Cooper - diabetes and cushings - sweet Cooper has passed

I'm a new member as we just got the confirmed cushings diagnosis today. My poor Cooper has been through a lot the last 3 months. Cooper is a (approximately) 10 year old, previously 73 pound, now 58 pound German shorthaired pointer. He's been drinking excessively for 2 years or so. He was tested multiple times for diabetes. Every time it can back normal but his liver enzymes were elevated, but not enough to be concerned about.

3 months ago he started peeing in the house and very quickly lost weight. That time his blood glucose level was over 500. We were told he also showed signs of cushings but the vet wanted to control the diabetes first. We did a steady increase in insulin (humulin n) until we reached 28 units. For the first time his blood glucose level was 230. He also had a bladder infection that required tougher and tougher antibiotics. Throughout the 3 months of insulin increases, there were so many factors that had to be considered, was the bladder infection causing insulin resistance? Was the possible cushings causing insulin resistance?

Once his bg level was somewhat acceptable, we waited 2 weeks then did a urinalysis to make sure the bladder infection was gone. Of course it wasn't and a urine culture was ordered. And the tested his bg again since the sugar was high in his urine. His level was up in the upper 300s. The vet said it's probably time to switch insulin. And he also thought it was time to test for cushings.

Cushings test was positive (I don't know the levels but it was an acth test). The vet has decided to keep him on humulin with the hope that his dose will decrease as his cushings is controlled. We'll be starting vetoryl tomorrow, along with a 6 week course of antibiotics since his bladder infection is still present.

At this point I don't have many questions since I've been doing an insane amount of research. I guess I'm just hoping for some stories of other dogs with diabetes and cushings. Specifically dogs being regulated for both at the same time. I haven't had much luck finding happy endings, which is something we're prepared for, we just want an honest idea of what to expect.

Hello and welcome to you and Cooper.
First thing, I'd like to suggest that you also join out sister site, http://www.k9diabetes.com/forum/
We do have members on both sites that are dealing with cushings and diabetes.
I'll let those who are familiar with both comment, but we have had members who have successfully controlled both. So it is doable, but it's hard and we understand that. The bladder infections just make a difficult situation that much harder of course. Definitely join the diabetes site.

Sharlene and Molly Muffin

Hi and a big welcome to you and Cooper from me as well!

I can be of absolutely no use to you in anything regarding the diabetes, but I can tell you this place and the k9diabetes site is full of wonderful, caring and helpful people. It would be my guess that if anyone can guide you through the road ahead, they will be here and at k9diabetes.

Hang in there and don't assume the worst just yet.

Hello and welcome from me, too! Coincidentally enough, we have another new member with a little girl Cooper who is also challenged by both diabetes and Cushing's -- if you both end up posting at the same time, perhaps we'll need to shift to "Mr. Cooper" and "Ms. Cooper!" ;)

On a serious note, though, I can imagine how worried you are feeling and I "second" the recommendation that you join k9diabetes.com, too. We have several dual members of both sites, and I know you'll receive extra support. We have a long history of dogs who are very successfully managed with both diseases. So even though there may be bumps along the way, please do not give up hope.

Can you tell us what dose of trilostane Cooper will be starting with today? Also, I'm rather hoping you'll tell us he will be dosed twice daily rather than only once, because many endocrinology specialists believe that dogs being treated with insulin benefit from better management with twice daily trilostane dosing so as to keep their cortisol levels as consistent as possible at all times (rather than peaking and troughing at more inconsistent levels within every 24-hour time period).

We'll be very anxious to hear how things are going for you, so please give us an update when you are able.

Marianne

I will definitely go join the k9diabetes website.

I can't remember what the vet said his dose would be, it was either 60 or 80 mg. The vet did not mention anything about giving it twice a day. He did say that while he's treated lots of dogs with diabetes and lots with cushings, he's never treated one with both. Which seems a bit odd since they appear to go hand in hand. The vet has been fantastic and seems to be doing everything that should be done (according to what I've been reading), but I'm going to check around for a vet that has treated both at the same time. I'd hate to do it since this vet is so attentive and Cooper is finally comfortable going to his office, but I also want to give Cooper his best chance.

