Cooper - diabetes and cushings - sweet Cooper has passed

[juliwilliams]

OK, just a quick update here. Cooper is doing well today, still real tired and drinking a lot but no other issues. I called the vet and he suggested starting the vetoryl again tonight at 60mg once a day then doing an ACTH test on friday, while also weening him off the prednisone for the next 4 days. I asked for a referral to a specialist. I just got back from registering my daughter for kindergarten and now I'm off to call the new vet and see when I can bring him in. I'm hoping today and in the meantime I am not going to start a vetoryl again.

[Jenny & Judi in MN]

I like your instincts. I had a vet who wanted me to give Jenny Lysodren and prednisone at the same time. It seemed insane to me and that is when we went to the specialist. Keep us posted!

[labblab]

I called the vet and he suggested starting the vetoryl again tonight at 60mg once a day then doing an ACTH test on friday, while also weening him off the prednisone for the next 4 days. I asked for a referral to a specialist.

Good for you, Julie!!!!!

In my opinion, the dosing/testing protocol your vet is suggesting is absolutely idiotic, and for multiple reasons. I'll try to come back and write more later.

Marianane

[lulusmom]

Hi Julie,

I've been MIA a lot lately and am just trying to catch up on things and wow, my mouth is still hanging open in horror after reading your thread. I actually had to read it three times to make sure I didn't miss something that could possibily excuse your vet's complete and utter ignorance. Thank God Marianne has been here to provide you with valuable information and I'm beyond ecstatic that you are not going to give Cooper any more Vetoryl and are taking him to a specialist. Good for you. I only wish Cooper hadn't had to go through so much to get to this point.

I have so many questions, I don't even know where to start but the most logical place would be the cushing's diagnosis. We've seen lots of breeds with cushing's here but Cooper's breed is not one of them and while I may not have immediately questioned the diagnosis after reading your first post, it became more and more suspect as your vet's inexperience continued to take a toll on Cooper's physical well being.

Did Cooper have any symptoms other than excessive drinking and peeing that would be consistent with cushing's, such as thinning or loss of coat, skin issues, panting or a voracious appetite? Did your vet run any differentiation or validating tests such as an abdominal ultrasound or endogenous acth test? Did your vet ever tell you which form of cushing's Cooper has..adrenal or pituitary? If not, I seriously doubt that he did either of these tests.

Dr. Mark Peterson, a world renown endocrine specialist, defines insulin resistance as doses greater than 1unit per pound to control hyperglycemia, and Cooper had a ways to go before he reached that point. I therefore believe your vet was premature in jumping on the cushing's bandwagon and then it appears he did an inadequate job of testing for it. Some breeds are known for being insulin resistant but regardless of breeding, dogs with high lipids in their blood or hypothyroidism (low thyroid) can cause insulin resistance. I don't think you have posted the results of any tests that have been done so I'd like to request that you round those up and post the results now. With respect to the blood chemistry and cbc, you need only post the highs and lows and please include the normal reference range. If triglycerides and cholesterol are moderately to severely elevated, lipids could be the problem. Cushing's and diabetes can transiently lower the thyroid hormone, T-4 which usually normalizes once the underlying problem is addressed. However, it could be that a dog with diabetes and low T-4 could have primary hypothyroidism, requiring thryoid supplementaton. If Cooper had low T-4 your vet should have ruled this out. Honestly, seeing those test results will help us all understand more about Cooper's history.

I'm sure I'll think of some more questions later but I wanted to give you some more food for thought before you have a consult with the specialist. Take a note pad so you can take notes and don't be afraid to ask questions because that's how we learn. Believe me, our IMS may appreciate me now but in the beginning, I'm sure he hated to see me coming.

Looking forward to your response to my questions and test results.

Glynda

P.S. Members have recommended that you join our sister site, k9diabetes.com. I do hope you have done so but if not, I strongly suggest you consider it. In the meantime, I'm going to ask Natalie to check in on your thread here. She is not only one of our admins but she is also the owner of k9diabetes and I dare say you'll not find anybody with more experience and knowledge of diabetes mellitus than Natalie.

