Cushing's and Diabetes, what's been your experience?

[anotherk9lover]

Hi all! I have just come across this website and posting for the first time. Just wanted to hear what everyone is doing for their dogs with cushing's, and if anyone else has experience with battling both Cushing's and diabetes at the same time. My maltese is 8.5 years old, fairly young to be having all of these endocrine issues. We have suspected Cushing's for a couple of years, but decided not to put her on medication and formally diagnose based on what I had read about Vetoryl being a dangerous medication. Until July of this year when Daisy started to drink excessively and urinate a lot. We figured it was the fact that her cushing's was progressing, and somehow diabetes didn't cross my mind at all! Until Daisy went into a DKA episode, she got really sick, and we had to hospitalize her. It was a very heartbreaking time as we thought we would lose her. The hospital bill for just 2 nights was outrageous of course, and caused debates in our family about whether or now we should have hospitalized her to begin with, but anyway that's another topic.

So after we diagnosed her with Diabetes and started treating with insulin, the vet suggested that she be formally diagnosed and treated for Cushing's as well, as it's most likely that Cushing's was the underlining cause for the Diabetes. So she did test positive for Cushing's, and we have had her on 5mg of Vetoryl once a day for over 3 months now. The initial lab test was within good limits. Now we have to take her back in for a ACTH test 3 months later. Daisy's sugars have not been easy to regulate. I do glucose curves at home from time to time, and they're always different. Sometimes she's within good limits of 100's-200's, other times she's in the 300's-500's. We feed her 12 hours apart the same way, so that doesn't vary too much. Not sure what else to do for Daisy at this point, should we continue her on Vetoryl? What can we do to stabilize those sugars? All of it is adding up to so much money between the medications, and the tests, the insulin, syringes and glucose strips, and not to mention the time everyone has to put into it to be home at certain time for the shots. Of course we love our little fur baby, and are willing to go above and beyond for her. I just wish we could establish more or less a stability with her cushing's and diabetes, without always feeling like things will go downhill at any moment.

What is your expert advice?

Thank you!

-Daisy's mom

[labblab]

Hello and welcome to you and Daisy! We’re so glad you’ve found us, and I’ll be back later on to talk with you in greater detail. Unfortunately, I only have a few moments free right now, but I wanted to let you know that we’re glad you’re here, and that more information will be coming ;-).

Marianne

[Harley PoMMom]

Hi and welcome to you and Daisy!

It is extremely hard to diagnose Cushing's in a dog with unregulated diabetes. It is recommended that the diabetes be under some kind of control before performing any diagnostic testing for Cushing's. Can you post the results of all monitoring ACTH stimulation tests that were done on Daisy? Also, what test did the vet use to diagnose the Cushing's? Did the vet tell you to give her the Vetoryl with a meal so that it is properly absorbed?

We have a sister forum that deals with canine diabetes and I do suggest that you join there also, here is their link: http://www.k9diabetes.com/forum/ In this way you'll have the best of both worlds!

Please know we will help in any way we can and don't hesitate to ask any questions you have, again welcome to the family!!

Lori

[labblab]

Hello again from me, too. I’m so glad that Lori’s had the chance to greet you, as well, and to give you the link to the k9diabetes group. At this point, I just have a couple thoughts to add — actually, mainly a couple more questions to ask. Can you tell us more about Daisy’s overall health history, and especially about the symptoms that originally led you to suspect Cushing’s a couple of years ago? Lori is absolutely right that it can be really hard to untangle the chicken vs. the egg when it comes to Cushing’s and high glucose levels. As she says, it’s difficult to accurately diagnose Cushing’s in a dog with uncontrolled glucose levels, because the uncontrolled diabetes can cause a “false positive” on the Cushing’s tests. However, diabetic dogs who truly suffer from uncontrolled Cushing’s may never achieve well-regulated glucose levels. In fact, that can be one reason to test for Cushing’s — if a diabetic dog with consistent symptoms cannot be controlled with even large doses of insulin.

As far as Daisy’s specific situation, if you had reason to suspect Cushing’s long before the diabetes manifested, then it does make it seem more likely that the Cushing’s is a genuine underlying problem. And if so, it may simply be the case that she needs a higher dose of Vetoryl to bring her cortisol under effective control. In turn, that can help make her diabetes more manageable, as well. So we’ll all be really anxious to find out the results of this next monitoring ACTH test. And it’ll be great if you can get us exact numbers for the previous Cushing’s tests, as well.

Thanks in advance for any additional information!
Marianne

[anotherk9lover]

Sure thing! I'm glad to answer any additional questions, and really grateful to you guys for being willing to dive deeper into each pets case. That's true love for animals right there! :o
As far as the symptoms of why we suspected cushings for a while, is because daisy has been struggling with constant skin infections that would reoccur every 3-4 mo no matter what we tried. This has been going on for years. At first we thought it was just allergies, but then the vet started suspecting that it's probably the high cortisol creating these skin infections. She also started getting thinner hair on her back, and instead of it being that silky hair that maltese have, it started to resemble the texture of fur more. Her back skin also got some white bumps on it, forget what the vet called them, but he said those deposits are also common with cushings, kind of like white heads. Another symptoms is that she stopped jumping up on any furniture completely. Probably since she was about 4-5 yo she stopped jumping up on the couch or even lower surfaces. But she can jump down off of them. Her belly is also more potted than concave as it should be, even though we don't overfeed her. These are the major symptoms. Polyuria and polydipsia we only noticed when she developed the diabetes, which seems to have developed rather fast. The last labs prior to hospitalization we did on her were in Jan of 2019, which didn't show any signs of diabetes. Until her DKA crisis in July.

That is the main reason why we ended up putting her on Vetoryl, because the vet is also saying that diabetes will be hard to control if the cushing's isn't managed. According to him the glucose wasn't interfering with the cushing's test here, he said the low dex test tends to be pretty sensitive. We did test her a couple weeks after we started her on insulin, not right away. Not sure if that's enough.

Here's the first test result of ACTH after we put her on 5mg Vetoryl once a day, this was taken about 2 weeks after she started on it.

