Adrenal Dependent Cushings with secondary Diabetes: Squeaker needs a specialist!!!!

[bichons9]

Squeaker 15 yo chihuahua was found to have BORDERLINE Cushings assumed to be apituitary related but no treatment recommended. He had Patella and ACL surgery with BG 165..Everything went fine. Over months. weight loss unable to be ignored..4/26 diagnosed with full blown ADRENAL Dependent Cushings with mass on gland that extended to caudal ven cava. Adrenalectomy considered and plan discarded by DVM after reading CT Scan= too risky Squeaker ...started initial dose of Vetoryl at 3mg..then 6mg. now 10 mg at 6am and 3 mg at 6pm..Cortisol went from ??.9 in January and 44 on 4/26??. Cortisol vs Blood Glucose challenging to deal with .His spreadsheet has hour by hour real time care listed if interested..Thank for reading Oh, I just looked at the protocol that states. "do not give am Vetoryl before test???? DVM told me to give the Vetoryl 10 mg exactly 4 hours before the test???

https://docs.google.com/spreadsheets/d/1KcyKMl3nQWtN0E8eFH-Bmk4DpVDoR1DM-VNV1ZXowD4/edit#gid=0

[labblab]

Hello and welcome to you and little Squeaker, although I’m surely sorry for all the challenges you’re confronting! It looks as though he’s receiving very specialized care and monitoring, though, so that is an advantage. Are there any specific questions about the Cushing’s that we can try to help you with? I do know that the joint regulation of diabetes and Cushing’s can be tricky. Has Squeaker been dealing with diabetes for a lengthy time, or is that newly developing?

Once again, I’m really glad you’ve found us, and I hope we can help with any questions that you may have for us.

Marianne

[bichons9]

NO!! Squeaker had torn ACL in January 2021..borderline cushings ACTH test .9 but no treatment started? When huge lweight loss noticed in April, i wondered about Diabetes only to learn Cushings ACTH test >40..BG for surgery was 165..In last year BG has been 125..so Cushings tumor?? in Adrenal gland may have been acting up up in January..I have had 3 Bichons with Cushings. They were all pituitary dependent and treatment was easy. Squeaker goes tomorrow for another ACTH teat... has been on 10 mg Trilostane 6 am and 3 mg @ 6pm since Friday..was on 6 mg after on only 3 mg. It seems as if dosage is low????? but DVM said he doesn't like to start high due to awful side effects??? The hyperglycemia is ridiculous and only regular Insulin seems to work...Does/ Has anyone had pup with Adrenal dependent Cushings??? This is new to me!!!! And as you said..difficult with both DM and cushings!!! Any indo/ advice appreciated!!!!!! I guess .9 vs >40 are the cortisol readings from the ACTH Dexamethazone test??? Thanks for reading. Fran

[lulusmom]

I have reviewed your comments as well as your excel spreadsheet and it appears that the acth stimulation test used to confirm the cushing's diagnosis was done while the blood glucose was extremely high. Whenever an acth stimulation test or LDDS test is done, the vet has to make a valiant effort to gain some semblance of control of blood glucose before starting the test. Range should be between 150 and 350 mg/dl. This is equally important when doing the acth stimulation tests to monitor Vetoryl treatment. If this is not done, then the results are invalid and your vet should refund the cost of that test or credit your account. The CT findings of an adrenal tumor is not a slam dunk diagnosis of adrenal dependent cushing's. If an adrenal mass is functional, meaning the tumor has taken on a life of it's own, it doesn't care what the pituitary gland is telling it to do and keeps pumping out cortisol. Because the pituitary gland is functioning just fine, it recognizes all that cortisol in the blood and stops releasing acth. The opposing gland is not receiving that signal anymore so it goes to sleep and shrivels up. Can you please let us know what the other adrenal gland looked like? If it was normal or enlarged, then that would be a fairly good sign that the adrenal mass is not functional. I am a bit confused as to the 0.9 number you posted as being borderline cushing's. If this was an acth stimulation test result, that would indicate your dog is more likely not producing enough cortisol. I think that result is more likely the LDDS test which takes 8 hours to complete. A 0.9 ug/dl on this test is not borderline, it is negative for cushing's. Can you please look at the actual test results and confirm which test yielded that low result as well as provide the date of that test in relation to the diabetes diagnosis? Diagnosing cushing's is difficult enough but diagnosing concurrent cushing's in a diabetic dog is extremely difficult and unless it is done by the book, the likelihood of a misdiagnosis increases exponentially. Is your vet a general practitioner or an internal medicine specialist? I have provided a link below in support of the information I have provided as to proper testing protocol. It is very important that you ask your vet if he made sure blood glucose was low enough to do any cushing's tests? If the answer is no, then you may want to share this link with your vet.

