Cushing's, Diabetes and Hypothyroid

[MikeMurphy]

Originally Posted by Lulu'sMom

Mike she was started on Thyro-tabs (?) 0.4mg twice daily. I give it to her at least 1-2 hours before feeding to make sure she has an empty stomach. We are due to recheck labs next Tuesday to see if this is a good dose, but she does seem to have a bit more energy. Any idea how long it might take to show an improvement in insulin utilization once thyroid is corrected?

It looks like you’re doing everything right. Within a week we started to see that Lily’s insulin resistance was broken. It took a couple more months to get her BG into the 150 - 300 range.

[Judi]

hi: I'm sorry you are going through this. It is emotionally and financially draining. I'm glad you went to a specialist. We did almost everything the same as you.

With my Jenny we did have to start the cushings meds before her insulin had any effect. It took at least 4 weeks of the cushings meds then suddenly her insulin needs started to drop. She went from needing 7.5 units twice a day, to 3.5 units twice a day

So, keep that in mind. We didn't have the thyroid issues you have though so I feel for you.

I'm not real technical but hang in there! We managed to not kill Jenny for 3.5 years with all of these diseases and when she finally went, it was just that her little body and mind were beaten down.

If we can do it, you can do it. I would suggest you learn how to test blood sugar at home if you aren't already. I had a hard time getting blood and since Jenny's sugar was so high for the first 6 or 7 months, I didn't sweat it. Then after being on the Cushings meds she went scarily low. We learned how to test.

We did have some excellent months with our feisty perky girl back. So hang in there. But their bodies and their needs change so testing at home at least helps with the diabetes. At one point Jenny was down to only needing .5 unit of insulin twice a day. It was my busy season and my Mom was very ill so I just patted myself on the back that I was doing a great job. WRONG. Her cortisol levels had plummeted. We'd tested them in December and by April they didn't register. So, Jenny got a break from cushings meds for the rest of her life. it wasn't horrible, just a new reality

I'm writing a book to let you know stuff happens. You can really get stressed out and start obsessing over these dogs. I had to take a step back and say if Jenny was happy I was happy and not sweat the numbers. We all do the best we can.

Best of luck to you and your girl (if you are still reading this lol). I try to pop in to offer moral support to the cushings/diabetes dogs because it was really hard when I went through it and this forum helped me get through some rough spots. xoxo Judi

[amydunn19]

I am a bit concerned that all those raises were done without 12hour curves. It might have shown the same thing but I don’t think you can base dosing without some complete 12 hour curves. My Maggie would have been the poster child for doing curves, because it was almost a disaster that nobody did them. I didn’t even know what they were until I started my own research. I don’t know if it will change the suspicions of what is going on but I don’t feel comfortable with a vet who doesn’t believe they are important. Assumptions are very dangerous with diabetes.

[Lulu'sMom]

Thank you all. We have been on thyroid meds now for a month and while her energy is a bit better her glucose levels haven't changed. I was hoping that she would be responding to her insulin by now. She seems perkier so I'm happy with that even though her glucose is still in 500's.

I have been testing at home for 7-8 months now and it has helped greatly. I can't take her to the vet every for a 12 hour curve, too expensive, so I do them at home. My original vet didn't ask me to do curves, just 3-4 readings a day and would increase based on that. Honestly, it's no different with her numbers now. She is rarely out of the 500's and never below about 480. I'm just afraid that like Judi said, her little body and organ systems will not tolerate this state for very long and she will decline. It's so hard to watch as it is.

[Judi]

I would strongly encourage you to start the cushings meds. I bet it works. Jenny lived for 3 1/2 years with both diseases. hang in there, Lulu CAN feel better.

[Lulu'sMom]

My IM vet is one that believes in good glucose control prior to trying to accurately diagnose cushing's much less begin treatment for it. She says high glucose can alter the cushing's tests which makes it difficult to get a definitive diagnosis. That's why this is so frustrating. I'd so hoped treating her hypothyroid would break this resistance and allow the insulin to work, but we're not there yet.

[labblab]

Originally Posted by Lulu'sMom

My IM vet is one that believes in good glucose control prior to trying to accurately diagnose cushing's much less begin treatment for it. She says high glucose can alter the cushing's tests which makes it difficult to get a definitive diagnosis. That's why this is so frustrating. I'd so hoped treating her hypothyroid would break this resistance and allow the insulin to work, but we're not there yet.

