Sheri's Montana has passed on

[piggie40]

We are new here, although we have visited the site many times. I don't know which board I should be posting on, the Cushings board or here. It is a bit confusing to me. I will try to include as much as I can in Montana's information, but I'm sure I will leave out parts as it is all starting to run together. But here goes.

Montana is an 11-year-old doberman from a rescue group. I have only had Montana for 4 years. I don't know anything about her medical history prior to my adopting her. Everything has been great except for some arthritis visits. About 1 year ago, she started having some hair loss, lethargy, and some other mild symptoms. We took her to see the vet and she was diagnosed with hypothroidism. We started to see some improvements and then about 5 months later, she became ill. In the beginning it was just vague symptoms. Then she became worse and on the Friday before Christmas, we were making an emergency trip to the vet with a really sick pup.

Montana was in the midst of a diabetic emergency. She hadn't been eating, drinking excessively, diarrhea, lethargy, eyes very red and glassy. When her BS was taken, it wouldn't read on the monitor. She was diagnosed after a glucose curve with diabetes. She was placed on vetsulin initially, but after proving to be insulin-resistant, she was switched to humulin N. There was only a slight improvement, but that is where things stayed. Her symptoms improved, she felt better so we didn't push the issue. It stayed this way for awhile as we continued to monitor her BG. Then, 2 - 3 months ago she begin to get worse.

The most noticeable sign initially was the hair loss worsened. The excess urination, water drinking worsened. Her BG went even higher and was very insulin resistant. She had more testing and my vet determined she had cushings disease. We treated it with lysodren, which was a mistake in my opinion. On day 6 of a prescribed 8 days of treatment we stopped the lysodren because we saw an improvement in her symptoms and that was how we were instructed to do. Her BG didn't improve and on day 8 we noticed she was wobbling. Monts ACTH was repeated and the vet said she had "no" cortisol production but her electrolytes were normal. Montana was given 10 mgs of prednisone to take in the am. Her BG numbers went up. We cut it to 5 mg. and her BG's were better, but still on the high side. Now we are taking 5 mg in the morning and 2.5 mg in the evening. She takes it twice a day because she seemed to crash in the late afternoons. Her gait worsened and she began with hind leg weakness. She was so pitiful my heart was breaking.

I came home 1 day from work and she seemed a little better with the walking. Two or three days later she was a lot better and things had been great, until yesterday. She is heading in the opposite direction.

Her symptom of drinking excessively has never gone away. Now we can add lethargy, eating A LOT, diarrhea, and her BG has gone up. We just so happened to be doing a glucose curve today per my vets request. Here is what I have so far:

08:20 475 - before breakfast and medications
08:30 breakfast and all meds
10:30 565
12:30 407
02:30 445
04:45 454
07:00 386
07:10 supper and insulin

I'm open for input. If I need to be on the cushings board (and I plan to post there too) instead of here, sorry to put you through such a long post.

[k9diabetes]

You probably think I sound like a broken record, but I'd say it's time for an ACTH.

Probably her adrenal glands are now finally recovering from the lyosdren overdose so the prednisone you're giving her is driving up her blood sugar, which is what it would do with a normal or more normal adrenal gland function.

If your vet still refuses to do the ACTH, you could try cutting the prednisone and see what happens to the blood glucose.

How is her ability to walk?

Natalie

[piggie40]

We are scheduled to do the ACTH stim test this week. It will probably be Wednesday, depending upon which days my vet is working. Her walking is okay, but not as well as it was 2 days ago. There are some subtle changes we can pick up on. I am trying to remain calm and not over react, but I am thinking maybe its best I mention the symptoms I think I'm seeing even if I am just paranoid.

[We Hope]

I think you need to get this sorted out with a vet as soon as possible. The bg's Montana is running now can be the beginning of another emergency stay for diabetes. If you don't have ketone testing sticks, I think you need them to check her urine with what you've posted as her a curve.

You've not said how much insulin you're using--with bg's like this, I'd suggest that you contact your vet about possibly raising the insulin and keeping a good check on whether or not she is running ketones.

Another problem here is whether or not she needs that prednisone now--if her adrenal gland is now producing enough (or in the case of Cushing's, too much) cortisol, the oral meds are adding fuel to the bg "fire". You're basically not going to find that out without getting a stim test done.

Many of the signs or symptoms you're describing can be attributed to Cushing's AND diabetes mellitus; this is why it can be such a challenge to sort out which one it is:

http://www.vet.uga.edu/vpp/clerk/Zwicker/

Canine Hyperadrenocorticism, Diabetes Mellitus, or Both?

Cushing's Signs

Clinical Signs Incidence Comment

Polydipsia /Polyuria ~80-85% Due to interference w/ release of antidiuretic hormone

Polyphagia ~80-90% Sign unique to the dog

Muscle Weakness
Exercise Intolerance
Lethargy ~75-85% Due to the direct protein catabolic effect of excess cortisol


Diabetes Signs

Clinical Signs Incidence Comment

Polydipsia/Polyuria Very common Due to osmotic diuresis secondary to glucosuria.

Polyphagia Very common Glucose cannot enter cells at the hypothalamic satiety center, so patient constantly feels hungry.

Muscle Weakness,
Lethargy Common Common in ketoacidotic patients due to breakdown of muscle and fat as energy sources

The sooner you get someone who is capable of performing a valid stim test, the better because until those results are in, no one can say what the state of the adrenal gland is (re: the prednisone you're giving now). You also need to talk with a vet about an insulin increase to attempt to handle these bg's before there's another emergency because of them, regardless of what's making them so high.

[k9diabetes]

We Hope has made an important point. Check her urine for ketones and you could consider giving a bit more insulin until the stim test - I believe you have upped it a unit or two on your own before.

[Denise]

Hello!

I have a diabetic/atypical Cushings dog that is pretty much asymptomatic except he wanted to eat and his glucose was a mess. A couple ACTH tests weren't conclusive, then radiographs and ultrasound wasn't conclusive and it wasn't until an adrenal panel was sent to the Un. of Tn. that we got a dx and it wasn't so much a cortisol problem but other hormones the adrenals were putting out, sex hormones.

We didn't get a load on him the first time with Lysodren and several months later tried another one and crashed him. He needed pred for weeks and was very sick. We stopped treatment and he came around but it took awhile and yes, his bg is still a mess sometimes but sometimes it's good. The adrenals don't pump out the same amount of anything on a schedule so you just never know from day to day.

What does he weigh? What is he eating? How much insulin is he getting?

I too would be urine testing with bg's that high. He sure doesn't need ketones too!

I have another non diabetic that was just through all the testing for Cushings and while it seems she has it the test results aren't telling me what I need to know.

I have become non trusting of vets in dx'ing Cushings and if you can, please consider an adrenal panel because you get the whole picture not just part of the picture. If he has other hormones at play then knocking cortisol down alone won't help his diabetes regulation.

I pay 135.00 for a ACTH, 175.00 for an LDDS and I think the adreanl panel was 265.00. Well worth it in my opinion.

Will be watching this thread for more info!

[acushdogsmom]

Will be watching this thread for more info!Denise, if you (or anyone else here) want to read more about Montana, here's a link to the thread about Montana on the Cushing's board:

http://caninecushings.net/forums/showthread.php?t=6755

[acushdogsmom]

Another problem here is whether or not she needs that prednisone now--if her adrenal gland is now producing enough (or in the case of Cushing's, too much) cortisol, the oral meds are adding fuel to the bg "fire". You're basically not going to find that out without getting a stim test done.We Hope is right. Cortisol and pred (which is a synthetic form of cortisol) are insulin antagonists. So the level of circulating cortisol and/or pred in the bloodstream can affect the way the insulin works.

With Cushdogs who have been "overloaded", it's a wait and see sort of situation, regarding whether or not the adrenal cortex is going to regenerate and start up the production of cortisol again or not.

The usual tendency is for the adrenal glands of a Cushing's dog to regenerate, often rather quickly, although with some dogs, the regeneration process is faster than with others. But there are also some dogs whose adrenal cortex never does regenerate enough to warrant resuming the Cushing's treatment. Our members refer to those dogs as "being in remission".

Another "trend" that we have noticed with the overloaded Cushdogs on the Cushing's message board is that when the electrolytes are affected, it's more likely that the adrenals are not going to regenerate much, if at all. Not written in stone, but that is the tendency we've seen. When electrolytes are not affected, it's more likely that the adrenal cortex is going to regenerate and that those dogs will not be permanently "Addisonian".

My cushdog (not Diabetic) had too-low cortisol several times within the more than 6 years that he was on Lysodren, and with electrolytes always okay. Each time, we stopped the Lysodren and waited ... and his adrenals did regenerate ... sometimes within weeks and a couple of times it took several months before we needed to start him back on a weekly Lysodren dose. We did periodic ACTH stim tests (and checked his electrolytes each time) to watch the cortisol production and when it was back up to around 2 or 3 post-ACTH, we'd start back on the weekly Lysodren maintenance dose, to be sure that the adrenals did not regenerate any further. (if we waited too long, we would have had to re-load, and it's better if you can catch it before a reload is needed).