Symptoms and lab abnormalities for both diseases are much the same, except for skin and coat issues which is a symptom of cushing's, not diabetes. Does Squeaker have loss or thinning of coat? Diabetes takes priority and I highly recommend you consider joining a diabetes support group. The first few months can be a rollercoaster ride so having others who have walked in your shoes share their knowledge and experience can be a great comfort and an amazing learning experience. It looks like you are doing home testing already so you are already ahead of the curve, no pun intended. :)

https://www.dvm360.com/view/diagnosis-and-management-cushingoid-diabetic-dog-proceedings

P.S. I just noticed that your thread title says "Squeaker needs a specialist". I 100% agree! I asked whether your vet was an internal medicine specialist because if not, I was going to recommend that you ask for an immediate referral to one. I often tell members that treating both conditions is like walking a tight rope while juggling and the vast majority gp vets simply do not have the experience and extensive education to safely and effectively diagnose and treat two very serious endocrine diseases. Even before Covid, getting a consult within a week was difficult but now it's three to four weeks out. You can always do what I did to get my last cushdog seen right away. I was told by a 24/7 ER facility with internal medicine specialists on staff that if I didn't want to wait, I could bring him in through the ER. No referral necessary for that either so that's an option for you.

[bichons9]

Oh my!! thanks for your reply..I am trying to get the nerve to show it to the DVM..However, I already read that one must get control of the BG before performing the ACTH test..and told him what I read. $23,000 later..I did not realize that the test was $440.00 each time...so doing one every week worried me..but mainly because of what you said and what I read. His new results are 11 post test vs the previous 44..I don't really know what it means ( I am an RN and seem to have lost brainpower..I am so tired..since I have 2 insulin-dependent diabetics and a cat now in remission thanks to the cat people in their wonderful forum.. They were there every minute to get me through the cat's diabetes telling me what to do that put him (Elliott) in remission (Lantus) ....never saw DVM for the cat after having the expertise of the cat people. Yes, I belong to the Canine diabetes forum ..Natalie used to help me with Suzie on Vetsulin, that I hate. but seems to do okay after 4 years on it. No, the DVM's are not certified internal medicine specialists but are referred to by the other local DVM's. After all, I am not in NY anymore..I am in "good ole Mississippi" I used to take 3 of my Bichons to Mississippi State Univ..but they have not offered to help me with Suzie's crazy BG -will go through DVM if asked. and my dislike of Vetsulin by Merck..They claim they look at my ss but ..... Her ss is a mess. You seem to have great wisdom and knowledge..I would like to share the CT results and Dex test with you but don't want to be inappropriate..expecting more from you. Marley (1 of7 dogs)_ has pulmonary hypertension..went to the "supposed" ER...It was unreal and they did not know what to do..they gave her Stadol (human name) and let her go after 40 minutes..She couldn't breathe and my DVM said luckily I got her to him by 7: 30 am..She is on 8 meds/day and is doing well....sorry for rambling but I just sit here and stare waiting for what is to happen next!!! I don't know if you can open this: file:///C:/Users/bicho/Downloads/SQUEEKER-MUNSCHAUER-2021-05-14-0914.pdf..Also, file:///C:/Users/bicho/Downloads/203647541_8F140183-813A-4131-B976-7B19D66CABBF.pdf..I am desperate for help.. Oh...DVM said to give the Vetoryl exactly 4 hours before test..the new protocol shared with me states NOT to give the Vetoryl ..I give up on what to do....and no thinning of coat...weight loss was 11lbs now 8lbs, > H20 and urination...Fran...Thanks so much!!!

