Cushing's, Diabetes and Hypothyroid

[Lulu'sMom]

Thank you all so very much for your input and support.
Mike, yes she went from 2units Detemir to 12 units twice a day with virtually no change, so she has put her back at 2 units twice a day while we try to get her thyroid right, however, after one month there has been really no change in glucose levels. When we first started with Detemir we started at 2 units and went up to 12 hoping for a break in resistance and it just never happened. I was getting really concerned with giving her so much potent insulin with no response.

Jesse, I have not yet been given the option to treat with R insulin, however, due to work I would not be able to give it every 6 hours, but I'll ask about that as an option. Would giving R break an insulin resistance?? The thought was to treat her hypothyroid to break the resistance but after a month with no change I don't think it's working. We are still at 2 units Detemir twice daily.

Marianne, thanks for your input as well and I am beginning to agree with you. It's just hard to see her go through all this. She is a pretty good eater unless her numbers get really high, then she's just listless and not interested in anything. She has developed more skin issues, peeling patches, dry callous like patches, and her ear is again getting red and inflammed. I just can't seem to keep ahead of the complications.

I was not able to get her to vet today. My daughter was in a car accident and I am currently sitting in the ER with her while she gets checked out. I am about to email the curve to my vet that we did over the weekend, as she asked me to, so I will post it here as well. I'll also post previous labs just to give some back ground.

Labs from 7/25/18:
UA 4+ glucose, 3+ ketones, 2+ blood, 10-25 calcium oxalate crystals (was diagnosed with UTI this day)
ALK Phos 1177 H 23-212
ALT 577 H 10-125
Choles 473 H 110-320 Down from 1082 in 3/2018
PLT 706 H 148-484
Total T4 1 L 11-60
Total T3 0.4 L 0.8-2.1
Free T4 2 L 6-42
TSH 1.32 H 0.00-0.58

Curve from 9/2/18:
7am BG 556 fed then given 2units Detemir
9am BG 503
11am BG 506
1pm BG 494 (went for 15 minute easy walk)
3pm BG 512
5pm BG 537
7pm BG 542 fed then given 2 units
9pm BG 530
11pm BG 522

So you can see my curves look more like lines
Thanks for all your help.

[jesse girl]

You could give it with the detemir insulin as 2 shots . Not sure if it could break resistance but i dont see how it could not hurt to try

[Lulu'sMom]

Jesse,
Would using a Novolin 70/30 insulin work?

[jesse girl]

I find it better to use r separately at least at this point since your using detemir if you cant break the resistance with these 2 insulin's i think the next step would to try the cushings meds .

Its fairly cheap if walmart is available. In the states usually we dont need a prescription but in other countries it can be cheap also in any pharmacy. it all depends on your location

I think you cant be looking at regulation at this point the goal is to see some movement lower .

[jesse girl]

Novolog maybe a better choice than r . The advantage is its in and out in a couple hours so your not waiting around all day to see if it has an affect . You will be able to maybe give a larger dose and not worry as much if you do break resistance and numbers do drop fast it wont be in the system that long and you should be able to intervene with some liquid sugar if necessary

Now r can work also but it hangs around allot longer 4 to 6 hours and onset is a half hour . The logs last about 2 hours and onset is 15 minutes

you may have to be a bit more aggressive and the safety protocols may have to be on hold in your dogs situation but i cant know what place your at with your dogs situation being on the internet

I have used fast and short acting insulin's early in jesses diagnosis to buy her time to figure things out . They were not for regulation purposes in her case . It was used to correct higher sugar but for jesse it was never a long term solution

[Lulu'sMom]

I'll ask the vet about these two insulin types, R and Novolog. I'm still unsure if giving R, in the setting of insulin resistance, will actually bring the glucose down??

[momofdecker]

My diabetic dog suffered from insulin resistance until his hypothyroidism was diagnosed. He was up to 10u of levemir with glucose consistently in the 500s.

You mention that your pup has had infections and that she doesn’t eat much. Infection and some medication can contribute to insulin resistance. Has she been tested for pancreatitis? Spec Cpl is a good test for pancreatitis. Pancreatitis can also cause insulin resistance. High lipids (cholesterol & triglycerides) can cause pancreatitis. Uncontrolled diabetes, hypothyroidism and cushings can all cause high cholesterol. Cushing often causes high triglycerides though hypothyroidism can cause that as well.

I wonder if you could ask about having a uc:cr urine test for Cushing? It’s a collection of the first morning pee - so little stress and lower in cost. If negative it would rule out Cushing. If positive, it would not confirm - it would only indicate further Cushing testing would be warranted.

I know it’s a lot of information. Sounds like you are doing a great job advocating for her. Keep up the good work!

One additional thought - is it possible the thyroid meds are working but the 2u of Levemir insulin is too low? Have you tried an insulin increase since starting the thyroid meds?

[amydunn19]

Well, her curve is practically a straight line. At least, she is not having wild swings from high to low and all over the place.

I had the same thought as Holli that now that she is on thyroid meds, maybe the dose is too low. It may just require some adjustments.

You probably didn’t know you would have to be a detective to figure this out. Hang in there!

[labblab]

Labs from 7/25/18:
UA 4+ glucose, 3+ ketones, 2+ blood, 10-25 calcium oxalate crystals (was diagnosed with UTI this day)
ALK Phos 1177 H 23-212
ALT 577 H 10-125
Choles 473 H 110-320 Down from 1082 in 3/2018
PLT 706 H 148-484
Total T4 1 L 11-60
Total T3 0.4 L 0.8-2.1
Free T4 2 L 6-42
TSH 1.32 H 0.00-0.58

Just wanted to pop back to comment on Lulu’s lab results. The presence of calcium oxalate crystals and elevations in ALK Phos, ALT, cholesterol, and platelets are all consistent with Cushing’s.

I am not a thyroid expert by any means, but I believe her thyroid results are consistent with primary hypothyroidism as opposed to being secondary to another illness such as Cushing’s. So the thyroid supplementation does appear to be a primary need for Lulu. Per Michigan State’s thyroid information summary:

Check thyroid hormone concentrations and TSH. In most dogs with overt primary hypothyroidism, thyroid hormone concentrations will be well below the reference ranges and TSH will be high. In euthyroid but sick dogs, thyroid hormones will be below and TSH within the reference range.

As far as the UC:CR testing, Holli is exactly right with her description. With as much as is going on with Lulu right now, an elevated UC:CR would not be surprising regardless of whether or not Cushing’s is a part of the mix. But if the result was normal, Cushing’s would be ruled out. If you do opt to start there, many specialists now recommend testing a pooled sample of urine collected (and refrigerated) on three successive mornings. This helps balance the variability that can come from any one single sample alone.

Marianne

[Lulu'sMom]

Thanks again for the input. I love getting ideas and suggestions from this group.
Momofdecker, yes she has been checked for pancreatitis and has been negative for that. Also, neg abdominal ultrasound.
This week her insulin was increased to 3 units Detemir twice daily and I will do another curve this weekend. I've added boiled chicken to her diet which she loves, so that has helped her appetite a great deal. I think the vet is just being ultra conservative on dosing now since Detemir is so potent.
Thanks for the info about the urine collection test. I'll ask about this as well, but as you all say, this is most likely indeed Cushing's with concurrent hypothyroid and DM. A truly difficult combination. I so appreciate all the info and support and hope to begin to make some headway soon on getting my Lu feeling better.