I do know of several dogs on the Cushing's board whose adrenals never did regenerate enough to warrant resuming the Lysodren (or Trilostane) treatment. We've had another few whose dogs' adrenals always regenerated after an oversuppression situation ... until the one time when they did not regenerate. And we just had a member come back to tell us, about a year after the "overdose" happened, that her dog's cortisol was back up to a level that required Lysodren again.

So you can see why it's important to watch and wait and see what is going to happen for each particular dog. Seems that every dog is a little different from the next.

If you want more information about the oversuppression of the cortisol production after a Lysodren loading, we have a member at the Cushboard whose posts you can look up by doing a search for all posts that she has made on the Cushing's board. If you read her reply posts to others, you can pick up quite a bit of useful information.

Her name is AudreyW ... although she still pops in to the Cushing's message board every now and then, she isn't there really regularly anymore. Her dog (Malthus) became permanently Addisonian (too-low cortisol production with electrolytes affected) shortly after loading him and his adrenals never did regenerate. Although he passed away last year, Malthus lived very well as an Addisonian dog for years after the initial Lysodren loading overdose.

I know that it's frustrating and not always easy to get everything back on track, especially when an overloaded Cushdog is also Diabetic, but it definitely can be done with success.

You now need to know whether Montana's adrenals are regenerating or not (via the ACTH stim test). If they are, you can probably stop the pred, and you'll then have to watch to see if the cortisol goes back up enough to warrant starting her on a Lysodren maintenance dose. If you are able to stop the pred, that will likely help the insulin dose that Montana is getting to work better.

In any case, I think that home bg testing is going to be a wonderful and very helpful monitoring tool for you.

Hope this helps.

[piggie40]

Montana weighs 100 lbs. She is a bit heavy as the vet wants her around 85 - 90 lbs. I've really not been happy with the insulin dose, she is only on 28 units of humulin N. I am actually giving her 30 units. I have asked to be to do a sliding scale, but my vet flat out says no. I have asked for more insulin and my vet is very reluctant because she is already on a "large" dose and she is afraid she is going to be hypo. Montana has from the beginning been insulin resistant so I don't understand the reluctance to increase the dose to bring the BG down.

Her diet is difficult to manage. Montana is a picky eater normally unless she is in the stage of eating us out of house and home. The doctor wanted her to eat this w/d stuff (can) but Mont simply turned her food bowl over and refused to eat. The vet then told us to try Purina Fit and Trim (dry) and Montana wasn't having for any of that either. She will eat it if she is very hungry but for a everyday thing she turns the bowl over. A mutual decision between the me, vet, and Montana is to let her stay on her normal food because with the diabetes she wanted Mont eating consistently so it would help us manage her diabetes. Montana eats Beneful in the cups. We have tried a large amounts of food, but Beneful seems what she will eat consistently. I've tried to get her on some holistic foods but she just won't eat it. I've tried mixing half dry with half can because I rather she eat the dry, but I've had little success with it. I can't begin to tell you how much food has been wasted trying to get her on a better food. I didn't know when she first adopted me what she ate previously. There wasn't a lot of information made known to me about her medical history nor her habits, except for she stayed in a 6 ft cage during the day.

Today I can really see evidence of her gait beginning to change again. I hope we can fix this before she has to go through that again. I will get up with my vet first thing in the morning and see if we can't move the ACTH stim test up by a day, and hopefully some other testing as well. I'm not sure if she has had an adrenal panel previously, but I know the other tests she has had. I'm curious about her electrolytes too. I feel reasonably confident when I take her in they will check for ketones. I know when she was originally diagnosed with diabetes she tested positive for ketones but the following visits when they checked there were no ketones present.

I haven't checked out the uga website for cushings and diabetes but I'm going to do that now. Thanks.

[We Hope]

Montana weighs 100 lbs. She is a bit heavy as the vet wants her around 85 - 90 lbs. I've really not been happy with the insulin dose, she is only on 28 units of humulin N. I am actually giving her 30 units. I have asked to be to do a sliding scale, but my vet flat out says no. I have asked for more insulin and my vet is very reluctant because she is already on a "large" dose and she is afraid she is going to be hypo. Montana has from the beginning been insulin resistant so I don't understand the reluctance to increase the dose to bring the BG down.

If we convert Montana's weight into kilograms (2.2 lb), she weighs 45.45 kg.

http://www.vin.com/VINDBPub/SearchPB/Proceedings/PR05000/PR00105.htm

WSAVA 2001 Diabetes Mellitus:Treatment Options

Insulin Therapy

"In dogs we like to start with Humulin-N at 0.5 units/kg q12h."

This means 1/2 unit of insulin for every kilogram (2.2 lb) of body weight every 12 hours. So if I round off Montana's 45.45 kg to 45 kg for the sake of doing this example and multiply that by .5 for the 1/2 unit of insulin for each 2.2 lb she weighs, I get 22.5, or a starting dose for her would be 22.5 units of insulin. You're not very much removed from that point with the "official" dose being 28 units 2X per day.

Montana's 10-15 lb of extra weight adds to her insulin resistance. Starting to take off some of the added pounds will also lower her insulin needs.

http://www.vet.uga.edu/vpp/clerk/Zwicker/

"Obesity Common Common in patients with early diabetes mellitus"

http://petdiabetes.wikia.com/wiki/Insulin_resistance

"Overweight is linked in humans to insulin resistance, though the mechanisms are not fully understood. Obese cats and dogs also display a degree of insulin resistance, also known as a lack of insulin sensitivity, due to obesity, which may in turn, in some cases, lead to diabetes.

"In the case of dogs, losing weight is helpful with reducing the resistance, but will not cause reversion to non-diabetic status or permit transfer from insulin injection to oral medications."

http://petdiabetes.wikia.com/wiki/Overweight#Slimming_down--gradually

"Reduction of weight to normal levels also reduces any insulin resistance the added weight caused. Weight reduction for both pets and people should be done gradually, over an approximate 2-4 month period."

Right now, she doesn't appear to be insulin resistant as per medical definition, but seems to be underdosed with it due to her extra weight, (possibly) diet, and possible active Cushing's status.

http://www.ncbi.nlm.nih.gov/pubmed/7660542?dopt=Abstract

Diagnosis and management of insulin resistance in dogs and cats with diabetes mellitus.

Veterinary Clinics of North America-Small Animal Practive May 1995

"Clinical insulin resistance should be suspected in any animal in which marked hyperglycemia persists throughout the day despite insulin doses of greater than 1.5 U/kg per injection."

So if we break out the calculator again, Montana at (rounded) 45 kg wouldn't be classed as resistant to any given insulin unless she was receiving 67.5 units of it each time and not responding. I don't think she will need to go to 67.5 units per injection to control her bg's, but I do believe she is not receiving enough of an insulin dose to control them adequately at this time.

Her diet is difficult to manage. Montana is a picky eater normally unless she is in the stage of eating us out of house and home. The doctor wanted her to eat this w/d stuff (can) but Mont simply turned her food bowl over and refused to eat. The vet then told us to try Purina Fit and Trim (dry) and Montana wasn't having for any of that either. She will eat it if she is very hungry but for a everyday thing she turns the bowl over. A mutual decision between the me, vet, and Montana is to let her stay on her normal food because with the diabetes she wanted Mont eating consistently so it would help us manage her diabetes. Montana eats Beneful in the cups. We have tried a large amounts of food, but Beneful seems what she will eat consistently. I've tried to get her on some holistic foods but she just won't eat it. I've tried mixing half dry with half can because I rather she eat the dry, but I've had little success with it. I can't begin to tell you how much food has been wasted trying to get her on a better food. I didn't know when she first adopted me what she ate previously. There wasn't a lot of information made known to me about her medical history nor her habits, except for she stayed in a 6 ft cage during the day.

You can learn how to adjust Montana's insulin to the type of diet she's willing to eat; people with diabetes don't eat the same food day after day. They learn how to adjust their fast/rapid acting insulin to cover what they're eating. You can learn how to do something like this with her also.

Today I can really see evidence of her gait beginning to change again. I hope we can fix this before she has to go through that again. I will get up with my vet first thing in the morning and see if we can't move the ACTH stim test up by a day, and hopefully some other testing as well. I'm not sure if she has had an adrenal panel previously, but I know the other tests she has had. I'm curious about her electrolytes too. I feel reasonably confident when I take her in they will check for ketones. I know when she was originally diagnosed with diabetes she tested positive for ketones but the following visits when they checked there were no ketones present.

I haven't checked out the uga website for cushings and diabetes but I'm going to do that now. Thanks.