Here's a quick link to an article that addresses twice daily dosing for diabetic dogs. Since you haven't actually started yet, I'd strongly encourage you to discuss this with your vet before purchasing the drug, if possible. Dr. Peterson is a noted authority on the treatment of endocrinological issues, and here's a quote:

Quote:

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In diabetic dogs with concurrent Cushing’s disease, twice-daily administration is essential in avoiding large fluctuations in serum cortisol concentrations during the day (1,2). With once-daily*trilostane*administration,*adequate*diabetic control will be next to impossible in many dogs with concurrent Cushing's syndrome.

---

Here's the article: http://endocrinevet.blogspot.com/201...rilostane.html

Here's another similar quote from Dr. Ellen Behrend:

Quote:

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In diabetic patients with hyperadrenocorti- cism, twice-daily dosing is absolutely recommended to avoid large fluctuations in serum cortisol con- centrations.

---

http://www.dechra-us.com/Files/dechr...trilostane.pdf

If your vet has questions about this, he can also contact Dechra directly (manufacturer of brandname Vetoryl). They have vets on staff who are happy to consult about issues such as this, and I feel confident that they will back up the recommendation for twice daily dosing in diabetic dogs, since both Dr. Peterson and Dr. Behrend provide continuing education on their behalf.

http://www.dechra-us.com/Default.aspx?ID=365

I totally understand your hope to remain with your current vet, and as long as he open to consultation with other folks, I would hope that he will be able to successfully continue to manage Cooper's care. I think that consultation is the key -- as long as your vet is open to talking with other more experienced specialists, there is no reason why he can't remain on top of things.

Marianne

Thanks so much for that article! I just printed it out and I will bring it with me to the vet today.

And yes my vet is very open to consultation. He has already been consulting with internists when it was just the diabetes we were trying to control so now that it's both issues I'm sure he'll be consulting like crazy!!

That sounds great! Also wanted to add that with twice daily dosing, you are splitting the recommended daily total into two half doses -- you are not doubling the recommended once daily total.

Marianne

We went to the vet today. The vet said he had not read about giving it twice a day for diabetic dogs. But he said it makes sense to him and to go ahead and do it. He was going to start us at a very conservative dose of 60mg. He said to go ahead and give him one 60mg pill twice a day.

Now I have another question for anyone out there: what is loading? I keep reading about giving them a loading dose then testing. Should that be a high dose or a low dose? Right now our plan is to just test is blood glucose in a week.

Hi,

I want to be sure you read Marianne's previous post about twice a day dosing. You do NOT double the dose so be sure your vet understands this. If he was going to prescribe 60mg a day he will keep very close to that total amount for the day with twice a day dosings - say 30mg in the morning and 30mg at nite.

Loading only occurs when one is using the drug Lysodren. With Trilostane (Vetoryl) there is no loading phase. Instead, ya'll Trilo parents get to play around with tweaking doses and deciding between once a day or twice a day dosing. :D

Be SURE your vet understands the dosing for twice a day BEFORE you buy or start giving the med to Cooper.

Hugs,
Leslie and the gang

Leslie, thanks so much for emphasizing that. Yes indeed, a daily total of 60 mg. does sound reasonable for Cooper -- but that means only 30 mg. twice a day! That's per the initial dosing formulas given in both of those links (1 mg/kg twice daily, which translates into approx. 1/2 mg. per pound twice daily).

Marianne

I am just chipping in as I haven't read that an ACTH test is scheduled for 10-14 days this is part of the protocol for giving vetoryl, that result will then give you a reading to determine what your next steps will be for continued testing.

Has your vet spoken to anyone at Dechra yet? Might be worthwhile nudging him in that direction sooner rather than later

Mel

Xxx

We discussed it and he thinks 60mg twice a day is still a conservative dose for him.

We don't have an acth test scheduled for 10-14 days. The vet said 3 weeks from the start date but we'll be testing his insulin dose more often.

