Cushing's, Diabetes and Hypothyroid

[Lulu'sMom]

Hi all, I'm new here and thankfully directed here by the Cushing's forum group. Lulu's journey has been almost a year and has been one complication and set back after another. First diagnosis was diabetes after excessive thirst and urination. We tried 3 different insulins, none with any real regulation. Our glucose curves look like straight lines. Several months into this she developed Cushing's signs like thinning hair, bony head, pot belly. I've read conflicting treatment recommendations as to which disease to treat first, the diabetes or Cushing's. Needless to say I have no regulation of either disease and now hypothyroidism has been added to her list. I'm mentally, emotionally and financially drained and am losing hope of ever getting my girl back to good health. She is about 49 pounds and has been on Novolin 30u twice a day, on Vetsulin 32u twice a day and now on Detemir 12u twice a day and glucose remains in 500's most days. After 10 months with my regular vet I finally was referred to an internal medicine vet. She is amazing and I learned more from her in the first four days than the previous 10 months. Her labs are bad, elevated liver enzymes, sky high cholesterol, and of course high glucose. Even on 12u Detemir twice a day her glucose curve remained almost a straight line determining that she is now insulin resistant. The vet has now cut her insulin back to 2u twice daily (a typical dose) and glucose hasn't changed. About 3 months ago she started developing neurological symptoms like stumbling walking, falling down, unable to jump onto bed, hind leg muscle weakness, and circling. This is killing me to watch this decline. As explained to me gaining good glucose control will be difficult to impossible with her Cushing's and treating her cushing's without good glucose control is not beneficial either. I'm so frustrated and defeated. Do I withdraw all treatment and just let her live her days? Do I continue to give her this potent insulin if her body is not going to utilize it? And there is also the issue of almost continuous infections, ears, UTI's etc which keeps her feeling bad too! ANY advise would be appreciated

[MikeMurphy]

Re: Cushing's, Diabetes and Hypothyroid

Hi and welcome to you and Lulu... she is gorgeous.

I’m not that up to speed on Cushings, but there are several members here that will hopefully chime in.

However... one of the primary causes of insulin resistance in dogs is untreated hypothyroidism. After being diagnosed with diabetes, my Lily’s BG stayed in the 400 and 500s for 4 months, even after slowly increasing her insulin from 14 units to 28 units of Novolin N. To make a long story short, I took her to an IMS who diagnosed her with hypothyroidism. Within a week after starting thyroid meds, her insulin started working and we dropped her back down to 18 units. Five years later she’s holding steady at 16 units.

Her primary hypothyroidism symptoms were hair loss, lethargy, sky high triglycerides and cholesterol.

I’d talk to your IMS about this. They normally do a full thyroid panel to confirm the issue. Other than the pot belly, hypothyroidism and Cushings symptoms can be very similar. If she is indeed hypothyroid, I’d treat that first. The meds are very inexpensive.

You can see the symptoms here...

http://www.caninediabetes.org/pdorg/hypothyroid.htm

[jesse girl]

Re: Cushing's, Diabetes and Hypothyroid

Hi and welcome

It does sound like you guys have had a difficult time . My jesse was difficult to regulate and she had other problems also . It was hard but we found a place that worked that was over 8 years ago and there is many stories like jesse but she was young only 5.5 years old

I think if you want to make a go of it you may have to really look outside of the box . Not sure you have tried some of the fast short acting insulin's just to see if you could get a movement lower and penetrate that resistance it may not be a long term solution but just an experiment

Food can play such a big role with the body and maybe a homemade diet with a high nutritional value foods leaning with allot of vegetables with some lean meats and low fat . Jesse has been on something like that since the beginning and i think that had a big impact on her longevity .

We struggled so much with jesse that i switched her to one meal a day thinking if we could eliminate digestion playing a role for half the day we may have some hope and that actually worked and improved her overall pattern and regulation

Now my jesse was the complete opposite of your pup and very sensitive to insulin needing a lower dose than most . You may have to explore further possibility's on a road that may have not been traveled yet . WE are only limited by are imagination

Now the symptoms you have discussed show a deterioration of the body and sometimes you reach a point where the clock cant be turned back but only you will know that and when that time has come

[labblab]

Re: Cushing's, Diabetes and Hypothyroid

Hi Lulu’s Mom <waving wildly!>

I’m so glad to see you registered over here! For the benefit of the K9D folks, we’re following Lulu’s journey over on K9Cushing’s, as well. So I’ll personally try to keep checking in at both places in order to keep abreast of relevant thoughts and suggestions. I know the three disorders (diabetes, Cushing’s, and hypothyroidism) can produce a conundrum of overlapping symptoms. Dogs can have any of the three disorders in their own right, or they can be linked. For instance, uncontrolled Cushing’s can depress thyroid readings as a secondary consequence of the disease. For some Cushdogs, thyroid readings will return to normal once cortisol levels are stabilized with treatment.

One of the main reasons why I was so anxious for Lulu’s Mom to register here is so that you guys can help guide her in terms of gauging genuine insulin resistance. I’m a dummy when it comes to diabetes, but I know that Dr. Mark Peterson tells us that true insulin resistance can be a diagnostic marker in terms of arriving at a Cushing’s diagnosis in a diabetic dog.

https://endocrinevet.blogspot.com/20...e-in-dogs.html

From joint members of our two forums, I’ve also gotten the impression that if a diabetic dog does indeed suffer from Cushing’s and is truly insulin resistant, it may be necessary to first stabilize the cortisol levels before the insulin control becomes manageable? I was hoping you guys might know whether or not that is true.

