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Thread: Cushing's and Diabetes, what's been your experience?

  1. #11
    Join Date
    Dec 2019
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    25

    Default Re: Cushing's and Diabetes, what's been your experience?

    Hi Squirt's mom, I did check that specific forum, and it seems like there's only one post there from 2019, if i'm checking correctly. That's really unfortunate as I have a lot of questions about the diabetes side of it specifically.

  2. #12
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    Dec 2019
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    Default Re: Cushing's and Diabetes, what's been your experience?

    Unfortunately I don't have the labs on hand from Jan of last year because we were just happy with what the vet said it was. I started asking for copies after the July episode. I can post the labs from July when she was hospitalized, the follow up ones unfortunately I can't post because they're pdf version, but i can write out the ones of interest. One weird thing she presented with during her DKA episodes was elevated Bilirubin, she was jaundiced. Does anyone have an idea of what that could be from? No one could tell us, the doctors at the hospital were confused why that's so elevated as well. It went as high as 8, and then decreased back to undetected levels.
    Here's her results from July:

    Patient: DAISY
    Species: CANINE
    Breed: MALTESE_CANINE
    Age: 8Y
    Gender: FEMALE
    Requisition #: 1233369
    Accession #: 8200518792
    Order recv'd: 7/19/2019
    Ordered by: SINGH


    TOTAL HEALTH WITH SPEC cPL : CHEM 27 w/ TRIG SDMA
    Test Result Reference Range
    GLUCOSE (1) 452 63 - 114 mg/dL HIGH
    SDMA (2) 10 0 - 14 ug/dL
    CREATININE 1.0 0.5 - 1.5 mg/dL
    BUN 21 9 - 31 mg/dL
    BUN/CREATININE RATIO 21.0
    PHOSPHORUS 4.5 2.5 - 6.1 mg/dL
    CALCIUM 8.9 8.4 - 11.8 mg/dL
    SODIUM 141 142 - 152 mmol/L LOW
    POTASSIUM 4.6 4.0 - 5.4 mmol/L
    CHLORIDE 96 108 - 119 mmol/L LOW
    NA/K RATIO 31 28 - 37
    TCO2 (BICARBONATE) 22 13 - 27 mmol/L
    ANION GAP 28 11 - 26 mmol/L HIGH
    TOTAL PROTEIN 6.2 5.5 - 7.5 g/dL
    ALBUMIN 2.9 2.7 - 3.9 g/dL
    GLOBULIN 3.3 2.4 - 4.0 g/dL
    ALB/GLOB RATIO 0.9 0.7 - 1.5
    ALT 253 18 - 121 U/L HIGH
    AST 169 16 - 55 U/L HIGH
    ALP (3) 5559 5 - 160 U/L HIGH
    GGT (4) 128 0 - 13 U/L HIGH
    TOTAL BILIRUBIN 0.7 0.0 - 0.3 mg/dL HIGH
    BILIRUBIN UNCONJUGATED 0.4 0.0 - 0.2 mg/dL HIGH
    BILIRUBIN CONJUGATED 0.3 0.0 - 0.1 mg/dL HIGH
    CHOLESTEROL (5) 666 131 - 345 mg/dL HIGH
    TRIGLYCERIDE 167 20 - 150 mg/dL HIGH
    AMYLASE (6) 2774 337 - 1469 U/L HIGH
    LIPASE 1155 138 - 755 U/L HIGH
    CREATINE KINASE 332 10 - 200 U/L HIGH

    HEMOLYSIS INDEX (7) 1+
    LIPEMIA INDEX (8) N

    Comments:

    (1) RESULT VERIFIED BY REPEAT ANALYSIS
    (2) BOTH SDMA AND CREATININE ARE WITHIN THE REFERENCE INTERVAL which indicates kidney function is likely good. Evaluate a complete urinalysis and confirm there is no other evidence of kidney disease.
    (3) RESULT VERIFIED BY REPEAT ANALYSIS
    (4) RESULT VERIFIED BY REPEAT ANALYSIS
    (5) RESULT VERIFIED BY REPEAT ANALYSIS
    (6) RESULT VERIFIED BY REPEAT ANALYSIS
    (7) Index of N, 1+, 2+ exhibits no significant effect on chemistry values.
    (8) Index of N, 1+, 2+ exhibits no significant effect on chemistry values.

    TOTAL HEALTH WITH SPEC cPL : IDEXX CBC-SELECT
    Test Result Reference Range
    WBC 29.8 4.9 - 17.6 K/uL HIGH
    RBC 5.06 5.39 - 8.70 M/uL LOW
    HGB 11.6 13.4 - 20.7 g/dL LOW
    HCT 36.0 38.3 - 56.5 % LOW

    MCV 71 59 - 76 fL
    MCH 22.9 21.9 - 26.1 pg
    MCHC 32.2 32.6 - 39.2 g/dL LOW
    % RETICULOCYTE 0.7 %
    RETICULOCYTE 35 10 - 110 K/uL
    RETICULOCYTE COMMENT
    The appropriateness of the regenerative response should be evaluated considering the degree of anemia and reticulocytosis (see guidelines below).