I just calculated that his meds are now costing us close to $400 a month. Ugh!! I hate to gripe about money when it's about a dog's life, but ugh!!! I hope the cushings meds will at least lessen his dose of insulin and save some money.

Whoever started this forum is my new hero! What a wealth of information already. Thank you all!

My Jenny used Lysodren but she is also diabetic and once her cushings got under control her insulin needs dropped from 7 units twice a day to 3 units twice a day. (she was 7 pounds at the time)

So it made a huge difference for her. Good luck!

Uh oh.....now I am getting worried. :( :( :(

I don't think your vet will find many specialists with large Cushing's practices who currently agree that starting a 59 lb. dog on a daily total of 120 mg. is a conservative dose. At one time in the past, yes. But no longer. Here's another quote from that article by Dr. Peterson:

Quote:

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When this drug was first used in Europe over a decade ago, the original starting dose was 4-10 mg/kg/day (7-12). However, as experience with the drug grew, it became apparent that these doses were too high in many dogs and lower doses were needed. Accordingly, the dosing recommendation on the US package insert states that an initial daily dose of 2.2-6.7 mg/kg is recommended (4).

My recommended starting dose is either 2 mg/kg given once daily or 1 mg/kg given twice daily. This is similar to the doses used in this study by Feldman (13), where the mean trilostane dose administered to his dogs was 0.86 mg/kg, twice daily (or a mean total daily dose of 1.72 mg/kg). Like Feldman, I feel that it is best to start with a daily dose that is at the low end or even lower than that recommended in the package insert. I would never start a dog on a dose at the higher end of the recommended dosage range (4-7 mg/kg), although some dogs with Cushing’s disease will eventually require daily doses that may be this high or even higher.

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Dosing Cooper at 120 mg. each day works out to approx. 4 mg/kg -- exactly the level that Dr. Peterson is cautioning against! Starting Cooper at a dosage level this high not only increases the risk of unwanted side effects (which of course is the most important issue), but it also makes the drug more expensive for you. I just checked a couple of online pharmacies and as an example, find that you can purchase sixty 30 mg. capsules of brandname Vetoryl for $120 from Drs. Foster and Smith.

Also, I'm not sure how your vet has arrived at the three-week ACTH testing date, as it is not the timeframe that is recommended by Dechra. :( :(

I am including another link for you. It is Dechra's U.S. Product Insert for Vetoryl, and it contains a lot of important info re: appropriate treatment and monitoring. PLEASE DISREGARD THE DOSING CHART, because it contains the outdated dosing information to which Dr. Peterson is referring. Pay attention instead to the fact that the conservative end of the published dosing range is a daily total of 1 mg. per pound. Several of us who have spoken personally with Dechra technical reps have been advised that the 1 mg. per pound formula is the initial dosing amount that they are now generally recommending. Once again, if you or your vet have doubts or questions about this, I encourage you to contact Dechra directly.

http://www.dechra-us.com/files/dechr...ts/Vetoryl.pdf

If you already have the 60 mg. capsules in hand, I realize this presents a dilemma for you. You may be better off sticking with 60 mg. once daily until such time that you are ready to reorder new capsules as opposed to risking an early overdose. Once you have 1-2 ACTH tests under your belt, then you'd have a better idea as to what daily total Cooper truly can handle. But I would want to discuss the pros-and-cons of that approach (starting out once daily) with somebody more knowledgeable about diabetic management. And I would hope that your vet has not ordered more than just a thirty day supply at this point, since dosing changes are not at all unusual after the first thirty days of treatment and sometimes even sooner. (Plus, you likely can find less expensive options for buying your trilostane in the future if you explore options other than directly from your vet.)

Marianne

My children kept me real busy tonight, but I'm going to give him just one pill a day until I can read through that info and talk to the vet. Getting so overwhelmed here. This sure is a steep learning curve! I have no doubt I'll get a handle on this...eventually.