As we've already discussed, your vet's position has support -- but in my nonprofessional opinion, only up to a point. That is to say that if you are launching into initial treatment with a dog who has a definitive diabetes diagnosis and a possible Cushing's diagnosis, I think most specialists recommend trying to first gain control of the glucose levels. This is for both physiological reasons and also diagnostic reasons. However, if the glucose levels remain unmanageable and genuine Cushing's symptoms also exist, it's been my experience that clinicians move on to serious consideration of Cushing's. If a dog is truly Cushingoid with highly elevated cortisol levels, it otherwise may never be possible to manage the glucose levels. Over the years, we've seen this situation on multiple occasions, and it's not until the Cushing's is treated that the diabetes becomes manageable.

Lulu truly exhibits many symptoms that could be the result of Cushing's, including the low thyroid as well as the insulin resistance. You mention elevated liver markers -- if Lulu has a highly elevated ALKP, that is especially a hallmark of Cushing's. I respect your vet's caution in not rushing to a Cushing's diagnosis, because we've seen many vets who do the reverse with diabetic dogs and leap to Cushing's treatment before it is really warranted. But it seems to me that there comes a point where Cushing's simply cannot be disregarded, and you may be at that point with Lulu.

Again, I can't presume to have all the info in hand that your vet does. But I have to disagree with her position if it is to say that you should never treat Cushing's in a dog who is insulin resistant. We have seen too many examples where the glucose levels only became manageable after abnormally elevated cortisol levels were reduced, as was the case with Judi's Jenny.

It is true that the Cushing's meds carry risks, especially if overdosing occurs. They should not be given to a dog who is overtly ill, or who suffers from actual kidney and/or liver damage. However, as I stated above, elevated liver markers are common among untreated Cushpups, so certain elevations alone are not a contraindication to treatment. The expectation is that Cushing's treatment will improve the liver markers rather than worsen them.

If you and your vet do decide to test for Cushing's, probably the preferable diagnostic blood test would be the ACTH stimulation test. For dogs without any other known illnesses, the LDDS is generally preferred. But the ACTH is less likely to return a "false positive" in a dog who suffers from other non adrenal illnesses or bodily stress.

Unless Lulu has already degenerated to a point where it's not fair to push her any further, or unless the neurological symptoms do indeed worsen, it seems to me that you have little to lose by at least testing her if her glucose levels remain unmanageable. Once again, we can provide some cost savings tips re: both the medication and also the monitoring testing. Your vet may not even be aware of a quite new monitoring protocol that is now being used with success in the UK. We can talk about all those details further over on K9C if you wish to do so.

But anyway, I just couldn't resist adding a few more of my long-winded thoughts into the mix!

Marianne

[jesse girl]

Are you seeing diabetic symptoms which sometimes mimics cushings with extreme thirst . Now you sugested your dog is a picky eater which would not follow a symptom of ravenous appetite as you might see in a cushing dog or a dog with uncontrolled diabetes with ketones and possible DKA

Is your dog showing ketones ? If cortisol levels are high for what ever reason insulin resistance is possible . If you give a diabetic dog steroids usually they will need more insulin to lower sugar

The only thing that you are doing now is treating a possible thyroid problem and if that was the problem for resistance i would think after a couple weeks of medication you would see some sort of movement lower in blood sugar

I still would try using an insulin like r and give it every 6 hours . This is something a vet would use to get a dog stabilized at the vet from high sugar . If you cant get any movement from a higher dose of r to lower sugar then move onto possibly giving cushing meds

It does sound like something else is going on and the diabetes is probably exasperating it

[amydunn19]

Originally Posted by Lulu'sMom

Thank you all. We have been on thyroid meds now for a month and while her energy is a bit better her glucose levels haven't changed. I was hoping that she would be responding to her insulin by now. She seems perkier so I'm happy with that even though her glucose is still in 500's.

I have been testing at home for 7-8 months now and it has helped greatly. I can't take her to the vet every for a 12 hour curve, too expensive, so I do them at home. My original vet didn't ask me to do curves, just 3-4 readings a day and would increase based on that. Honestly, it's no different with her numbers now. She is rarely out of the 500's and never below about 480. I'm just afraid that like Judi said, her little body and organ systems will not tolerate this state for very long and she will decline. It's so hard to watch as it is.