I agree with you re: checking electrolytes.

http://petdiabetes.wikia.com/wiki/Hyperglycemia#Primary_metabolic_effects

"Polyuria: Glucose cannot leave the body by itself--it must take water with it. Losing too much water means the body tries replacing it and this causes thirst, or polydipsia. When too much water is lost through excess urination and the excess drinking cannot make up for it, dehydration can occur."

http://petdiabetes.wikia.com/wiki/Hyperglycemia#Short-term_symptoms

"Neuropathy (nerve damage to legs) especially in cats

"Dehydration

"Malaise or lethargy "--among others

http://petdiabetes.wikia.com/wiki/Hyperglycemia#Medium-term_symptoms

More of the same type of bad news when the high bg's continue on and on.

I assume Montana has her sight--the longer she remains with high blood glucose, the more of a risk she will develop diabetic cataracts. Also think that she would be doing a LOT better with her diabetes if her insulin was increased. Increases aren't done every day or every other day--this can send the system into a wild, swinging high and low pattern called Somogyi.

http://petdiabetes.wikia.com/wiki/Somogyi

http://www.vetmed.auburn.edu/sac/mededu/diabetes/graphics/somogyi.gif
Here you see what raising an insulin dose too rapidly can do.

[piggie40]

Thanks everyone for your insight. You are teaching me a lot.

Montana does have her sight. I didn't realize weight made a difference in the amount of insulin she should receive. Being diabetic myself, I should have known better.

I have never been satisfied with her diabetes control. I have always thought it should be lower than what it has been. I know how bad you feel when your BG is high and I have wanted better control on her diabetes. Hopefully, the vet will get all of this figured out.

This coming week we will fax our glucose curve in. We will have an ACTH stim test done, hopefully her electrolytes, and ketones checked. Will try for an adrenal panel.

[piggie40]

I forgot to ask. I was considering purchasing the GlucoVet meter. I was reading through the information and it seems this particular meter is extremely sensitive on how you obtain the sample. Anyone have any experience with it and is it worth the money to purchase it vs. just using the meter I use every day?

Montana has developed extremely dry skin. She is flaking all the time. Her baths are with oatmeal based shampoo. Anyone with a suggestion on how I can help her?

[k9diabetes]

We had the GlucoPet (not GlucoVet) and didn't care for it. It wasn't any more accurate for Chris than the Freestyle and was less accurate than the OneTouch Ultra. I also now have an AlphaTrak, which is very accurate for Chris but so expensive to use that I rarely do.

One thing I really like about the OneTouch meters is you can see the strip fill and the meter errors out any time it's not filled properly.

Any meter you use should be compared to some lab values. AlphaTrak was accurate with Chris but GlucoPet was not so it's best to check any meter you use.

Ever use fish oil with Montana?

It's great for the skin and coat and for allergies and inflammation. You can get DermCaps from Drs. Foster & Smith or the Omega-3 gel caps, which is what we are currently using. Something in the DermCaps had started to bother Chris so we went with the Omega-3s, which have just cold water fish oil and a tiny amount of vitamin E. But if she doesn't mind them, the DermCaps are great for the skin and coat.

Natalie

[We Hope]

You already have a meter you use for your own diabetes needs. Most people with diabetic pets are not using the animal-validated meters but ones just like your "everyday" one. :)

What you can do with your meter is to take it with you to the vet's when you know you'll be doing bloodwork, and have them use a drop of the blood draw for a test on your meter. Comparing the results from the professional test against what the blood from the same draw gave you as a reading on your meter will tell you how many points--if any--your meter differs from the vet's professional testing. You can then use that as a guideline when you test Montana and get readings from her.

I'd bring the dry skin up with the vet to see if there's a supplement Montana might be able to use for this or if a change of the type of shampoo might do the trick.

[acushdogsmom]

Montana has developed extremely dry skin. She is flaking all the time. Her baths are with oatmeal based shampoo. Anyone with a suggestion on how I can help her?Just a quick note about that. :)

Cushing's dogs (before treatment) have high cortisol production, which tends to (among other things) affect the skin and the coat in particular (hair loss or thinning of the coat is common in untreated Cushing's dogs)

When we use a treatment such as Lysodren or Trilostane, what we are doing is lowering the cortisol production. Once the cortisol levels come down, the skin and coat issues usually resolve. The thing is, though, that right after the initial lowering of the cortisol, the skin and coat issues often get worse before they get better. It's as if the Cushing-affected (sick) skin and hair needs to be shed so that the new healthy skin and coat can begin to grow in.

So the flaking skin would actually be a pretty normal thing to see, shortly after the cortisol production was lowered with the loading doses of Lysodren.

After my dog was loaded on the Lysodren, his skin got pretty flaky, and even more of his hair fell out (than had fallen out before we started treatment) for a short time (maybe a few weeks). The Vet prescribed a special soothing shampoo and conditioner until his skin and coat "recovered" (I think both the shampoo and conditioner were an oatmeal formula type). His Vet also prescribed a fish oil supplement. Eventually, his skin flaking cleared up completely and a new and beautiful coat of hair grew in, even more beautiful than it ever had been before. :)

Also, some people have noticed that their dogs' new healthy hair often grows in softer (almost like puppy fur) or maybe sometimes even in a slightly different colour for a while, so if that happens, don't be surprised.

[rhodesian46]

Hi Welcome Montana,
I too have a dog with cushings,diabetes, and hypothyroidism. She is 58 lbs and is on 49 u of Novolin N bid. So the units that you are giving Montana are pretty low You have plenty of room to adjust Since she is a big dog you can probably go up 2 units at a time after 5 days or so.I have the AlphaTrak meter and a freestyle. The Alphatrak s strips are very expensive but I use that if I am suspicious Pebbles has been battling diabetes since 8/07 and cushings since 12/07 She has had a bacteria skin infection for months now and her skin where she was shaved for the ultrasound is all flaky. Has your vet wanted to to a skin culture?Hope that you have gotten an Internal Med specialist as these 2 diseases are quite complicated I guess I wanted to tell u that you are not alone that many of us have furbabies with these diseases. Be patient it will come together

[piggie40]

Things didn't go as I hoped when I talked to the vet. She is going to do an ACTH and a urinalysis. I was very much hoping for an electrolyte panel, but that isn't going to happen. I cant, or at least not suppose to, increase her insulin either until after the stim test.

I asked about the prep for the stim test because I could not remember. She said everything as usual on a typical morning. I thought you did a before prednisone and an after prednisone. Is this not the case?

[acushdogsmom]

Regarding checking the electrolytes ... it only takes a very small blood sample for the Vet to check those (the sodium, potassium and the ratio of sodium to potassium would be the most important things to check). The pre and post-ACTH stim blood samples have to usually be sent to a Lab for analysis, but the Vet should be able to (practically instantly) do an electrolyte check on a small blood sample too, right there in the Vet's own clinic.

So if the Vet is doing an ACTH stim test, the Vet should also easily be able to check the electrolytes. And especially in a dog who has been overloaded on Lysodren, electrolytes really do need to be checked.

As for the ACTH stim test, it's best if the dog hasn't had any pred for about 24 to 36 hours before the stim test is done, because pred and cortisol will both "read" as cortisol on the Lab's equipment when they analyze the sample. The Lab equipment can't tell the difference between pred and cortisol because they are almost identical chemically. So any test number that is scored on the test would actually be pred+cortisol rather than just cortisol alone, if there is any pred in the dog's bloodstream when they draw the samples for the test.

However, if it's really impossible to withhold the pred in certain situations, I think the Vet can at least make allowances for the fact that the dog has pred in the bloodstream, when interpreting the ACTH stim test results, as long as the Vet does know how much pred the dog is taking.

[k9diabetes]

Acushdogsmom,

Is the post test result still a valid measure of the adrenal gland's ability to produce cortisol despite the pred...

so if the pre value is elevated due to the pred (say 10), the post value should be at least that high and then how much higher would suggest how much adrenal gland function there is?

If the adrenal gland is not functioning as in Addison's, the pre and post value would be more or less the same?

Natalie

[piggie40]

Thanks We Hope for bring the graph to my attention. I didn't know that increasing it to fast would cause that type of problem. I wondered why my vet was going only 2 units at the time.

I just talked to the vets office, a different vet than I had been seeing, and he says Montana has a severe urinary tract infection. We will treat this for a few days and then reevaluate Montana. He said he didn't do a stim test today because he felt with her having such a bad UTI he felt the ACTH would not be accurate. I have to admit I was a little disappointed but I am glad they found the UTI. She had no ketones present in her urine but did have some glucose that showed up. He said this is normal for a dog with uncontrolled diabetes.

Does all of this sound legitimate??

