Rags

[Rags' Mom]

I cut and pasted this from another forum, I think I may have posted it incorrectly the first time:

Hi all,

New to this forum and would like to tell you a little about the little dog that could (and can).

Rags is a 13 1/2 year old Snorkie (1/2 schnauzer/1/2 yorkie). He came to us as a tiny puppy from the local humane society. Now he would be a designer dog - how funny.

He was supposed to be my dog, but went immediately to my husband. Later, it would become apparent that he was Heaven sent. In 1998, he became my husband's constant companion while he battled to live from an aggressive infection in his heart. Hubby beat the infection (with the care and love of a faithful dog) but is now an invalid, wheelchair bound, oxygen dependant. But Rags is still there for him.

At Christmas this year we noticed that Rags was losing a great deal of weight. He needed to lose a little, but this was way to much. As our vet had recently retired and sold the practice to a new vet, I got him in to be seen.

The diagnosis was Cushings - through me for a loop, but then the diabetes showed up. Sugars through the roof. Started small dose of insulin (3 units) and when the Trilostane was started (small delay there) the cortisol came within normal limits quickly - but the sugars are still horrible. Yesterday's was over 600 (meter read HI). He is now on 8 units. (he weighs 12 lbs - down from 21) I started checked his urine glucose this morning and it read 5000.

He is now blind, and appears not to see even light at this point.

We are hanging in there. He hates the shots, so I now have to wake up hubby each morning to hold him. He is still eating, but the drinking is a little less. We are making plans to enclose the deck for his safety without limiting his area. Thankfully the house is ramped, so that makes it a bit easier for him. He can still find the pet door on occasion. He is now barking when he gets lost.

We have another dog Scruffy who was watching him outside, but he isn't as devoted as I would like. The cats tend to purr up against him to keep him from the edges. Neat to watch.

If anyone has advice, would love to hear it. I really think that if he dies, it will impact negatively on my husband's health (not to mention my heart).

Janie

[peggy0]

Re: Rags

He's adorable. I don't know much about cushings, just learnning how to deal with diabetes but I will tell you that you came to the right place. The folks here can offer alot of great advise to you. Welcome and I hope Rags does well.

[Cara's Mom]

Re: Rags

Hi Rags' Mom, welcome to the forum. You came to the right place! I can't give any advice on Cushings. Cara and I are dealing with diabetes only. There are some here that are battling both Cushings/Diabetes . So I am pretty sure they are willing and very able to help you answer all questions you have Hang in there!

Hugs for you and Rags

[Soaphie & Sydney's Mom]

Re: Rags

Welcome! You have come to the right place! Friendly, supportive people with SO SO SO MUCH KNOWLEDGE!!!

Growing up, I had a dog named Rags....wired hair fox terrier, jack russell etc etc mix. Lived to 17. I love the name!

[Rags' Mom]

Re: Rags

Thanks for the welcomes. It is funny that I have spent 30+ years as a nurse and can't tackle one dog with diabetes.

Biggest problem right now is that he has lost so much weight that I can't find good places to stick him.

People have better places than little dogs.

Soaphie's Mom - That is what I thought our other dog was, wire hair and yorkie until our groomer told me I had another Snorkie. (his name is Scruffy - another rescue) Rags doesn't look much like this anymore, he is all ears. Can't go to the groomer cause it stresses him. Sooo thin.


Rags' Mom, Janie

[Cara's Mom]

Re: Rags

Thanks for the welcomes. It is funny that I have spent 30+ years as a nurse and can't tackle one dog with diabetes.
Rags' Mom, Janie

Just wait and see, you will be able to "tackle " this one in no time

[k9diabetes]

Re: Rags

Hi Janie,

I've copied some of your information from the Cushings forum. As I understand it, the cortisol test was only a urine test, which does not actually determine how much cortisol Rags is able to produce. So, if I understand what they are saying over there, we really can't be sure at this point that Rags' Cushings is controlled by the trilostane.

The other really big issue is that insulin was being given only ONCE a day. Last I heard, it was 3 units.

