Autumn is an angel August 21, 2016

[Autumn]

Hello
I just signed on but have read this site often for information and appreciate the knowledge of the kind people on this forum. This is long but I sincerely appreciate any input/advice. I will be discussing this with my vet tomorrow. Thank you in advance!

My dog is going to be 6 years old next month. When she was 4 years old, I had taken her to a vet for regular check up, who looked at her and said oh maybe a Cushing dog..... without any testings at all. She is a Dachshund mix, medium size dog but has that Dachshund round appearance but she is not pot bellied as pictures on line show of Cushing dogs. Our dog was also very over weight at this time. I finally found the vet we go to now and we have been very happy here. At that time, he said no cushings.

In January, she started drinking water excessively and going out at night to relieve herself. I took her to the vet and they diagnosed Diabetes. She is now 29 pounds and currently on 12 units of Vetsulin 2xs a day. She has been hard to regulate.

Since she has been treated for diabetes, we see a marked difference in her. She is a rescue dog and has always been very nervous. Now she seems happier and is no long over weight. She is a mellow dog, sleeps a lot but comes running whenever I say time for walk Walks with a bounce in her step.

She recently was tested for Cushings due to being resistant to insulin. I do know, her last blood sugar number when checked was 250, this was 4 hours after injection and breakfast. How do I get information as to how many units of Vetsulin for 30 pounds is considered resistant?

She was there all day for the . The Dr.called and confirmed Cushings.

The Dr. said, the Cushings is what has led to her having Diabetes.

She had a UTI and was on clavamox at the time of the dexamethasone suppression test. I read that a UTI could raise Cortisole levels. She has had 2 UTIs since January. Also, one in the fall.

I do have confidence in my vet. He has been wonderful. I do not want him to think I question his diagnosis. However, I do not want to put my dog on the Trilostane unless we are 100 percent certain. I read this can be dangerous.

If she does have Cushings and I don't treat her immediately , I hurt her. I want to do the right thing for my girl. If I don't treat her immediately I could be risking her to go blind from no treatment due to high blood sugar levels?

Should I have another test done or would that be putting her through another test unnecessarily. The more I read, the more confused I become as Diabetes can have similar symptoms as Cushings. Could she have had Cushings at the very young age of 4, as the first vet thought just by looking at her.

As you can tell, I'm confused and very worried about doing the right thing. Thank You for taking the time to read and respond!

[We Hope]

Re: Diabetes and/or Cushings

Welcome Autumn!

OK--first of all let's get a working definition of insulin resistance:

http://web.archive.org/web/200711231...EF+4-2+UC.html

"Insulin resistance is defined as a dose > 2.2 iu/kg"

And that would mean giving more that 2.2 units of insulin per kilo (2.2lb) of body weight every time there's an insulin shot.

Since your dog weighs 29lb, dividing 29 by 2.2 gives us 13.18..., which we will round down to 13kg for doing this example. Continuing on with the example and rounding down the 2.2 iu to 2 iu, for your dog, insulin resistance would mean using more than 26 iu at each shot.

It's true that Cushing's can cause diabetes. The mechanism behind that would be this: Cushing's is basically an excess of cortisol production and cortisol is one of the counter-regulatory hormones re: diabetes, meaning it drives the bg's up and keeps them up.

What happens is that this excess cortisol places a large demand on the insulin producing pancreas beta cells. They have to keep working to meet the demand placed on them by the excess cortisol--need to keep producing large amounts of insulin in an effort to try to lower the bg's the cortisol has raised and keeps raising.

Eventually, the pancreas can't keep up with this and the beta cells which produce insulin "burn out"; when they're no longer able to produce any or enough insulin, the result is diabetes.

UTIs or any type of infection generally tend to raise bg's because the body produces extra glucose to help it fight off the infection. Sometimes the first sign you get there's an infection is the high bg's; you see then go down in response to antibiotic treatment.

You're also right in that it's sometimes difficult to determine whether it's Cushing, diabetes, or both problems:

http://www.vet.uga.edu/vpp/clerk/Zwicker/

Canine Hyperadrenocorticism (Cushing's), Diabetes Mellitus or Both?
University of Georgia

We do have some members here whose dogs, when first diagnosed, were thought to have both diabetes and Cushing's. For some, it was determined that after they were being treated for diabetes a while (bg's became more manageable), Cushing's wasn't in the picture.