[bichons9]

Oh well, I tried 4X to send reports..don't know if you got them..Thanks

[Squirt's Mom]

You can search for an IMS on the ACVM website found here:

https://vetspecialists.com/

I did a search for Mississippi and found these results:

https://find.vetspecialists.com/search_results?tid=2&location_value=Mississippi%2C+USA&adm_lvl_1_sn=MS&country_sn=US&location_type=administrative_area_level_1&swlat=30.146096&nelat=34.9961091&swlng=-91.6550089&nelng=-88.097888&lat=32.3546679&lng=-89.3985283&faddress=Mississippi%2C+USA&place_id=ChIJGdRK5OQyKIYR2qbc6X8XDWI

Hope that helps with the search for a specialist!
Hugs,
Leslie

[labblab]

Hi again, Fran. Gosh, I’m sure sorry you’re having such a rough time with so many of your furkids! I do agree that consultation with a specialist seems advisable, and from the link that Leslie gave you, it looks as though Mississippi State and LSU vet schools are your best bets depending on your location. Since you say you’ve already taken pets to Mississippi State, I’m assuming that’s closest. For me, the status of that adrenal tumor would be a big question mark to try to unravel. I’m afraid I’m not really knowledgeable about adrenal tumors, but as Glynda has written above, I do know they can take different forms in terms of hormone production and overall severity of effect. It would indeed be interesting for us to read that ultrasound report. If you can’t upload it to your Google docs, maybe you could just take a photo of it and upload that here as a picture in your photo album. Or as a last resort, just type the relevant portion of the report in a reply here on your thread.

In the meantime, as far as the timing of giving the Vetoryl in conjunction with monitoring cortisol testing, your vet is correct that the medication should be given (along with a full meal) about four hours prior to performing a full ACTH stimulation test. An alternative testing protocol involves taking a blood sample right *before* giving the daily Vetoryl dose. This second protocol involves measuring only the baseline cortisol level, not the combination of the baseline and a subsequent stimulated level as is the case with the ACTH. The full ACTH probably remains more widely accepted among vets in the U.S., and it sounds as though it’s the protocol that your vet prefers.

However, going full circle, it seems as though there are enough questions about Squeaker’s entire diagnostic picture that a consultation with a specialist about his testing and his treatment truly would be warranted. Please do keep us updated.

Marianne

[bichons9]

Thanks..I will try to upload the C-T report

[bichons9]

https://docs.google.com/document/d/1EQDG6DDgAtMNECVVk3PrdCjvmzhTxj6yqY3SPQe-fDc/edit C-T SCAN

https://docs.google.com/document/d/1NChiVPFe_Vr-QmxIKP59bELnoTnjeApcSTMLy6v7Eaw/edit 2nd ACTH Stim test..First test on 4/27/2021 was Pre= 7 post= 44.4 ..I don't know why 1st test is not showing up in google docs??? Please let me know if this worked..Thanks again!!!!

[bichons9]

Squeaker has had no side effects from Trilostane..but I have so many issues when compounding is needed ..but more important....How many doses /day are most people giving their pups? Once or twice /day? Squeaker was on 6mg @ 6am...then went to 6mg@ 6 am and 3 mg @ 6pm..now he is on 15 mg @ 6 am only...Updates on BID or SID suggest that Vetoryl may only last 12 hours. I am just wondering what all of you really knowledgeable members think about this. I am sure it's a coincidence that this am Squeaker's BG > 600..but it made me think..Thanks for reading... Atricle-An Update on Vetoryl https://pubmed.ncbi.nlm.nih.gov/29606727/

[labblab]

https://docs.google.com/document/d/1EQDG6DDgAtMNECVVk3PrdCjvmzhTxj6yqY3SPQe-fDc/edit C-T SCAN

https://docs.google.com/document/d/1NChiVPFe_Vr-QmxIKP59bELnoTnjeApcSTMLy6v7Eaw/edit 2nd ACTH Stim test..First test on 4/27/2021 was Pre= 7 post= 44.4 ..I don't know why 1st test is not showing up in google docs??? Please let me know if this worked..Thanks again!!!!
Unfortunately, when I click on the Google doc links, I get a banner saying that my access is denied. Perhaps you need to reset the viewing parameters to allow for public access?

