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**Dollydog** · 02-13-2009, 07:03 PM

Re: Kramers Story

Hi Breanne,
If you're who I think you are (and I'm sorry that I don't have time to check right now) I think I followed your story with Kramer on the other diabetes sight almost 2 years ago.
Weren't you dealing with a specialist in Winnipeg? I hope it's not her who says that Cushings and diabetes can't be treated at the same time!!!
Please keep checking for a vet that isn't intimidated by Kramer's situation. I'll check back when I have more time!!
And tell your vet that my Lady has had Cushings for over 3 years and been diabetic for over 2!!
Wishing you all the best in your search,
Jo-Ann & Lady

**We Hope** · 02-13-2009, 07:14 PM

Re: Kramers Story

Welcome!

Is it possible for you to make some type of arrangement with an Internal Medicine specialist--one in private practice or possibly one at a University with a vet school and clinic for a consult?

This would mean Kramer's getting the benefit of the specialist's knowledge and his/her ability to consult with your vet regarding treating Kramer on an "everyday" basis. You wouldn't need to be taking Kramer to the specialist all the time--he/she could be monitoring Kramer's progress via shared medical files and test results, then the two doctors could consult.

It then wouldn't be all in the hands of your vet; Kramer would have a "health care team"; your vet might feel a little more "secure" knowing he/she can talk with the specialist when needed.

There are a lot of people here who have managed diabetes and Cushing's--Marianne managed THREE endocrine diseases--Cushing's, hypothyroid, and diabetes for Pebbles. She did a spectacular job with her girl!

True, Marianne went to Texas A & M, but I can remember something coming up and her A & M specialist worked with one of the vets nearby with Pebbles.

Any possibility something like this could be worked out?

Kathy

**KramiesSister** · 02-13-2009, 07:33 PM

Re: Kramers Story

We do have an IM specialist, she's actually the one who asked us to leave our previous vet (who wasn't fabulous) and see this one. And this vet seems to just push everything off on the IM specialist.

I haven't talked to the IM lately, but I called her in a panic tonite and I probably won't hear back until tuesday (usually I LOVE long weekends, but this may end up being the longest weekend EVER!!!). Its not the specialist that says that cushings and diabetes can't be treated together, its the insecure vet.

I so wish we weren't 28 hours from A&M but we are. We're also 8 hours from a vet college. BAH

Waiting sucks!

Breanne and Kramer

**pgcor** · 02-13-2009, 08:17 PM

Re: Kramers Story

Breanne I'm so sorry about this! I wish I had some words of wisdom, but I'm praying that Kramer is better and soon. I know how horrible the waiting is. You and Kramer have been through so much! Hang in there!

**k9diabetes** · 02-13-2009, 11:06 PM

Re: Kramers Story

Hi Breanne,

Happy 12th birthday Kramer!!

Can you bring us up to speed with Kramer...

How much does he weigh?

What's his current insulin and dose?

What is his blood sugar currently running?

Any changes to his diet at all? What does he eat?

And then of course give us the test results when you can get them.

Monday is President's Day here - what's the holiday there?

I assume you've tried all the standard stuff like at least two new bottles of insulin from different lots/shipments. There was a time a few years ago when a handful of dogs scattered across North American who were on Vetsulin lost their regulation - seemed to be a bad batch of insulin from the manufacturer. And whole lots or shipments can be damaged, especially by extreme weather. Just want to make sure that base has been thoroughly covered.

The high cholesterol and triglycerides is a pretty common Schnauzer thing, isn't it?

Any outward signs of Cushings?

Given the situation with the vet, is it possible for you to take Kramer to the IM? It seems to me that a thorough evaluation that would include an ultrasound and perhaps the blood sample sent to Jack Oliver at UTenn (I hope you can do that from Canada) would give you the best shot at determining what's up with Kramer.

Loss of regulation could come from totally unrelated things that cover a lot more ground than Cushings so something like x-rays and an ultrasound could help ferret it out. Pain, inflammation, infection, allergies, resistance to the insulin, and scarier stuff we won't go into.

