Cooper - diabetes and cushings - sweet Cooper has passed

[juliwilliams]

Yes, I'm seeing why everyone is worried. I am too. It all seems to make sense when they explain things, then I come home, look things up, and start second guessing everything.

And just to clarify, the vet didn't doubled it with no test results, he just ran a blood glucose not an ACTH. The vet started us on once a day at 60mg. At this point we had already spent months trying to get his insulin regulated. The vet said, and everything I've read has said the same thing, that we had to get his diabetes under control before we should even run the ACTH for cushings. Cooper was at 30 units twice a day of insulin and still getting ridiculously high blood glucose readings. He did stop losing weight though which seemed like a good sign that the insulin was doing something. The vet thought it was insulin resistance due to cushings. He was going to switch insulin, but it seems as though getting other types of insulin is pretty expensive and somewhat hard to find. So, he ran the ACTH test and I hate to say but I never got the actual number that came back.

The vet started him on vetoryl. One 60mg pill once a day. I showed him that article and he did some research and said we should do twice a day when we returned from a vacation. He did a glucose test before we upped his dose. The reading was in the 200s which was a huge improvement, but not in the desired range. Based on that he doubled it and we switched to a 60mg pill two times a day, I'm guessing he thought the vetoryl was having a good effect on his insulin resistance but we weren't quite there yet. Now that I'm reading more on how these medicines work, I'm thinking that 30mg twice a day would have a far different effect on his insulin than 60mg once a day.

I will be sure to get ACTH tests before any changes to his vetoryl!! I don't think that my vet is a terrible vet or anything, in fact quite the opposite. They are by far the best bets we've ever had. But I think they just don't quite know what to do. My vet has never had a dog with both cushings and diabetes and I feel like he's just feeling his way through this. Given all the problems Cooper has had, I think it's definitely time to see someone with some experience with this!

Sorry for rambling! It's very late and it's been a long day!

[frijole]

Julie, We understand that the vet did blood test for glucose but you can't just double the dosage of the vetoryl without doing an acth test. It measures cortisol which is what is high in cushing's dogs. You must always test to find out where the cortisol is before making any dosage changes. If it is low or close to desired range there is no reason to double the dose. In fact you put the dog at risk. Giving the same amount twice a day would have been the logical next step as others have said.

Just wanting to clarify what we are talking about. Not doing an acth test before increasing the dose would be exactly like doubling the insulin amount without doing a glucose reading. Unacceptable. Kim

[labblab]

Hi again, Julie.

I am so sorry that Cooper had another episode and that he had to be taken in once again. I am really glad to hear that you will be requesting a referral to a specialist. You may find out that there is not really that much greater expense involved when you are only taking Cooper in for some regular office visits with the internist. These emergency visits, especially involving IV meds and overnight hospitalization, have to be expensive for you. And in truth, you really shouldn't have to pay for either of these last two episodes because they have resulted from your vet violating standard recommended protocol. Especially after a serious electrolyte imbalance, there was absolutely no way your vet should have immediately resumed the Vetoryl without testing the cortisol level. If your vet is treating other Cushing's dogs, with or without diabetes, he really needs to familiarize himself with the proper testing protocol that accompanies the prescribing directives for the medication. Because in the absence of proper testing, any other dog he treats has the potential to crash just as Cooper as done. If this is the first time it has happened for your vet, he is just plain lucky.

I hope it doesn't feel as though we are piling on here. But I am just trying to stress the importance of getting that referral for Cooper. At this point, your vet has already struck out twice. The third strike could have even worse results.

Do hang in there! It is great that you otherwise have had a really good relationship with your vet. And consulting a specialist doesn't mean that you need to "lose" your vet in the long-term or in conjunction with other more routine aspects of Cooper's medical care. But on behalf of all his patients, your vet definitely needs some guidance re: Vetoryl, and at this point, I don't want poor Cooper to continue to be the guinea pig.

