REMY diagnosed last week

[Squirt's Mom]

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

[Remy’s Mom]

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??

[labblab]

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.

[Remy’s Mom]

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.

[labblab]

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.

[Remy’s Mom]

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.

[labblab]

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 :-).

[Remy’s Mom]

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!

[Harley PoMMom]

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!!

[Remy’s Mom]

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!