Cortisol pre-ACTH test= 3.6
Cortisol post-ACTH test= 4.3


As far as her initial diagnosis low dex stim test, these were her results:

Cortisol pre- dex shot= 8.9 (ref range 1-6)
Cortisol 4 hr post dex= 4.9
Cortisol 8 hr post dex= 4.7

So according to this, my vet said she does show indication for cushings, the fact that it did get suppressed after 4 hours though I read indicates that it's pituitary in origin, right?

Also important to mention, that when she was hospitalized, they did do an abdominal u/s to look at her pancreas etc. And coincidentally looked at the adrenal glands and said that they did not stand out as being enlarged. She did have a weirdly shaped liver though, no tumors, but looked like it was a fatty liver. When she was hospitalized her liver enzymes were through the roof! like 5k I want to say, something really crazy, but have since come down back to normal the last time we checked in Sept.

That's pretty much all I got now, is there anything else I can add? Thank you so much ladies! We will be taking her to the vet this week to see where her cortisol is at and will report the results.

[anotherk9lover]

Hi Lori, yes we are giving the Vetoryl with food every morning. I have visited the diabetes forum as well, is it active would you say? I noticed that a lot of the posts are from years ago and not very current.

[Squirt's Mom]

Hi Daisy's mom,

Let me add my welcome to you and Daisy!

The problem with the LDDS is that it IS so sensitive. Cortisol will rise naturally in response to any streesor...even just visiting the vet's office. That is cortisol's job; it is one of the fight or flight hormones. So the LDDS, and ACTH, will pick up that elevated cortisol BUT neither test can tell us why that cortisol is elevated - only that it is elevated. The LDDS has a quirk in that while it is the gold standard for diagnosing Cushing's in otherwise healthy dogs it is more likely to return a false positive in a dog who has any other illness present - like diabetes. In dogs with diabetes the ACTH is the preferred diagnostic test for this reason - you can't get an accurate result with the LDDS in a diabetic dog. So this is one red flag on the Cushing's diagnosis for me.

You said the ultrasound showed normal adrenal glands...second red flag. In a dog with Cushing's the adrenals are almost always enlarged because those glands are working very very hard to produce and release all that excess cortisol. They are either both enlarged or one enlarged with the other very small or even atrophied. So normal appearing adrenal glands red flag #2.

While Daisy was hospitalized her liver enzymes were very high but then returned to normal on the next test in Sept...3rd red flag. The ALP in particular is almost always extremely elevated in a cush pup and it does not return to normal without treatment and sometimes not even then. It would be much more likely that 5000 or so level seen in the hospital would have remained or increased by Sept., not returned to normal. So red flag #3 on the Cushing's diagnosis.

If you could get copies of the lab work from Jan of this year and post the abnormal results here that would be huge help. We look for specific values on the super chem, or wellness check as my vet calls them (this test shows things like the liver values, BUN, CHOL, CREAT, etc) and the CBC which shows things like leucocytes, monocytes, eosinophils, etc.

Now, all these red flags that I have may well by my over-active mind because I have had 2 dogs misdiagnosed with Cushing's. One tested positive on all the tests but all were false positive because of a tumor on her spleen that was removed, returning her cortisol level to normal. She did eventually develop conventional Cushing's with elevated cortisol but the second baby never had Cushing's as proven via a necropsy (autopsy for animals). So I am always overly cautious when it comes to diagnosing Cushing's, especially based on one test and doubly when the pup has anything else going on, like diabetes.

I'm glad you found us and look forward to seeing those other test results so my mind might find some peace. ;)

Hugs,
Leslie

[Squirt's Mom]

OH! and on the diabetes site check out the board titled "Diabetes Discussion: Your Dog". There are current posts on that board.

[labblab]

Thanks so much for supplying all this additional information! As Leslie has said, however, some of it raises additional questions. I agree with all three of her “red flags” in terms of diagnostic concerns. However, on the flip side, Daisy’s observable symptoms — especially the white bumps — are indeed consistent with Cushing’s. If the white bumps were accurately diagnosed as being “Calcinosis Cutis,” that is pretty much a guarantee that Cushing’s is present. That skin condition can only be definitively diagnosed through a skin biopsy, however, and generally would not clear up in the absence of treatment to lower cortisol. In fact, it typically spreads and worsens without treatment. Does Daisy still have any of those bumps? If not, did they clear up before or after she started the Vetoryl?

Turning to the LDDS and assuming for the sake of argument that Daisy does have Cushing’s, her pattern of results actually do not distinguish between the pituitary or adrenal form.


As far as her initial diagnosis low dex stim test, these were her results:

Cortisol pre- dex shot= 8.9 (ref range 1-6)
Cortisol 4 hr post dex= 4.9
Cortisol 8 hr post dex= 4.7
The 8-hour result is definitely elevated and therefore consistent with Cushing’s. But neither the 4-hour nor 8-hour result shows enough suppression to point towards pituitary disease. For that to be the case, either one of them would need to be less than 50% of the baseline reading (or the 4-hour would need to be less than the overall diagnostic cut-off number, which is typically 1.4 or 1.5). However, you did end up having the abdominal ultrasound which didn’t show any adrenal masses or growths. That leads us to conclude that a pituitary tumor must be the culprit. As Leslie has noted, though, typically both adrenal glands are enlarged in the presence of pituitary Cushing’s. It is not always the case, but Daisy’s lack of adrenal enlargement is one of those oddities that makes us scratch our heads a bit.


Cortisol pre-ACTH test= 3.6
Cortisol post-ACTH test= 4.3
As far as this first monitoring ACTH, that is a great result — right within the desired therapeutic range. However, to be honest with you, it would have been better had at least one additional reading been taken between the two-week mark of Vetoryl treatment and now. Cortisol levels can continue to drift downward during the first month of treatment, even when the dose remains unchanged. Therefore, for safety’s sake, most clinicians retest again at the 30-day mark. If cortisol is dropping too low, the dose can be remedied. Conversely, if the cortisol is edging up again at that point, the dose can be increased. So waiting for 90 days before retesting is really a longer gap than most clinicians would recommend. That’ll make us doubly anxious to see how the ACTH results turn out now.

Please bear in mind that we are not vets, but we do feel obligated to identify questions that you might want to pursue further with your own vet, especially if Daisy’s treatment course remains rocky. Given her symptoms, I don’t necessarily doubt that she truly has Cushing’s. But as we’ve noted, there are features of her testing profile that are not necessarily consistent. I’m especially interested in learning more about those white bumps.

