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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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...00/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/Ov...own--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/7...?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/Hy...abolic_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/Hy...-term_symptoms

"Neuropathy (nerve damage to legs) especially in cats

"Dehydration

"Malaise or lethargy "--among others

http://petdiabetes.wikia.com/wiki/Hy...-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

Here you see what raising an insulin dose too rapidly can do.

[piggie40]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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.