Adrenal Dependent Cushings with secondary Diabetes: Squeaker needs a specialist!!!!

[bichons9]

Squeaker 15 yo chihuahua was found to have BORDERLINE Cushings assumed to be apituitary related but no treatment recommended. He had Patella and ACL surgery with BG 165..Everything went fine. Over months. weight loss unable to be ignored..4/26 diagnosed with full blown ADRENAL Dependent Cushings with mass on gland that extended to caudal ven cava. Adrenalectomy considered and plan discarded by DVM after reading CT Scan= too risky Squeaker ...started initial dose of Vetoryl at 3mg..then 6mg. now 10 mg at 6am and 3 mg at 6pm..Cortisol went from ??.9 in January and 44 on 4/26??. Cortisol vs Blood Glucose challenging to deal with .His spreadsheet has hour by hour real time care listed if interested..Thank for reading Oh, I just looked at the protocol that states. "do not give am Vetoryl before test???? DVM told me to give the Vetoryl 10 mg exactly 4 hours before the test???

https://docs.google.com/spreadsheets...wD4/edit#gid=0

[labblab]

Hello and welcome to you and little Squeaker, although I’m surely sorry for all the challenges you’re confronting! It looks as though he’s receiving very specialized care and monitoring, though, so that is an advantage. Are there any specific questions about the Cushing’s that we can try to help you with? I do know that the joint regulation of diabetes and Cushing’s can be tricky. Has Squeaker been dealing with diabetes for a lengthy time, or is that newly developing?

Once again, I’m really glad you’ve found us, and I hope we can help with any questions that you may have for us.

Marianne

[bichons9]

NO!! Squeaker had torn ACL in January 2021..borderline cushings ACTH test .9 but no treatment started? When huge lweight loss noticed in April, i wondered about Diabetes only to learn Cushings ACTH test >40..BG for surgery was 165..In last year BG has been 125..so Cushings tumor?? in Adrenal gland may have been acting up up in January..I have had 3 Bichons with Cushings. They were all pituitary dependent and treatment was easy. Squeaker goes tomorrow for another ACTH teat... has been on 10 mg Trilostane 6 am and 3 mg @ 6pm since Friday..was on 6 mg after on only 3 mg. It seems as if dosage is low????? but DVM said he doesn't like to start high due to awful side effects??? The hyperglycemia is ridiculous and only regular Insulin seems to work...Does/ Has anyone had pup with Adrenal dependent Cushings??? This is new to me!!!! And as you said..difficult with both DM and cushings!!! Any indo/ advice appreciated!!!!!! I guess .9 vs >40 are the cortisol readings from the ACTH Dexamethazone test??? Thanks for reading. Fran

[lulusmom]

I have reviewed your comments as well as your excel spreadsheet and it appears that the acth stimulation test used to confirm the cushing's diagnosis was done while the blood glucose was extremely high. Whenever an acth stimulation test or LDDS test is done, the vet has to make a valiant effort to gain some semblance of control of blood glucose before starting the test. Range should be between 150 and 350 mg/dl. This is equally important when doing the acth stimulation tests to monitor Vetoryl treatment. If this is not done, then the results are invalid and your vet should refund the cost of that test or credit your account. The CT findings of an adrenal tumor is not a slam dunk diagnosis of adrenal dependent cushing's. If an adrenal mass is functional, meaning the tumor has taken on a life of it's own, it doesn't care what the pituitary gland is telling it to do and keeps pumping out cortisol. Because the pituitary gland is functioning just fine, it recognizes all that cortisol in the blood and stops releasing acth. The opposing gland is not receiving that signal anymore so it goes to sleep and shrivels up. Can you please let us know what the other adrenal gland looked like? If it was normal or enlarged, then that would be a fairly good sign that the adrenal mass is not functional. I am a bit confused as to the 0.9 number you posted as being borderline cushing's. If this was an acth stimulation test result, that would indicate your dog is more likely not producing enough cortisol. I think that result is more likely the LDDS test which takes 8 hours to complete. A 0.9 ug/dl on this test is not borderline, it is negative for cushing's. Can you please look at the actual test results and confirm which test yielded that low result as well as provide the date of that test in relation to the diabetes diagnosis? Diagnosing cushing's is difficult enough but diagnosing concurrent cushing's in a diabetic dog is extremely difficult and unless it is done by the book, the likelihood of a misdiagnosis increases exponentially. Is your vet a general practitioner or an internal medicine specialist? I have provided a link below in support of the information I have provided as to proper testing protocol. It is very important that you ask your vet if he made sure blood glucose was low enough to do any cushing's tests? If the answer is no, then you may want to share this link with your vet.