If you haven't already done so, I'd suggest you also become a member of k9cushings:

http://www.k9cushings.com/forum

While we can talk about how UTIs can mean for high bg's, the Cushing's folks can tell you whether or not the UTI may or may not have been a factor in the stim test results.

Kathy

[Autumn]

Re: Diabetes and/or Cushings

Thank You so much, Kathy, for the welcome, information and links. You do validate my concerns and that it's not just me being overly worried. I should resolve any question before going any further with treatment.

When you did the insulin resistance number, (thank you so much for doing the numbers.) You mean she still has room up to 26 units per shot of vetsulin before being considered insulin resistance? If that is the case she is far from this. Just making sure I'm reading this correct. I did have a concern that we were not working on regulating her bg as much as we could.

I will go post this over at Cushings Forum also.

Thanks again and have a great day!

[We Hope]

Re: Diabetes and/or Cushings

Autumn,

We were at insulin resistance levels twice--with both human and beef insulin with Lucky. We were giving a 10lb (4kg) dog 8 iu of insulin twice a day and not seeing any response to Lucky's 500-600 and up bg's. Believe me, we searched for Cushing's more than once, but we found normal cortisol levels.

This is what insulin resistance looks like, no matter what the cause:

The animal in this example was being treated with twice-daily Lente-type insulin injections. When you examine the graph of the curve carefully, you'll see that not long after the every 12 hours shots, there's a slight "dip" in the bg levels, then it's right back up to high. Curve and graph were done in mmol values, not mg/dl, but you can still see how high these bg's are, how they go down ever so slightly, and then revert back to the awfully high levels.

This is what we were seeing with Lucky; his insulin resistance was immune-related. Lucky's body was seeing the insulin which wasn't just like his own as something similar to a virus or bacteria--something the body destroys. You would see the slight "dip" on him, and then his system would "take care" of the "foreign" insulin by destroying it before it had any real chance to lower his bg's. Lucky needed an insulin that was identical to the one his pancreas used to produce and that's pork.

The Axiom definition of insulin resistance posted was the one we were working with for Lucky. Roughly, right now, you're at about the "halfway" point to IR, so there is still room.

Kathy

[Patty]

Re: Diabetes and/or Cushings

Hi Autumn and Welcome!

Kathy's a great source of information!

She had a UTI and was on clavamox at the time of the ACTH Stimulation test. I read that a UTI could raise Cortisole levels. She has had 2 UTIs since January. Also, one in the fall.

I just wanted to address the UTIs. My heart goes out to others that have experienced multiple UTIs. My Ali had 3 consecutive infections, different organisms, last fall. Do you know what type of bacteria was cultured? E.coli is the most common.

I talked to Margaret a while back about using D-Mannose to reduce the chance of e.coli adhering to the bladder. Here's the link to our discussion. http://k9diabetes.com/forum/showthre...?t=596&page=24

There can be many different reasons for UTIs and what works for one may not work for another, but I was very glad someone shared this info with me. Ali's been UTI free since last Dec.

Hope you get some good info on the Cush board as well.
Take care,
Patty

[Autumn]

Re: Diabetes and/or Cushings

Thanks Kathy.
I'm so glad to have posted here. I feel so much less intimidated questioning diagnosis. Cushing may well eventually be the case, but I need to be secure with it as fact before treatment.

We had tested her blood 2 times by lab, I believe it is the blood curve. Taking her blood and sending it out to review blood sugar for a period of time. I need to see those results. I can't think of the name for that particular test. The 2nd was a bit better. I'm thinking to present it as getting her BG regulated more before we consider treating for Cushings. Then do another test for Cushings in a month. Thanks so much!

[Autumn]

Re: Diabetes and/or Cushings

Hi Patty
Thanks!

I was wondering if the UTIs are common with Diabetes or Cushings or a seperate issue all together.

Not aware of what culture it is. Need to find out. I will also look into D-Mannose. Hopefully, this will be an answer to this problem for us too!

You all are terrific! I'm getting more information this morning than I have in a long time. I need to be more assertive doing research and asking questions for my girl.

[Patty]

Re: Diabetes and/or Cushings

Autumn,
Definitely diabetics are more prone to urinary tract infections due to the sugar spilling into the urine. It's a great breeding ground for bacteria.

There are a couple of ways to test for UTI. One is a free catch where you catch a sample in a sterile container (usually the vet's office can provide one). But, especially with our girl dogs, it's hard to tell if bacteria is from the urinary tract or external contamination so it may not be as reliable.