[lemstar]

Julie--
I am sorta jumping in in the middle of things, and I don't know if you've seen my posts, but my Strider has diabetes and maybe Cushings too.

In short, my vet, who is very experienced with both, just returned from a conference, where our approach was confirmed as the way to go: keep adjusting insulin until we reach that 1u/lb of body weight. Strider weighs 60 lbs, although he should weigh 70 or 75 lbs, and we are up to 50u of HumulinN twice daily. His ketones stay negative, but glucose stays up. We have not seen it go below 400 since diagnosis, and at his last curve, it was up over 500 all day long.

Within a week or two, we may hit that 60u mark, and then we will re-evaluate.
Hope Cooper does well....and your new vet is awesome....

[juliwilliams]

Cushings has been a consideration for years. He started drinking a lot 2 or 3 years ago. I first thought diabetes and took him to our previous vet in Ohio. He said no on the diabetes but ran bloodwork and said his liver enzymes levels were high and we had to keep an eye on it. Two or so years go by with regular 6 month checks and his liver enzymes were holding steady at slightly elevated.

Then this past thanksgiving he started drinking even more than normal and having accidents in the house and early December (I think) he started losing weight very, very quickly. He is a German shorthaired pointer but has longer than average fur, at the nape of his neck it's about 2 inches long. We shaved him in the early spring last year and it grew back very quick then we shaved him again in the summer (he really hates the heat and we moved him to Texas so we thought he could use some relief) that time the fur never grew back. He definitely had the pot bellied look to him before he started losing weight. And his skin became very thin, like he lost the fat layer underneath. He was panting like crazy, and still does. And he started stealing food from our other dog and our children. I honestly think the cushings diagnosis is correct.

Our vet never did any differentiation tests, he just did the ACTH. He said if we wanted he could run tests to tell us which kind he had but that he'd treat them both the same so there was no real reason to spend the money on it.

I don't have any test results. I'm going to request them tomorrow, if I remember. Unfortunately I always have a very active 2 year old in tow and most of the time a 4 year old too. So usually I'm pretty scatterbrained and trying to keep my 2 year old from jumping off the counter! I do know his thyroid was tested when we were first diagnosed with diabetes and the results were normal.

In terms of insulin resistance. The vet thought it was possibly insulin resistance brought on by a bladder infection or from the cushings. He had a raging infection and we're still on antibiotics for it. After the first few rounds of antibiotics he did a urine culture and found out it was enterobacter and is treating it with a 6 week course of antibiotics specifically for enterobacter. We were going to do a urinalysis when he was done with the antibiotics.

He did finally do the ACTH test when we were at 28 or 30 units of insulin. He wanted to get the diabetes under control but Cooper was really not doing well. If he had cushings we needed to start treating it so he wouldn't spiral downhill anymore.

I think I answered everything, Glynda, except for test results (which is probably the most important part).

I think I joined k9diabetes, I'll have to double check. I don't have too much time nonlinear but I do need to spend more time on both of these sites!!

[labblab]

OK Julie, I am finally back again. I am so glad to see that Glynda has joined in the discussion and I will leave the initial diagnostic piece alone for the moment and just address my immediate concerns about your vet's proposed schedule for this week.

First, even if no other issues were involved, it would not be a good idea to begin once daily dosing in the evening. Dogs who receive only one trilostane dose each day need to receive it in the morning with breakfast so that the drug is metabolized properly and so that the monitoring ACTH test can be performed 4-6 hours after dosing.

Secondly, if no other issues had been involved and f the monitoring test was intended to gauge how well a 60 mg. dose was working, you would want the dog to have been maintained consistently on that dose for 10-14 days, not for for just 4 days, and not while it was being given simultaneously with a prednisone taper.

And finally and most importantly in your case, if the goal is to check the safety of even resuming trilostane at all after an electrolyte crash, you would perform the ACTH prior to beginning the dosing at all, and at least 24 hours after dosing with prednisone.