[We Hope]

While I don't have any information re: infections and ACTH testing, I can tell you that those with diabetes do tend to have urinary tract infections:

http://petdiabetes.wikia.com/wiki/UTI

"Diabetics are particularly prone to urinary tract infections (UTIs) because hyperglycemia causes sugar to spill into the urine, and that sugary urine, while still in the body, becomes friendly to bacterial cultures. Since another symptom of hyperglycemia is excess urination, all the tissues of the urinary tract are being frequently bathed with this sugary bacterial culture."

http://www.gcvs.com/internists/diabetes_mellitus.htm

"Diabetic patients are also at a higher risk for developing infections due to a compromised immune system. Any infection can cause dysregulation of their diabetes. One of the common areas where we see infections is in the bladder so your veterinarian may need to culture your pets urine to ensure there are no bacteria present."

http://www.ncbi.nlm.nih.gov/pubmed/10587255?dopt=AbstractPlus

Retrospective evaluation of urinary tract infection in 42 dogs with hyperadrenocorticism or diabetes mellitus or both.
Journal of Internal Veterinary Medicine |November-December 1999

"We conclude that UTIs are common in dogs with hyperadrenocorticism, diabetes mellitus, or both diseases. Clinical signs of UTI, however, are uncommon and results of urinalysis may be normal. Therefore, it is appropriate to recommend urine culture as part of the evaluation of dogs with these endocrine disorders."

When you get into infections, it's quite common for them to raise the bg's. People with diabetes usually are asked to develop a "sick day plan" where they keep a closer watch on their blood sugar and may need to use more fast or rapid-acting insulin to combat those higher bg's from an infection.

http://petdiabetes.wikia.com/wiki/Regulation_problems#Infections.2FIllness

"Any infection in the body, including dental, Urinary tract infections AKA UTIs, kidney, colds, and even hidden infections, will often cause stubborn high blood glucose levels."

I'm glad the UTI was found also--sometimes they don't have many or any real outward signs of having one. That doesn't mean it isn't there; the problem is that it's hidden to us when we try to find it with the usual methods--they call this type of an infection an occult infection. UTIs without treatment can progress to becoming kidney infections.

The vet is right when he says there will be glucose in the urine when the diabetes is not controlled. The renal threshold for dogs according to the Merck Veterinary Manual is 180:

http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/40302.htm

"The renal threshold for glucose is ~180 mg/dL in dogs and ~240 mg/dL in cats."

When you get to or over that point and stay there, this is when the glucose starts appearing in the urine; this is the point where you'll see a positive reading if you are using urine glucose test sticks:

http://petdiabetes.wikia.com/wiki/Renal_threshold

http://images.wikia.com/petdiabetes/images/8/8e/Dm_006b.gif

Renal threshold: When blood glucose level rises over a certain level, it spills into the urine.

I'm also glad that Montana doesn't have any ketones, since that's a worry when the bg's get so high and stay that way for a while. I think the vet has given you some very good, sound advice--to concentrate on treating Montana's UTI for now, and when that's under control, start working on the other problems that need help.

When you think about it, making too many quick insulin changes doesn't give the body a chance to respond before you've thrown something else at it that it's going to have to deal with. Something like getting in an elevator, pushing every one of the buttons on the panel and then wondering why you need to use the "Help" phone in it. ;)

Hang in there, I believe you're on the right track now! :)

[Kiska'smom]

Hi there!

I left you a note at the other site, but wanted to contact you here as well. I think that you are doing a great job with Montana. It just takes a lot of time and patience to get things under control. Then add a UTI into the mix, and it all goes a little crazy again! (Been there, done that!) I did see your latest curve, and wanted to tell you to hang in there! It looks so much like Kiska's curves when we first began treating the diabetes. After two months of adjusting insulin, Kiss finally has some numbers in the high 100's! I never thought that I would see it! I am only raising her dosage after two weeks of consistency. I recently went from 41 U to 42. I'm going slowly now, as she is getting close to being regulated. Kiska is a big girl and weighs about 102 pounds now. So, after a couple more weeks, I might increase it a bit again. If my Lysodren arrives soon, she will also begin a maintenance dose of that; and I will have to monitor her BG very carefully to see if it needs to adjust downward. It all seems as though months have gone by! In reality, the Atypical Cushing's was diagnosed in February, and the Diabetes in March. So, even though it has been frustrating and heart-wrenching, I am beginning to see some light at the end of the tunnel. I know that you will not be far behind!

Hugs,

Jeanne and Kiska

[piggie40]

Just a little update, Montana has developed what sounds like kennel cough. It just doesn't end sometimes.

[We Hope]

If you haven't done this already, I think you should let the vet who's treating her now know she has this cough as he/she may need to do some adjusting of meds because of it.

[k9diabetes]

Hoping for an update soon on Montana!

Natalie

[eyelostit]

Piggy, I hope all goes well for Montana, I know how frustrating all this can be.:)

[piggie40]

I posted this on the other board but I wanted input from here as well. What ingredients am I looking for in dog food or what shouldn't be in food? There was an article about my dog food being linked to cushings. It was also the reason why my neice's Pug was passing out and having seizures. I know dog food has been discussed here but in addition to brands to use I wanted to know ingredients to look for as well.

I've started having days when Montana just won't eat. Yesterday we couldn't get food in her, only water. This am, I couldn't fill her up for breakfast. Why is she eating only part of the time? It makes it hard for me to know what to do with her insulin dose.

[We Hope]

I know Montana was given antibiotics for her UTI--don't know if she's still taking them yet or not. Sometimes they can produce some upsets and the result can be not eating or not eating properly. The other side of this coin is that if you don't finish the treatment course which has been set up, the infection may not clear up 100%.

You're right about Montana still needing some insulin when not eating because the body needs it to keep healthy. Many people go over a "what if" list with their vet with one of the questions being about how much insulin should be given to that particular pet if he/she doesn't eat or only eats part of his/her food. Intervet's thought on the subject is this:

http://www.intervet.com.au/binaries/82_103335.pdf

Page 15

"If the diabetic patient is unwilling or unable to eat due to illness, administer a lower dose of insulin (approximately 30% of the normal dose) until appetite is restored."

There are times you can coax a pet to eat with an extra or two. The rare times I couldn't get Lucky to eat, my choices for those were--no sugar, low-carb baby food, low sodium chicken broth, and low sodium canned chicken breast. Almost everyone has his or her favorites which got them through this with their dog--maybe others will post what they've used here too.

I'll post some reading links re: ingredients for you here. Since Montana has diabetes and no other conditions which would make fiber a problem, you'd ideally like to get her to eat something with more fiber in it than most canned food has. The norm for canned food fiber is roughly .5-1.5%. Why we're always talking about fiber is because it helps the dog use the insulin better and can even reduce insulin needs. Getting more fiber into Montana can also help her take off some of those extra pounds.

http://www.uq.edu.au/ccah/index.html?page=43392&pid=41544

Beyond Insulin Therapy: Achieving Optimal Control in Diabetic Dogs
Drs. Fleeman and Rand, University of Queensland (Australia) 2005

This article covers all the bases, with some special attention to food for diabetics and why fiber is so beneficial.

http://petdiabetes.wikia.com/wiki/Fiber

http://www.doberdogs.com/foodcht1.html

Understanding Pet Food Labels

http://www.doberdogs.com/foodcht2.html

Definitions of what's seen in the label ingredient list.

This site hasn't been updated in quite a while, but he has quite a bit of good information there.

http://www.acreaturecomfort.com/ratingpetfood.htm

How to rate your pet food.

http://www.dogfoodproject.com/index.php?page=badingredients

Dry dog food ingredients to avoid.

http://www.itchmoforums.com/

If you want to do even more reading, Itchmo Forums is the place. Just be aware that there are people posting there who are singing the praises of certain pet foods because they are working for the company in some way without coming out and telling everyone this. Right now, there are people working for Nutro, Nature's Variety and Kumpi who post regularly. Don't want to name names here--if you want to know more, please PM me.

Every food isn't the "right" one for every animal with diabetes--some of us have had great success with the prescription based diets, others have had the same with non-prescription foods, and still others say that home cooking is what works for them. Hope that at least some of this helps! :)

[eyelostit]

I feed Niki 1/2 C ground turkey, 3/4 c brocolli/gr bean mixture and 1/3 c of Nutro lite. she is doing well with this, i have increased her veg's since they last longer in her bloodstream to match the insulin.

I know it all gets frustrating, I've been there with the foods etc.

try what you think, see how the BG goes, its mostly trial and error, better hi than too low.

Take care:)

[k9diabetes]

Can you point me to the article about food and Cushings? - I'd like to see what it says.

How's Montana's blood sugar?

Highs do tend to cut the apetite.

Natalie

[Kiska'smom]

Hi there,

I just wanted to add that antibiotics can make your doggie feel yucky. Kiska was on Cephalexin for several weeks. She sometimes acted like she wasn't feeling well, even though she always ate. It would be very scary not to know how to deal with the insulin and have a dog with no appetite. My dogs will always eat catfood! You might try flavoring Montana's regular food with a very little bit of canned catfood the next time that she avoids her food. I have never dealt with kennel cough. I am so sorry to hear that you are dealing with that, too. When it rains, it pours! Keep us posted.

