REMY diagnosed last week

UPDATE REMY: Finally got the ACTH Stem tests back on Remy and his adrenal has recovered and he is back within normal range. (135 and 129) So they are recommending we resume trilostane this morning at 5mg once a day since that is the lowest available dose without compounding. We will recheck in a few weeks to see how he is responding. They also recommended changing his insulin but the past couple of days I’ve had some luck by giving his insulin around 300 even if it’s a little early. He always spikes after eating so my thinking is why must we let him get uncomfortably high just so he can eat and have his insulin at exactly 12 hours? Also, I don’t want to change too much at the same time. I would rather take steps as far as introducing different medications or treatments so we know exactly what is affecting. Anyone with experience with Diabetic pets or Cushings/Diabetic pets please reach out to me because I would sure love to pick your brains!! The K9 Diabetes forum doesn’t seem to be active anymore. Meanwhile, thank you all so much for your thoughts on Remy’s situation. You are wonderful and provide so much help and support!! I will continue to update as we see how he does on his new dose!!

As you know I'm new to this diabetic thing myself, but the vet told me that the one important part is feeding my cat a low carb wet cat food, and I see for myself that this does play an important part in blood sugar numbers. I don't always inject at exactly 12 hours, usually within 1/2 hour of next scheduled shot, so for me and cat it's 6-6:30 am and 6-6:30 pm. He's usually high at the beginning and slowly declines around 2-3 hours after insulin shot.

We try use a low carb wet dog food. He won’t eat the same thing ( for breakfast and dinner the same day) so Remy is very picky. We spoon feed him It’s a lengthy process sometimes but it works. He’s done when we finish the bowl. Otherwise he would graze or be inconsistent in his eating. I use the same brand and type food which we found agrees with him and to maintain consistency. Still, he’s all over the place with his glucose. We do 10 am and 10 pm since he’s a very late riser. He also has almost immediate post prandial spikes as soon as he starts eating so I’m experimenting with not letting him get up quite so high before giving the insulin. It’s definitely complicated and has pretty much taken over my life. If this doesn’t do the trick I’m game to try a new insulin but I’ll want to do it when I’m home all week so I won’t have to worry about any hypoglycemic episodes if I’m gone. Thank goodness for the continuous glucose monitor!!

What type of insulin are you using? In the beginning we used Lantus but that seemed to drop him too low, so we've switched to Prozinc which is working better.

For the most part Remy has been on Vetsulin. The problem is it takes too long to take effect and doesn’t last long enough. We tried PZI (prozinc) but didn’t have much luck with it either so went back to Vetsulin. They want me to try Degludec which I believe is similar to Lantas. My concern would be the risk of hypoglycemia. I don’t think we should make a change until Remy has been back on the trilostane for a bit to make sure he has adjusted, cortisol levels are normal etc. Then we can see about a change in insulin. Right now I am experimenting with giving him the Vetsulin a little earlier instead of adhering to a rigid every 12 hour schedule. If he’s within a couple of hours of that and his glucose is over 300 I will go ahead and feed him and give him his insulin. On average it takes 4 hours to kick in. When he eats his glucose spikes so maybe this will help his glucose from going to the moon.I figure it’s worth trying while he acclimates to his new dose of trilostane. I don’t like to change too many things at once in case he has some negative reaction.

A little update on Remy. Had a snap cortisol a couple of weeks ago and he was at 2.6u (mid 70s on nmol scale) which isn’t bad but I do not want him to fall too low again. Since 5mg is the lowest dose of Vetoryl without compounding his primary care and I decided to try 5 mg trilostane every other day and see where we get. We will do an ACTH next week and get more precise results. (I had to switch from evening to morning dosing). Once we get this resolved I will work on the diabetes situation. K9 Diabetes forum no longer seems to be active. There are new approaches with hard to regulate diabetic dogs using a BBIT (basal / bollus insulin therapy)protocol but most veterinarians seem reluctant to try it even though it has been used in humans for many years due to the risk of hypoglycemia. As always any comments and suggestions are greatly appreciated!

I can't help with the diabetes but I do have a concern with the resumption of treatment with a normal cortisol reading...and dosing schedule.

Vetoryl is used to lower cortisol when it is elevated. It is not used to maintain a normal reading after a dog has dropped too low. The protocol says to wait until the dog is showing strong signs again AND has an ACTH showing the cortisol is once again HIGH...not normal, and then restart at a lower dose than previous. So the risk of dropping too low again is higher by restarting with a normal cortisol reading. I am basing this on the 2.6u reading as 2.6ug/dl which isn't too low but you don't want it going lower, as you said.