Marianne

[labblab]

Squeaker has had no side effects from Trilostane..but I have so many issues when compounding is needed ..but more important....How many doses /day are most people giving their pups? Once or twice /day? Squeaker was on 6mg @ 6am...then went to 6mg@ 6 am and 3 mg @ 6pm..now he is on 15 mg @ 6 am only...Updates on BID or SID suggest that Vetoryl may only last 12 hours. I am just wondering what all of you really knowledgeable members think about this. I am sure it's a coincidence that this am Squeaker's BG > 600..but it made me think..Thanks for reading... Atricle-An Update on Vetoryl https://pubmed.ncbi.nlm.nih.gov/29606727/
I saw that you had posted this reply on another member’s thread, but I’ve taken the liberty of moving it here so it can join your other questions and updates that are specific to Squeaker. That way all of his info will be consolidated in one place, especially since I’m not sure whether or not that other member will be returning to the forum soon.

As far as the frequency of trilostane dosing, clinicians have bern debating for years as to whether once vs. twice daily dosing is more desirable. My personal opinion is that a lot seems to depend on the individual metabolism of any given dog. Some dogs seem to do fine on once daily dosing and that’s certainly an easier regimen for an owner to follow. However, for other dogs, the clinical benefit does wane before the end of a 24-hour time period and symptoms may rebound daily as a result. For those dogs, twice daily dosing indeed appears to be preferable.

In Squeaker’s case, diabetes may be the most important factor. We’ve been told that twice daily dosing is generally preferable for diabetic dogs so that cortisol levels can be controlled as evenly as possible at all times during a day/night. The goal is to avoid peaks and valleys in cortisol that may have a similar effect on glucose levels. I see you started out with once a day dosing, then shifted to twice daily, and have now returned to once daily. Did the vet give you a reason for returning to once daily?

Marianne

[bichons9]

NO..he has changed dosage a few times..wanted to start low low... but wants Cortisol <10 so increased to 15 once a day. I really would prefer to give twice a day..I do not think that the DVM thinks it through or maybe he likes once a day..I will ask him next week...he sounds overwhelmed with the CT results and has his partners consulting on what to do....Plan was for MY other DVM to do Adrenalectomy until they saw CT results and ESPECIALLY BECAUSE IT IS THE right adrenal gland??? He and others have not had Adrenal Cushings WITH Diabetes at same time before..but I don't know..I am afraid at times to ask more questions even though I constantly do practically every day...but the dosage has been changed and compounded a few times so now, I would have to give 10 mg caps and then 5 mg caps 12 hours later. I would like to do this but am not sure whether the unequal doses makes a difference. As a HCP, I don't think so but I just don't know what to do. What do you think?? There's an ER DVM that takes over on weekends..I may ask him what he thinks, though who knows if he will opine on the matter. My head is spinning 24/7.. Marley with Pulmonary Hypertension on 8 meds/day..Suzie has been an insulin-dependent diabetic 4 years, 2 needed ACL and luxating patella surgery but only Squeaker could have it..Marley too weak for surgery? Elliott in remission no longer needing insulin...and so..Bonnie and Trouble only 2 not in need of all of the above. Any advice from all will be greatly appreciated. P.S. I wanted to send him the updated articles on Trilostane but decided not to ...yet...Thanks Lablab!!!!