Hugs,

Jeanne and Kiska

[piggie40]

Montana is having problems. She is not eating no matter what we try. We've been very creative trying to get her to eat. No meals means she doesn't get medicine either. I took her to the vet tuesday (not my regular vet) and her glucose was so high it wouldn't read. It had been like that for a couple of days for us. Her UTI was improving, He also said she had intestinal worms (said it come from eating dirt) and I know she has eat grass a lot. I've always been told that when a dog eats grass it is to settle the stomach or make them throw up. Her insulin has been adjusted now to 32 units twice a day. We haven't been on this dosage to be able to tell a difference. Her ACTH test (don't know the numbers) was done Tuesday and according to my vet it showed her adrenals had no function. She is to continue on her predinisone. I quess Montana is addisonian with uncontrolledd diabetes. She has been very sick the past 2 weeks, at times almost to the point of being comatose.

[We Hope]

Montana needs to have some insulin for her body's basic needs, even without food. If she no longer has functioning adrenal glands, she has then gone fron Cushing's to Addison's Disease.

Having Addison's means that she needs to replace the cortisol and trace hormones her body no longer makes, just as she needs to replace the insulin her pancreas doesn't make, so she does need to take prednisone in some fashion.

http://petdiabetes.wikia.com/wiki/Addison%27s_disease

http://www.addisondogs.com/

Canine Addison's support group website

http://pets.groups.yahoo.com/group/k9Addisons/

Canine Addison's Yahoo e-mail support group

She's also going to need something to get rid of the worms.

Since she isn't eating right for you and the diabetes isn't controlled at present, what about hospitalizing her, so that she could be either force-fed or fed intravenously, while the doctor tries to get a handle on the diabetes as well? Many times they don't care to eat when they have such high bg's. Having her at the vet's where they can see that she eats and try to get the high blood glucose under control, might mean that once they've done this, you won't have the eating problems one she's stabilized there.

She's a very sick girl and she really needs to be in hospital to get everything ironed out for her with all of these problems.

[k9diabetes]

Does she have ketones?

How were her electrolytes?

Please post her ACTH test results?

(just have the hospital staff read them to you or fax them - don't need to get them from the vet)

Natalie

[piggie40]

It's been a bad time. Today, so far has been much better. While her BG has never been in great control, it has just skyrocketed over the past week or two. I saw her as close to death as I have seen. I was so scared I was going to lose her.

The vet says she doesn't have any adrenal function so we have to continue with the prednisone dose, 5 mg in the am, 2.5 mg in the pm. She has upped the insulin dose to 32 units twice a day. One of the big problems we face is Montana not eating. She acts like she wants to eat, but she will smell the food and then walk away. She asks for treats, but when we try to give them to her she will only turn her head. I have every variety of food in my house and go through each of them trying to get food into her. I know this is probably a bad thing to do but we even take the food to her, sit on the floor, and hand feed her morsel by morsel. Sometimes this works, sometimes it doesn't.

Today has been a good day. She wants to eat everything in sight. Someone posted the web address to rating certain dog foods and also information on the ingredients in food. It was an eye opener. As a result, I have been trying to get her on to a better, healthier food. The food I was giving her was rated the absolute worse. I am trying to use the healthy foods as a "treat" to get her eating the new stuff. The vet recommended Fit and Trim and she eats it occasionally, but if you look at the ingredients, it doesn't rate very well. You would think the vet would be giving you stuff with better ingredients. At any rate, I want to say thank you to the person to open my eyes at looking at the food she eats.

Her BG have been awful. Mostly "high" readings. We still are giving her insulin whether she eats or not. I know it is not the textbook way of doing things, but if we don't her BG rises and puts her almost in a comatose state. We've NEVER had good control of her glucose and being low hasn't even been an issue. Vet says she has to have the prednisone because the adrenals still aren't working. I wish we would have done the lysodren differently, but we didn't and we have to deal with it. It's just hard to believe that a total of 7.5 mg of prednisone is wreaking this much havoc on Montana's system.

[We Hope]

It's been a bad time. Today, so far has been much better. While her BG has never been in great control, it has just skyrocketed over the past week or two. I saw her as close to death as I have seen. I was so scared I was going to lose her.

The vet says she doesn't have any adrenal function so we have to continue with the prednisone dose, 5 mg in the am, 2.5 mg in the pm. She has upped the insulin dose to 32 units twice a day.

And if we take a look back here where we did the math:

If we convert Montana's weight into kilograms (2.2 lb), she weighs 45.45 kg.

http://www.vin.com/VINDBPub/SearchPB/Proceedings/PR05000/PR00105.htm

WSAVA 2001 Diabetes Mellitus:Treatment Options

Insulin Therapy

"In dogs we like to start with Humulin-N at 0.5 units/kg q12h."

This means 1/2 unit of insulin for every kilogram (2.2 lb) of body weight every 12 hours. So if I round off Montana's 45.45 kg to 45 kg for the sake of doing this example and multiply that by .5 for the 1/2 unit of insulin for each 2.2 lb she weighs, I get 22.5, or a starting dose for her would be 22.5 units of insulin. You're not very much removed from that point with the "official" dose being 28 units 2X per day.

http://www.ncbi.nlm.nih.gov/pubmed/7660542?dopt=Abstract

Diagnosis and management of insulin resistance in dogs and cats with diabetes mellitus.

Veterinary Clinics of North America-Small Animal Practive May 1995

"Clinical insulin resistance should be suspected in any animal in which marked hyperglycemia persists throughout the day despite insulin doses of greater than 1.5 U/kg per injection."

So if we break out the calculator again, Montana at (rounded) 45 kg wouldn't be classed as resistant to any given insulin unless she was receiving 67.5 units of it each time and not responding. I don't think she will need to go to 67.5 units per injection to control her bg's, but I do believe she is not receiving enough of an insulin dose to control them adequately at this time.

Montana is not insulin resistant until she's getting 67.5 units every shot--this was done based on her weight of 100 lb at the time of the original post. If Montana's lost any weight, the number of units would of course be reduced when doing the calculations. She's still not receiving enough insulin or her bg's would be much more responsive.

Her BG have been awful. Mostly "high" readings. We still are giving her insulin whether she eats or not. I know it is not the textbook way of doing things, but if we don't her BG rises and puts her almost in a comatose state. We've NEVER had good control of her glucose and being low hasn't even been an issue. Vet says she has to have the prednisone because the adrenals still aren't working. I wish we would have done the lysodren differently, but we didn't and we have to deal with it. It's just hard to believe that a total of 7.5 mg of prednisone is wreaking this much havoc on Montana's system.

The vet is correct when saying that the prednisone is needed because Montana is not producing enough cortisol and trace minerals on her own for her body's needs.

But we can't just look at the prednisone she needs to take and put all of the blame on that for her high bg's either. Uncontrolled diabetes produces high bg's without any prednisone added because the body doesn't make enough insulin to control them. Montana's diabetes problem and her adrenal gland problem have a lot in common in that both of them are caused because those organs or glands in her body aren't producing enough of what she needs to be healthy.

The lack of production of cortisol and the other necessary for life trace minerals from the adrenal gland means that one needs to replace them from the outside for as long as the adrenal gland is not working. This means for life in the case of those with Addison's Disease.

When the insulin producing beta cells of the endocrine portion of the pancreas are no longer working or not working enough to supply the insulin the body needs, they need to be replaced in the proper amounts from the outside. In the case of dogs with diabetes, this means insulin and it means for the life of the dog.

Giving some insulin whether or not an animal eats IS by the book, because this addresses their body's basal needs--the need of the body for insulin minus the need for the insulin to handle the food eaten.

http://www.intervet.com.au/binaries/82_103335.pdf

Page 15

"If the diabetic patient is unwilling or unable to eat due to illness, administer a lower dose of insulin (approximate 30% of the normal dose) until appetite is restored."

Right now, it appears that the problems with controlling the diabetes are the biggest threat to Montana's health. I believe you are skilled and able to test Montana at home. Is it possible that you and the vet could work something out where you test Montana regularly, advise the vet of the readings, and then together work out needed increases on a regular basis?

You also have another option open to you, and that would be to begin a discussion with Montana's vet about the use of some R insulin in addition to the NPH to try to get her bg's more manageable.

On the other diabetes board, we had someone with a dog who had an immune system disorder which, when in active status, would only respond to prednisone. She needed to take it for her medical problem just as Montana needs to use prednisone since her adrenal glands are not working. The person was able to get a handle on her dog's high bg's due to the amount of prednisone she had to give by working with her vet regarding using some R insulin in addition to the NPH to get them controlled.

I don't know if your diabetes requires the use of insulin or not, but if it does, you are certainly skilled enough in the use of a fast/rapid-acting insulin for your needs and can use that knowledge to help Montana.