Now, Vetoryl/Trilostane has a VERY short life in the body (2-12 hours) so dosing every other day 1) puts the dog on a sort of cortisol roller coaster which is not good for the adrenal glands, 2) offers little to no control of the cortisol, and 3) is a complete waste of your money. The beauty of compounding medicine is that you can get an exact dose. The liquid Trilostane is especially nice because often you can adjust the dose without having to buy a new prescription...simply increase or decrease as needed per the vet. FYI...Trilostane is compounded Vetoryl.

If the vet is running the ACTH vs the PVC test to monitor treatment then dosing at night won't work due to the strict testing schedule for the ACTH. The PVC had a bit more leeway.

Hope I haven't confused you more.
Leslie

Hi Leslie, Thank you so much for your thoughts. We are taking Remy this afternoon to recheck his cortisol level. Internist had us switch him back to morning dosing (still every other day) to better faciliate an accurate test. Have not heard of liquid Trilostane so I assume this is compounded. I don’t know why the vets seems so adverse to compounding but they aren’t recommending it. (I have used compounded medications in the past successfully). I was told to resume Vetoryl at 5 mg once a day after he retested at 135/129.That was after a couple of weeks off trilostane. Primary care did a snap cortisol (not an ACTH Stim) and he was 2.6 and that was on trilostane once a day. I was concerned he was headed back to a too low situation and we talked about trying it every other day. Internist mentioned some dogs are very sensitive and only take it a couple of times a week. I see your point though that given the short life of 2-12 hours doing an every other day doesn’t really achieve stability. Remy never had much in the way of Cushings symptoms. They were very mild (like he stopped being such a picky eater and was showing more interest in food like a normal dog) a little panting at night time. No increased urination or water consumption. Hair coat a little thinner but he lives in a hot climate and thyroid is at the lower end of the scale. Still, he doesn’t have bare patches and most people would say he has a lovely coat. no pot belly. So maybe we should keep him off trilostane and retest say in a month or two depending upon symptoms?? My problem is cortisol affects his diabetes which is not controlled and I’m about to lose my mind with it. I guess we see what it is this time and I will discuss what you’ve told me and see where we’re at I’m also keeping in mind just the stress of going to the vet is going to bump up the cortisol. I don’t see why the liquid trilostane would be a problem if he needs it at all. Thanks so much for your suggestions and I will ask and see what he says. I really appreciate it!!

Hi Leslie,
Got the report back on Remy’s last ACTH test. Baseline was 29.2 nmol/L and post 34.8 nmol/L so his cortisol is low again and obviously 5 mg. Trilostane every other day is too much for him. My opinion, he shouldn’t be on any trilostane until his cortisol is actually high. They put him back on trilostane at 135 and 129 which is still within normal range back in January. We have discontinued trilostane for the moment. If he shows symptoms or tests ‘high’ I am going to push for a compounded liquid Trilostane because as you said, it is much easier to adjust the dose. With a 5 mg capsule I can’t adjust it. Prior to the test we did switch him back to Vetoryl in the morning with breakfast to faciliate a more accurate test. For whatever reason his internists aren’t crazy about using compounded medications but I have done so for many years with other drugs and didn’t have a problem. So his Internist is trying to connect with the Endocrinologist to see what they come up with. Between this and the irregular glucose I may just lose my mind LOL!

I agree with you 1000% - he should not be on treatment at this time. You are doing a great job with a difficult situation so keep up the good work!
Hugs,
Leslie

Thank you Leslie. It’s been a very difficult week. Lots of ups and downs with Remy’s glucose. Had the Internist do an abdominal ultrasound Wednesday. Results weren’t too bad, some age related changes etc. Appears to be a polyp in the trigone area of the bladder but since I have had two dogs previously with bladder cancer we will do a BRAF test just to be on the safe side. Internist agreed that until Remy test high cortisol or shows symptoms we will not give trilostane. Ultrasound showed his adrenals appear perfectly normal, same size as they were in 2018. He said usually with Cushings there will be some enlargement or changes but Remy’s seem to be fine.So that’s good news….makes us wonder if he was misdiagnosed. He does have high platelets though so that may require some further investigation. Thank you so much for the advice and support! I aappreciate it so much!!