Much of this your vet could do in consult with the IM but it probably would be best if the IM could do the ultrasound herself. If you could go in for one comprehensive day and do it all and then let the IM guide everything from there, that would work.

Kay, when Bo started having his horrible diarrhea problems, eventually found an IM who worked with her mostly over the phone for many months after initially evaluating Bo and she made a huge difference in his care.

I know you're tired and frustrated and getting scared. You just need someone to help you and the vet isn't doing it - the last thing anyone needs is a vet who isn't up to a challenge - that's how Chris wound up seeing the bad endocrinologist!

Definitely go over all of this with the IM on the phone and make a plan from there.

I'll be looking for the test results next week.

Natalie

**AlisonandMia** · 02-13-2009, 11:24 PM

Re: Kramers Story

Loss of regulation could come from totally unrelated things that cover a lot more ground than Cushings so something like x-rays and an ultrasound could help ferret it out. Pain, inflammation, infection, allergies, resistance to the insulin, and scarier stuff we won't go into.

Hi - I was going to reply on the Cushing's forum but I'll reply here as Natalie has brought up more or less what I was going to bring up over there.

Another thing that Schnauzers can be particularly prone to is gall bladder problems, usually in the form of sludge or what is called a mucocele that acts like a gallstone in a human and can block the flow of bile. This can cause rises in liver enzymes and could also cause inflammation and general illness sufficient to send diabetes out of kilter. It is usually diagnosed with high-resolution ultrasound.

High res ultrasound (the IMS is probably equipped to do this) is part of a standard Cushing's workup so maybe getting that done first may be the way to go.

Diabetes - and any other illness or stress- can throw out Cushing's tests and produce false positives. Many diabetic dogs, particularly if their diabetes is not under control, will test positive on the Low Dose Dexamethasone Suppression test particularly and this test is often not of much value in a diabetic - the ACTH stim test is more reliable in this sort of situation.

Alison

**bowens2** · 02-14-2009, 06:45 AM

Re: Kramers Story

Hi Breanne and Kramer

I remember you both from the other site. Hopefully Natalie and the others can help you get back on the right track. I hate to hear you are having so much trouble.

I'll keep checking back to see how things are going. I keep you both in my prayers.

**KramiesSister** · 02-14-2009, 12:19 PM

Re: Kramers Story

not sure if i did that right

**We Hope** · 02-14-2009, 01:36 PM

Re: Kramers Story

Breanne,

You did it exactly right. Is it possible for you to also post a link to the report so we might be able to see a little bigger version of it?

Kathy

**KramiesSister** · 02-14-2009, 05:34 PM

Re: Kramers Story

http://s197.photobucket.com/albums/a...s_results1.jpg

There, I uploaded it to be a little bigger too.

These values look really really bad to me.

**Cara's Mom** · 02-14-2009, 05:48 PM

Re: Kramers Story

Hi Breanne and Kramer, welcome!!!!
Sorry to hear things are going a little rough, but you came to the right place!! Lots of knowledge around here and Natalie ad Kathy will keep you on the straight a narrow with all their excellent insight and advice!

Hugs to you and Kramer

**We Hope** · 02-14-2009, 06:37 PM

Re: Kramers Story

Breanne,

I wish I didn't have to agree with you about some of those values looking bad--the lab has included their normal "reference" ranges next to Kramer's results for each one.

What I did find is something we've had around this board/website and others for quite a while. It's from the University of Georgia and is a comparison of the symptoms and lab indications of both Cushing's and diabetes, called "Canine Hyperadrenocorticism, Diabetes Mellitus, or Both?"

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

If you take a look at Table 3, Similarities and differences of hyperadrenocorticism and diabetes mellitus, when we start looking at the serum chemistry, you'll see that both diseases share the following:

High serum alkaline phosphatase activity

Increased ALT activity

Lipemia and high cholesterol concentration

Decreased BUN concentration

Fasting hyperglycemia is common for them both, but the results of this is higher with diabetes than Cushing's.