And as far as the activity level over on k9diabetes, I’m afraid that neither of our sites garner as many replies as they did in the past. Unfortunately for us, it seems that other social platforms such as Facebook may now seem more attractive to some folks than do message boards such as this. But those of us who continue to post here surely hope that we’re able to provide both continuity and depth to our replies. So if you stick with us, we’ll continue to do our very best to be of help!

Marianne

[anotherk9lover]

Thank you all for responding. We took her in for another ACTH test today, so will have to wait until Monday to know the results.

I spoke to my vet again, and he doesn't seem to have any doubt that she has cushings, just from all the symptoms throughout the years, he's taken care of her since she was a pup. Also, it's been almost a year since her last major skin breakout, her skin seems to have cleared up since we put her on the medications, which tells me that it's doing something. Before we would always have at least some form of a skin infection every 3-4 mo. She seems to have also perked up a bit on her energy level. She's always been a mellow dog, but the last year or so she's just been sleeping mostly, didn't seem like she was enjoying much of anything. Now she's more lively than she's been in a while.

Also when the vet diagnosed her, he used the urine creatine ratio test as well which showed up positive. And he says that if she wasn't with Cushing's, then the Vetoryl would have suppressed her too much on the recheck lab, which it didn't. So I don't know of course, maybe something else is going on here, but everything seems to be pointing to it being Cushings. Also it doesn't seem to be a rare condition at all, especially in spayed dogs apparently.
Have you guys come across any correlation between spaying dogs before their first heat and Cushing's disease? I was watching Dr. Becker's video on that, and she seems to be convinced that the dogs she insisted on spaying before their first heat, all started coming back to her older in life with Cushing's disease, so she is convinced that there is a link, and no longer recommends spaying until a dog is grown up.
That makes me feel terrible, as I did spay Daisy before 6 mo because that's what seemed to be recommended by everyone at the time. :(

[anotherk9lover]

Hi Squirt's mom, I did check that specific forum, and it seems like there's only one post there from 2019, if i'm checking correctly. That's really unfortunate as I have a lot of questions about the diabetes side of it specifically. :(

[anotherk9lover]

Unfortunately I don't have the labs on hand from Jan of last year because we were just happy with what the vet said it was. I started asking for copies after the July episode. I can post the labs from July when she was hospitalized, the follow up ones unfortunately I can't post because they're pdf version, but i can write out the ones of interest. One weird thing she presented with during her DKA episodes was elevated Bilirubin, she was jaundiced. Does anyone have an idea of what that could be from? No one could tell us, the doctors at the hospital were confused why that's so elevated as well. It went as high as 8, and then decreased back to undetected levels.
Here's her results from July:

Patient: DAISY
Species: CANINE
Breed: MALTESE_CANINE
Age: 8Y
Gender: FEMALE
Requisition #: 1233369
Accession #: 8200518792
Order recv'd: 7/19/2019
Ordered by: SINGH


TOTAL HEALTH WITH SPEC cPL : CHEM 27 w/ TRIG SDMA
Test Result Reference Range
GLUCOSE (1) 452 63 - 114 mg/dL HIGH
SDMA (2) 10 0 - 14 ug/dL
CREATININE 1.0 0.5 - 1.5 mg/dL
BUN 21 9 - 31 mg/dL
BUN/CREATININE RATIO 21.0
PHOSPHORUS 4.5 2.5 - 6.1 mg/dL
CALCIUM 8.9 8.4 - 11.8 mg/dL
SODIUM 141 142 - 152 mmol/L LOW
POTASSIUM 4.6 4.0 - 5.4 mmol/L
CHLORIDE 96 108 - 119 mmol/L LOW
NA/K RATIO 31 28 - 37
TCO2 (BICARBONATE) 22 13 - 27 mmol/L
ANION GAP 28 11 - 26 mmol/L HIGH
TOTAL PROTEIN 6.2 5.5 - 7.5 g/dL
ALBUMIN 2.9 2.7 - 3.9 g/dL
GLOBULIN 3.3 2.4 - 4.0 g/dL
ALB/GLOB RATIO 0.9 0.7 - 1.5
ALT 253 18 - 121 U/L HIGH
AST 169 16 - 55 U/L HIGH
ALP (3) 5559 5 - 160 U/L HIGH
GGT (4) 128 0 - 13 U/L HIGH
TOTAL BILIRUBIN 0.7 0.0 - 0.3 mg/dL HIGH
BILIRUBIN UNCONJUGATED 0.4 0.0 - 0.2 mg/dL HIGH
BILIRUBIN CONJUGATED 0.3 0.0 - 0.1 mg/dL HIGH
CHOLESTEROL (5) 666 131 - 345 mg/dL HIGH
TRIGLYCERIDE 167 20 - 150 mg/dL HIGH
AMYLASE (6) 2774 337 - 1469 U/L HIGH
LIPASE 1155 138 - 755 U/L HIGH
CREATINE KINASE 332 10 - 200 U/L HIGH
HEMOLYSIS INDEX (7) 1+
LIPEMIA INDEX (8) N

Comments:

(1) RESULT VERIFIED BY REPEAT ANALYSIS
(2) BOTH SDMA AND CREATININE ARE WITHIN THE REFERENCE INTERVAL which indicates kidney function is likely good. Evaluate a complete urinalysis and confirm there is no other evidence of kidney disease.
(3) RESULT VERIFIED BY REPEAT ANALYSIS
(4) RESULT VERIFIED BY REPEAT ANALYSIS
(5) RESULT VERIFIED BY REPEAT ANALYSIS
(6) RESULT VERIFIED BY REPEAT ANALYSIS
(7) Index of N, 1+, 2+ exhibits no significant effect on chemistry values.
(8) Index of N, 1+, 2+ exhibits no significant effect on chemistry values.