Hi Leslie and all who are here…..OK I am in a real quandary with Remy. His private practice internist and primary care were pretty much against changing his insulin because they are totally unfamiliar with what the university endocrinologist was suggesting. It concerns me as well because IF we run into a problem (always at night, holiday, weekend it seems) who will be around to help us who is familiar with this product? He was going to get with the endocrinologist and discuss it. Well, after three weeks that doesn’t seem to have happened and Remy’s Vetsulin no longer seems to be working. The thing is though, he has also been off trilostane for three weeks now. So hopefully his cortisol levels have returned to normal or perhaps they are high and thus affecting his glucose and causing some resistance. I am so frustrated at lack of response by his doctors. Meanwhile Remy gets very uncomfortable and has up until all hours of the night and we are worn out and my brain is feeling very stupid at this point. I can’t say I am seeing any clinical signs of the Cushings yet. But we never did see many symptoms with him. The ultrasound last week showed his adrenal glands looked quite normal. Internist had said to wait a couple of months to retest (ACTH) but with the sudden insulin resistance I can’t just let that go on. I am going to pick up a new vial of insulin just in case there is something wrong with the present one. Any suggestions? I have tried to connect with someone from the K9Diabetes Forum but no luck getting on and no response from the Admin. Any suggestions as to dosing if his cortisol tests above normal? Obviously 5 mg. Every other day was too much. I know there are mixed opinions on compounded trilostane. Thanks so much for any advice!! Claire

Claire, I’m so sorry about all the stress that you and Remy are under. And I’m surely sorry about the difficulty you’re having over at K9D. I’d be happy to try to contact the site administrator, too, on your behalf. Are you already registered over there and just having trouble posting, or have you not been able to register yet? Just let me know if you’d like me to try and help with any of that.

Marianne

Hi Marianne, Oh yes PLEASE I would love to have help getting on K9Diabetes. I was registered and used to post on there previously but it won’t accept my information. Not sure if it’s the user name or password. I asked for password reset but never received anything. I have checked junk mail/spam but nothing. When I try to register again it says my email is already in use. So I don’t know what it is but I haven’t had any luck and I am desperate for some help. I would so appreciate it if you know how to reach the site administrator! THANK YOU!!!

Claire, I’ll be glad to help. I’m a member over at K9D, myself, and just checked the membership list. I see there is a “Remy’sMom” listed over there, having joined 2-12-21, and last activity on 3-7-22. Does that sound like you? If so, I see that your username there is all run together, with no space between “Remy’s” and “Mom,” the way your username is here.

Also, a few years ago we experienced an oddity with our forum software that sometimes created log-in problems for members who used apostrophes in their usernames. We haven’t had any problems for a long time, and K9D is running on a more recent version of the software, anyway. But just for the sake of interest, here’s a link to a posting about the problem we were having here:

https://www.k9cushings.com/forum/sho...e-and-Password

Anyway, let me know if you think I’ve identified you as the right user over there. And if you still can’t log in with “Remy’sMom” (no space), I’ll contact Natalie, the Admin over there. And we’ll go from there!

YES!! That’s me and I did have the ‘apostrophe’ issue trying to get back on K9Cushings. I can’t be sure if it’s the apostrophe situation or if I have the wrong password but I never get a password reset via email either to try and change it just in case. I’ve been double checking ‘junk/spam’ just in case it winds up in there. Between Remy’s Cushings and diabetes I’m losing what little mind I have left! :). I would really appreciate it if you can let Natalie know! Thank you so very much!! We are suddenly having a problem with only minimal response to Remy’s insulin (Vetsulin) He has been totally off trilostane since February 17 so I’m wondering if his cortisol level has increased to the point where it is affecting his glucose and response to insulin.

I figured it had to be you:-). I’ll go ahead and send an email to Natalie asking her to contact you directly. I’ll also give her a link to your thread here so she catch up on Remy’s treatment journey. She’s a member here, too, so she’ll have access.

It sounds as though K9D has your correct email address on file, but if you want to send me a Private Message here just to confirm what it is, I can pass that on to Natalie so that she can contact you directly. Once you get settled back in on K9D, I’ll keep following you over there, too, so as to add any more Cushing’s thoughts that come to mind.

So let me know about confirming the email, and then I’ll contact Natalie.

