more recently because of insulin resistance / symptomatic for some time). Being fed glycobalance by prescription. Vet confirmed earlier curves were not Somogyi as low reads were still extremely high. Is anyone else seeing insulin wearing off this quickly on such a consistent basis? If the goal is to maintain read between 100-200, but we are seeing a low that will now dictate holding dosing to avoid hypoglycemia, but still seeing highs in the 4-700's, it doesn't seem like we are really controlling the diabetes at all.
I am trying to be patient, but I don't want to continue putting my dog through this if the long term prognosis is more of the same. Symptoms have improved substantially overall since initial hospitalization, and quality of life seems to be decent most of the day / night, but I want to get things leveled out more.
--Thank you for your reply. Kelsey is a Vizsla. Breed has certainly crossed my mind as Vizsla's are extremely high energy / high metabolism. My initial concern after her first curve was that the dose was too high, but she is currently at 52 lbs and she was started at 12 units BID. I monitored her very closely for any signs of hypoglycemia when we started, but her levels were only dropping into the mid 300's 4 hours post dose before going back up. Regarding her hypothyroidism...she has been stable on the same dose of levothyroxine for several years. It was diagnosed with a full thyroid panel initially, and we either do full panel or T4 re-checks every 6 months. Also notable: we did a full abdominal ultrasound to rule out presence of sizable tumor involvement, and there was nothing significantly abnormal with her kidney's or adrenal glands. She also had a full set of high res x-rays for orthopedic purposes taken just prior to her diabetic "crash", and there were no abnormalities with organs or soft tissue visible noted there either.
The Cushing's treatment was just introduced, and that may be why we are seeing her first 5-6 hour numbers finally drop into a normal range (I am in the process of verifying the most recent results from yesterday today, and so far the numbers are spot on). We are doing a follow-up ACTH stim to see where her Cortisol levels are at based on her initial dosing soon. My hope is that the trilostane dosing is either spot on or only in need of one more dose increase, and that regulating her Cortisol will finally be the catalyst to break the insulin duration of action issue. I fully expect to reduce her insulin if we end up increasing her trilostane based on her ACTH re-check.
Thank you in advance for any feedback!
I first posted over on K9 Diabetes, but I am leaning towards Cushing's being the key to determining whether Diabetes plays into symptoms. Kelsey is 13.5 and a Vizsla. She has had Cushing's symptoms for a long time (since age of 7), but they have been relatively stable, so they opted against doing formal diagnostics and treating, but she has been treated for Thyroid with Levothyroxine and has been pretty stable on that since 2015.
Her "crash" came about in early March 2018. Started with vomiting, diarrhea, 20 pound weight loss in a week, no longer eating, and was drinking water like no tomorrow with accidents to go along with the excess water intake...she was brought to the clinical for full blood tests that showed most notably a spike in glucose (over 680 mg/dl). Her BUN was elevated in the mid-30's mg/dl, and her ALK PHOS was reading out at 1649U/L. PHOS and Potassium were only slightly elevated. There was nothing considerably concerning on her hematology panel. Her UA showed ketones (15mg/dL) and Glucose (1000mg/dl). She was hospitalized for two days with initiation of long acting insulin along with bolus insulin to get her glucose back down and get her back to eating again.
Since the initial hospitalization, I have been struggling with getting a glucose curve anywhere near normal range, and after 3 consecutive insulin increases, ACTH and Low Dex Tests were done. As with everything, her results were borderline, but that in combination with years of clinical symptoms lead to the decision to try trilostane treatment (30mg morning / 10mg evening) to see if that would give us any improvement on glucose levels. Her results for her Low Dose Dex and ACTH tests are below, but I'm looking for feedback on anyone else with a similarly complex case on next steps...we are two months into this and while she is doing much better based on observation, her glucose is still severely out of control. I feel like her ACTH results are telling us to reduce her trilostane dose to avoid pushing her to Addison's, but initiating trilostane yielded the first glucose reading down in the 100's! Her weight is stable (within 2 pounds of her hospitalization weight)...
