Newly diagnosed with potential Cushing

Aida, my 16yo sweet girl, has been diagnosed with Cushing after an abdominal ultrasound. It was set to get her adrenal gland surgically removed, but we needed to have a biochemical confirmation of the Cushing, with a positive result from a LDDST test. It came back inconclusive, so for now, we're stuck.

She's developed diabetes in the meanwhile. The vet first said that it's pointless to try and treat it since it's very difficult to control it when the adrenal gland is involved, and since she'll be having the surgery soon.
Since the LDDST result, we started her on Prozinc.

Kind of weird that the vet sold me the insulin and the syringes without making sure how we'll proceed with testing, maybe it's my fault: I told her that I'm planning on buying a glucometer and she was very happy about it.
But she's let me a bit alone on the entire process: between me getting the insulin and getting a functioning glucometer, 10 days have passed, and I have yet to master the art of getting a drop of blood.
Until I'm more sure with the testing, I'm giving her 2 units of insulin, and not the 3 that the vet prescribed. I'm dead scared of hypoglycemia.

I've also found an alphatrak 3 at a somehow affordable price: is it preferred to have this glucometer instead of a human one? Should I buy it, or is it an unnecessary expense? I'm moving soon back to my home country, Greece, and I guess that it would be easy enough to get the test strips from the alphatrak but not the ones for the human glucometer.

Sorry for the silly questions, but after getting a feline hyperthyroidism crash course, followed by hypothyroidism, hypertension, and CKD crash courses, all for my other cat, I'm just starting with the feline diabetes one, so I'm really not knowledgeable…

I haven't yet included the spreadsheet in my signature: I have managed to test her glucose just once, so I haven't yet filled it out.

Many thanks for any advice, and your understanding!
Daphne

Cushing ultrasound: April 10, 2024
LDDST test: May 17th
Diabetes diagnosis: May 15th
Started with 1 unit Prozinc on May 20th, and I've slowly upped it to 2 units. Vet's prescription is for 3 units.

 

Welcome. Waving from Canada.

Tagging @Wendy&Neko regarding Cushings.

Tagging @Yanna and @Kokkinoulis regarding glucometers and strips available in Greece.

 

Thank you Red & Rover!
Testing the new signature with the empty spreadsheet (with labs added) as per Marje's suggestion.

 

Tagging @Suzanne & Darcy regarding ProZinc

 

@Suzanne & Darcy
Suzanne if you look at @Daphne and Aida SS it looks
like she is only giving one shot only in the AM
Daphne insulin should be given twice a day 12 hours apart
I tagged Suzanne to take a look at your SS
I see you did a few tests
I see you are using the human meter which is good
OneTouch Verio Reflect

Edit @Daphne and Aida
Suzanne Daphne is giving insulin twice a day per her post #11

 

@Daphne and Aida
Hi Daphne we need more information about Aida to add you your Signature
Here is a link helping us to help you link. If you noticed, our members have some basic information about their cat's in their signature. This helps us to not pester you by asking the same questions (your cat's name, insulin type, date of diagnosis, etc.) repeatedly. We also have a link to our spreadsheet in our signature. We are very numbers driven. The spreadsheet is a record of your cat's progress. By linking it in your signature, we can follow along and provide feedback should you need the help

• Add info we need to help you:
  • Caregiver & kitty's name
  • DX: Date
  • Name of Insulin (do not include dose or frequency)
  • Name of your meter
  • Diet: "LC wet" or "dry food" or "combo"
  • Dosing: TR or SLGS or Custom (if applicable)
  • DKA or other recent health issue (if applicable)
  • Bexacat or Senvelgo (if applicable) and dates
  • Acro, IAA, or Cushings (if applicable)
  • Spreadsheet link. Please put the signature link on the bottom line of your signature information, on its own, so it is easy to find.
  • Please do not put any information about your location in the signature for security reasons. If you wish to add your country location, please add it to your profile.

Be sure to click the 'Save Changes' button at the bottom. If you need help urgently it is important we know these things at a glance. We don’t want to waste valuable time finding out information.

 

@Daphne and Aida
If you tap on @Yanna and @Kokkinoulis and @Anna1
Who are From Greece and look at their signature who will see which human meter they are using.
Tap on their profile page then information and look at their signature
I would stay with a human meter since that's what our numbers are based on

 

When will you be moving from France to Greece
@Daphne and Aida

 

Tagging @manxcat419 who has experience with a kitty with adrenal Cushings and still stops by occasionally. Search the Acro/IAA/Cushings forums for more. Here are a couple posts with her posts and about adrenal Cushings;

https://www.felinediabetes.com/FDMB/posts/2528945/

https://www.felinediabetes.com/FDMB/posts/2528949/

More members from Greece @Carol & Rico @Anna1 @MariaKokont

 

Hi Daphne, welcome to the forum!

Which part of Greece are you moving to?
I'm in Evia and I know members from Athens and Volos.

You can get Lantus vials or pens from any pharmacy in Greece without prescription.

You can order the BD microfine +demi 0.3 ml syringes online or ask your pharmacy to order them.

We use human meters for testing. Pharmacies give you the meter for free when you buy the strips. I use Contour Next.
Not sure if alpha track 3 is available in Greece at all.

Vets here don't follow protocols regarding feline diabetes, they usually suggest dry diabetic food, caninsulin and 1 ml syringes.