THANK so much!! I think you do have the correct email. I’ll try to PM just to confirm. Right now I am wondering if his cortisol level has gone back up and is affecting his glucose and insulin since the reduced response to Vetsulin seems to fit with taking him off Trilostane. Obviously I need help from both K9D and K9C !!!I really appreciate it!

Got your message and will now forward the info on. I’ll keep checking K9D, too, in the hope I’ll soon see your posts appearing there!

Thank you so much! I really appreciate your help!!

OK, everybody, we’ve got Claire set back up over on K9D. So if anybody wants to monitor Remy’s journey over there, as well, here’s a link to the thread:

https://k9diabetes.com/forum/forum/d...nosed-diabetes

And Claire, of course you’re always welcome to continue posting here, too ;-)))

Thanks for all your help. Since Remy’s problems are both Cushings related and unregulated diabetes I need help from all fronts! This morning is the first time in a week he has down into a normal glue range. He ran above 400 from 5 PM yesterday to 5 AM this morning and suddenly went down. So at least we know he still responds to insulin. Tomorrow we will see the Internist and I think he should check Remy’s cortisol level to see if it’s gone back up above normal or not. He has been off the Vetoryl (trilostane) for about three weeks now. He seems to be very sensitive to it so IF it’s decided he needs to go back on and we know 5 mg is too much for him even every other day, what is the alternative? Mixed opinions on a compounded liquid from what I have read. As far as symptoms, Remy has never had much in the way of Cush symptoms. I’d be very happy for advice here!!

I really do endorse the idea of re-checking Remy’s cortisol. And if the decision is made to restart treatment, I really don’t see how you have a reasonable alternative other than shifting to a compounded product. In general, I personally endorse using brandname Vetoryl if that is “do-able” for the reason given in my quote below. I recently posted this on another member’s thread, so you may have seen it already. But I’ll go ahead and repeat it here.

Quote:

---

…over our years here, I think there are few issues that have generated more discussion than the question of brandname meds vs. compounded alternatives. People have had, and probably continue to have, differing opinions. I’ve certainly come to appreciate the fact that compounded trilostane can be a positive game-changer for folks, either because their dogs need doses that aren’t available in brand form, or because the high cost of Vetoryl would make treatment a huge financial burden, or because their dogs simply won’t take pills in a conventional form. However, the downside is that compounded products are not inspected nor regulated in the same manner as FDA-approved pharmaceutical products, and as Marissa has pointed out above, some past studies have shown some dosage/efficacy irregularities in certain compounded trilostane products. So that remains somewhat of a worry to me. And for this reason, I think the reputation of any given compounder is especially important to investigate. On the thread below, we give people some tips in that regard:

https://www.k9cushings.com/forum/sho...ushingoid-Dogs

---

If Remy’s cortisol is elevated again, then I think turning to compounding is your only viable option — especially as opposed to giving a higher dose on a less than daily basis. As Leslie has discussed earlier, you really want to keep cortisol levels continually as consistent as possible for all Cushpups. But for diabetic dogs, we’ve been told this is especially important. Even to the extent of preferably dosing diabetic dogs twice daily, when that is feasible. Given Remy’s apparent sensitivity to trilostane, once daily dosing probably remains the most likely option. So that would mean less than 5 mg. daily. And that means necessarily switching to a compound.

Even though a compounded liquid would be the easiest route to go, I’m personally not a big fan of trilostane in liquid form. My opinion is not based on any research or professional guidance. But again, over our years here, it just seems to me that we’ve seen more dogs experience unpredictable results on liquid compounds rather than solid compounds of trilostane. Solids do offer far less flexibility. But heck, in Remy’s case you could probably even get an initial batch of compounded pills or capsules in 1 mg. dosages. Presumably a compounder could make it that small. That way you’d have total control over dosage changes. So that’s likely the direction I’d try to go myself if Remy’s cortisol is up again. But again, other folks feel differently about liquids and that would also remain an option.

Definitely good luck tomorrow, and let us know what you find out as soon as you can.

And P.S., I went ahead and copied our conversation here into your K9D thread so folks over there will know where things stand with Remy’s Cushing’s.

Thank you so much. The diabetes is a big problem for us especially for me as far as my stress levels (LOL) but despite all our efforts we have not been able to obtain and sustain regularity for him. We thought he was well regulated as far as the Cushings until Christmas when we learned he was now very low. The endocrinologist kind of raised her eyebrows at how long he has been on Vetoryl. We did have an ultrasound done a week ago and his adrenals appear normal and are the same size as six years ago. I might be wrong but I was under the impression that even with pituitary Cushings there would usually be some changes to the adrenals. I will let you know what we find out tomorrow!!