TOTAL HEALTH WITH SPEC cPL : IDEXX CBC-SELECT
Test Result Reference Range
WBC 29.8 4.9 - 17.6 K/uL HIGH
RBC 5.06 5.39 - 8.70 M/uL LOW
HGB 11.6 13.4 - 20.7 g/dL LOW
HCT 36.0 38.3 - 56.5 % LOW
MCV 71 59 - 76 fL
MCH 22.9 21.9 - 26.1 pg
MCHC 32.2 32.6 - 39.2 g/dL LOW
% RETICULOCYTE 0.7 %
RETICULOCYTE 35 10 - 110 K/uL
RETICULOCYTE COMMENT
The appropriateness of the regenerative response should be evaluated considering the degree of anemia and reticulocytosis (see guidelines below).

Degree of bone marrow response (reticulocytes K/uL):
Mild 110-150
Moderate 150-300
Marked >300

View the VetConnect Plus Differentials for additional information.

RETIC HGB 26.2 22.3 - 29.6 pg
% NEUTROPHIL 87.8 %
% LYMPHOCYTE 1.0 %
% MONOCYTE 8.5 %
% EOSINOPHIL 2.5 %
% BASOPHIL 0.2 %
PLATELET 401 143 - 448 K/uL
REMARKS
Slide reviewed microscopically.
Large platelets present.

NEUTROPHIL 26164 2940 - 12670 /uL HIGH
LYMPHOCYTE 298 1060 - 4950 /uL LOW
MONOCYTE 2533 130 - 1150 /uL HIGH
EOSINOPHIL 745 70 - 1490 /uL
BASOPHIL 60 0 - 100 /uL


TOTAL HEALTH WITH SPEC cPL : SPEC cPL
Test Result Reference Range
SPEC cPL (1) 2000 0 - 200 ug/L HIGH

Comments:

(1) Serum Spec cPL concentration is significantly increased which occurs with pancreatic inflammation. If clinical signs of pancreatitis are not present, consider additional diagnostics, instruct owner to monitor closely and recheck Spec cPL in 2 to 3 weeks. If clinical signs of pancreatitis are present, treat appropriately, investigate for risk factors and concurrent diseases including gastroenteritis or foreign body. Monitor Spec cPL to help assess response to treatment.

Result is greater than 2000 ug/L.

[anotherk9lover]

Then the August ALP=755, and in September it came down to completely normal 156. It's pretty mind blowing to me really! When we took her out of the hospital she had some pancreatitis going on, she was pretty sick with these terrible labs. We did a recheck right after the hospitalization with my regular vet just to see where the labs were trending, and then an unfamiliar vet called me back to discuss the labs the next day because my vet wasn't in. She just looked at the numbers and told me that Daisy was in all organ failure and that we basically need to make a decision if we will put her down. All weekend I spent crying and saying goodbye. Then decided to call the hospital doctors again where she was hospitalized, and they said it wasn't necessarily the case, that sometimes labs come up before they go down, like a lagging effect. And that what matters more is how Daisy looks, which she was looking better. To think that she went from those 5500 ALP numbers to 156 and felt better than she has in a long time, makes me so angry at that vet who gave us no hope! :mad:

[Squirt's Mom]

I would have been out of my mind with those lab results from July! :eek::eek::eek::eek: Bless your heart having to see those results and then being told by the GP vet what you were. But Daisy's case points out very clearly why some pups need to be seen by specialists - because no matter how good they are otherwise GP vets simply do not have the education nor experience of the specialists and therefore can easily miss something completely or misinterpret what they do see.

I remember when my Squirt had her spleen removed and I saw her labs while visiting her in the hospital one day - I burst into tears just knowing my Sweet Bebe was not going to make it. One of her nurses told me not to worry about them right then because her little body was under extreme duress and doing what it was supposed to do in the situation. Nice words to hear but so very hard to believe at the time. After that I asked to see her labs every time and they were returning to normal at a rapid pace which was very comforting to say the least. To be honest, I became such a pest at the hospital with my visits and phone calls they put ME on restrictions telling me they would call me daily with reports and let me know when I could come visit Squirt. :D:D:o:D:D

It is good that Daisy has recovered from that horrible time and is acting more like herself lately. Let us know what the ACTH showed when you get a chance! Praying for great numbers!
Hugs,
Leslie

[anotherk9lover]

Just got the results back over email, haven't spoken to the doctor yet though. The Pre ACTH cortisol was 0.9 ug/dl, and the post was 4.6. Is she being over suppressed? That pre cortisol seems to be lower than the desired number. :confused: And this is only on 5mg once a day! Thank God he started her on the lowest dose possible!

[anotherk9lover]

As to your previous email, I would love to take her to all the best specialists in town, but they cost a crazy amount of money. I asked at the hospital how much an internist who specializes in diabetes would be, and they said he's about $150 a visit. The pet bills with all of Daisy's health issues are getting to be too much. We spent well over 5k in the last 6mo. So at this point we have chosen to do the least invasive maintenance care for her to the best of our ability. She's not a young pup anymore, so if things just continue to go down south we will choose comfort measures, we decided against another hospitalization, as heartbreaking as it may be.

I totally understand your feeling though, of wanting to check on your furry friend, I was also calling a lot, and asking to see her. Some vet techs (well one in particular) was so rude about it, she wouldn't let me back there to see Daisy during her DKA hospitalization bc it made it more inconvenient for them when daisy would start to bark. And she would keep me away from talking to the MD, which as an RN myself, I find that behavior absolutely unacceptable! I finally was let inside, and the vet had plenty of time to talk to me about everything! There was no reason to lie that the doctor was "busy". It was a very distressing time, it's so different when it's your family or pet in the hospital, than it is for those who work there. That's actually a lesson that I took away to my own bedside nursing.

[anotherk9lover]

So I just spoke to the vet regarding her ACTH results, and he suggests to take her off of vetoryl for now to avoid over suppression. And if anything restart her on a 2.5mg, but that's not even sold on the market, which means it would have to be compounded which i'm sure will cost me a pretty penny. He seems to be out of ideas on what to do at this point. He's suggesting a referral to an medicine specialist. Sigh... I'm not sure what to do next. Do you guys have any suggestions?

[labblab]

I surely do understand the financial burden associated with all this, and how stressful it is. However, I truly think that if you can swing it, a consultation with a specialist is the best thing you can do for Daisy right now. She may or may not be overly suppressed. It’s true that her pre-ACTH level is low, but her post-ACTH level really is ideal. So I’m not sure how much concern there should be over the pre-level. And as complicated as Daisy’s health history has been, spending a bit more on an expert opinion upfront could end up saving you a lot of money down the line.