Any questions you have just pop in and ask them. :) Someone will be around to answer.
Starting at 60mg once a day is a good place to start. You will eventually know way more than you probably would ever want to about dosing and standards and testing and everything else, cushings related. :)

I hope you had a good evening. Let us know how things are going!

Sharlene and Molly muffin

Yes, I also agree that starting with the single 60 mg. in the morning is likely the best move for the time being. We do have some diabetic dogs here who are dosed only once daily, so it's not as though it is never done. Twice daily dosing is the newer recommendation for diabetics, though, so that's why I want you and your vet to be able to consider it in the future.

Marianne

Hi,

Learning curve is right! :eek::p Just don't learn while giving a massive dose of this med to Cooper. ;)

It worries me with Trilo that folks have the idea it is safe - it is NOT any safer than Lysodren so please do not take any chances with Cooper, and your vets attitude is rather cavalier. It will not hurt one little thing to wait before starting the treatment to get this business with the dosage worked out. That is much preferable to giving this dose to him and him ending up in the hospital, or worse. So learn before starting this huge dose. ;)

Hugs,
Leslie and the gang

I just wanted to post a quick update on my Cooper. We did the 60mg dose of vetoryl once a day and 30units of insulin twice a day for about 2 weeks because we were going on vacation and didn't want to push things with Cooper while we were gone. When we got back from vacation we did a glucose check and 6 hours after his morning insulin his blood sugar was in the upper 200s (which was the absolute lowest we'd seen but still not in the desired range). The vet said to start giving 60mg of vetoryl twice a day.

He wanted us to stay at that dose for 3 weeks then do an ACTH test. We're 2 weeks into it and I just rushed him to the vet. His teeth were chattering for a bit so I left a message with the vet to see if this was some indication that the insulin was too high. Cooper went and took a nap then woke up and his back legs were twitching and he walked into a wall.

I took him straight to the vet. His blood glucose reading was 169. But she said she's more worried about him getting an overdose of vetoryl and that it sounds like he's getting addisonoid (is that a word?). His electrolytes were very low so he's spending the afternoon at the vet getting fluids and when we pick him up we'll find out how we're going to adjust his dose.

I had never heard about the teeth chattering or muscle twitching, so I thought I'd post his update so more threads would show up if people were searching!

Oh dear. It looks as though our worst fears have been realized as far as the possibility of overdosing Cooper with the addition of that second 60 mg. capsule. :( :(

I will keep my fingers crossed that he rebounds quickly. But depending upon how low Cooper's cortisol actually went, do be aware that Vetoryl's manufacturer advises against resuming dosing entirely until clinical symptoms reoccur and the cortisol is back to a normal level:

Quote:

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If the ACTH stimulation test is <1.45 μg/dL (<40 nmol/L) and/or if electrolyte imbalances characteristic of hypoadrenocorticism (hyperkalemia and hyponatremia) are found, VETORYL Capsules should be temporarily discontinued until recurrence of clinical signs consistent with hyperadrenocorticism and test results return to normal (1.45-9.1 μg/dL or 40-250 nmol/L). VETORYL Capsules may then be re-introduced at a lower dose.

---

Thank you so much for letting us know what has happened. We will continue to warn against starting dogs off at too high a dose, and so Cooper's experience may end up helping another doggie further down the road. :o

In the meantime, sending many healing hugs your way. Please keep up updated!

Marianne

My Jenny, also diabetic and Cushings went Addisonian from too much Lysodren. Thank goodness you caught it

The only hope I have for Cooper is that his BG stayed at 169. Jenny dropped as low as 40 so maybe you caught it in time.

Jenny's ACTH was at .2 after her overdose last April and she was on prednisone for about 4 months and hasn't been on anything but insulin since August 2012

It isn't the end of the world if it happens. Her hair looks better and she is frisky. And her cortisol is very very slowly coming back up

Please keep us posted. good catch. hugs, Judi

Wait, so when they go Addisonian it's a long term, new condition sort of thing? I had assumed it was just a short term effect and that once the vetoryl was out of his system he'd go back to normal.