Marianne

[juliwilliams]

Cooper is the guinea pig...that's exactly how I feel! I know he's treated lots of dogs with cushings and some very successfully for long periods. I know he's never had a case as hard as cooper but i can't imagine they're all easy and he's lucked out. I don't know why they're dropping the ball so much with Cooper. One of my friends just had her dog diagnosed with it and sees the same vet. I'm going to call her and make sure she knows about testing first before he changes the dose.

[juliwilliams]

Oh, and I'd say clinical signs of cushings are returning. He woke us up at 4am so he could lee and drink a bowl of water. Smells like he peed somewhere in the house overnight but I can't find it. He hasn't done that in a while.

[labblab]

Julie, how much prednisone are you giving Cooper? If he is receiving more prednisone than he needs to replace lost cortisol, then the prednisone will cause exactly the same symptoms as Cushing's. I've forgotten what the "replacement" formula is for prednisone, but I'll look it up and come back. Plus, there's always the chance that Cooper's cortisol has not ever dropped too low and he didn't need the prednisone at all. Electrolyte imbalances can occur while taking trilostane even in the absence of low cortisol. That's why the ACTH testing is so important in the event of an imbalance -- to find out what the issue is.

[labblab]

OK, the formula for calculating the "rescue" dose of prednisone for a dog who has crashed is .25 mg/kg. So if Cooper weighs 59 pounds (and my math is correct ), then the most prednisone he could need to replace lost cortisol is approx. 6-7 mg. (59 divided by 2.2, times .25). So if, in fact, his natural cortisol is being oversuppressed, he should not need any more prednisone than that. And again, that is assuming that his cortisol really is too low. We do not know if that is the case.

Oh, and so you'll know, you cannot perform an ACTH accurately within 24 hours of Cooper having been given prednisone. This is because the prednisone will skew the test and register as though it was his natural cortisol. So this is another reason why you would have wanted the ACTH performed when he first presented last week in crisis with his electrolytes -- to find out whether his natural cortisol had truly bottomed out without the confounding addition of the prednisone.

[juliwilliams]

He's getting half a 20mg tablet, so 10mg every 12 hours. That's probably as close as we could get to 6 or 7mg.

I'm going to stop with the prednisone for now. I really don't want to compound things at this point. I'm just going to keep him on his insulin, antibiotics (he's on a 6 week dose to try and get rid of a lingering bladder infection), and proin (for some incontinence issues).

Hopefully we'll be able to get in and see a specialist early in the week and I want to make sure the prednisone is out of his system.

Thank you all so much!! I really appreciate all this help and such quick responses!!

[labblab]

Julie, that rescue dose of 6-7 mg. of prednisone is the daily total! If you have been giving 10 mg. twice daily, then Cooper has been getting a daily total of 20 mg. which is definitely WAY too much even if he had crashed, and that much prednisone would totally account for the "Cushing's" symptoms.

I am so beyond annoyed with your vet right now I could scream!!!!!

But given Cooper's diabetes and insulin needs, I really don't know whether or not it is now safe for you to completely quit the prednisone altogether after you've had him on that high dose of prednisone for a couple of days. You may need to cut back more gradually so as not to totally disrupt his glucose/insulin level -- like maybe give at least 10 mg. for a couple of days before attempting to cut back even more. Plus, he may actually need "some" prednisone in rescue -- just not 20 mg.! What a mess.

I am not a vet, and truly do not know what you should be doing right now, especially because I am not that knowledgeable about diabetes. Do you test his glucose level at home? Has it stayed OK in the face of the prednisone?

[juliwilliams]

Ah!! This is a clusterf*** if I ever saw one!! Besides the increase in water he seems to be ok. He's been real tired since his first episode on Thursday and hasn't really gotten his energy back. But it's also getting close to 80 degrees here in Texas and he doesn't do well with heat. I'm going to look up some stuff about prednisone and see if he should be weened off it. If so I'll cut back to one dose a day.
I'll call the vet first thing in the morning and let you all know when we'll be seeing a specialist.