If it turns out that a lower dose of Vetoryl is recommended, compounded trilostane is actually typically less expensive than is the brand name medication. Even if her overall dose remains unchanged, a specialist might recommend that you get a compounded version, anyway, so that you can split the daily dose in half and give it twice a day. Twice daily dosing is often recommended by specialists as the best route to go with diabetic dogs so that their cortisol level is kept at a more consistent level throughout an entire 24-hour period.

You guys have already been through an awful lot, and my heart goes out to you. But as I say, I really hope you can find a way to manage a visit with a specialist. That might make the path forward a whole lot easier. Specialists have their own networks of colleagues with which to consult about difficult cases, and they also often communicate directly with the drug company that makes Vetoryl when dogs have unusual responses to the medication.

Whatever you decide, please do keep us updated. But I’ve got my fingers crossed that maybe a specialist could be a big help to you.

Marianne

[anotherk9lover]

You may be right, I might take her in for a consultation, but they will likely want to repeat all the blood work which will just be too much!
Good to hear though that compounded vetoryl may be better priced. I found vetoryl 5mg for a decent price though, about $27-30 a pack, doubt the vet will be able to match that, it's always a better price online. Splitting the medication would make sense though.

As far as the levels, is the post really idea? Because in the reference range it said the post should be between 6-9.

Thanks for responding Marianne! :)

[labblab]

As far as the levels, is the post really idea? Because in the reference range it said the post should be between 6-9.

The post-ACTH reference range of 6-9 is the “normal” range for a dog who does not have Cushing’s when the test is being used initially for diagnostic purposes. When the ACTH is instead being used to monitor trilostane treatment, the desired range is very different. Take a look at Dechra’s U.S. product insert for Vetoryl — you’ll see a box near the top of the insert that shows how to interpret post-ACTH results for dogs taking trilostane, and a reading between 1.45 and 5.4 is really right where you want to be.

https://www.dechra-us.com/Admin/Public/Download.aspx?file=Files%2fFiles%2fProductDownload s%2fus%2fvetoryl-5mg-pack-insert.pdf

As long as a dog is clinically doing well and the post-ACTH falls within that range, I’m not sure whether or not there is cause to be unduly concerned about that lower pre-ACTH result. If consulting with a specialist just doesn’t seem like an option for you right now, I’d encourage your vet to contact Dechra so as to discuss Daisy’s test results with one of their staff veterinary professionals. They are happy to talk with vets, and can offer experienced guidance re: treatment guidelines in situations such as this. Here’s Dechra’s contact info that you can pass on to your vet. He can either call or email them with any questions. They’ll open up a case report on Daisy, and offer their advice as to the best path forward.

https://www.dechra-us.com/contact/technical-support

Good luck!
Marianne

[anotherk9lover]

I guess he was a bit more hesitant about that pre, since he said that a level of 0.5 or less can cause addisonian crisis, and she wasn't far from that, who's to say she won't drop lower, since she seems to be trending lower since her last lab check. It makes me nervous to continue her on the same dose as well.
I'm not sure if he will be too happy about me suggesting that he contact the company? it's like i'm saying he doesn't know how to treat this right and should reach out to additional guidance. I don't know how to approach it really. Do they talk to pet owners, or only vets?

[Squirt's Mom]

It is very difficult for some of us to talk to the vets in such a manner....I was one of those who found it very uncomfortable. But I had to remind myself that my dog's life depended on me, on my ability to stand up and speak for her because she couldn't speak for herself. I come from a medical family; my dad served on a state board that addressed negligent behavior of other doctors and know without question that those in the medical professions, vets included, are no more human than I am. They make mistakes daily. The ones who seem to make the most mistakes are those who refuse to listen, who think they currently know all they need to know, who have a bit of a god complex. If Daisy's vet is unwilling to listen to you and work with you, then it is time to find a new vet who recognizes the fact that they are human and nothing more, who realize they work for you not the other way around. So try to approach the suggestion that he contact Dechra, or read the literature that comes with the drug, as something he is doing for you, for Daisy, not as something he needs to learn...tho in the process of working for you and Daisy his eyes just might be opened. And if he comes back at you in a negative manner you will know it is time to get her records and walk out the door for the last time. There are too many vets out there to remain with one who refuses to keep up with changes in their profession. ;) Imagine me standing by your side, holding your hand and glaring at Daisy's vet, daring him to refuse your request. :o:D

[labblab]

I guess he was a bit more hesitant about that pre, since he said that a level of 0.5 or less can cause addisonian crisis, and she wasn't far from that, who's to say she won't drop lower, since she seems to be trending lower since her last lab check.
Actually, Daisy’s post-ACTH level is a tiny bit higher now than it was during the first check back three months ago. And as you can see from that chart, when a full ACTH test is performed, it’s the post-ACTH level that seems to be of greater importance in terms of dosing decisions. On it’s own, I understand why the .9 level would be a concern. But I really think it would be of value to find out whether or not the technical specialists at Dechra would be as worried about that .9 pre-ACTH level given the stability of her post-ACTH results over these past three months. Perhaps so, but perhaps not.

Unfortunately, the Dechra technical team prefers to consult directly with vets. However, since you’ve said that your regular vet is encouraging you to consider a specialist since he’s unsure as to the path forward, this would seem like a golden opportunity for him to personally make contact with a knowledgeable team. Often the simple truth can be the best strategy. You can tell him you’ve been worried about Daisy’s cortisol level, you’ve done some reading on your own, and you’ve discovered that Dechra is happy to consult with vets on difficult cases. Rather than you needing to take Daisy elsewhere right now, it would be really great if he would talk to Dechra on your behalf. If he refuses after already acknowledging to you that he doesn’t know what else can be done for Daisy, then sadly I must agree with Leslie — it’s really time to find a different vet who is willing to work with you and Daisy to find out some answers ASAP.