Symptoms and lab abnormalities for both diseases are much the same, except for skin and coat issues which is a symptom of cushing's, not diabetes. Does Squeaker have loss or thinning of coat? Diabetes takes priority and I highly recommend you consider joining a diabetes support group. The first few months can be a rollercoaster ride so having others who have walked in your shoes share their knowledge and experience can be a great comfort and an amazing learning experience. It looks like you are doing home testing already so you are already ahead of the curve, no pun intended.

https://www.dvm360.com/view/diagnosi...og-proceedings

P.S. I just noticed that your thread title says "Squeaker needs a specialist". I 100% agree! I asked whether your vet was an internal medicine specialist because if not, I was going to recommend that you ask for an immediate referral to one. I often tell members that treating both conditions is like walking a tight rope while juggling and the vast majority gp vets simply do not have the experience and extensive education to safely and effectively diagnose and treat two very serious endocrine diseases. Even before Covid, getting a consult within a week was difficult but now it's three to four weeks out. You can always do what I did to get my last cushdog seen right away. I was told by a 24/7 ER facility with internal medicine specialists on staff that if I didn't want to wait, I could bring him in through the ER. No referral necessary for that either so that's an option for you.

[bichons9]

Oh my!! thanks for your reply..I am trying to get the nerve to show it to the DVM..However, I already read that one must get control of the BG before performing the ACTH test..and told him what I read. $23,000 later..I did not realize that the test was $440.00 each time...so doing one every week worried me..but mainly because of what you said and what I read. His new results are 11 post test vs the previous 44..I don't really know what it means ( I am an RN and seem to have lost brainpower..I am so tired..since I have 2 insulin-dependent diabetics and a cat now in remission thanks to the cat people in their wonderful forum.. They were there every minute to get me through the cat's diabetes telling me what to do that put him (Elliott) in remission (Lantus) ....never saw DVM for the cat after having the expertise of the cat people. Yes, I belong to the Canine diabetes forum ..Natalie used to help me with Suzie on Vetsulin, that I hate. but seems to do okay after 4 years on it. No, the DVM's are not certified internal medicine specialists but are referred to by the other local DVM's. After all, I am not in NY anymore..I am in "good ole Mississippi" I used to take 3 of my Bichons to Mississippi State Univ..but they have not offered to help me with Suzie's crazy BG -will go through DVM if asked. and my dislike of Vetsulin by Merck..They claim they look at my ss but ..... Her ss is a mess. You seem to have great wisdom and knowledge..I would like to share the CT results and Dex test with you but don't want to be inappropriate..expecting more from you. Marley (1 of7 dogs)_ has pulmonary hypertension..went to the "supposed" ER...It was unreal and they did not know what to do..they gave her Stadol (human name) and let her go after 40 minutes..She couldn't breathe and my DVM said luckily I got her to him by 7: 30 am..She is on 8 meds/day and is doing well....sorry for rambling but I just sit here and stare waiting for what is to happen next!!! I don't know if you can open this: file:///C:/Users/bicho/Downloads/SQUEEKER-MUNSCHAUER-2021-05-14-0914.pdf..Also, file:///C:/Users/bicho/Downloads/203647541_8F140183-813A-4131-B976-7B19D66CABBF.pdf..I am desperate for help.. Oh...DVM said to give the Vetoryl exactly 4 hours before test..the new protocol shared with me states NOT to give the Vetoryl ..I give up on what to do....and no thinning of coat...weight loss was 11lbs now 8lbs, > H20 and urination...Fran...Thanks so much!!!