You say 8 units now... is that once a day or twice or two smaller injections twice a day that total 8 units?

Are you using urine strips that check for ketones?

February 16

The Trilostane is working well. It brought his cortisol down from 6.1 to 2.8 (as of last Thurs). However his blood sugar is still very high. It was 600+ last week.

So with the cortisol now being blocked, we are increasing the insulin to bring the glucose down. Tomorrow we go to 7 units. I see some very small glints of hope. Like right now he is barking his head off about something. However, he is also now totally blind, which, as you all know, brings it's own set of problems. His weight is now down to 12.9 lbs.

February 20

Rags went back in for a fasting glucose this morning. It was still HI on the meter (which is over 600). Vet mentioned that I get urine glucose test strips. I did and was knocked out of my shoes with the first test. It showed a level between 1000 and 2000. Leaving a message for the vet in the morning. Something has to give.

Rags is now on 8 units of insulin a day, didn't lose any more weight, and cortisol is stable at 2.8.

Does anyone know how to correlate urine glucose to blood glucose? I looked it up and am not finding a suitable formula.

Once upon a time I saw a table that related blood glucose to urine, very very roughly as a lot depends on how often it is tested.

But I don't think it matters at this point. You have lots of evidence that Rags needs more insulin and that his blood sugar is very very high.

Please let us know if Rags is getting insulin twice daily and what he is eating and how often.

I know it's very very difficult with your limited veterinary resources but Cushings needs to be handled properly, as does diabetes, for Rags to survive and thrive. I know the Cushings folks have suggested asking your vet to consult with an IM on this and think that is a wonderful idea. Rags can be healthy and happy with good treatment but bad treatment could kill him, even if it with the best of intentions. I would hate to see that happen.

We will help you with what most likely should be done and questions to ask. And there are lots of resources out there your vet can access. But I think you will have to be Rags' advocate. I'm sure this was true with your husband with his heart problem and the same is true for Rags - unfortunately, in any form of medical care, the best care comes when the patient has an advocate fighting for them and demanding the best care possible. I'm sure you saw this in your years as a nurse. With dogs it's even more important since they can't speak for themselves.

There are so many troubling signs with what the vet has done so far. I fear that he does not realize how far off the mark he has been...

Anxious to hear more about Rags' regimen,

Natalie

[CarolW]

Re: Rags

Hi Janie,

Welcome to you and Rags. (Rags is SUCH a cutie!) You surely have a handful with both Cushings and diabetes. We're rooting for you! I think maybe I detect a possible slight vet problem; if that's so, you might find the book _Speaking for Spot_, by Dr. Nancy Kay, helpful. It's about being your dog's medical advocate. I point to it on the links page of my web site, and you can also find a detailed discussion of the book on the following Yahoo group, for December, 2008:

http://groups.yahoo.com/group/DogRead/

I find that group extremely variable, but this past December was wonderful. This month is also excellent, with ethicist Jim Barry, on ethics for dog trainers and behavior counselors. I think the discussion there holds some relevance for this forum as well, if not as much as the December, 2008 one.

Sat, 21 Feb 2009 20:43:00 (PST)

[eyelostit]

Re: Rags

Welcome Janie & Rags

Its nice Rags is hubby's lil friend, that helps alot.

Usually insulin injections are given 2x day, so we can't tell if he is getting 8 units once a day or 4 units 2 x day.

I'm sorry Rags had to get both cushings and diabetes, another member I know had the diabetes first and the cushings second and its really hard to absorb all of this at one time, but you seem to be handling it pretty well.

You'll have lots of support here, ask any questions

again Welcome !

[BaileyBear]

Re: Rags

Just wanted to welcome you and Rags. I'm sorry to hear that you are dealing with so much, but you are definitely in the right place for support and advice.

[Rags' Mom]

Re: Rags

Rags is getting 8 units once a day (AM). Using Vetsulin and vet assures me he has never had a patient who needed to switch to twice a day. However, husband didn't hold him tight this morning so he missed a little of the insulin. This mornings chemstick was again 5000 with negative ketones. In people they would be in a coma, if that relates to blood glucose.