Diagnostic Low Dose Dex:
Cortisol Pre-Dex 2.1ug/dl
Cortisol 4 Hour Post-Dex 0.8ug/dl
Cortisol 8 Hour Post-Dex 1.5ug/dl
Diagnostic ACTH
Cortisol Pre-ACTH 2.4ug/dl
Cortisol Post-ACTH 21.3ug/dl
Post Trilostane ACTH
Cortisol Pre-ACTH 0.9ug/dl
Cortisol Post-ACTH 5.8ug/dl
Post Trilostane ACTH Re-Test
Cortisol Pre-ACTH <0.2ug/dl
Cortisol Post-ACTH 7.0ug/dl
Posts from K9 Diabetes for Reference:
I am struggling with insulin regulation in a newly diagnosed canine diabetic. Diagnosis was in March, insulin doses (U-100) started at 12 units 2x/day dosing, now up to 19 units 2x/day. I am doing curve testing using alpha track 2 at home, but I am seeing insulin duration of action as short as 2-3 hours, with the longest being 5 hours post dose before glucose spikes again.
When we first started out post hospitalization, curve started at mid 600 (pre-dose / 8 am), and dropped to mid 300 by noon, then spiked back to values between mid 500's and 700 for remainder of day. With the first dose increase, the curve started at mid 400 pre-dose, dropped to upper 300 at 10 am, and started increasing at noon with values ranging from mid 400's to mid 500's for remainder of day. With second dose increase, the curve started at upper 300 pre-dose, dropped to mid 200 at 10 am, and started increasing at noon with values ranging from mid 300's to mid 500's for remainder of day. Finally, the most recent increase resulted in 10-noon values that were in the 100's (most stable and favorable low I have seen), increasing to over 200 at 1 pm, and then spiking to 400's, and finally over 700 by the final read (just prior to evening insulin dose).
It seems we are making progress, but the glucose readings seems to be extremely dynamic and the insulin only seems to sustain a response for 3-4 hours at the most. I am under the impression the duration of action should be longer than 3-4 hours on 2x/day dosing. If the most recent numbers indicate we are in the 100's, why is the insulin wearing off and resulting in extremely high numbers the rest of the day?
Dog (13yo / 50+lbs) is being treated for thyroid (long term stable) and Cushing's (started treating more recently because of insulin resistance / symptomatic for some time). Being fed glycobalance by prescription. Vet confirmed earlier curves were not Somogyi as low reads were still extremely high. Is anyone else seeing insulin wearing off this quickly on such a consistent basis? If the goal is to maintain read between 100-200, but we are seeing a low that will now dictate holding dosing to avoid hypoglycemia, but still seeing highs in the 4-700's, it doesn't seem like we are really controlling the diabetes at all.
I am trying to be patient, but I don't want to continue putting my dog through this if the long term prognosis is more of the same. Symptoms have improved substantially overall since initial hospitalization, and quality of life seems to be decent most of the day / night, but I want to get things leveled out more.
--Thank you for your reply. Kelsey is a Vizsla. Breed has certainly crossed my mind as Vizsla's are extremely high energy / high metabolism. My initial concern after her first curve was that the dose was too high, but she is currently at 52 lbs and she was started at 12 units BID. I monitored her very closely for any signs of hypoglycemia when we started, but her levels were only dropping into the mid 300's 4 hours post dose before going back up. Regarding her hypothyroidism...she has been stable on the same dose of levothyroxine for several years. It was diagnosed with a full thyroid panel initially, and we either do full panel or T4 re-checks every 6 months. Also notable: we did a full abdominal ultrasound to rule out presence of sizable tumor involvement, and there was nothing significantly abnormal with her kidney's or adrenal glands. She also had a full set of high res x-rays for orthopedic purposes taken just prior to her diabetic "crash", and there were no abnormalities with organs or soft tissue visible noted there either.
The Cushing's treatment was just introduced, and that may be why we are seeing her first 5-6 hour numbers finally drop into a normal range (I am in the process of verifying the most recent results from yesterday today, and so far the numbers are spot on). We are doing a follow-up ACTH stim to see where her Cortisol levels are at based on her initial dosing soon. My hope is that the trilostane dosing is either spot on or only in need of one more dose increase, and that regulating her Cortisol will finally be the catalyst to break the insulin duration of action issue. I fully expect to reduce her insulin if we end up increasing her trilostane based on her ACTH re-check.
Thank you in advance for any feedback!