[BestBuddy]

If your dog is truly addison you need more than pred to get Montana feeling better. I know there is something else needed to be given along with the pred to replace electrolytes (I think). I don't have time at the moment to check it out but if you ask the q on the cush board I'm sure someone will help you out.
Jenny & Buddy

[We Hope]

Does this help?

http://petdiabetes.wikia.com/wiki/Addison%27s_disease

The adrenal glands produce two types of hormones; we're most familiar with the glucocortoid ones, such as cortisone. Cortisol and other hormonal levels rise during anger or fear, stress or injury. The term "getting one's adrenalin going" in response to these situations applies to the natural response a healthy body has to them. Those with faulty adrenal glands don't produce enough cortisol to allow the body to respond properly.

The other adrenal hormones, known as mineralcorticoids, are what keeps the system in balance regarding proper amounts of salt, potassium, and water in the body. Imbalances of these keys to life can have grave consequences also.

http://www.peteducation.com/article.cfm?cls=2&cat=1662&articleid=700

"Potassium toxicity generally does not occur from excessive intake as long as the kidneys are functioning normally. The potassium level in the blood, however, can reach a dangerous level in a disease called hypoadrenocorticism or Addison's Disease. This is a disease in which the adrenal gland does not produce enough of the hormone that helps regulate the amount of potassium in the blood."

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=endocrin.section.635

Aldosterone and the control of salt and water balance

http://www.percorten.novartis.us/about/en/index.shtml

About PERCORTEN-V

"Your dog's adrenal glands produce chemicals and hormones that help regulate many bodily functions such as metabolism, blood pressure and stress response. When a dog doesn't produce enough of these hormones, a sometimes-fatal disease known as Canine Addison's Disease may occur. With proper medical management, including PERCORTEN®-V (desoxycorticosterone pivalate) Injectable Suspension, a dog suffering from Canine Addison's Disease should live a normal, happy life.


How PERCORTEN-V Works

"PERCORTEN-V replaces the chemicals and hormones that the adrenal glands can no longer produce in dogs suffering from Canine Addison's Disease. These chemicals and hormones help the dog's body regulate sodium and potassium levels, which are important for controlling blood pressure, heart function, and the nervous system."

[k9diabetes]

I'm concerned that kidney issues or an electrolyte imbalance are contributing to her not wanting to eat and being so ill. I know her electrolytes were okay in the beginning, but they could be off now since her adrenals have not recovered and may not recover.

It could be the other illnesses that are driving her BGs high now.

She still has no ketones?

Ketoacidosis at this point is a grave concern and she will have to get her blood sugar reduced if they are now present.

Did they do a full blood panel to check her kidney function, electrolytes, etc.?

Poor kidney function was much worse for Chris' appetite than high blood sugar. When his kidneys were out of whack last year from Lasix, he was the same way - one day he'd eat something, the next day he wouldn't. It's pretty classic behavior from problems with the kidney or liver, in addition to a common response to very high blood sugar.

You can keep offering her new things but...

Getting her health to a better state is the key to getting her to eat.

Are you familiar with some of the organizations that offer assistance with veterinary care?

CareCredit is one way: http://www.carecredit.com/vetmed/whycc.html

IMOM also sometimes can offer assistance with veterinary expenses: http://www.imom.org/

Sometimes the organization who rescued your dog can help.

Our dog needed surgery just weeks after he was adopted. I talked to a friend at the local SPCA and they donated $100 toward his surgery, which at the time, fourteen years ago, was a big part of the $500 it cost.

[k9diabetes]

I don't think there's a magic cure here... Montana needs to feel better to eat and probably needs a lot more insulin than she's getting. With worms and UTI and all going on, sorting out what will get her back is going to be difficult.

Your best friend right now is information, starting with a full blood panel if one hasn't been done so you know what's working and what isn't. That's one investment I would make right away if it hasn't been done already.

Montana needs a specialist.

She's got a complex set of issues going on that need targeted, very competent care if she's going to survive. You've said yourself that she's been near death.

If finances are the problem, that's understandable, but then I'd suggest you find a vet who is willing to consult with a specialist and/or attempt to find some financial assistance to take her to the college vet school directly.

I don't want to chase you away... I don't want to offend you...

and I totally understand if paying for specialist care is the problem.

But I don't think Montana is going to survive this without more skillful help and more aggressive treatment.

And more aggressive treatment could be as simple as giving her a dose of insulin that actually brings down her blood sugar. A dog with Addison's disease should not have high blood sugar!!

**********

Please know that our dog would not have survived if we had not given him more aggressive care, if we had not found a vet willing to treat his diabetes aggressively.

He was on the same path Montana is on in March and April 2004. The lack of "care" he was receiving then was killing him. Getting the right care is what has allowed him to enjoy a good, healthy, happy life for the past three and a half years. And largely, we had to take the initiative to get him that care.

You can have Montana for many many many years to come if you can find the strength to get her the care she needs so desperately now.

I'll help in any way I can but you are the only ones who can make it happen.

Natalie

[Brandy mom]

Sorry your baby is so sick. Brandy was on Prednisone eye drops and they did raise her BG alot. So the vet had me do several curve giving the drops at different times. What we were trying to acheive was to have the Prednisone raise the Bg when she was at the lowest point from the insulin. We found a time that worked for us. Sometimes I had to use R insulin. Talk it over with the vet and see if this would help.

With all the medical problem you are having now. You need to sit down and talk with the vet. Put it all on the table at one time. You have had some great suggestion from this board. Why don't you print them off and talk to the vet about it. You could also explain about the financial problem some vet will work with you.

Dawn and the girls

[eyelostit]

Just hoping Montana is getting better, hope today is a better day

[ladysmom06]

Hi,

So sorry to hear that Montana is not feeling well. You have been given some great suggestions by others here - I don't have anything to add but want you to know that I'm thinking of Montana and hoping you can get things sorted out. Hugs to the two of you.

[piggie40]

I think when she gets better that we are on the mend. Then out of nowhere, we have a big relapse. It's difficult to understand why she does so well and then gets so sick again with all factors staying the same. Maybe its just the course of diabetes.

In reference to percorten, I have a friend with a komodor that has addisons. His dog takes percorten injection once a month. I wondered why Montana wasn't on it but the response was because her electrolytes were normal. I would agree for Montana to try the injection if it would help. I'll pursue this again.

I quess I see Montana as being insulin-resistant because the insulin isnt working and the increases in dose so far haven't really changed anything. She does have a wayto go to get to 67.5/injection. I quess I am not very patient with the increases in insulin. I understand why it has to be done in small increments, 2 of the vets have said the same thing, but I am wanting this process to go faster. I am suppose to do a glucose curve again on the weekend. I quess we will see how it goes.

Natalie I will check out the possible financial assistance to see what happens. There are many issues other than money that factor in the specialist referral. The doable thing would be for a consult call.

I'm at ease to know that giving insulin without Montana eating is perfectly fine. I felt as if I was doing something wrong, but she needed it just to maintain her where she was at, which was "high".

Today Montana is have a good day. She is eating us out of house and home. She has barked all day wanting treats.....she is driving us NUTS! It's great to have her eating so hopefully we are back on the right road again.

[We Hope]

When diabetes is well-controlled, one doesn't necessarily need to go through these bouts. It's more than likely that Montana's other problems play a role in what she's going though, but with just taking diabetes alone, that isn't the case.

My little one never spent any time in hospital for his only health problem--diabetes. After his diagnosis, he had one minor problem with colitis which was easily treated as an out-patient; he was about 14 when we got the diagnosis.

Having gone through immune-mediated insulin resistance with him on both human and beef insulin, I can tell you what resistance is like. It means that you get to the point where you are at the number of units of insulin you get from working out the 1.5 U/kg for the individual dog and that insulin is not doing anything at all--it might as well be water in the syringe instead of insulin.

When you do a curve, this is what it looks like because there's no response to the insulin at all--except that of the immune system to destroy it before it can do anything about the blood glucose. Within 2-4 hours after being given human or beef insulin, even long acting ones like Ultralente and PZI, his system had destroyed every bit of it.

http://www.vetsulin.com/vet/images/insulin_resistance.gif

Doing a curve should show you whether Montana is having a response to the insulin or not by the lowering of her bg's. That should tell you if the problem is not enough insulin or not as the curves do look different .

http://www.vetsulin.com/PDF/Glucose_Curve_Interpretation.pdf

Page 2 of this pdf file shows a sample curve where the problem is not enough insulin; it's directly next to a copy of the graphic in this post. You'll see that where the problem is not enough insulin, you are getting more of a "dip" in the bg levels and that they stay at that point for a bit, then return back up. With the resistance example, they take a slight downturn but return to high levels within a very short period of time--there's a much faster return to the high levels than from not enough insulin.

As long as you say that the doable thing is to consult with a specialist, I'd suggest you do this soon. Doing that will get a number of questions squared away about Montana, some of them not diabetes-related. It will get things straight with regard to the status of her adrenal glands, whether or not she does need Percorten injections, and some expert advice on where her insulin dose should be now and how much and how often to increase it, if necessary. Consulting a specialist and getting it done soon should put her on the right road with all of the medical issues she's dealing with.

I think life would be a lot easier and happier for all of you if you get a specialist's input soon.