The other is a cystocentesis, where the vet inserts a needle into the dog's abdomen and pulls out urine from the bladder. It's not fun but sounds worse than it is. The needle is fairly thin and it's over very quickly. This is the most sterile method.

The sample is then usually sent to a lab for urinalysis and culture & sensitivity. The culture is where they watch for bacterial growth over 2-3 days to determine what type, if any, bacteria are found and the sensitivity test tells which antibiotic is appropriate to use. There are cases where an antibiotic may be resistant to the organism.

Hope that helps!
Patty

[k9diabetes]

Re: Diabetes and/or Cushings

Hi Autumn,

Welcome!

Can you tell us more about how you are monitoring your girl's blood sugar?

Do you test urine or blood glucose at home?

Has the vet done any "curves"? A fructosamine test?

Has her drinking returned to normal?

Please get a copy of all tests that have been done of her blood sugar levels and the ACTH tests - also need to know if this was an ACTH (2 readings over 2-4 hours) or LDDS (three readings over eight hours)

From what I see so far, a Cushings diagnosis is definitely premature. As Kathy noted, she wouldn't be considered insulin resistant until she was on 26 units of insulin per injection and still had very high blood sugar - in the 300s and 400s.

If the size of her insulin dose is the only reason the vet suspects Cushings, I don't think Cushings is likely unless she "looks" like a Cushings dog.

Plus the UTI definitely could be elevating her blood sugar. Does it seem like that has completely cleared up?

The ACTH test also will likely spike her blood sugar so it may be running higher now.

Since it looks like she's getting down into the 200s, the insulin is working, which is the good news! It could be that she's not on enough or that there's an imbalance in her food and insulin.

I would really like to see a curve of her blood sugar on her current dose and I would hold off on any Cushings treatment until you check in with the folks at the Cushings forum with her ACTH test results and we find out how her regulation is when she doesn't have a UTI.

I see an awful lot of diabetics who are misdiagnosed with Cushings so I always urge caution in proceeding with treatment for Cushings unless you can just look at a dog and they have all the signs.

Cushings is a slowly progressing disease so even if she has it you have time to really sort things out before treating it.

Natalie

__________________


Dachshund mix, medium size 6 years old next month

Diagnosed in January
29 pounds
12 units of Vetsulin 2xs a day
She has been hard to regulate.

Recently tested for Cushings due to being "resistant to insulin."
Last blood sugar number when checked was 255 4 hours after injection and breakfast.
All day for the ACTH Stimulation

Had a UTI and was on clavamox at the time of the ACTH Stimulation test.

[Autumn]

Re: Diabetes and/or Cushings

Thanks Patty
That sure does help! It's good information for me to know that UTIs do occur due to the diabetes. I will definitely look into this matter further.

[Autumn]

Re: Diabetes and/or Cushings

Hi K9diabetes
Thank you for your questions. Your insight gives me confidence over my gut feeling that it is too soon for Cushings diagnosis.

My dog had the fructosamine test twice. He didn't give me those results on paper and I will request them. He did indicate her values were very high on the first and better on the 2nd, I wish I wrote it down.

I see that many do check blood sugar values at home. I think this is something I need to do learn. I've been going into the office and having them check it.

The ACTH test was over an 8 hour period. I have to confirm whether it was taken 2 or 3 times.

I feel so fortunate to come across this forum. You are right, Cushings is a slow going disease. It is best not jumping into treatment. I need to discuss getting her blood sugar regulated, getting her records, figuring out how to do home testing. At a later time, redo the ACTH test over again. I do like this vet so much but I'm concerned her blood sugar levels are high after almost 5 months and she should have been put on a higher units of Vetsulin sooner. I'm thinking there is not enough checking of her blood sugar on a more regular basis.

Thank You

[We Hope]

Re: Diabetes and/or Cushings

Autumn,

The fructosamine test basically turns out to be an average of how bg control has been for roughly 7-14 days; it's based on the life of a dog's red blood cells:

http://petdiabetes.wikia.com/wiki/Fructosamine

"The higher the serum fructosamine concentration, the higher the blood glucose levels have been over the lifespan of the albumin protein, which is 1-2 weeks in dogs and is presumed to be the same in cats. The serum fructosamine concentration is meant to reflect the blood glucose concentration level over a 7-10 day period prior to testing."

