Sheri's Montana has passed on

[k9diabetes]

Re: Montana with Cushings and Diabetes

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.

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]

Re: Montana with Cushings and Diabetes

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/pro...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]

Re: Montana with Cushings and Diabetes

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 and dexamethasone) 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) 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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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/Co...atory_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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

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]

Re: Montana with Cushings and Diabetes

Rebound from lows is a possibility...

[k9diabetes]

Re: Sheri's Montana has passed on

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...



Natalie

[Fishslayer]

Re: Sheri's Montana has passed on

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


Rick

[eyelostit]

Re: Sheri's Montana has passed on

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]

Re: Sheri's Montana has passed on

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]

Re: Sheri's Montana has passed on

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

[Patty]

Re: Sheri's Montana has passed on

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