    Degree of bone marrow response (reticulocytes K/uL):
    Mild 110-150
    Moderate 150-300
    Marked >300

    View the VetConnect Plus Differentials for additional information.

    RETIC HGB 26.2 22.3 - 29.6 pg
    % NEUTROPHIL 87.8 %
    % LYMPHOCYTE 1.0 %
    % MONOCYTE 8.5 %
    % EOSINOPHIL 2.5 %
    % BASOPHIL 0.2 %
    PLATELET 401 143 - 448 K/uL
    REMARKS
    Slide reviewed microscopically.
    Large platelets present.

    NEUTROPHIL 26164 2940 - 12670 /uL HIGH
    LYMPHOCYTE 298 1060 - 4950 /uL LOW
    MONOCYTE 2533 130 - 1150 /uL HIGH

    EOSINOPHIL 745 70 - 1490 /uL
    BASOPHIL 60 0 - 100 /uL


    TOTAL HEALTH WITH SPEC cPL : SPEC cPL
    Test Result Reference Range
    SPEC cPL (1) 2000 0 - 200 ug/L HIGH

    Comments:

    (1) Serum Spec cPL concentration is significantly increased which occurs with pancreatic inflammation. If clinical signs of pancreatitis are not present, consider additional diagnostics, instruct owner to monitor closely and recheck Spec cPL in 2 to 3 weeks. If clinical signs of pancreatitis are present, treat appropriately, investigate for risk factors and concurrent diseases including gastroenteritis or foreign body. Monitor Spec cPL to help assess response to treatment.

    Result is greater than 2000 ug/L.
    Last edited by Squirt's Mom; 12-09-2019 at 09:03 AM.

  3. #13
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    Dec 2019
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    Default Re: Cushing's and Diabetes, what's been your experience?

    Then the August ALP=755, and in September it came down to completely normal 156. It's pretty mind blowing to me really! When we took her out of the hospital she had some pancreatitis going on, she was pretty sick with these terrible labs. We did a recheck right after the hospitalization with my regular vet just to see where the labs were trending, and then an unfamiliar vet called me back to discuss the labs the next day because my vet wasn't in. She just looked at the numbers and told me that Daisy was in all organ failure and that we basically need to make a decision if we will put her down. All weekend I spent crying and saying goodbye. Then decided to call the hospital doctors again where she was hospitalized, and they said it wasn't necessarily the case, that sometimes labs come up before they go down, like a lagging effect. And that what matters more is how Daisy looks, which she was looking better. To think that she went from those 5500 ALP numbers to 156 and felt better than she has in a long time, makes me so angry at that vet who gave us no hope!

  4. #14
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    Mar 2009
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    rural central ARK
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    Default Re: Cushing's and Diabetes, what's been your experience?

    I would have been out of my mind with those lab results from July! Bless your heart having to see those results and then being told by the GP vet what you were. But Daisy's case points out very clearly why some pups need to be seen by specialists - because no matter how good they are otherwise GP vets simply do not have the education nor experience of the specialists and therefore can easily miss something completely or misinterpret what they do see.

    I remember when my Squirt had her spleen removed and I saw her labs while visiting her in the hospital one day - I burst into tears just knowing my Sweet Bebe was not going to make it. One of her nurses told me not to worry about them right then because her little body was under extreme duress and doing what it was supposed to do in the situation. Nice words to hear but so very hard to believe at the time. After that I asked to see her labs every time and they were returning to normal at a rapid pace which was very comforting to say the least. To be honest, I became such a pest at the hospital with my visits and phone calls they put ME on restrictions telling me they would call me daily with reports and let me know when I could come visit Squirt.

    It is good that Daisy has recovered from that horrible time and is acting more like herself lately. Let us know what the ACTH showed when you get a chance! Praying for great numbers!
    Hugs,
    Leslie
    "May you know that absence is full of tender presence and that nothing is ever lost or forgotten." John O'Donahue, "Eternal Echoes"

    Death is not a changing of worlds as most imagine, as much as the walls of this world infinitely expanding.

  5. #15
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    Dec 2019
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    Default Re: Cushing's and Diabetes, what's been your experience?

    Just got the results back over email, haven't spoken to the doctor yet though. The Pre ACTH cortisol was 0.9 ug/dl, and the post was 4.6. Is she being over suppressed? That pre cortisol seems to be lower than the desired number. And this is only on 5mg once a day! Thank God he started her on the lowest dose possible!
    Last edited by anotherk9lover; 12-09-2019 at 06:55 PM.

  6. #16
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    Default Re: Cushing's and Diabetes, what's been your experience?

