Cushing's, Diabetes and Hypothyroid

[Lulu'sMom]

Re: Cushing's, Diabetes and Hypothyroid

My IM vet is one that believes in good glucose control prior to trying to accurately diagnose cushing's much less begin treatment for it. She says high glucose can alter the cushing's tests which makes it difficult to get a definitive diagnosis. That's why this is so frustrating. I'd so hoped treating her hypothyroid would break this resistance and allow the insulin to work, but we're not there yet.

[labblab]

Re: Cushing's, Diabetes and Hypothyroid

My IM vet is one that believes in good glucose control prior to trying to accurately diagnose cushing's much less begin treatment for it. She says high glucose can alter the cushing's tests which makes it difficult to get a definitive diagnosis. That's why this is so frustrating. I'd so hoped treating her hypothyroid would break this resistance and allow the insulin to work, but we're not there yet.

As we've already discussed, your vet's position has support -- but in my nonprofessional opinion, only up to a point. That is to say that if you are launching into initial treatment with a dog who has a definitive diabetes diagnosis and a possible Cushing's diagnosis, I think most specialists recommend trying to first gain control of the glucose levels. This is for both physiological reasons and also diagnostic reasons. However, if the glucose levels remain unmanageable and genuine Cushing's symptoms also exist, it's been my experience that clinicians move on to serious consideration of Cushing's. If a dog is truly Cushingoid with highly elevated cortisol levels, it otherwise may never be possible to manage the glucose levels. Over the years, we've seen this situation on multiple occasions, and it's not until the Cushing's is treated that the diabetes becomes manageable.

Lulu truly exhibits many symptoms that could be the result of Cushing's, including the low thyroid as well as the insulin resistance. You mention elevated liver markers -- if Lulu has a highly elevated ALKP, that is especially a hallmark of Cushing's. I respect your vet's caution in not rushing to a Cushing's diagnosis, because we've seen many vets who do the reverse with diabetic dogs and leap to Cushing's treatment before it is really warranted. But it seems to me that there comes a point where Cushing's simply cannot be disregarded, and you may be at that point with Lulu.

Again, I can't presume to have all the info in hand that your vet does. But I have to disagree with her position if it is to say that you should never treat Cushing's in a dog who is insulin resistant. We have seen too many examples where the glucose levels only became manageable after abnormally elevated cortisol levels were reduced, as was the case with Judi's Jenny.

It is true that the Cushing's meds carry risks, especially if overdosing occurs. They should not be given to a dog who is overtly ill, or who suffers from actual kidney and/or liver damage. However, as I stated above, elevated liver markers are common among untreated Cushpups, so certain elevations alone are not a contraindication to treatment. The expectation is that Cushing's treatment will improve the liver markers rather than worsen them.

If you and your vet do decide to test for Cushing's, probably the preferable diagnostic blood test would be the ACTH stimulation test. For dogs without any other known illnesses, the LDDS is generally preferred. But the ACTH is less likely to return a "false positive" in a dog who suffers from other non adrenal illnesses or bodily stress.

Unless Lulu has already degenerated to a point where it's not fair to push her any further, or unless the neurological symptoms do indeed worsen, it seems to me that you have little to lose by at least testing her if her glucose levels remain unmanageable. Once again, we can provide some cost savings tips re: both the medication and also the monitoring testing. Your vet may not even be aware of a quite new monitoring protocol that is now being used with success in the UK. We can talk about all those details further over on K9C if you wish to do so.

But anyway, I just couldn't resist adding a few more of my long-winded thoughts into the mix!

Marianne

[jesse girl]

Re: Cushing's, Diabetes and Hypothyroid

Are you seeing diabetic symptoms which sometimes mimics cushings with extreme thirst . Now you sugested your dog is a picky eater which would not follow a symptom of ravenous appetite as you might see in a cushing dog or a dog with uncontrolled diabetes with ketones and possible DKA

Is your dog showing ketones ? If cortisol levels are high for what ever reason insulin resistance is possible . If you give a diabetic dog steroids usually they will need more insulin to lower sugar

The only thing that you are doing now is treating a possible thyroid problem and if that was the problem for resistance i would think after a couple weeks of medication you would see some sort of movement lower in blood sugar

I still would try using an insulin like r and give it every 6 hours . This is something a vet would use to get a dog stabilized at the vet from high sugar . If you cant get any movement from a higher dose of r to lower sugar then move onto possibly giving cushing meds

It does sound like something else is going on and the diabetes is probably exasperating it

[amydunn19]

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.

I misunderstood then. I didn’t know anyone was doing a full curve. Glad to see you have been testing. I think it probably is Cushings but I also like to know history of everything to get an idea if anything was missed along the way.

[MikeMurphy]

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.

After going back through Lulu’s thread, something really stands out... that she at one point was up to 12 units of Detemir(Levemir). Levemir is 4 times as potent as Novolin N, so that means she was on the equivalent of 48 units of Novolin N every 12 hours! I think you could officially declare her insulin resistant at that point. It looks like she is currently on 2 units of Levemir. That would be about 8 units of Novolin N. The normal starting dose of Novolin N for a 49lb dog would be about 10 units, so your basically back to a starting dose and working your way back up. If you stay with your vets current plan of treating the diabetes first, it may take a while before you get to the point where the thyroid meds, or Cushings meds, for that matter, will help in breaking the insulin resistance.

If you do the curve over this weekend, please post the results here. Good luck with your Tuesday appointment with the IMS. Let us know what she says.

[Lulu'sMom]

Re: Cushing's, Diabetes and Hypothyroid

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]

Re: Cushing's, Diabetes and Hypothyroid

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]

Re: Cushing's, Diabetes and Hypothyroid

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

[jesse girl]

Re: Cushing's, Diabetes and Hypothyroid

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]

Re: Cushing's, Diabetes and Hypothyroid

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]

Re: Cushing's, Diabetes and Hypothyroid

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]

Re: Cushing's, Diabetes and Hypothyroid

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]

Re: Cushing's, Diabetes and Hypothyroid

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]

Re: Cushing's, Diabetes and Hypothyroid

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]

Re: Cushing's, Diabetes and Hypothyroid

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.