[k9diabetes]

In my mind, it wouldn't take a lot to get Montana more on the road to recovery - what's standing in the way is the vets' approach. So to me, that's what needs to change.

Intervet, which makes Vetsulin, has suggested starting at a dose of 1 unit per kilogram plus 4 units for a dog larger than 20 kg (44 pounds) for once daily therapy and cutting that amount by 25% for twice daily therapy.

Montana weighs about 45.5 kg so that would be 45 + 4 units of insulin or 49 units of insulin recommended by Intervet. Cutting that 25% would be 37 units of insulin twice a day for a dog Montana's size.


http://www.k9diabetes.com/userimages/vetsulindosingtable2008.jpg


Note that this is the recommended "initial dose." Not the most you can give. Just a place to start.

Intervet recommends evaluating the dose after 5-7 days and making 10% increases.


Monitoring and Adjusting Dose


Six to seven days after starting Vetsulin, the dog should be returned for evaluation.

• Obtain owner’s overall impression of the dog’s progress.

• Re-weigh the dog. Overall dosage of Vetsulin should be modified for significant weight gains or losses.

• Blood glucose sampling should be evaluated to determine if regulation is achieved.

• Adjustments in dose based on the glucose curve evaluation should be in increments of 10 percent.

For example, if a dog is currently receiving 12 IU twice daily and has a blood glucose curve that indicates inadequate regulation, the dose should be increased 10 percent, or 1 IU.

• Additional adjustments in dose should be made no more frequently than every five to seven days.

• Once regulated on Vetsulin, the dog should be rechecked every two to four months.


All of the above is from the following document, which can be downloaded and reviewed with Montana's veterinarian. This document is designed for veterinarians and is a manual of how to treat diabetes. I don't agree with everything in it but it does give a decent basic map to managing diabetes: http://www.vetsulin.com/PDF/20585.pdf

So after all these months, you might finally be getting up to maybe a proper dose of insulin for Montana. Caution is warranted when Addison's is making her sensitive to insulin but that certainly isn't the case at the moment. Plus you are home testing so will know (not guess from signs like water consumption) what her blood sugar is doing. That's a piece of information that the manuals presume does not exist.

We already know she is not resistant to the insulin because we have seen it lower her blood sugar down into the 200s and 300s.

So the insulin works.

The currently high blood sugar may be simply that she's getting more prednisone than she needs.

Because if her adrenal glands truly aren't functioning... and I don't take that as a fact until I could see the test results for myself... then even stress and illnesses should not be raising her blood sugar. She would have to have cortisol production capacity for that to happen..

We Hope, correct me if I'm wrong there. Wouldn't she have to be able to produce cortisol from the adrenal gland for the stress and illnesses to be raising her blood glucose levels?

In my mind, things are out of balance and the vets continue to slap at it without getting serious about sorting out what Montana does and doesn't need and how much of it she needs.

I fear that they are going to kill her with this approach.

That's why I am hoping fervently for some change immediately before she suffers irreparable harm.

I know they probably sound confident and tell you you don't know what you're talking about. Every vet.... every doctor.... can be wrong. And with vets, especially in rural areas, the experience with these kinds of things doesn't necessarily go very deep.

I've been there. I had a man who "wrote the book" on diabetes in dogs tell me we were using the right insulin. I knew in my heart that we weren't. That we could do better than that. I took Chris to another vet who would not accept that man's confident but erroneous decision as the best we could do and it saved Chris' life.

Sadly, vets do sometimes kill a dog with ignorance or neglect of care.

And I never trust a vet who isn't open to learn, consult, or refer.

Let me know if there's anything more I can do to help make the consult happen. I will go dig up some links now to authoritative sites that may be helpful.

Natalie

[We Hope]

In my mind, it wouldn't take a lot to get Montana more on the road to recovery - what's standing in the way is the vets' approach. So to me, that's what needs to change.

Intervet, which makes Vetsulin, has suggested starting at a dose of 1 unit per kilogram plus 4 units for a dog larger than 20 kg (44 pounds) for once daily therapy and cutting that amount by 25% for twice daily therapy.

Montana weighs about 45.5 kg so that would be 45 + 4 units of insulin or 49 units of insulin recommended by Intervet. Cutting that 25% would be 37 units of insulin twice a day for a dog Montana's size.



Note that this is the recommended "initial dose." Not the most you can give. Just a place to start.

Intervet recommends evaluating the dose after 5-7 days and making 10% increases.




All of the above is from the following document, which can be downloaded and reviewed with Montana's veterinarian. This document is designed for veterinarians and is a manual of how to treat diabetes. I don't agree with everything in it but it does give a decent basic map to managing diabetes: http://www.vetsulin.com/PDF/20585.pdf

So after all these months, you might finally be getting up to maybe a proper dose of insulin for Montana. Caution is warranted when Addison's is making her sensitive to insulin but that certainly isn't the case at the moment. Plus you are home testing so will know (not guess from signs like water consumption) what her blood sugar is doing. That's a piece of information that the manuals presume does not exist.

We already know she is not resistant to the insulin because we have seen it lower her blood sugar down into the 200s and 300s.

So the insulin works.

The currently high blood sugar may be simply that she's getting more prednisone than she needs.

Because if her adrenal glands truly aren't functioning... and I don't take that as a fact until I could see the test results for myself... then even stress and illnesses should not be raising her blood sugar. She would have to have cortisol production capacity for that to happen..

We Hope, correct me if I'm wrong there. Wouldn't she have to be able to produce cortisol from the adrenal gland for the stress and illnesses to be raising her blood glucose levels?

In my mind, things are out of balance and the vets continue to slap at it without getting serious about sorting out what Montana does and doesn't need and how much of it she needs.

I fear that they are going to kill her with this approach.

That's why I am hoping fervently for some change immediately before she suffers irreparable harm.

I know they probably sound confident and tell you you don't know what you're talking about. Every vet.... every doctor.... can be wrong. And with vets, especially in rural areas, the experience with these kinds of things doesn't necessarily go very deep.

I've been there. I had a man who "wrote the book" on diabetes in dogs tell me we were using the right insulin. I knew in my heart that we weren't. That we could do better than that. I took Chris to another vet who would not accept that man's confident but erroneous decision as the best we could do and it saved Chris' life.

Sadly, vets do sometimes kill a dog with ignorance or neglect of care.

And I never trust a vet who isn't open to learn, consult, or refer.

Let me know if there's anything more I can do to help make the consult happen. I will go dig up some links now to authoritative sites that may be helpful.

Natalie

Something very interesting turned up while I was reading more about Percorten. It's comprised of the non-cortisol-hormones only for the hormone replacement therapy needed.

http://www.percorten.novartis.us/product_label/en/index.shtml

"Glucocorticoid replacement must be supplied by small daily doses of glucocorticoid hormones (e.g., prednisone or prednisolone) (0.2 - 0.4 mg/kg/day)."

So they are telling you that the Percorten injections alone are not enough for replacement therapy--that you need to give daily doses of prednisone or prednisolone and what amount should be administered, according to the kg weight of the patient.

When we did the math for Montana's weight in kg for the insulin resistance examples, we found that dividing 100 lb by 2.2 gave us a 45.45 kg figure, so we'll hang onto the 45.45 kg weight to do this example.

If I take Montana's 45.45 kg weight and the lower end of the dosing advisory Percorten indicates is proper for the prednisone/prednisolone portion of the hormone replacement necessary for Addison's, 0.2 mg per kg of body weight per day, I get a figure that the total dose daily should be 9.09 mg.

The vet says she doesn't have any adrenal function so we have to continue with the prednisone dose, 5 mg in the am, 2.5 mg in the pm. It's just hard to believe that a total of 7.5 mg of prednisone is wreaking this much havoc on Montana's system.

This is more than the 7.5 mg total dose of prednisone she's getting currently. So with the reasoning that her adrenal glands don't function, she would not be getting enough prednisone to replace what the adrenals no longer produce and would be at risk for serious issues with Addison's, if she has it:

http://petdiabetes.wikia.com/wiki/Addison%27s_disease

"Dogs with diagnosed and treated diabetes but undiagnosed/untreated Addison's disease may have reduced insulin needs."

http://www.dcavm.org/01mar.htm

Endocrinology: Addison's Disease & ACTH Testing Procedures
March 2001 DC Academy of Veterinary Medicine--Dr. Greco

My thought is that there is some function in the adrenals and that in addition to the prednisone, they are driving the bg's.

This is why we are strongly suggesting you have a specialist consult for Montana, because until these questions get answered and her problems get treated properly, she's not going to get better and stay better.

[k9diabetes]

From: http://www.marvistavet.com/html/addison_s_disease.html

Corticosteroids are the hormones that enable us to adapt physiologically to stress. The "Glucocorticoids" (such as cortisol and related synthetics, prednisone (http://www.marvistavet.com/html/body_prednisone.html) and dexamethasone (http://www.marvistavet.com/html/body_dexamethasone.html)) act on the mechanics of sugar, fat, and protein metabolism. They gear the metabolism towards the preparation of burning (rather than storing) fuels so as the be ready for a "fight or flight" situation.