I do feel that the vet is trying to do his best for Rags, he calls often to check. He doesn't want to bump up the insulin to fast because of the trilostane lowering the cortisol.

One thing I have learned in years of nursing that it is rare for any 2 doctors to treat the same illness in the same way. I can only hope that the outcome will be some sort of balance.

I am going to do a 6 hour post parandial chemstick today, more for grins and giggles than anything else....

One thing I know for sure, if I were still working fulltime and had full caregiving for my husband, Rags' care would put me over the edge. Good thing I quit work to care for hubby.

Janie and Rags

[ladysmom06]

Re: Rags

Hi Janie and Rags,

Welcome to both of you. I have a 10 yr old Jack Russell Terrier - Lady - who has both diabetes and cushing's. Having both diseases does make things a little more complicated but they can be managed. Lady is on Humulin N insulin - she gets 5 1/2 units twice a day and she's on 30 mgs of trilostane for the cushing's once a day. She is doing really well and both diseases are under control. Here is a link to her story -
http://k9diabetes.com/forum/showthread.php?t=76

Good luck to you and Rags and please keep us posted. Hugs to the two of you.

Luv,
Lynne and Lady

[k9diabetes]

Re: Rags

Rags is getting 8 units once a day (AM). Using Vetsulin and vet assures me he has never had a patient who needed to switch to twice a day.

Janie,

I am going to be very blunt because Rags' survival depends on it.... Rags' veterinary treatment and monitoring of both his Cushings and his diabetes have been substandard and are putting Rags' life in danger.

He cannot remain at these high blood sugar levels. You can sense that yourself. The only way he will get better is for you to find him competent veterinary advice.

Even the makers of Vetsulin will tell you that many many many dogs require twice daily dosing. Your vet is failing to follow the guidelines set down by the makers of the insulin.

This comes from the Vetsulin manufacturer's own website for veterinarians (http://www.vetsulin.com/vet/DosingOverview.aspx):

Dosing overview

Vetsulin® (porcine insulin zinc suspension) should be mixed by gentle rolling of the vial prior to withdrawing the dose. Using a U-40 insulin syringe, administer the injection subcutaneously, 2 to 5 cm (3/4 to 2 in) from the dorsal midline, varying from behind the scapulae to the mid-lumbar region and alternating sides.

Starting dose

In dogs, the initial recommended Vetsulin dose is 0.5 IU insulin/kg of body weight. This dose should be given once daily concurrently with or right after a meal.

Veterinarians should reevaluate canine patients at appropriate intervals and adjust the dose based on clinical signs, urinalysis results, and glucose curve values until adequate glycemic control has been attained.

Achieving effective glycemic control

In the US clinical study, glycemic control was considered adequate if:

• An acceptable blood glucose curve was achieved (ie, reduction in hyperglycemia and a nadir of 60−160 mg/dL)
• Clinical signs of hyperglycemia (polyuria, polydipsia, and ketonuria) improved
• Hypoglycemia (blood glucose <50 mg/dL) was avoided

Further adjustments in dosage may be necessary with changes in the dog's diet, body weight, medications, or if the dog develops concurrent infection, inflammation, or other medical disorder.

Avoiding hypoglycemia

Hypoglycemia is a major concern. To help avoid it:

• The dog's body weight should be rounded down to the nearest whole kilogram
• The calculated dose of insulin should be rounded down to the nearest whole unit

This helps to avoid overdosing particularly during initial stabilization.

Twice-daily dosage

If the initial insulin duration of activity proves to be inadequate, begin twice-daily therapy. If twice-daily treatment is initiated, each of the two doses should be 25% less than the once-daily dose of Vetsulin required to attain an acceptable nadir.

For example, a 20-kg dog would receive 10 IU of Vetsulin once daily or 7 IU of Vetsulin administered twice daily. See product label for more information.