Due to the mechanism by which trilostane works, more often than not, cortisol levels do rebound relatively quickly in dogs who have "crashed" while taking the drug. However, there are exceptions and there is no way to predict in advance. For some dogs, it may take months before cortisol levels normalize. And a few dogs remain permanently "Addisonian" (meaning that they will require lifelong steroid supplementation from that point onward). But at this point, it is far too early to suspect longterm issues for Cooper. In the short term, the important thing is to stabilize him with IV support as is being done.

But since trilostane does have the potential to cause longterm adrenal suppression, you want to make sure your vet doesn't leap right back into resuming the trilo -- even at a lower dose -- until you are certain that his adrenal function has normalized once again based on his behavior and ACTH monitoring results.

Marianne

I'm getting so antsy to talk to the vet now, there's nothing worse than looking things up on the Internet! She had mentioned doing his ACTH test early (he was scheduled for it next friday.) I'm hoping she wants to do it tomorrow, although I think I still would have to wait until Monday for the results.

Yes, I agree with you. If Cooper's electrolytes have dropped low enough to need IV support, he also needs to have his cortisol level checked ASAP. If it has dropped too low, he may need some oral prednisone for at least a few days in order to make up for the loss. The last thing you want is for him to go into a crisis over the weekend when your vet is unavailable. So even if the ACTH results are not known until Monday, I encourage you to ask your vet for prednisone to have on hand should Cooper appear to need it over the weekend.

I realize this is even a bigger issue for him since he's diabetic, and big changes in his steroid levels have an impact on his insulin needs. So I'd definitely want a gameplan in place before the weekend.

Thanks! I will be sure to ask for some emergency meds in case we need them.

Just wondering how you and Cooper are? Hope everything is ok

Mel
Xxxxx

Thanks for asking! He's doing well today. He got fluids all afternoon yesterday and sent home with prednisone (sp?). The vet had me give him half a 20mg tablet last night. She said to skip the vetoryl last night but to start again this morning since he really seems to need it to get his insulin to work. We're cutting back his dose from a 60mg pill twice a day to a 60mg in the morning and a 30mg at night. She said at the first sign of twitching or anything else unusual to stop the vetoryl, give him a prednisone and bring him right in.

He'll have an ACTH test in a week and a half. I think the vet is trying to hold back a bit on testing since he's got so much going on. I guess the vet wants to let his body adjust to everything. But if Cooper does have another Addisonion episode, I'll be stopping his vetoryl and making sure I don't start it again until his ACTH test comes back above 1.45 or whatever it's supposed to be.

Luckily I'm a stay at home mom and I have a 2 year old who naps around noon. Cooper had his little episode at 11am and I hate to think what would have happened if I wasn't here giving my son lunch. With the way the insulin and vetoryl work together he's most at risk 6 hours after his morning meds, which is right at noon. We're almost always home at that time for my son's nap.

Thanks so much for this update and I'm really glad that Cooper seems better. I must tell you, though, that I am extremely worried about your vet's decision to resume the trilostane without the benefit of an ACTH test. If I am understanding things correctly, Cooper has been taking trilostane for a month now -- and even had the trilostane doubled during that time -- without the benefit of any ACTH monitoring testing whatsoever. To now layer on an episode of electrolyte imbalance requiring IV stabilization and STILL not perform an ACTH test before immediately resuming the trilostane is truly contrary to safe protocol.

I know you will watch Cooper very closely, and you absolutely need to because he can get into serious trouble very quickly under these circumstances. I will be blunt here, but I do not understand your vet's reasoning re: postponing the recommended monitoring testing, and I do think she is putting Cooper at risk.

Please continue to keep us updated, OK?
Marianne

Hi Julie. Glad Cooper is a bit better. I too was very surprised that the vet recommended putting Cooper back on Trilostane without an ACTH test after this episode. How does she know where his cortisol level is currently at and if he needs a dosage or not? Strange.

Anyway, main thing is that Cooper is better and we know you'll have your eye on him and taking good care of him.