The "Mineralocorticoids" (such as aldosterone and related synthetic fludrocortisone acetate) (http://www.marvistavet.com/html/body_fludrocortisone_acetate.html) influence the electrolytes: sodium and potassium. As a general biological rule, where there's sodium or salt, there's water. When the mineralocorticoids circulate as part of the "fight or flight" preparation, sodium is conserved in anticipation of blood loss so that there will be extra fluid in the vascular compartment (spare blood). When sodium is conserved, potassium is lost as part of the biological balance. This whole picture of fat mobilization, sodium conservation etc. which is part of the "fight or flight" preparation is far more complex than can be reviewed here but the bottom line is:

Corticosteroid hormones are needed to adapt to stressful situations and without these hormones, even small stresses could lead to physiologic disaster.

...

In animals with Addison's disease, there is a deficiency of the corticosteroid hormones.

...

A normal animal will show an elevation in cortisol in response to ACTH while an Addisonian has no corticosteroids to respond with. This lack of response is diagnostic for Addison's disease; however, a false positive may be obtained if corticosteroids have been used in the treatment of the crisis prior to the test. Only dexamethasone does not interfere with the assay for cortisol; if any other steroid has been used, the test will not be valid for at least a couple of days.


A dog who has Addison's can't produce the fight or flight hormones so should not be able to raise the blood glucose levels in response to stress. That's why they try to liimit stress and sometimes increase meds to counter this problem in a stressful situation.

Perhaps the strong action of the immune system is contributing to her high blood sugar. I know allergies also raise blood sugar and I don't know if that is a separate response unrelated to cortisol production.

Addison's dogs suffer from low blood sugar, which is why it is sometimes confused in a nondiabetic with an insulin-producing tumor.

I'm sorry... I really don't think the vets know what they're doing here. They could have, for example, switched her over to the Dexamethasone for cortisol replacement so the ACTH would be a valid test. And I'd really like to see the actual results of the tests and and even whether they are doing the test properly since I suspect she never had Cushings to begin with. I still haven't heard whether they have even checked her electrolytes, which if they actually believe she has Addison's, it seems to me they should be doing...

I'm sorry to go on and on. I'm just so worried that something horrible is going to happen to Montana and it doesn't have to be that way.

Natalie

[AlisonandMia]

I believe the situation with Montana’s adrenal function is that she overloaded on Lysodren and to date has not been producing any cortisol of her own. Her electrolyte balance is, however, OK so she must still be producing the electrolyte-balancing hormone aldosterone. This means she does not need Percorten or Florinef and in fact, for Montana, these meds would actually cause an electrolyte imbalance in the opposite direction to the imbalance you get with Addison’s – too much sodium, fluid retention and high blood pressure would be the result.

There are two types of Addison’s, one where only cortisol production is deficient and another where both cortisol and aldosterone are not produced. Montana has the cortisol-only type, fortunately.

If she did actually have Cushing’s it is quite likely at some point her adrenal function will return but how long this will take is impossible to predict. If the Cushing’s diagnosis was not accurate then it is probably less likely that her adrenal function will return. That she is not producing her own cortisol is not, in itself a problem, as long she is getting enough prednisone so make up for what she cannot produce herself. Exactly how much an individual Addison’s patient needs does vary. Dosages per unit of weight are only a rough guide. It would be a lot easier if her adrenal function never did return and she could stay on a stable dose of pred to supplement cortisol but I fear that one day her adrenals will get back into business. That is why getting her diabetes under control now is so important.

I do tend to think she did actually have Cushing’s as she has recently shed her coat and had a lot of dandruff etc which is a very normal response to previously excessive cortisol levels returning to a more healthy level.

We really do need to see the stim test numbers to be sure that she doesn’t in fact have any adrenal function – sometimes vets make broad statements that are not – well – quite accurate. If she doesn’t have any adrenal function you would expect the pre and post numbers to be the same as all that would be showing was the prednisone.

Something must be causing these big swings in BG. I don’t know if other stress hormones such as adrenaline could be affecting BG. The part of the adrenals that produce adrenaline and other similar hormones is not affected by Lysodren as far as I know and even if it was these hormones are produced elsewhere in the body anyway – which is why people and animals who have both adrenals surgically removed only need corticosteroid and aldosterone supplementation.

The other possibility is that her diet is not particularly stable and that she is getting different quantities of food, particularly carbohydrates, on some days. Could she be going through a cycle where she her BG gets so high that she feels so sick she cannot eat then a combination of not eating and insulin brings it down a bit to the point where she hungry and starts eating again and when she will eat you are feeding her and feeding her for a couple of days with treats here and there etc to tempt her to eat and then she goes too high again and won’t eat and the cycle starts again. I don’t know if this is what could be happening but when you say “she is eating everything in sight” it makes me wonder if this is case. If she is getting high-carbohydrate foods at times then this could make the problem even worse.

As the others have said some input from a specialist to sort things out and get treatment on track sounds like it is necessary.

Good luck and I hope that Montana can soon start to feel well all of the time.

Alison

[piggie40]

I just wanted to update everyone about Montana. Her cushings had improved to the point they were using the term addisons. Her glucose levels stayed elevated I guess partly due to the prednisone. Things for the past couple of months had started return to normal, but she started about a month ago exhibiting signs of cushings. We brought her in to the vet and all the lab work was normal, with the exception of a UTI. Her vet stopped her prednisone but we found Montana could not function well without it. We started giving her 2.5 mg and this has worked well for the past 2 weeks. I guess this is presenting a problem with her glucose because now her sugar is too low. The only thing that has changed has been cutting her prednisone dose by 2.5 mg. I get nervous in the mornings when I have to leave for work.

At her age and given all her problems she is doing fairly well. I realize that things won't be easy for the remaining time we have with each other. It's okay though, I will love her to the end whenever that may be.

On a personal note, I found out today my biopsy showed NO cancer cells. I'm so excited, relieved, grateful, and blessed! The results came out with the best possible scenario we could have!

[We Hope]

It's been a long time since you posted, so we don't know what insulin dose Montana is currently using.

It seems that she also needs some type of insulin reduction to go along with the prednisone reduction as she's having hypoglycemia problems.

You personally would be far better and safer to have Montana reading a little high than getting into the lows--especially since there's not always someone at home to "catch" them.

Cortisol (prednisone) is one of the counter-regulatory hormones in that it raises bg's:

http://petdiabetes.wikia.com/wiki/Counterregulatory_hormones

"Counterregulatory hormones have opposing effects to the actions of insulin. Where insulin, endogenous or exogenous, lowers blood glucose, one effect of these counterregulatory hormones is to raise it.

"Cortisol, growth hormone, adrenalin AKA epinephrine, glucagon, progesterone and thyroid hormone are considered counter-regulatory hormones as far as diabetes and blood glucose levels are concerned."

Congratulations on getting a good medical report! :)

Kathy

[k9diabetes]

It was nice to chat with you briefly by email and I'm very happy to see you came over here to give us an update. You and Montana cross my mind often. Congrats to you on the good news today!!!

Natalie

[piggie40]

This morning Mont's glucose monitor read "hi". It was obvious she was sick. Today when I came home from work, she was low. It was obvious she was sick. Its like all of sudden we can't control her sugar anymore.

[k9diabetes]

Rebound from lows is a possibility...

[k9diabetes]

I heard from Sheri that Montana passed away on January 12 of kidney failure. She had been refusing food for a while.

Sheri will come by and post something about Montana when she's able. In the meantime, I asked her to send me a picture of her beautiful dobie... Godspeed Montana...

http://www.k9diabetes.com/userimages/Montana.jpg

Natalie

[Fishslayer]

Awww... I'm so sorry to hear that. R.I.P. Montana.


Rick

[eyelostit]

Aw, such a pretty baby, I'm so sorry :( I wish I could somehow ease your pain, maybe this will help a little.

"Although it's difficult today to see beyond the sorrow, may looking back in memory help comfort you tomorrow"

Theres a new star up there now and its name is Montana

[BaileyBear]

What a beautiful girl. I'm so very sorry for your loss. After reading through the entire thread, it looks like you went through so much together. Montana was certainly loved and I hope you have many happy memories of her that will bring a smile to your face as your heart heals.

[birdk]

I am sorry for your loss. Such a beautiful girl!!!

[Patty]

Sheri,
Such a sweet picture. I'm very sorry for your loss.
God Bless,
Patty

[Ricksma]

I am so sorry for the loss of your sweet Montana. God bless.

Love and hugs, Teresa

[rhodesian46]

SHERI
I am sorry for the loss of Montana.When you are ready you will want to come back on to help others.I know alls you can do is read this and cry. I have been there Pebbles passed away on 10/22 It still hurts.We sre here for you if you need to talk PLease take care