So I honestly don't see any logic to your vet's instructions. I don't know what a specialist will advise you to do this week. But assuming the Cushing's diagnosis is correct, one possibility may be setting up an appropriate prednisone taper, then performing an ACTH and electrolyte recheck, and then if the labwork/behavior gives the green light -- start over with the trilostane at either 60 mg. once daily (in the morning) or 30 mg. twice daily as we discussed may be the better option for a diabetic dog. That was an appropriate initial daily total given Cooper's weight, and he seemed to tolerate that dose OK with a positive response in his glucose level. But that's when the wheels came off the cart. This time around, you'd perform another ACTH after 10-14 days or certainly before any additional increase. Just some thoughts, although the specialist may go in a different direction. Bottom line, I'm so glad you've requested the referral!

Marianne

[k9diabetes]

Hi Juli,

I am the administrator of the K9 Diabetes forum - I checked and it looks like you are not yet a member (www.k9diabetes.com/forum) - and I have had only a quick skim of your thread.

But what I have had time to read and digest is scaring the pants off of me.

A couple of weeks ago, I might have been able to give you some fairly direct advice about an approach to take with Cooper with his insulin and the Cushing's question... now, in the face of two overdoses of Trilostane and no reliable idea of what his current natural levels of cortisol are...

The overall picture is a muddy mess and I don't think anyone can tell you what should be done with Cooper as far as Cushing's goes until things can be settled on a routine that keeps Cooper safe without Cushing's treatment and his natural cortisol production level can be determined.

If Cooper was my dog, I would, not give any more Trilostane, period.

Even in a diabetic dog, there is no rush to treat Cushing's disease, and Cooper's insulin dose was never raised to a level high enough to come close to determining whether he was "resistant" to insulin.

In fact, there were numerous signs that he responded well to insulin. Blood sugar in the 200s was quite good.

I'm gonna continue in a second post to address some other issues.

Natalie

[molly muffin]

Hi Julie, where you able to get in to see the new vet today?

hugs,
Sharlene and Molly Muffin

[k9diabetes]

Me again!

I understand how it can feel wrong to second guess a kind and compassionate veterinarian. I have been in your exact spot and that's exactly what I had to do. Best decision I ever made.

I can tell you, based on my 10 years of intense experience with diabetic dogs, 5 years with my own diabetic dog, and association with the great folks here regarding Cushing's disease, that the veterinarian has very badly mismanaged Cooper's care. To the point that I wouldn't allow your veterinarian to make another single decision about his care.

I know the vet doesn't adequately understand Cushing's, diabetes, Trilostane, and prednisone based on a just one piece of information:

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.

When you got home to a dog on 30 units of insulin twice a day and 60 mg of Trilostane once a day whose blood sugar was in the upper 200s, regardless of the time of day of that reading, Cooper's Trilostane dose absolutely should NOT have been increased. An overdose of Trilostane and/or dangerously low blood sugar were all but guaranteed when the vet did that.

Two crashes later and the vet still does not seem to understand the problem.

In addition, the vet has you giving two medicines that oppose each other!

Prednisone is basically cortisol in pill form. So the vet seems to have suggested that you (1) give prednisone (cortisol), and (2) simultaneously give Trilostane (anti-cortisol).

Cooper needs a reboot with a really good specialist who will thoroughly assess his ability to produce his own cortisol and his current level of diabetes regulation and then basically start over.

If you are close enough to Texas A&M, they are a pretty good teaching hospital, among my top four or five in the country in terms of dealing with these two diseases.

Just so you don't think I'm a crackpot (maybe too late!), I will refer you to the long sad story of regulation of our dog Chris. We saw the man who literally wrote the book on Cushing's disease and diabetes, and he got it wrong with our dog. In the end, I regulated him myself through home blood glucose testing. He taught a lot of vet students rather poorly when it comes to diabetes and too many dogs are suffering from the results...

www.k9diabetes.com/k9diabetes.pdf

You are always free to email me also. k9diabetes@gmail.com

Natalie