So if you've been told that the second fructosamine test was lower than the first, this means that the blood glucose control for the second time period was better than the first. It says there's been some improvement in controlling her bg's with insulin alone and without any treatment for Cushing's administered as yet.

Kathy

Just going to add here--as Patty has told you, those with diabetes are more prone to infections of all types. Those with Cushing's or any type of endocrine problem are also because endocrine problems affect the immune system. Here's an abstract about UTI's in dogs with diabetes and/or Cushing's:

http://www.ncbi.nlm.nih.gov/pubmed/1...t=AbstractPlus

Retrospective evaluation of urinary tract infection in 42 dogs with hyperadrenocorticism or diabetes mellitus or both.

Department of Small Animal Clinical Sciences, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg 24061-0443, USA

J Vet Intern Med. 1999 Nov-Dec;13(6):557-60

"We conclude that UTIs are common in dogs with hyperadrenocorticism, diabetes mellitus, or both diseases. Clinical signs of UTI, however, are uncommon and results of urinalysis may be normal. Therefore, it is appropriate to recommend urine culture as part of the evaluation of dogs with these endocrine disorders."

[Autumn]

Re: Diabetes and/or Cushings

Thanks Kathy, Patty and Natalie

I'm grateful to you all for taking time and answering today with such detailed information. I'm a lot less stressed. I have the answers I need to make an informed decision. We need to get back to regulating her blood sugar as the priority. Taking care of the UTIs. Looking into D-Mannose.

I will go back now to re-read, taking my time, the links given to me for information.

I will do whatever she needs. If some day she needs to be treated for Cushings, she will, but there needs to be more definite diagnosis.

Tomorrow I'm speaking to the vet. I like this vet a lot and hope that it works out.

Again, many, many, thanks from me and my sweet angel dog!

[k9diabetes]

Re: Diabetes and/or Cushings

The 8-hour test was most likely an LDDS - Low-dose Dexamethasone Suppression Test.

That's where they take a pre-LDD reading and then a reading at 4 hours after and 8 hours after the dexamethasone (cortisol basically) suppression injection is given.

A low-dose of dexamethasone (0.01-0.015 mg/kg) administered intravenously to healthy dogs, causes inhibition of ACTH secretion and reduced plasma cortisol concentrations within 2 to 3 hours lasting up to 8 hours. In hyperadrenocorticism, the 8-hour cortisol value is not sufficiently suppressed and remains above approximately 30 to 40 nmol/l.

That information is from:
http://www.vin.com/proceedings/Proce...8195&O=Generic

This document also notes that this test can generate false positive values in a dog with a nonadrenal illness... like diabetes!

Unfortunately, false-positive test results frequently occur in dogs with non-adrenal disease and the specificity of the test has been reported to be as low as 0.44. In general, the more severe the non-adrenal illness, the more likely that cortisol suppression will not occur.

For dogs with diabetes, the Cush folks actually prefer the plain ACTH - which is where a drug that stimulates the adrenal gland is given rather than one than suppresses it.

The standard protocol is measurement of circulating cortisol concentration before and 1-hour after a single intramuscular or intravenous injection of synthetic ACTH (tetracosactrin, cosyntropin) at 250 μg/dog, although doses as low as 1.0 µg/kg can be used.
Dogs with hyperadrenocorticism theoretically have an exaggerated response to ACTH.

Regardless, if you're able to get good control over the blood sugar Cushings is unlikely. That's actually a really good diagnostic test for Cushings in a diabetic dog! If you can regulate the blood sugar, you don't have to worry about Cushings!

Natalie

[Autumn]

Re: Diabetes and/or Cushings

Thanks Natlie
This information is terrific! I certainly did not find any of this kind of info on google. Detailed information. I was so confused and overwhelmed before posting. All the help has made it possible for me to make an informed decision. I cannot tell you how grateful Autumn, I and my family are to you all here on the forum for taking the time to provide detailed information. I actually had a good night's sleep last night for the first time in a week.

Autumn will be so much better off. She needs not to go through undue illness from side effects of such strong drugs now. Especially since, she is doing so well and has no symptoms of Cushings. Even if she does have Cushings, there's no rush to medicate.

Your last point makes the total point, controlling her blood sugar is the best test for diagnosing Cushings. We have a lot of room to go with units on insulin before she is considered resistant. Thank you so much!

Anna