I sure do understand your stress! I’m a champion worrier, myself, and especially over health-related stuff related to furbabies. If *only* they could talk to us and tell us how they’re feeling!

And I really hope you’ll start getting some replies over on K9D. Both their traffic and our traffic has really slowed down these past couple of years as the Facebook groups have become more popular. But hopefully you’ll get some feedback over there soon.

Internist sent out a cortisol test for Remy. Hopefully have the results back in a day or so. His glucose curve has been pretty good since we opened a new bottle of insulin. Interestingly his primary care called me today and when I mentioned it he said one of their vet techs had the same experience recently so it’s possible they had a shipment that got too warm during shipping. Meanwhile he is going to give me a Rx for a rapid acting insulin for those times when Remy is uncomfortably high.I should know more when the test results come back in. He did mention compounded trilostane and the controversy about the product. He has a vet friend who has a dog very sensitive to storyline and only gets it once a week which goes against conventional thinking. At this point we don’t even know if Remy will need it. Will keep you updated as I learn more. Thanks for all the encouragement and advice!

Everything has changed this past week. We had Remy in for a baseline cortisol recheck and I also asked for an abdominal ultrasound. Got the results Thursday. Cortisol was 6.09 ug/L which would be 168 nmol/L. This was not an ACTH test just a baseline to see if he had recovered from low cortisol since he stopped Vetoryl February 17. Internist recommends we not treat until we see symptoms of Cushings. We know cortisol affects his diabetes and the past few days we had a nice curve going through Wednesday. Now he is trending back to the Vetsulin not lasting long enough.

The big change though is the ultrashowed Remy had transitional cell carcinoma (bladder cancer) so although at the present he is not showing symptoms we know the tumor produces inflammation and this adds yet another dimension to things. At the moment this is my biggest concern because we don’t know how long it has been there or how aggressive it is. I think it is fairly recent. So the question is whether or not to treat it and how treatment will affect all his other issues. I cannot believe Remy is the third dog I have had with TCC! We don’t smoke, don’t use chemicals to clean floors (I just steam them) don’t allow pesticides or herbicides in the ‘dog areas’ of the yard. He hardly goes out except to potty and right back in the house. We are dumbfounded as to how this can be. I don’t use pest control in the house at all which is very common here in south Louisiana. I put up with a few bugs rather than risk my pups. And yet here we are again. Bichons are one of the more susceptible breeds but still it was a shock to learn my fears were confirmed. More decisions to make. Unfortunately I don’t see much in the way of new treatments since my last TCC dog a couple of years ago. Given Remy’s stress levels even deciding where to go for treatment is a decision. I suspect his cortisol level is rising but since 5 mg every other day was too much my options are limited on the Vetoryl. As the cortisol level rises so does his glucose. I’m not sure there are answers anymore for us.

Oh my goodness. Claire, I'm so sorry to read this news. I agree, it's unbelievable that you would have three dogs diagnosed with this form of cancer. And yes, it certainly further complicates an already very complicated situation :-((((. From the standpoint of Remy's cortisol, it's good to know that his adrenal function doesn't appear to be oversuppressed. So that is worthwhile information from the baseline cortisol. However, even if nothing else was at play, I wouldn't feel comfortable starting back with the Vetoryl until a complete ACTH was performed. Random baseline cortisols can vary markedly throughout the day even in normal dogs depending upon stress level, etc. For dogs being treated with Vetoryl, we've been told a random baseline cortisol can reassure that cortisol isn't dropping too low, but otherwise shouldn't be used for dosing decisions. And now, with this new diagnosis in hand, restarting Vetoryl at any level would seemingly present a lot of question marks. For instance, it could be that the cancer itself is stressing Remy's adrenal system right now as opposed to Cushing's. And even though we know higher cortisol can also elevate the glucose readings, maybe a higher level of circulating hormone may have a beneficial anti-infammatory effect on the cancer? I have no idea about that part of things.

I guess (hope!) an oncologist might have better guidance about the path forward. I just hate it that you and your husband and Remy have this additional huge worry. Even if you don't decide to start back on the Vetoryl now or ever, please keep us updated, OK? I continue to send you all my healing wishes.