    As to your previous email, I would love to take her to all the best specialists in town, but they cost a crazy amount of money. I asked at the hospital how much an internist who specializes in diabetes would be, and they said he's about $150 a visit. The pet bills with all of Daisy's health issues are getting to be too much. We spent well over 5k in the last 6mo. So at this point we have chosen to do the least invasive maintenance care for her to the best of our ability. She's not a young pup anymore, so if things just continue to go down south we will choose comfort measures, we decided against another hospitalization, as heartbreaking as it may be.

    I totally understand your feeling though, of wanting to check on your furry friend, I was also calling a lot, and asking to see her. Some vet techs (well one in particular) was so rude about it, she wouldn't let me back there to see Daisy during her DKA hospitalization bc it made it more inconvenient for them when daisy would start to bark. And she would keep me away from talking to the MD, which as an RN myself, I find that behavior absolutely unacceptable! I finally was let inside, and the vet had plenty of time to talk to me about everything! There was no reason to lie that the doctor was "busy". It was a very distressing time, it's so different when it's your family or pet in the hospital, than it is for those who work there. That's actually a lesson that I took away to my own bedside nursing.

  7. #17
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    Dec 2019
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    Default Re: Cushing's and Diabetes, what's been your experience?

    So I just spoke to the vet regarding her ACTH results, and he suggests to take her off of vetoryl for now to avoid over suppression. And if anything restart her on a 2.5mg, but that's not even sold on the market, which means it would have to be compounded which i'm sure will cost me a pretty penny. He seems to be out of ideas on what to do at this point. He's suggesting a referral to an medicine specialist. Sigh... I'm not sure what to do next. Do you guys have any suggestions?

  8. #18
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    Default Re: Cushing's and Diabetes, what's been your experience?

    I surely do understand the financial burden associated with all this, and how stressful it is. However, I truly think that if you can swing it, a consultation with a specialist is the best thing you can do for Daisy right now. She may or may not be overly suppressed. It’s true that her pre-ACTH level is low, but her post-ACTH level really is ideal. So I’m not sure how much concern there should be over the pre-level. And as complicated as Daisy’s health history has been, spending a bit more on an expert opinion upfront could end up saving you a lot of money down the line.

    If it turns out that a lower dose of Vetoryl is recommended, compounded trilostane is actually typically less expensive than is the brand name medication. Even if her overall dose remains unchanged, a specialist might recommend that you get a compounded version, anyway, so that you can split the daily dose in half and give it twice a day. Twice daily dosing is often recommended by specialists as the best route to go with diabetic dogs so that their cortisol level is kept at a more consistent level throughout an entire 24-hour period.

    You guys have already been through an awful lot, and my heart goes out to you. But as I say, I really hope you can find a way to manage a visit with a specialist. That might make the path forward a whole lot easier. Specialists have their own networks of colleagues with which to consult about difficult cases, and they also often communicate directly with the drug company that makes Vetoryl when dogs have unusual responses to the medication.

    Whatever you decide, please do keep us updated. But I’ve got my fingers crossed that maybe a specialist could be a big help to you.

    Marianne

  9. #19
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    Dec 2019
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    Default Re: Cushing's and Diabetes, what's been your experience?

    You may be right, I might take her in for a consultation, but they will likely want to repeat all the blood work which will just be too much!
    Good to hear though that compounded vetoryl may be better priced. I found vetoryl 5mg for a decent price though, about $27-30 a pack, doubt the vet will be able to match that, it's always a better price online. Splitting the medication would make sense though.

    As far as the levels, is the post really idea? Because in the reference range it said the post should be between 6-9.

    Thanks for responding Marianne!

  10. #20
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    Georgia
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    Default Re: Cushing's and Diabetes, what's been your experience?

    As far as the levels, is the post really idea? Because in the reference range it said the post should be between 6-9.
    The post-ACTH reference range of 6-9 is the “normal” range for a dog who does not have Cushing’s when the test is being used initially for diagnostic purposes. When the ACTH is instead being used to monitor trilostane treatment, the desired range is very different. Take a look at Dechra’s U.S. product insert for Vetoryl — you’ll see a box near the top of the insert that shows how to interpret post-ACTH results for dogs taking trilostane, and a reading between 1.45 and 5.4 is really right where you want to be.

    https://www.dechra-us.com/Admin/Publ...ack-insert.pdf

    As long as a dog is clinically doing well and the post-ACTH falls within that range, I’m not sure whether or not there is cause to be unduly concerned about that lower pre-ACTH result. If consulting with a specialist just doesn’t seem like an option for you right now, I’d encourage your vet to contact Dechra so as to discuss Daisy’s test results with one of their staff veterinary professionals. They are happy to talk with vets, and can offer experienced guidance re: treatment guidelines in situations such as this. Here’s Dechra’s contact info that you can pass on to your vet. He can either call or email them with any questions. They’ll open up a case report on Daisy, and offer their advice as to the best path forward.

    https://www.dechra-us.com/contact/technical-support

    Good luck!
    Marianne

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