So we are seeing that Cushing's can cause some of the results like Kramer's, just as diabetes can. I know as a Schnauzer, he's more prone to having high lipids.

http://www.vin.com/proceedings/Proce...1009&O=Generic

Primary Hyperlipidaemias

"Miniature schnauzer hyperlipidaemia. The pathogenesis of idiopathic hyperlipoproteinaemia in this breed is not clear, but hypertriglyceridaemia is the major abnormality. Serum CHL levels are moderately increased and LPL activity impaired. The majority of affected dogs are middle aged or older. There is not sex predisposition. Clinical signs include abdominal pain, diarrhoea, seizures and behavioural abnormalities. Many schnauzers will not show clinical signs and serum lactescence is frequently an incidental finding."

Going back to the VIN 2004 presentation, Hyperlipidaemia in Dogs and Cats, I see that they list one of the primary medical problems causing this as hypothyroid for dogs, diabetes, and Cushings as well.

Table 2: Causes of Hyperlipidaemia in the Dog and Cat

Post Prandial
Hyperlipidaemia Dog Cat

Secondary

Hypothyroidism----Y----N

Diabetes mellitus--Y----Y

Liver disease------Y---Y

Obesity-----------?---?

Nephrotic
syndrome---------Y--Y

Hyperadrenocorticism--Y--Y

Pregnancy/
pseudopregnancy--?--N

Acromegaly------?---Y

Primary

Idiopathic hyperlipidemia of miniature schnauzers
Dogs-Y
Cats-N

Idiopathic hyperlipidemia, other
Dogs-Y
Cats-Y

Hyperchylomicronaemia of cats
Dogs-N
Cats-Y

Acid Cholesteryl ester hydrolase deficiency
Dogs-Y
Cats-N

Maybe I'm not seeing it on the report, but do you know the status of Kramer's thyroid--whether those values are normal or not? If not, that might also be a place to try looking in addition to the proposed Cushing's testing.

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

"Hypothyroidism can cause Insulin resistance-meaning more insulin needed, but it can also decrease the body's metabolic rate. If this is the case, the decrease in the metabolism would reflect as decreased insulin requirements."

http://web.archive.org/web/200702081..._diabetes.html

10. How do other endocrinopathies affect the management of diabetes mellitus?

"Dr. Scott-Moncrieff: Dogs: Hypothyroidism may cause insulin resistance in dogs but may also decrease metabolic rate and so decrease insulin requirements, so the effect is variable in individual dogs. I do not screen all diabetic dogs for hypothyroidism; it depends on clinical signs."

Kathy

**acushdogsmom** · 02-14-2009, 09:17 PM

Re: Kramers Story

Hi Breanne,

I don't think you know me, but I've seen your posts about Kramer on another board so I sort of know you.

I personally love the birthday photo you recently posted there. You should post it here too! It's adorable! I even found Kramer in the picture.

Anyway, I agree with what the others have said and I have a few things to add.

First, I've got a couple of links for you regarding doing the ACTH stimulation test on a Diabetic dog, rather than doing the LDDS in a dog who has a non-adrenal illness (Diabetes is a non-adrenal illness)

http://www.michvma.org/documents/MVC...s/Nichols2.pdf

on page 3 ...

Is nonadrenal illness present? The LDDS and ACTH response tests can give false positive results in the face of nonadrenal illness, but the LDDST is more likely to do so.

Thus, the ACTH response test is recommended when nonadrenal illness is present.

And http://www.finnpathologists.co.uk/do...yProtocols.pdf

page 6:

LDDS
False positive results may occur, especially in animals with significant nonadrenal illness, such as diabetes mellitus

And regarding the ACTH stim test it says there:

ACTH stimulation test
This test is less sensitive than the LDDST, but less prone to false positive results. It is used in the following situations:

To detect hyperadrenocorticism in cases where there is stress or concurrent non-adrenal illness

There are other veterinary references that say the same thing, and you should probably check with your Internist before doing any Cushing's tests, but in my lay opinion, I think would agree that it might be better to do an ACTH stimulation test (which only takes an hour or two to do) than the all-day LDDS test (low dose dexamethasone suppression test).

By the way ... the two tests tell you two different things ... the ACTH stim tells you how high the cortisol production is, by stimulating the adrenal glands (with an injection of synthetic ACTH) to release their stored up cortisol into the bloodstream. The LDDS test tells you how well a dog can suppress cortisol production in the presence of another injected steroid (the dexamethasone).