Marianne

Thank you so much Marianne for the support. It definitely makes things more difficult. Now I don’t know if he’s fussy because he is becoming painful, high glucose, Cushings or ‘who knows’ at this point. His glucose was looking pretty good just a couple of days ago, now it’s running high again.Just to come up with an appropriate dose if we wanted to restart Vetoryl would be difficult because we know 5 mg every other day was way too much for him.And we can’t know how much the tumor is affecting things. When we did the baseline cortisol he seemed stable on the insulin and we didn’t know about the the TCC. Now everything changes. And I am torn between pursuing treatment because of his personality and how he is always so stressed with anything new. Being left for six hours of chemotherapy treatment would be very hard for him. First we have to see an oncologist and see what our options would be. Today he is already high glucose at 6 Pm. He was doing pretty well until the last couple of days. I can’t even seem to get one of his issues resolved. Monday I will see if we can get scheduled with an oncologist and go from there. I’ll keep you posted and thanks again!

Oh Clair,

I was heart-broken to read about the TCC. :( And the third baby as well. Bless your heart. I've always said these babies know who will take the best care of them and that's why we end up with multiple dogs with the same issue. One of our members has her third cush pup. Doesn't make the diagnoses any better to swallow tho.

One thing I want to put out here for you to keep in mind. ANY illness, trauma, etc will cause the cortisol to rise naturally. That is the job of cortisol...to rise in the face of any stressor, external or internal, in order to help the body cope better. It is a fight or flight hormone. An elevation of cortisol with cancer is EXPECTED due to the nature of cancers. This does not need treatment...it is a natural process not a Cushing's disease process. So keep in mind that Vetoryl is probably the very last thing Remy needs right now. The cortisol is more than likely helping him at this point as Marianne suggested. Definitely worth discussing with his specialist but in your shoes, I would flat forget about Cushing's for now. BUT that does not mean you get to leave us....no no no. You and Remy are family, always, no matter what.

Hugs,
Leslie

Thank you all for your support and advice. Last night was awful. NO response to his Vetsulin so he was miserable pacing, panting, thirsty. It was after 2 AM before I got him to sleep. I’m pretty sure his cortisol levels are up and trigging insulin resistance. If I don’t treat with Vetoryl how do I keep him from being hyperglycemic? It’s been a steady progression of worse and worse response to his insulin. We know 5 mg every other day was too much. The Internist has a veterinarian friend with a dog who is extremely sensitive to Vetoryl so he gives it to his dog twice a week and it works for them. I’m wondering about something similar for Remy. Like every 4 days maybe? Then we can retest and see what level he is maintaining. I have to get some action with the insulin though and get that glucose down. I’ve read some studies where increased glucose in the urine can predispose to bladder cancer. And maybe that’s why he has it. For the most part he doesn’t fit the typical TCC criteria. He’s not around pesticides or herbicides (in fact he hates it outside and hardly goes out). He’s not obese and he’s not a female. We don’t smoke and I don’t use chemicals on the floors, I just steam clean. He likes the cold marble floors. He’s not exposed to anything I can think of that I have any control over. But IF there is a tie to glucose in the urine and that diabetics are more prone to bladder cancer then that seems to fit. So what to do? We see his primary care vet this morning. Thoughts??

I’m so sorry things are going poorly again. But first off, if Remy were mine, I would not start back with the trilostane until you’ve had an ACTH that confirms abnormally elevated cortisol once again. There may be other causes for his lack of response to the insulin, and adding trilostane back into the mix if it’s not called for can just make things worse. If an ACTH is abnormally elevated once again, then I’d strongly advocate for a small compounded daily dose. As I’ve written above, I do understand why your vet prefers Vetoryl, as do I when it’s feasible. But giving Remy a dose of Vetoryl that’s too large on a spaced out basis does not seem like a workable solution to me. In essence, you’d be overdosing him part of the time and underdosing him most of the time. It seems to me that would only add to the rollercoaster effect. For a dog who doesn’t have diabetes, spacing out a larger dose over a few days may work OK, as is the case for your vet’s friend. But for a diabetic dog, I’d have to think that giving an appropriate daily dose, even if compounded, would be preferable in terms of maintaining glucose stability throughout a 24-hour time period.

But I’d think that step one would be to start with the ACTH. Once we have those results, the path forward may be clearer for us all.