[bichons9]

Oh well, I tried 4X to send reports..don't know if you got them..Thanks

[Squirt's Mom]

You can search for an IMS on the ACVM website found here:

https://vetspecialists.com/

I did a search for Mississippi and found these results:

https://find.vetspecialists.com/sear...IYR2qbc6X8XDWI

Hope that helps with the search for a specialist!
Hugs,
Leslie

[bichons9]

Squeaker has had no side effects from Trilostane..but I have so many issues when compounding is needed ..but more important....How many doses /day are most people giving their pups? Once or twice /day? Squeaker was on 6mg @ 6am...then went to 6mg@ 6 am and 3 mg @ 6pm..now he is on 15 mg @ 6 am only...Updates on BID or SID suggest that Vetoryl may only last 12 hours. I am just wondering what all of you really knowledgeable members think about this. I am sure it's a coincidence that this am Squeaker's BG > 600..but it made me think..Thanks for reading... Atricle-An Update on Vetoryl https://pubmed.ncbi.nlm.nih.gov/29606727/

[labblab]

Squeaker has had no side effects from Trilostane..but I have so many issues when compounding is needed ..but more important....How many doses /day are most people giving their pups? Once or twice /day? Squeaker was on 6mg @ 6am...then went to 6mg@ 6 am and 3 mg @ 6pm..now he is on 15 mg @ 6 am only...Updates on BID or SID suggest that Vetoryl may only last 12 hours. I am just wondering what all of you really knowledgeable members think about this. I am sure it's a coincidence that this am Squeaker's BG > 600..but it made me think..Thanks for reading... Atricle-An Update on Vetoryl https://pubmed.ncbi.nlm.nih.gov/29606727/

I saw that you had posted this reply on another member’s thread, but I’ve taken the liberty of moving it here so it can join your other questions and updates that are specific to Squeaker. That way all of his info will be consolidated in one place, especially since I’m not sure whether or not that other member will be returning to the forum soon.

As far as the frequency of trilostane dosing, clinicians have bern debating for years as to whether once vs. twice daily dosing is more desirable. My personal opinion is that a lot seems to depend on the individual metabolism of any given dog. Some dogs seem to do fine on once daily dosing and that’s certainly an easier regimen for an owner to follow. However, for other dogs, the clinical benefit does wane before the end of a 24-hour time period and symptoms may rebound daily as a result. For those dogs, twice daily dosing indeed appears to be preferable.

In Squeaker’s case, diabetes may be the most important factor. We’ve been told that twice daily dosing is generally preferable for diabetic dogs so that cortisol levels can be controlled as evenly as possible at all times during a day/night. The goal is to avoid peaks and valleys in cortisol that may have a similar effect on glucose levels. I see you started out with once a day dosing, then shifted to twice daily, and have now returned to once daily. Did the vet give you a reason for returning to once daily?

Marianne

[bichons9]

NO..he has changed dosage a few times..wanted to start low low... but wants Cortisol <10 so increased to 15 once a day. I really would prefer to give twice a day..I do not think that the DVM thinks it through or maybe he likes once a day..I will ask him next week...he sounds overwhelmed with the CT results and has his partners consulting on what to do....Plan was for MY other DVM to do Adrenalectomy until they saw CT results and ESPECIALLY BECAUSE IT IS THE right adrenal gland??? He and others have not had Adrenal Cushings WITH Diabetes at same time before..but I don't know..I am afraid at times to ask more questions even though I constantly do practically every day...but the dosage has been changed and compounded a few times so now, I would have to give 10 mg caps and then 5 mg caps 12 hours later. I would like to do this but am not sure whether the unequal doses makes a difference. As a HCP, I don't think so but I just don't know what to do. What do you think?? There's an ER DVM that takes over on weekends..I may ask him what he thinks, though who knows if he will opine on the matter. My head is spinning 24/7.. Marley with Pulmonary Hypertension on 8 meds/day..Suzie has been an insulin-dependent diabetic 4 years, 2 needed ACL and luxating patella surgery but only Squeaker could have it..Marley too weak for surgery? Elliott in remission no longer needing insulin...and so..Bonnie and Trouble only 2 not in need of all of the above. Any advice from all will be greatly appreciated. P.S. I wanted to send him the updated articles on Trilostane but decided not to ...yet...Thanks Lablab!!!!