I misunderstood then. I didn’t know anyone was doing a full curve. Glad to see you have been testing. I think it probably is Cushings but I also like to know history of everything to get an idea if anything was missed along the way.

[MikeMurphy]

Originally Posted by Lulu'sMom

First, thank you all so much for your input and responses. In response to Mike, yes she did exhibit hypothyroid signs and symptoms from early on, within the first 2 months, and I brought up testing this as I had read that this could be a barrier to improper insulin utilization, and twice it was dismissed as not really a beneficial lab to run and wouldn't help in her management. When I asked for her medical records to take to internist it was actually noted how her physical symptoms appeared and how many times I had asked for her thyroid to be checked! So frustrating!

Jesse, yes we have altered her diet some, but she is a picky eater. Her initial labs showed sky high triglycerides and cholesterol and I was advised to change to low fat, higher fiber food which I have and have added boiled chicken at times to get her to eat.

Marianne and Amy, my regular vet started her initial insulin dosing and he was very conservative. Started with Novolin and went up by 1 unit increments over two weeks each time. Not a true curve done, just spot checking her glucose at home three times a day. At something like 20u twice a day glucose not really regulated. this was over 2-3 months it seems? Still 400-500's. On to Vetsulin, same process, same outcome. At 32u twice a day, I was going through a vial every 6 days. Not Cheap! Then changed to Detemir, which is very expensive but at the low dose I was told it would take, 2 units twice a day, it would be more cost effective for me in the long run. Same story, started at 2u, went up by 1u every 2 weeks with glucose check 3 times a day during that time and never got out of 400-500's. She got up to 12u twice a day, which is a huge dose, still over the same 2-3 months, still with same outcome. The only time she has ever gotten in low 400 or very high 300 is with vigorous activity/exercise. She did not tolerate that well. Once we got to the IM vet she listened to all we had done and decided we should tackle the glucose issue first, but she suspected a Cushing's and hypothyroid component from the beginning just from her exam and previous treatment outcomes. She looked like a textbook hypothyroid dog. We did a 24 hour curve in her clinic/hospital and she didn't curve much at all. She then took her back down to 2u twice a day and started a thyroid med once her panel confirmed it was indeed low. We have been at that for 3 1/2 weeks now with some improvement in her activity level, she seems to have more energy, and her pot belly is slimming a bit, but her glucose has remained unchanged, still upper 500's. So I believe her thyroid meds are helping, I had just hoped it would improve her insulin utilization too and as of yet that has not occured. I will do another 24 hour curve at home this weekend and we will see the IM vet again Tuesday.

Also, we have not yet done any formal testing for Cushing's such as the ACTH or LDDS since her glucose is not yet regulated. This vet is a fan of glucose regulation first so that's where we are. Unfortunately if these next labs can't provide any meaningful hope for improvement then I don't know what I'm going to do. I should also mention the concurrent ear and bladder infections that are almost chronic. The cost of all this is killing me and there doesn't seem to be an end in sight. I do believe the vet does suspect a tumor as she has mentioned imaging and treatment/radiation, but again cost will be prohibitive for me on that. Her neuro symptoms persist and she did warn me about seizures, changes in personality like new aggression, could present later. I believe this vet truly cares and has been very diligent with me thus far and has had me text her readings and updates even over the weekend. She's been amazing. But she has also been very realistic with me in that even after all this her prognosis is still guarded. I'm a nurse so I appreciate her directness and honesty of the situation. I only wish I had been referred to her earlier and maybe we could have had a better chance at winning this battle.

After going back through Lulu’s thread, something really stands out... that she at one point was up to 12 units of Detemir(Levemir). Levemir is 4 times as potent as Novolin N, so that means she was on the equivalent of 48 units of Novolin N every 12 hours! I think you could officially declare her insulin resistant at that point. It looks like she is currently on 2 units of Levemir. That would be about 8 units of Novolin N. The normal starting dose of Novolin N for a 49lb dog would be about 10 units, so your basically back to a starting dose and working your way back up. If you stay with your vets current plan of treating the diabetes first, it may take a while before you get to the point where the thyroid meds, or Cushings meds, for that matter, will help in breaking the insulin resistance.

If you do the curve over this weekend, please post the results here. Good luck with your Tuesday appointment with the IMS. Let us know what she says.