[bichons9]

I changed to anyone that has link..hope it works...CT scan https://docs.google.com/document/d/1EQDG6DDgAtMNECVVk3PrdCjvmzhTxj6yqY3SPQe-fDc/edit?usp=sharing

2nd dex test https://docs.google.com/document/d/1urnQr-u3UIEVEBrATp-eAvW3Mcahe8XeBNiyGG1N2Hw/edit?usp=sharing

[labblab]

Hello again! Yes, I’m now able to view those documents — thanks very much for changing the permissions. Unfortunately this is a busy day for me so I haven’t yet had the time to write down my thoughts. But I will definitely try to get back with you either today or tomorrow. I at least wanted to pop in now, though, to let you know that you were successful in allowing us to view those documents. Good job ;-).

Marianne

[bichons9]

Thanks.... for letting me learn from you...pdf's, google docs, sheets???? Well, at least I learned how to deal with PDF documents!!!

[labblab]

OK, I’m finally back again and so sorry for the delay. After again reading through the CT report, I wish I could give you some simple answers to your questions. But I’m afraid it looks as though little Squeaker has a lot going on, and once again, my recommendation would be to enlist the help of a specialist to sort it all out. Since I’m not a vet myself, I’m afraid all I can do is offer some basic impressions.

First, as far as the adrenal mass, I think Glynda hit the nail on the head in her earlier reply to you. If the tumor was causing the right adrenal gland to be pumping out cortisol, you’d expect the left adrenal gland to be smaller than normal. However, in Squeaker’s case, his left adrenal gland actually seems to be enlarged. So if he does indeed have Cushing’s, we have to suspect that it is a *pituitary* tumor that is causing the excessive cortisol as opposed to the adrenal tumor. The adrenal tumor does carry other “negatives,” however. It may be malignant, and it appears as though it has invaded the caudal vena cava, which is a major blood vessel. As you already know, that invasion makes surgery much more risky if not impossible. The report states that there is another larger mass near the liver, which may or may not be connected to the adrenal tumor. There are other issues for Squeaker, as well, which all contribute to a very complicated picture. So as I say, I’m afraid it will require someone with a lot of expertise to determine an optimal treatment plan for your little boy.

As far as the results of this second monitoring ACTH stimulation test (as opposed to a dexamethasone test which is a different type of test that is used for Cushing’s diagnostics only), it’s true that your goal would be to lower a Cushpup’s post-ACTH result to at least approx. 9 ug/dL or less. The trilostane has lowered Squeaker’s cortisol significantly from the initial 44, but it’s still not down within desired therapeutic range. If Cushing’s were his only problem, I’d feel more comfortable about coaching you regarding the monitoring protocol. But as I say, the combination of all his issues makes me more uncertain as to how Cushing’s fits into the overall puzzle, including exactly which physical factors aside from a possible pituitary tumor may be fueling his elevated cortisol.

I’m truly sorry that you have so many worries from all your furkids on your shoulders! I cannot even imagine how stressful it must be for you. But again, I think the best thing you can do for your own peace of mind is to try to enlist the help of a specialist to guide you. Please do feel free to continue to ask us questions and to share updates, but I’m afraid there’s a lot about Squeaker’s situation that is just outside of our skill set. But that doesn’t mean we won’t want to continue to hear how things are going, so please do keep us in the loop!

Marianne

[bichons9]

Thank You and all for caring..I do not get email notices that you respond so I am sorry that I did not see this message sooner. Right now I am trying to keep his BG as low as I can by giving regular insulin every few hours, in addition to his Vetsulin. As far as the Cushings...I just don't know...will look for an endocrinologist ..but 2 only want to consult with my DVM's..not with me. Squeaker is active, eating, happy...I have read some of what you suggested in some VIN articles..not sure the DVM'S have!!!! However, when DVM's wanted to and did keep Squeaker overnight simply to encourage me to get some sleep..I was shocked....at NO CHARGE..but reminded me that they will try to stabilize Squeaker but that things are not going to get better..We'll see ..They don't know for sure anything...and I am willing to spend every hour of the day caring for him...and Suzie and Marley and Bonnie and the others...as always. Squeaker has gained >1 lb and I will hope that he continues to be happy!!!! Thanks!!!!