Diabetes & Cushings Diagnosis April/May

[SidneyDog]

My 12 year old (13 in August) Australian Cattle Dog was just diagnosed with diabetes April 9th. We have been unable to get his diabetes under control with increased insulin. After multiple hospitalizations and an ultra sound, ACE test, blood work he was diagnosed with Cushings on May 8th.
We started Vetoryl 30 mg on May 9th.
So far his diabetes has not gotten under better control and the poor sweetheart is still very sick.
He weighs 54 pounds, has been losing weight over the last month. Was 58 in March.
I started him on the diabetic Hill's W/D canned & dry food in April. He hates it & was eating the I/D food after a hospitalization for pancreatitis. He likes that. He has not being eating too well the last few days.
We started seeing an Internist May 10th. He happens to be one of the doctors who worked on the panel that brought Vetoryl to the US.
I realize 30 mg 1xday is low for his weight, but I'm assuming he's approaching slowly because of the diabetes & Cushings.
He seems to be panting a lot more than normal.
Anyone else have diabetes & Cushings or started at such a low dose.
I am also a member on the k9 diabetes forum.
Thank you for any input!!! Me and poor Sidney have been on an awful roller coaster the last month trying to get this under control. Any advice is appreciated

[lulusmom]

Hi and welcome to the forum.

I only had a chance to quickly scan your thread on k9diabetes and I have some real concerns about the cushing's diagnosis. Things I noted are:

1. It doesn't appear that Sydney was symptomatic at all prior to the diabetes diagnosis as it wasn't until he was unable to walk due to extremely high blood sugar that you took him to the vet. Cushing's is a very graded disease but at some point, especially before an uncontrolled cushdog experiences a diabetic crash, you would observe some symptoms.

2. Per Dr. Mark Peterson, a dog should not be deemed insulin resistant until insulin is 2.2 u/kg per injection. I'm by no means good at math but I believe that according to Sydney's weight, that trigger would be no less than 25 units. As I recall, before testing for cushing's, Sydney was getting 18 units.

3. The vet did testing while blood glucose was completely out of control and a recent Spec cPL test yielded an abnormal result. Abnormal result is indicative of pancreatitis so now we have a dog with uncontrolled diabetes and an inflamed pancreas with no history consistent with cushings and instead of increasing insulin, the vet recommended testing for cushing's. Given the tremendous stress Sydney's body was under, I would be absolutely shocked if any of the diagnostic tests for cushing's came back normal, including the abdominal ultrasound.

4. Vet said abdominal ultrasound showed enlarged adrenal glands and enlarged kidneys which are consistent with cushing's. Enlarged livers are consistent with cushing's but kidneys are rarely mentioned on interpretation. Enlarged adrenal glands should also be expected in a dog with chronic uncontrolled diabetes and pancreatitis so this is not a big red flag that Sydney has cushing's. It is an enlarged liver that contributes to a pot belly and diabetic dogs can have a pot belly as diabetes causes the same fat accumulation in the liver as cushing's does.

5. The specialist actually said that Sydney looked great and appears just to be a typical dog with diabetes. In my layperson's opinion, that very well could be the case. I would think it would be highly unlikely that a cushingoid dog who has had cushing's long enough to cause Diabetes Mellitus would look great. I've had three dogs with very advanced disease and all three looked absolutely horrible. These dogs all had severe skin and coat issues. You mentioned that Sydney's coat is so thick that you can't tell if he has any skin issues.

6. There has been discussion on the possibility of hypothyroidism on k9diabetes and I wanted to mention that I would not recommend testing for hypothyroidism until you get Sydney completely under control. Both uncontrolled diabetes and cushing's can transiently reduce the T4 thyroid hormone. This normalizes once treatment for the underlying condition is addressed.

Your poor Sydney has been through a horrible time with this and my heart goes out to both of you. What I don't want to happen is that you make him sicker by giving him Vetoryl, if in fact he does not have cushing's. I am so disappointed that you could not get in to see Dr. Peterson. You may have already seen Dr. Peterson's blog on the difficulty in diagnosing cushing's in a dog that is diabetic but if not, I've included the link below.

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

I'm very glad you decided to start a thread for Sydney here. Between members here and our sister site, k9diabetes, we'll do everything we can to help you help Sydney. The more information you can provide, the more meaningful feedback we can give you. Can you please let us know which diagnostic tests were done to confirm a cushing's diagnosis? Can you please get copies of those and post the results here? Please share any other information you might have.