Marianne

[anotherk9lover]

I totally understand what you're saying! We have walked away from bad vets before, I wouldn't hesitate to walk out if I felt like they were there for the wrong reasons. I have to say I do like my current vet though. He truly loves animals you can tell, he's at that clinic 6 days a week 10 hour shifts. He also knows Daisy basically her entire life, so starting from scratch wouldn't be ideal. But with that being said, I feel like he may not be as knowledgable as like the doctors were at the hospital where Daisy was hospitalized. They were all UCD trained and they just seemed to know more. But I guess maybe that's true in all acute care hospitals over just regular vets. I will mention Dechra to him, see what he has to say. However I've already taken Daisy off the Vetoryl. Is it ok to just take off and restart whenever, or labs have to be done all over again?

[labblab]

I wouldn’t think you’d need to repeat the labs before restarting. If/when you decide to do so, the question will just be as to which dosage level to resume. Once you get some expert advice in that regard, I think you’ll be good to “go.”

If the recommendation is to use a dose smaller than 5 mg. (due to an overall daily decrease or a switch to twice daily dosing), take a look at the tips on this thread in order to help locate a reliable veterinary compounding pharmacy:

https://www.k9cushings.com/forum/showthread.php?9066-Cost-Savings-for-Owners-of-Cushingoid-Dogs

There are other useful tips there, as well ;-).

Marianne

[anotherk9lover]

Hi again! Happy New Year! I have decided to take my Daisy in to see an internist specialist, our apt is on the 6th on Monday. I just wanted to ask for advice of what exactly I should ask her as far as treatment plan?

Also, unrelated, but has anyone here noticed a foul smell from your pets mouth? I wonder what it's related to exactly. Yesterday we took daisy on a road trip and she was barking a lot in the car, and her bark would fill the whole car with a bad smell that comes from her inside. It was like a fishy/sewage type of smell. We haven't really noticed a smell like that before, but then again we haven't been on a long road trip in a while with her. I googled what it could be and looks like diabetes or liver issues could cause that sort of smell. I don't think it's from her teeth as it was more pungent when she would bark. Any thoughts?

[labblab]

I’m so relieved to hear that you’ve scheduled the appointment with the specialist! In the long run, I truly believe it will turn out to be money well spent. As far as the foul odor, I’m afraid I don’t know anything about that. However, can you update us re: the status of Daisy’s diabetes treatment? You originally mentioned that it’s been very difficult to control, and I’m wondering where things stand in that regard.

Marianne

[anotherk9lover]

So far we just continue with the 6 units NPH N every 12h. I did a curve recently and it was 300's down to 100's and back up to 300's, which isn't her worst curve. So from here on not sure what else to do.

[labblab]

I’m surely hoping your vet visit on Monday may answer some questions! Good luck, and when you have the chance to update us, we’ll really be anxious to hear how things go.

Marianne

[Squirt's Mom]

My little Tilly has an odor like that from her mouth, too, but nothing have been found as a cause. She had most of her teeth removed just before she came to me and I wonder if hers isn't caused by food sticking to her gums. But the vet said her mouth looked good last time he checked so I am interested in what you find out about Daisy's stinky mouth. :D

[anotherk9lover]

Do you guys have any advice on what questions to address exactly regarding Cushing's and Diabetes? Don't want to miss anything.

[labblab]

I think my best suggestion is to make sure to take copies of all available labwork along with you as you visit the specialist. Daisy has had a lot of abnormalities over time, and it’ll be good for the new vet to be able to evaluate the changes — both positive and negative. Since we’ve especially been concerned about those most recent monitoring ACTH results, for sure you’ll want to point those out.

Overall, we’re seeking confidence in the Cushing’s diagnosis, as well as finding optimal medication doses for both the diabetes and Cushing’s. As far as the Cushing’s, be sure to list out all the symptoms you’ve been seeing over the past couple of years, including the white spots on her skin.

I totally leave the insulin dosing up to the specialist, since I know nothing about that. As far as the Vetoryl, in addition to determining an appropriate total daily dose, I’d ask the specialist whether it would be better to dose Daisy twice a day since she’s diabetic. As I believe we’ve mentioned earlier, many specialists believe that’s it’s better for diabetic dogs to split the daily total into two doses given twelve hours apart.

That’s all I can think of for now. Good luck, and please let us know how things go!

Marianne

[anotherk9lover]

So we had the appointment with the specialist today. It was good and bad. As far as cushing's, since they are a sister hospital of the hospital where daisy was hospitalized and where they did her ultrasound, they offered to do an adrenal scan for free, because the previous hospital for some reason didn't focus on the adrenal glands during the u/s. That was nice of them to do that for me, and like it was mentioned to me before, the adrenal glands are normal sized, which she says makes Cushing's unlikely, but doesn't rule it out.. sigh.. it seems like nothing is ever conclusive! But in a way that's good news I guess, doesn't explain some of the symptoms Daisy has been having though. And why was the low dex test positive for cushing's? Anyway as of now, she said to not restart the Vetoryl.

As far as Diabetes, she really didn't tell me anything new. Maybe I didn't get the best specialist, but I feel like I didn't take anything away from this apt that my regular vet didn't tell me.

[Harley PoMMom]

So we had the appointment with the specialist today. It was good and bad. As far as cushing's, since they are a sister hospital of the hospital where daisy was hospitalized and where they did her ultrasound, they offered to do an adrenal scan for free, because the previous hospital for some reason didn't focus on the adrenal glands during the u/s. That was nice of them to do that for me, and like it was mentioned to me before, the adrenal glands are normal sized, which she says makes Cushing's unlikely, but doesn't rule it out.. sigh.. it seems like nothing is ever conclusive!

I'm glad that they performed another ultrasound for free! And to read that Daisy's adrenal glands are normal in size.


But in a way that's good news I guess, doesn't explain some of the symptoms Daisy has been having though. And why was the low dex test positive for cushing's? Anyway as of now, she said to not restart the Vetoryl.

Exactly what symptoms is Daisy displaying right now? And regarding the positive result from the LDDS test, any non-adrenal illness such as uncontrolled diabetes, can yield a false positive response from the LDDS test.


As far as Diabetes, she really didn't tell me anything new. Maybe I didn't get the best specialist, but I feel like I didn't take anything away from this apt that my regular vet didn't tell me.

I'm sorry the visit with the specialist wasn't as beneficial as it should have been, but the bright side is that it looks like Daisy doesn't have Cushing's, that's definitely one good thing!