We have Remy scheduled for Monday for ACTH. We need to find out exactly where he is at and if it’s actually high and affecting his glucose. Right now he seems rather insulin resistant with little response to it. I am also going to have him run a CBC and chem panel and urinalysis so we can take the results with us to the vet school on April 1rst for Oncology consult. I was looking at Wedgewood Pharmacy’s website and apparently they have trilostane compounded from Vetoryl down to 1mg capsules. I think that would work for us if we need to put Remy back on. We know 5 mg every other day was too much.At 1 mg per day we would be at 30 mg per month instead of 75 at 5 mg every other day which was much too much. BUT we have to wait until we get test results back which I’m hoping will be by mid week. I have used Wedgewood many times in the past and been happy with them. I have no idea if his bladder tumor is contributing to any of the changes he is experiencing as far as his diabetes. He has so many issues it’s hard to know how far to push things. In the past we at least gave chemotherapy a try but given Remy’s extreme stress to change it might be too much for him. We can’t ignore how much affects stress affects health. We can give NSAIDs at home which may help keep the tumor from progressing for awhile. That’s a conversation for the Oncologists. His quality of life has to be paramount.

It sounds like a very reasonable plan to me, Claire. I know there are still a lot of question marks to figure out, but you’re taking things step-by-step, which is the best thing you can be doing for Remy. I’ll sure be hoping that you guys have a relatively calm weekend, and we’ll be waiting alongside you for those results.

UPDATE: Finally got the test results back for cortisol. Click image for larger version

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Baseline 138 and post ACTH 178. He has been off Vetoryl since February 17th.
So he is not ‘high’. Yesterday we went up to 6 units Vetsulin morning and evening and he got down to 109 a little while ago so this dose seems to be working. First time he’s been below 190 in nearly 2 weeks. He seems to be feeling pretty good so I’m going to stick with this and see how it goes. I’m surprised 1/2 U made such a difference but since it seems to be working I’m not going to question why. I assume being off the Vetoryl has changed his insulin requirements. Bloodwork was OK as was urinalysis. No abnormal cells were seen in the urine sample but since we have a positive BRAF and the mass is visible on ultrasound we have to assume it is positive for transitional cell carcinoma. Our appointment with Oncology is Monday. For the moment I’m calm, Remy is happily sleeping away and we are thankful for the support and advice you have all provided!! I always welcome your invaluable input! Thanks to everyone and I will continue to update.

Claire, I’ve been anxiously watching for your update and I’m so relieved to read tonight’s summary! For folks who are more familiar with ACTH results reported in units of ug/dL, here’s the conversion:

Baseline cortisol: 5.0 ug/dL
Post-ACTH level: 6.4 ug/dL

So at least for the time being, it’ll sure make things a lot easier to not have to worry about restarting the Vetoryl. Whew!

And I’m so glad Remy’s glucose level is doing better, too. I know we’re still just taking things one day at a time. But thank goodness today sounds like it’s been a good one :-).

It gets a little confusing because the vet school uses nmols and some of the vet’s offices use ug/dl. But for now his cortisol level is pretty good so we will not need to treat. I went ahead an upped the insulin half a unit and he has done very well today. It’s almost time for his dinner and evening dose of insulin and he’s at 289. It’s been a couple of weeks since he had such a good curve as today. We will just keep going day by day. The next trick will be his food because the brand he’s been eating for years now has discontinued all but I think, 3 flavors. We liked it because he could have different protein but the rest of it was pretty much the same. He’s so picky he liked the variety. Changing his diet could affect his glucose which will be another hurdle to cross. But for tonight I’m happy to know he is doing OK and it’s peaceful. Thank you so much for your support and encouragement!

I know my cat's diabetes has been very challenging, I've reconciled if I can keep his BG under 230 I'm happy. I did have to up his carb amount to 15% because his BG was going too low and now he's in the target range 50% of the time, he's 14 years old and in great spirit so we're staying the course. It sure is a juggling act! Keep up the good work, you're doing a great job!!

It is so difficult at times. But you’re doing everything right and the main thing is that your kitty feels good. The endocrinologist we see said not to get too hung up on numbers. Few or no clinical signs are good. We just learned the dog food we have been feeding is discontinuing all but three flavors which will be another hurdle to jump. We have had three good days now in a row so I’m happy. So many things to be aware of and they can’t tell us how they feel. Low glucose can be so scary! Kitty is lucky to have such a devoted Mom!