Right now, the dilemma really does seem to be the egg vs. the egg vs. the egg: what to treat first, if anything! Lulu’s Mom, here are a couple quick questions for you. It sounds as though the hypothyroidism has just been diagnosed. More complete thyroid panels can point to the likelihood as to whether the low thyroid reading is a primary problem in its own right, or whether it’s secondary to another issue (“sick euthyroid syndrome”). Did your new internist talk about that at all? My knee-jerk thought is that if Lulu’s low thyroid readings and insulin resistance both may stem from the elevated cortisol of Cushing’s, then treating the Cushing’s would be the place to start. But I am not a vet, and I am just musing here.

Secondly, it’ll help us Cushing’s folks if you can find out the actual numerical results for the diagnostic Cushing’s test. One of two tests will have been done: either an ACTH stimulation test (two cortisol readings one hour apart), or a LDDS (three cortisol readings consisting of a baseline, and then a 4-hour and 8-hour reading). Thanks in advance for this info!

Marianne

[labblab]

Re: Cushing's, Diabetes and Hypothyroid

One more wild card to throw into the mix are the neurological symptoms that Lulu has started exhibiting. Over on K9C, we’ve mentioned the possibility of a pituitary macrotumor that could account for both Cushing’s and also neurological deficits due to expanding pressure being placed on other areas of the brain. Unfortunately, both the diagnostics and treatment associated with that possibility are so very expensive that it may well remain on the back burner. But if that is genuinely an issue, that would be a game-changer in terms of charting a path forward. Just wanted to mention it so that you all would be aware of this possibility.

Marianne

[amydunn19]

Re: Cushing's, Diabetes and Hypothyroid

Do I understand that no treatment for Cushings has happened yet? I think the problem is that many diabetic dogs have been deemed as potential Cushings if there is even slight resistance. I was told Maggie potentially had Cushings but my vet instead had raised the insulin at a very fast rate without doing any blood sugar curves, and she was overdosed tremendously. She never exhibited any physical signs of Cushings. The false positives for Cushings tests among diabetics make the decision murky. Once the physical signs are present, however, and a great deal of time has passed without any change in blood sugar, it seems treatment for Cushings or the Thyroid issue or both should be started.

Has there been any times through the process that her blood sugar has dropped to a lower level? Do you test blood sugar at home? Have curves been done before upping dosage? If so, how often? How long did you guys try each insulin type?

It is important to remember that some dogs did not show any significant improvement with blood sugar until they treated the cushings. It could be a matter of deciding to treat the thyroid issue first and if the medication didn’t help with the insulin resistance, then go to the Cushings treatment. There is always a chance that the thyroid issue could be treated and solve the problem before Cushings treatment.

[Lulu'sMom]

Re: Cushing's, Diabetes and Hypothyroid

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.

[labblab]

Re: Cushing's, Diabetes and Hypothyroid

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.

It definitely sounds as though this internist is being very thorough and diligent, indeed. Since she’s privy to all the actual test results and physical examination, I surely do respect her guidance. As Dr. Peterson notes in that article I cited, pursuing glucose control whenever possible is his first objective, as well. And since both the ACTH and LDDS are subject to “false positives” in the face of nonadrenal illnesses such as uncontrolled diabetes, proceeding with formal diagnostic testing would indeed be dicey in Lulu’s situation. There is plenty of support for your vet’s approach here.

I guess my only thought is that, if all else fails and the glucose level remains unmanageable, Cushing’s treatment might be worth a final try if Lulu does test positive for the disease. For diabetic dogs, what is involved is oral medication given twice daily, accompanied by monitoring blood testing. To ease the cost, compounded versions of the medication might be approved by the vet, and a new simplified monitoring protocol largely requires only periodic pre-pill baseline cortisol checks. There may indeed be specific reasons of which I’m unaware as to why your vet thinks that Lulu is a poor candidate for giving treatment a trial run. If she does suffer from an expanding macrotumor, then lowering the level of circulating steroids may be a poor choice. Quality of life is the top priority of all, and if Lulu’s condition has degenerated such that it does not seem fair to her to keep experimenting, I totally understand. But if Cushing’s treatment appears to be a viable option at all, I just want you to know that we’ll be here to support you.

Marianne

[MikeMurphy]

Re: Cushing's, Diabetes and Hypothyroid

Hi again. Just a couple of questions concerning her hypothyroidism.

1. What is her thyroid med dosage and frequency?
2. When do you give her the Thyroid medication?

Check out these articles by Dr. Jean Dodds, the foremost authority on k9 hypothyroidism...

There’s a section near the end of this article that explains dosage.

http://www.hemopet.org/clients/14145...and_Dosing.pdf

This article explain the proper administration of thyroid meds. You should give the meds twice daily, either 1 hour before OR 3 hours after feeding.

https://drjeandoddspethealthresource...oid-medication

[Lulu'sMom]

Re: Cushing's, Diabetes and Hypothyroid

Thank you both for your replies. Marianne, your information helps tremendously that supports managing diabetes first as it can skew the cushing's diagnostic testing and the conflicting information I've been reading on which to do first was really confusing. My vet was concerned about Lulu's ability to tolerate the cushing's treatment since she was pretty ill when she saw her and her liver enzymes were already elevated perhaps she would not have handled it well and she did not want to make her feel worse as I understand those drugs are quite powerful and can be hard on the animal. Will see how things go, I'm pretty much on a week to week basis here. I have read Dr. Peterson's article and it has very good information.

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?

[MikeMurphy]

Re: Cushing's, Diabetes and Hypothyroid

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]

Re: Cushing's, Diabetes and Hypothyroid

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]

Re: Cushing's, Diabetes and Hypothyroid

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]

Re: Cushing's, Diabetes and Hypothyroid

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]

Re: Cushing's, Diabetes and Hypothyroid

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.