Glynda

[SidneyDog]

Hi Glynda,
Thank you for the response. I took Sidney to the vet in January because he was un characteristically being bad: eating things off the counter, going through the garbage, stealing food, aggressively trying to eat the other dogs food, drinking a lot and having accidents in the house. My vet said she thought he had Cushings. She didn't do any blood work (I could kick myself now for not insisting). He has a pot belly and his eyes look red. These can also be symptoms of diabetes. I continued to watch him carefully and kept calling saying I was very concerned. We went again in March when I took my other dog and she said I shouldn't worry that he was just getting older. The first Saturday in April I came home and he could no longer get himself up from a sitting position. I thought he had terrible arthritis, I bought him these rubbery wraps for his legs hoping to help him get a grip on the wood floors and made the first appointment I could.
They did an X-ray and said he had no arthritis but his blood and urine tests showed he was a very bad diabetic with keytones in his urine. They gave me insulin to start 10 units and I ended up back the next afternoon with him & they hospitalized him and gave him the fast acting insulin and IV fluids. I brought him home 2 days later and shortly after he was very sick again. We stayed at 10 units for 5 days and I increased him 2 units because I could tell he was still so so sick. So here we are a month later in no better position.
He was hospitalized again for pancreatitis where he again received the fast acting insulin and it brought his sugar to an almost normal number. I take him home again & he's sick all over again. Barely lifting his head off the floor. I took him to the emergency room & the next day he saw the specialist. (I did call Dr Peterson since I am 20 min from NYC) but he is booked indefinitely.
So he had the tests for Cushings...
We started the Vetoryl Friday May 9th & he was back in the hospital Sunday because his BG was over 750!
I need to get copies of the blood tests still. I have an appointment Monday for the 10 day ACE levels test. I'm concerned with everything, I really don't know if it's a correct diagnosis.
Dr. Kantrowitz, the specialist, wanted to start at a low dose of Vetoryl and keep the insulin the same because he didn't want the meds to start working & the insulin would be too strong & he'd swing the other way. I feel like I'm taking matters into my own hands because my poor best friend is suffering while we wait. I bought the fast acting insulin because he is so so high & I have the BG monitoring system at home. Because he is so sick with diabetes I can't tell if Vetoryl is making him sick.
My regular vet told me she wouldn't even address Cushings until Sidney was truly insulin resistant, meaning that 1 unit per pound. The whole process takes long because you need to wait 5-7 days to increase units and can only do like 2 units at a time.
Sidney's liver enzymes have been elevated for quite some time, he had his spleen out 2 years ago for a tumor & I've suspected the same was happening to his liver. The ultra sound confirmed discoloration on his liver and the appearance of a non aggressive nodule.
I guess I will find out more Monday after the second Cushings test?
I'll ask my vet to fax me records.
Thank you!!!!

[lulusmom]

If the test you will be doing on Monday is an ACTH stimulation test, then I would agree that it should be done; however, if blood glucose is still out of control, the results will be artificially high, in which case the specialist should be very wary of using the results as justification to increase the dose of Vetoryl. Vetoryl can drop insulin requirements and bring on a hypoglycemic crash but a drop in blood glucose can also cause cortisol to drop too low, bringing on an Addisonian crash.

It seems your original vet concurs with Dr. Peterson as to when to deem a dog as insulin resistant but unfortunately, your specialist broke ranks. Did your specialist give you specific instructions on what to watch for in the event Sydney's cortisol drops too low? Unfortunately, the symptoms are much the same as hyperglycemia so you really are walking a tightrope here. Are you home testing during this time? If not, I highly recommend that you do. If bg drops to acceptable levels, Sydney won't be out of the woods yet until an acth stimulation test can be done under optimum conditions. Optimum conditions are diabetes controlled, no pancreas problem and no other illnesses that would skew results. It's a balancing act that few of us have ever had to go through so hang in there and know that we're here.

Glynda

P.S. I forgot to mention that polyphagia (increased appetite) is also a symptom of diabetes, particularly at onset of diabetes. That makes it so difficult to distinguish between the two, especially since Sydney has no skin and coat issues which would more readily allow you to make the distinction. :(

P.S.S. I also forgot to mention that excess steroids, as a result of cushing's or diabetes, can cause what is called hyperechoic changes in the liver. Hyperechoic lesions on the liver show up much lighter on imaging, which may be what your vet was referring to when s/he said the liver was a different color.

[SidneyDog]

I got the blood work, ultra sound and report from the Emergency Room and Internal Medicine Doctor this afternoon. What do you make of his report, he does say that the thyroid is probably out of whack because of the other stuff going on.
I moved him up to 20 units of insulin with his supper tonight because his BG (you can look at my chart I posted) was up to 685! The crazy part is I came home for lunch at 1 to check on him and his BG was 476 so I gave him 3 units of the R since he wouldnt be getting his insulin until 7 pm and was far beyond the 4-6 hour peak of the Novolin N.