Hugs, Lori

[anotherk9lover]

So how certain is it that there is no Cushing's if the adrenals are a normal size? Because from what the doc said it's about 80-90%, not 100%. The symptoms were constant infections that she had of her skin, the clogged comedones on her back, some fur thinning on her back. She stopped jumping up on sofas and anything really for a few years now, things like that. My vet was fairly certain in his suspicion of cushing's. I guess we made a mistake in testing her so soon after hospitalization. (~3 weeks). Also Daisy really stresses out when she's at the vet, so maybe that could've also contributed to high cortisol? no idea, no one seems to have certain answers. Now they're suggesting that we retest her again for the entire day test, as if the time and money is just growing on trees.. sigh.. Sorry, it's just all been pretty frustrating. I don't like how little information this specialist provided to me regarding Diabetes. It's like she expected that I ask her for all the info, instead of providing it to me. But any questions that I did ask, she just gave me vague answers, and then told me that she doesn't have time for certain things like discussing skin infections etc. Even diet for diabetes she didn't give me any in-depth insight on that, she really didn't provide much of anything. It wasn't a great experience, not sure why my vet referred us to her. If it wasn't for the free adrenal scan, I would be really annoyed with this appointment being a rip off.

[labblab]

After encouraging you to see the specialist, I’m furious that she was so useless. I was mad enough on your behalf, but when I got to this part, I really thought I’d explode!


But any questions that I did ask, she just gave me vague answers, and then told me that she doesn't have time for certain things like discussing skin infections, etc.

She doesn’t *have time* to discuss skin infections, when they can be central issues for dogs with either diabetes or Cushings? Are you kidding me????

I’m so sorry that this was your experience, but now we’re stuck with figuring out where you go from here. I do believe she’s correct that the normal size of the adrenal glands does not rule out Cushing’s 100%. It’s uncommon, but not a total rule-out. As far as repeating Daisy’s LDDS test, yes, we could hope that it might be more accurate now than it was just three weeks after her acute hospitalization. But any time that a dog is suffering from additional illness, it makes the possibility of a “false positive” more likely. Here’s a quote from a laboratory that provides diagnostic blood testing.


Specificity of LDDS is poor (51%) in dogs with non adrenal disease and concurrent illness (particularly diabetes mellitus and renal failure.) Positive test results should always be interpreted in light of history and clinical signs.

b) Determination of whether animals with diabetes mellitus have concurrent hyperadrenocorticism may be difficult. In such cases both the ACTH stimulation test as well as the low dose dexamethasone suppression test have been reported to produce false positive results. In most instances a combination of both tests in addition to an ultrasonographic examination of the adrenal glands are necessary for complete diagnostic evaluation. Please contact the laboratory to discuss the approach to such cases.
Our experience here is that a diagnostic ACTH may be the preferred choice in diabetic dogs because it may be a bit less likely to give false results. But as the quote above demonstrates, both of the diagnostic tests can be skewed. And obviously, Daisy’s normally adrenal glands throw another question mark into the mix.

I do have one more suggestion for you to consider, although I realize I totally struck out re: the particular specialist you saw on Monday. A renowned endocrinology expert, Dr. David Bruyette, has established a consultative service that vets from anywhere in the world can use. Dr. Bruyette was previously the director of a specialty hospital in Los Angeles, was an advisor to Dechra re: the development of Vetoryl, and helped pioneer groundbreaking pituitary surgery for the treatment of enlarged Cushing’s macrotumors. Given the nature of his specialty practice, I’m confident that he and his staff are well-versed in diabetic treatment, as well. Over the years, a number of our members here have consulted with him about difficult cases. Per his current website, for a fee of $200, your vet can submit all of Daisy’s records and receive a month’s worth of consultative advice. Additional months of service would cost $150. Here’s a link to his information page. You can show this to your vet, and see whether he thinks this is a service that could be useful to you all.

https://www.veterinarydiagnosticinvestigation.com/services-subscribe

In the meantime, it’ll be interesting to see what happens during a time period that Daisy isn’t taking the Vetoryl. Do any of her symptoms worsen, or does she remain pretty much status quo?

Marianne

[anotherk9lover]

Regarding the bad breath, she thinks it has to do with her dental condition, she suggests a deep cleaning under anesthesia. But I really don't want to do that! Not only is it expensive, but I'm too scared to put daisy under for that. A friend of mine lost a dog to a heart attack because of anesthesia during a teeth cleaning. It's not something I want to risk unless there's just no other way.

[anotherk9lover]

haha! you're cute Labblab :) thanks for being willing to explode on my behalf! :D I know you meant well, and it's great that you had a good experience with a specialist, unfortunately mine wasn't quite that. She seemed to want to refer Daisy out to all other specialists like derm, ortho, etc. It's honestly ridiculous. I just want to find one very knowledgeable vet who can help us manage everything without needing to see 10 different specialists. Heck! Most humans wouldn't do that for themselves. We tend to do a lot more for our pets than for humans.

It seems like neither test is very conclusive LDDS or ACTH, with diabetes. Therefore I don't really see a reason to repeat this test again, just to be told that it's not 100% certain. We haven't seen any issues since daisy has been off of Vetoryl, which has been a month. But then again, she never had super clear signs of Cushings, I'm not ever sure what exactly they are? The drinking and urinating that has started with her diabetes, and managed fairly well at this point.

Daisy's skin issues have been going on for several years, as well as her not jumping up on furniture, so the specialist was saying if that has been going on for years, then at this point we would expect to see some changes in her adrenal glands, as opposed to someone who just started showing symptoms. And since there's no issue with the glands then Cushing's is less likely. Who knew that this disease would be such a mystery to diagnose! I'm just very thankful that the Vetoryl didn't suppress her too much if she infact DOESN'T have cushings.

[anotherk9lover]

What is everyone doing for skin though? Those who get skin infections/yeast infections from Cushing's, are there any helpful products that you have found that I can maybe utilize. I hate using antibiotics on daisy constantly. Her urethra area has folds around it which traps moisture, and tends to be prone to yeast infections, redness and itching. Any recommendations for that?