If the ACTH is positive, that will tell you that the cortisol production is much too high and that could be the reason for the current insulin resistance.

I also really think you should get the Internist to do an abdominal ultrasound. She can have a good look at the internal organs, to help determine the health status of those ... like the adrenal glands, the liver and bladder and kidneys etc. An ultrasound can often be a big help to rule out or rule in certain conditions. It's the most bang you can get for your buck, as far as I'm concerned.

About the high alt etc on the lab test ... I also would have given you that same link that Kathy gave you already -- showing that those lab values are often high in Diabetic dogs and in Cushing's dogs. But I also want you to know that although he did not have hyperlipidemia, my dog's alt and alkp and cholesterol etc were sky high when he was diagnosed with Cushing's and all of those abnormally high lab test values came down into within normal ranges once we got the cortisol levels down to where they needed to be for good Cushing's control. We did also give Milk Thistle, Sam-e, fish oil and a few other supplements, although I think that lowering the high cortisol helped much more, in my dog's case anyway. But it's possible to get those high numbers back down when you treat the conditions causing the numbers to be high.

About the hyperlipidemia ...

I read in an article that hyperlipidemia can cause insulin resistance too. So maybe that's something else to ask your IM Specialist.

Here's where I read it:

http://www.marvistavet.com/html/body...ulate_pet.html

And here's what it says there:

EXCESS CIRCULATING LIPIDS

High levels of circulating triglycerides (fats) interferes with the binding of insulin to the cells it needs to act upon. While most dogs with excess circulating lipids are not diabetic, when a diabetic patient is insulin resistant it may be helpful to attempt to reduce the circulating fats. Excess lipids in the blood usually occurs because of some other hormone imbalance (Cushing’s disease, hypothyroidism in dogs etc.) but can simply happen spontaneously in the miniature schnauzer. Circulating fats are reduced by treating the hormone imbalance that caused them if there is one. If there is no underlying disease, circulating lipids can be reduced with diet and omega 3 fatty acid supplementation.

I agree that there is also a possibility of hypothyroidism, so if you haven't already had one done, I think a thyroid panel (just a simple blood test) should be done ... including a canine TSH and definitely a free T4 by equilibrium dialysis (EQD) ... to check for hypothyroidism. Not sure about how common that is with diabetic dogs, but if it can affect the bg regulation or possibly be a cause for insulin resistance, you need to check it out.

You have maybe hit a bit of a bump in the road, but your GP Vet is wrong to have given you the idea that it's gotta be Cushings (maybe it is but maybe it isn't) and that if it is Cushing's that it can't be managed right along with the Diabetes. That Vet has caused you and your Mom alot of unnecessary grief, if you ask me.

If it turns out that Kramer does have Cushing's, it's just a matter of learning what you need to know and then doing what needs to be done ... the first part might be a little tougher, until you get used to it, just like it was when you first got the diabetes dx, I'm sure. But once you get into a routine, it's really not a huge deal.

Treating the Cushings by lowering the cortisol production is definitely doable. And you actually already know people whose dogs have been dxed with both conditions and who were, or who still are being very well managed. As a matter of fact, it usually becomes much easier to manage the diabetes if you get the cushing's under control.

I think the answers you've gotten should help you to be able put together a bunch of reasonable questions to ask your Internist. You need to put the questions to her and discuss with her and figure out what is going on with Kramer and then you will be able to figure out how to fix it.

I better stop typing now. This is turning into a book!

P.S. Please post Kramer's birthday picture in this thread, or I might have to do it for you!!!

**KramiesSister** · 02-14-2009, 10:53 PM

Re: Kramers Story

Thanks so much for all the information. I've been working 16 hour days and just spending all of my other time on the internet searching for info like this. I've gotta head to bed because I work early in the morning again, but tomorrow afternoon I'll be intensely studying the links and probably be back here with a myriad of questions!

Until then, here is Kramer at his "party" with his "friends".

Announcement

Kramer got his wings... March 18, 2010

Kramer got his wings... March 18, 2010

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