Here is a link to his report: https://www.dropbox.com/s/3wvdqp8wwfa6euc/Sidney%20Internal%20Medicine%20Report.pdf

Here is a comparison sheet I did on his blood work:
https://www.dropbox.com/s/2rkcnz74sknsvkw/Sidney%20Blood%20Work%20Comparison.xlsx

Here is his glucose spreadsheet:
https://www.dropbox.com/s/l9zb2q4mkfyfdby/Sidney%20Blood%20Glucose%20April%202014.xlsx

I need to learn more about Cushing's Disease and what to look for. I have been researching Diabetes and Pancreatitis, etc.
The Pancreatitis, I don't even think was accurate because he had no vomiting or diarrhea or a temperature, etc.

This is such a hard time getting an appropriate diagnosis and treatment plan.

[lulusmom]

Thank you for posting Sydney's labs. Unfortunately, I am unable to open the excel spreadsheets but will continue to try. There seems to be a lot of evidence that Sydney has pancreatitis. The amylase and lipase are elevated, the spec cPL was abnormal and the ultrasound results noted that the pancreas was abnormal. A dog doesn't have to be symptomatic to have pancreatitis and we have a few members who can attest to that. If you've been researching, you've probably seen that pancreatitis can also cause insulin resistance. It is also probably contributing to the elevations in all of the liver enzymes. Cushing's can cause severe insulin resistance so I think this may be why your specialist is hanging his hat on a cushing's diagnosis and opted to put Sydney on a low dose of Vetoryl.

I'll be back later, hopefully after I find a way to open the other two files you posted.

Glynda

[addy]

Well, my Zoe's ultra sound showed pancreas problems - IMS diagnosed probable chronic pancreatitis based on the ultra sound but Zoe never had symptoms of it. We never did do a Spec CPL for that reason.

I have every confidence that Glynda will be able to help you sort things out:)

[lulusmom]

For those interested in following both of Sidney's threads, here is the k9diabetes link:

http://www.k9diabetes.com/forum/showthread.php?t=5689

[SidneyDog]

What do you think I should do? Keep increasing the insulin? I raised him to 20 units last night & this AM because his BG was over 500. Should I give him the R to lower his BG? Should I keep Vetoryl at same? Should I call my vet or specialist and ask them to do any other tests or any specific questions.
My vet was saying Cushings since January, but of course diabetes onset can have same symptoms.
I'm so sad, I wish someone could just help us. I've been trying to figure things out with him for over a month and he's just as sick.
Any advice is appreciated.

[Jenny & Judi in MN]

As someone else who has been there, both diseases at the same time is very complex. I remember being angry at my vet because he didn't want to advise me and only wanted to see a specialist. Now we know why. So at least you are already there.

I know it is miserable seeing your dog be miserable but it does take some time. Just to give you some comparison. Jenny was diagnosed with diabetes on 5/11. We were increasing her insulin by 1 unit every week. Her readings were in the 400's to the 600's for over a month doing this.

On July 4 we started treating for Cushings and continuing our slow insulin increases. It was July 14, 6 units twice a day on an 8 pound dog that I saw 200's on her curve finally.

Sidney definitely has way higher swings and I don't feel knowledgeable to give you any advice other than to say the R is a short term insulin that can drop the highs down while you maintain a steady dose of the N.

I think you should email Natalie the glucose spreadsheet.

The cushings meds you shouldn't be adjusting without an ACTH test unless he shows signs of being overdosed. In Jenny's first 10 weeks of being treated for cushings we did 5 ACTH tests and adjusted accordingly.

I'd ask Natalie what she thinks about using the R. I so totally sympathize with how you are feeling. Judi

[lulusmom]

I second the recommendation that you send the glucose spreadsheet to Natalie. I also recommend that you contact the specialist and tell him what is going on. I'm surprised that he hasn't contacted you to check on Sidney.

[SidneyDog]

Thanks Judi. I spoke with specialist today. At feeding/dinner time he was at 455 so we did 20 N & 2 R.
I think we'll increase until he drops. He doesn't want to increase the Vetoryl too quickly because he said it's harder to cr back from too much than to have too little. I just want to get him down to 300's poor thing.
I can email anything anyone is willing to look at!
I put the info on Dropbox, on my phone it just pops up to either download the PDF or let's me view it as a spreadsheet. I can try again if there's still an error with it.
Thanks again!!

[k9diabetes]

I have posted to the thread at K9D and think a change in insulin should be tried. If possible, I'd try a week or R only four times a day and see if that demonstrates that the NPH is the problem.

Natalie