I'm sorry but it is absolutely essential that you take Rags to someone with more skill. That person should be able to see Rags and then may be able to either work with your local veterinarian or work with you by phone to follow up. I know this is a hardship but I truly believe that Rags' life depends on getting better veterinary care than he has received so far as there have been significant problems with his Cushings treatment as well.

I know the vet has tried to save you some money but you're not getting what Rags needs so this is wasting what you are spending and putting Rags at risk. He must be put on twice daily insulin.

Feel free to email me if you want to discuss further, k9diabetes@gmail.com.

Natalie

[We Hope]

Re: Rags

Since you are a nurse, you understand the different classifications of insulins. All Lente insulins, no matter what they are made from, as well as all NPH and NPH mixes, are classed as medium-or intermediate-length of duration insulins, whether they are used for people or in veterinary practice.

The Vetsulin you are using is pork Lente--intermediate-length insulin. It is the same as the old Lilly Iletin II Lente was with the exception of the strength. Lilly's Iletin was U 100 strength and Vetsulin is U 40 strength. Iletin, Humulin, and Novolin L insulins were all considered to be intermediate-length.

http://petdiabetes.wikia.com/wiki/Intermediate-acting

Article and tables showing all intermediate-acting insulins, including those which are analogs.

http://www.vetsulin.com/vet/AboutVet_Overview.aspx

"Intermediate-acting insulin

"As a lente insulin, Vetsulin is classified as an intermediate-acting insulin."

The mechanics of trying to "stretch" an intermediate insulin into a long-acting one involve giving the whole day's insulin in the morning after breakfast, then feeding a meal without insulin in enough time so the insulin doesn't peak without the additional food, thus creating a serious hypo.

I knew someone in Belgium who tried regulating her dog this way for 7 months without success. Often he had to be rushed to his vet because he'd gone into a serious hypo from too much insulin and not enough digested food when the insulin peaked. When they converted to splitting the day's dose in half and going to the food and insulin every 12 hours, he regulated quickly and easily.

I hope Jenny, who is a member of both this and the Cushing's board, will post telling you what problems she had with regulation and hypos when Buddy was first diagnosed and started with only one shot per day.

Speaking from experience, I can tell you that no matter what insulin we were using, human or beef which my Lucky's immune system destroyed before it could work, Lilly's Iletin II Lente, or Vetsulin, he was getting two shots a day of it. He was the first US patient to use Vetsulin (using it before it was approved) who was not part of a previous study--and it was two shots a day. I don't know anyone who was able to regulate their dog on the one shot a day method, but they certainly regulated easily and quickly when the dose was split and given twice a day instead.

Using Vetsulin, Lucky was able to maintain normal non-diabetic blood glucose levels with his two shots a day--doing 85 about 8-10 hours after his breakfast and split dose of insulin was normal for him. He never had a hypo either.

During your nursing career, I know you were aware that some doctors were more knowledgable and skillful than others. As a proactive family member, I certainly was aware of that, and dealt with the ones who were less skillful by having my family member removed from their care.

I once phoned my family member's attending from the emergency room of another hospital because of this; had our attending not given orders on the phone, I know my family member would have died; we divided the emergency room mentally in half and I moved my family member to the hospital our attending was on staff at the instant she was stable.

Rags seems to need, at bare minimum, a consult with someone in internal medicine. As you know, consultants are there to guide your attending because they are specialists in whatever problem or problems are at hand. Rags needs someone to set a course for much better diabetes and Cushing's management as his problems are serious ones right now. They need not remain that way.

Kathy

[rhodesian46]

Re: Rags

Hi and welcome,
I cannot stress enough that Rags needs an INternal Med Specialist. One endocrine disorder is bad enough but 2 needs the knowledge of a Dr that deal with this on an everyday basis.A Dr that will work along side you as a team. I has husky named Pebbles that had 3 endocrine disorders. 3 diseases that needed balance . I know being a nurse that you understand the lingo and the diseases. I myself was snow balled before so I am very leary on all of my other dogs treatment plans
Was wondering if Rags blood pressure was checked.? It is not unusual for a dog newly DX with Cushing to have high blood pressure Most high BP will go back to normal in a few months after being on meds.