[labblab]

So glad to hear that nothing has really worsened for Daisy since stopping the Vetoryl, and I agree this makes the Cushing’s diagnosis seem more questionable. As far as skin infections, my nonCushing’s Lab girl went through a year when she suffered from repeated staff infections all over her back. We never could isolate a cause, and still don’t know to this day what triggered them. Oral antibiotics did clear them up, but they always returned after we finished a course of antibiotics, and I also didn’t feel good about keeping her on them long-term. So I did some reading and found that, for many skin infections, regular bathing with topical antiseptic shampoos can work even better than oral meds.

I saw a recommendation online by a derm specialist for of a line of products made by Douxo, and especially their chlorhexadine shampoo and spray for treatment of bacterial and/or fungal infections. To begin with when the infection was acute, we bathed every 2-3 days. As it resolved, we spaced out the baths but also got their chlorhexadine spray to directly apply to spots in between. It took at least a couple of months to feel as though we were really getting the upper hand. But over time, the lesions were fewer and finally cleared up altogether. That was about five years ago now, and I still use that shampoo when I bathe my girl, just to nip any recurrence in the bud.

You may already have tried various shampoos without success, but this is a specific product that did work well for us. So fingers crossed for you if you decide to give it a try, too.

Marianne

[Squirt's Mom]

I would add that in the absence of some of the hallmark signs of Cushing's like voracious appetite, panting for no reason, and no pot belly - I wouldn't put her thru the stress of another round of testing myself. IF she does have Cushing's it will come to light in time - one thing will be the total inability to get control of the diabetes. But this takes time to determine. Treating the diabetes for a few months won't tell the tale. However I am not an expert on this disease by any means so I hope you are talking to the folk at one of the diabetes sites, either the forum or the FB group. They will be able to direct you better. Even if the forum isn't very active these days that is where I would start. Just like our site, it is always staffed by those who know that disease and are willing to chat with you. ;)

[anotherk9lover]

How soon after getting off medication do symptoms typically return?

Thanks for the shampoo advice, we have been using the dechra anti fungal shampoo on her regularly. It works to help maintain, but when the infection starts getting bad then the shampoo seems pretty powerless against it, she needs a course of antibiotics every time. And sometimes the vet would even give her like a steroid shot, which we opt out of now.

Daisy often gets yeast/redness in her groin area, she has folds around her vulva/urethra that get pretty deep, and moisture starts brewing infections there. Any tips for a product for that area? I asked the specialist, she said to use an ear cleaning solution to wipe that area, but the one she recommended seems to have a lot of negative reviews of people saying that their dog broke out from it and that it like burned them.

[anotherk9lover]

Yea i've been hanging out on the diabetic forum as well. :) What's the FB page called, is it also by same people or just general pages?

Yes I think we're going to hold off on testing for Cushing's again. There has to be some boundaries of how much poking and prodding we're doing, at this point is seems like we're running in circles without any answers. I was mostly worried that her Diabetes was brought on by the Cushing's, hence why we wanted to treat the root cause, but there hasn't been a clear answer.

One thing I'm still confused on though, is why wasn't her cortisol more suppressed if she DOESN'T have Cushing's? It was normal level upon recheck about 2-3 weeks after starting Vetoryl. Is it because the dose is so small that it doesn't have a huge effect?

[Squirt's Mom]

The FB diabetic group is found here - https://www.facebook.com/groups/CanineDiabetesSupportandInformation/

Bear in mind - as is the case with all FB groups you will get a LOT of opinion with little scientific support from the general membership. So find out who the Admins are and listen to them. As time goes on you will learn which members really know their stuff and which simply like to talk. ;)

As for the cortisol levels, what has happened is exactly what is most desired - the cortisol returns to normal range on a small dose. Daisy didn't have strong cush signs from what you have said. It was only as the diabetes came on that she started drinking and peeing excessively. What you saw prior to that diagnosis could have been very early signs of Cushing's, which was caught early, or could have been related to the BG starting its journey out the roof. With both diseases in play it is very hard to determine which causes what, even for the professionals. So just be grateful that Daisy's cortisol is where we want it to be. Remember that old adage about looking a gift horse in the mouth. :D

[labblab]

Yes I think we're going to hold off on testing for Cushing's again. There has to be some boundaries of how much poking and prodding we're doing, at this point is seems like we're running in circles without any answers. I was mostly worried that her Diabetes was brought on by the Cushing's, hence why we wanted to treat the root cause, but there hasn't been a clear answer.

One thing I'm still confused on though, is why wasn't her cortisol more suppressed if she DOESN'T have Cushing's? It was normal level upon recheck about 2-3 weeks after starting Vetoryl. Is it because the dose is so small that it doesn't have a huge effect?
I do commend you for trying to get at the root cause of Daisy’s elevated glucose, if there is indeed something going on other than the diabetes itself. I’m just sorry that the Cushing’s diagnostic journey has been so perplexing! As far as the absence of oversuppression by the Vetoryl, that medication is sometimes prescribed for dogs who don’t have traditional Cushing’s but who suffer from hair loss that may be related to a different hormonal imbalance (“Alopecia X”). In those instances, the dose is not large and oversuppression doesn’t necessarily occur for those dogs, either. So I don’t think the fact that Daisy’s cortisol didn’t drop too low on the Vetoryl really makes Cushing’s more likely.

For the time being, it does seem as though you’re stuck in a game of wait-and-see. But I agree with Leslie that the longer that Daisy goes without exhibiting a worsening of more typical Cushing’s symptoms, then the less likely it seems to me that she suffers from the disease.

Marianne

[labblab]

I forgot to mention that you might want to try these skin wipes. I’ve never used them myself, but as I say, the shampoo did seem to to be very helpful for our girl. Douxo also makes a related spray.

https://www.douxo.com/us/douxo-solutions/douxo-chlorhexidine/Pads

Marianne

[anotherk9lover]

Thank you, that is reassuring, also would explain why daisy's "pre" has dropped a bit lower upon recheck recently. Funny enough we were pretty sure that she fit some of the classic cushing's symptoms. Don't know if it's just one of those self fulfilling prophecies, or there's something there that wasn't conclusive. But you are right, it has been several years without any obviously declining symptoms, other than her hair getting less thick, but then again that can also be general aging.

Thank you so much Marianne for the rec of the wipes, I will check out that brand!