Sharlene and Molly Muffin

It was my regular vet's day off yesterday so I was dealing with the other vet in the practice. I know that she did call my regular vet and consult with him. But I think I'll call tomorrow and see if he's in and set up a meeting to talk this through. I know he's never had a case as complicated as Cooper's and can probably usually breeze through on his usual protocol, but it looks like Cooper is an unusual case and I'd rather be safe than sorry. I'll skip his vetoryl tomorrow and call the vet in the morning. This evening he seems to be breathing a bit quicker than normal. He's always panting but it seems a bit more than normal tonight so I was thinking of bringing him in anyway.

You had mentioned earlier that your regular vet was consulting with some internists, but I am thinking that now might be a good time for Cooper to be seen directly by a specialist who is really familiar with the combination of diabetes and Cushing's. I agree with you that it sounds as though your general vet practice may be over-reaching at this point :o. For instance, when Cooper shifted to twice-daily dosing, I am worried that your vet decided to double the once-daily dose rather than halving it as is generally recommended. And once again, all of this without any monitoring tests.

Diabetes and Cushing's are tricky enough, individually. But when they are combined, it can really take the expertise of a specialist to keep things on an even keel. So if you do have an internist available to you, I'm hoping you may request a referral, at least at this early stage as you are trying to get Cooper stabilized on his medication.

Marianne

I agree Marianne. In fact, once diagnosed I would see a specialist asap so that they can advise your general vet. If I had done so, I would have saved quite a bit of money that I would have had for Daisy's future tests etc.

Poking my head in to see how Cooper is today? Is he still breathing really fast? Did you get hold of your vet to have a chat? :)
let us know when you get a chance!
Sharlene and Molly Muffin

He had another little episode today. He went to get up and his back legs didn't work for a few steps, he just kind of dragged them. Then his back legs were twitchy again. I gave him a prednisone and rushed him in. His blood glucose was 330, they didn't check his electrolytes. We're going to keep him on the prednisone and off vetoryl for the weekend and then they want me to check in with them on Monday to see what to do next. I'm going to ask for a referral for a specialist then. I know it's going to be a whole lot more expensive, but hopefully it will keep us from having to go so often and keep him from going through so many swings. It has to be so rough on him.

Oh my, not good. I'm glad you won't be giving any more vetoryl for the moment. Frankly, it sounds like Cooper is being overdosed on trilostane. I wouldn't even think of starting back on that without knowing where the cortisol levels are at. This is very dangerous in combination with the diabetes. I do hope that you get to see a specialist and that they can get Cooper back on track. You guys need some worry free days and a break from this stress and Cooper needs to be well. :( I'm so sorry that this has happened.
Sharlene and Molly Muffin

So sorry to hear that Cooper is feeling unwell. If this were me I would insist on having his electrolytes checked along with his cortisol levels ( an ACTH stim test.)

Please do keep us updated and I hope Cooper is feeling much better soon.

Love and hugs,
Lori

I think I should clarify why so many of us are worried. The experts, do recommend that with a dog with both diabetes and cushings that twice a day dosing is optimal for control and not getting spikes. However, you don't go from 60 mg, once a day to 60 mg's twice a day. You split the dose and give 30mg in the morning and 30 mg in the evening, approximately 12 hours apart to start with. Your vet absolutely double his dosage from 60mg once a day to 120 mgs, split to twice a day. I have Never heard or read of this being an acceptable protocol and frankly, it scared the bejeebes out of me. All of this without any testing to see where the cortisol is at. Cortisol can very much mess with the insulin and his diabetes.
I think this is why Cooper is currently having so many issues.
I would recommend this article and even have it printed out for your vet if you want by Dr. Peterson.
In it he talks about dosage for one a day and twice a day dosing and further into the article, he talks about dosing in relation to diabetes.

http://endocrinevet.blogspot.ca/2012...rilostane.html

I hope this helps and you already know we are worry warts here, but for good reason. It's too easy for vets to not follow proper protocols and we are finicky about making sure that every advantage possible for successful treatment is given to both person and their furbaby.

hugs,
Sharlene and Molly Muffin