Careful with the 1 ml syringes, much confusion has been made about dosing with them because vets ask you to dose in ml not in units.


Feel free to ask me any questions you may have. I'm happy to help you.

 

Oh no sorry about that! I do give her twice daily, I just didn't notice it because I hadn't managed to test her BG in the evening!
I've added it now, so sorry about it!

 

Ok, I had to have a look again at the Glossary
One thing I couldn't find the meaning is LC wet, what does LC stand for?
The signature should be ok now, I managed to test her again today before her shot, after breakfast, yeah!

 

So, from what I understand, there is no reason to purchase the Alphatrak, that's a relief for my bank account!

We were due to go back in June, however, with Aida's condition, I've temporarily put a hold on it. I'm lucky to have an employer that hates seeing me leaving and that happily got the info that I'd be staying a tad longer!
But we'll have to be there by September at the latest. I'm starting to ask friends and vets to try and find a specialist referral clinic in Athens. The team I've found here is said to be one of the best in France, so I would rather have the surgery, if necessary, done here, it's not easy finding such specialists…

 

Thank you so much for the links!

 

Hi Yanna!

Thank you for all the information! For FREE??? FOR REAL??? Here the meters cost almost as much as getting the Alphatrak, the test strips are a tad cheaper, however…
Caninsulin really? That's weird…

One of my closest friends has a good friend who's a vet, I'm contacting him to get some general information about Greek vets and their modus operandi… I was kind of hoping that they would be a bit better than the vets here…I remember, when I was living there, we had a very good clinic nearby, and a humane clinic too, but they were rough with the handling.

I've found one cat-friendly clinic that will be easily accessible for us, my other cat Feloro was so mistreated that he dreads vet visits… but he needs to get regularly checked, the cat-friendly approach has been the best solution so far.

Oh I will certainly need your help with all the dose-measuring that's sure!!! I already find it quite difficult to wrap my head around the difference between human U-100 and animal U-40 syringes!
We're going to Athens, I hope that you weren't affected by the fires in Evia…

Thank you so much!

 

And Yes! Another test done! It never ceases to amaze me the level of trust they have for us, I've been pricking her ears for days now and she still comes towards me with no hate!
I still have to prick her a dozen times, she runs away, comes back and then I manage it… I really really hope it's going to get easier!

 

Is it possible for you to try to get a test during the PM cycle? You're seeing some good numbers. Some cats have lower numbers at night so getting a "before bed" test will let you know if your kitty's numbers are dropping. Without the PM tests, you're missing half of your data.

 

@Daphne and Aida
LC means low carb referring to food.
These were the syringes @Yanna was referring to if you ever switch to Lantus when you move to Germany from France



The syringes hold up to 0.3ml of Insulin and are marked in clear half graduations of 0.005ml (1/2 unit) for easy and accurate dosing.

Suitable for U100 Insulin only.

@Daphne and Aida

Here are some links for you, this one says for lantus , I know you are using Prozinc but gave it to you so you can see what the abbreviations mean
https://www.felinediabetes.com/FDMB/threads/lantus-basaglar-levemir-isg-slang-dictionary.1903/

Some Abbreviations for you



https://felinediabetes.com/FDMB/thr...portant-linksplease-read.224794/#post-2515254

The syringes for lantus half the half unit markings since we adjust the doses by 0.25 units, these will make it easier to do

• Full and half-unit syringe scales:

 

You can read about Prozinc here ,especially the dosing methods to chose from
https://www.felinediabetes.com/FDMB/forums/prozinc-pzi.24/
I would suggest the SLGS method since you are just starting out
I noticed on your spreadsheet you have
115 @12.30 in the 4 cell ( or square)

We don't use times ,if you meant 30 minutes
Going forward
You would enter it like this
115 +4.5 and you would have to manually color code it to match the color codes up top
15 minutes would be +25
30 minutes would be +5
75 minutes would be +75

@Daphne and Aida

 

Hi Daphne and Aida! Carol and Rico present as well. Do feel free to tag and ask about anything that worries you!

 

Yes, of course, it totally makes sense!
I'll try to do it, not sure if I'll manage today/night, but it makes sense. Thanks!

 

Oh god I really feel like my brain fries…

I need a break…
After hyperthyroidism, hypothyroidism, hypertension and CKD, now diabetes… phew exhausted…

I think I need to take my time to be able and assimilate it all…

For now, I give Aida her shot at 9:30 am and pm, the same time I give Feloro his levothyroxine pill. It's separated from food intake. Is that ok?

Many many thanks Diane for now, I'll come back tomorrow to see if I can master the courage to study it all!

 

@Daphne and Aida
You're very welcome

 

I just read in this site about it for pets it said

The medication absorbs into the body best on an empty stomach. Because food alters the absorption of levothyroxine, it is best to give the medication at a similar time or times daily and on the same schedule with regard to food
Found it on this site
https://veterinarypartner.vin.com/default.aspx?pid=19239&catId=102894&id=11642147

I also take levothyroxine lol. My doctor always told me to take it on an empty stomach because it absorbs better , then if I have other morning meds to take wait about 1/2 hour and then take them
@Daphne and Aida

 

I'm so happy that I spent the entire day reading on this board! What felt like a draining experience that sucked all my mental energy to the point that I felt unable to read the numbers and understand their meaning, has paid off, I believe: her BG was just 60 in the morning, and, before her shot, it was just 97, despite her having eaten quite a lot. So I didn't give it to her. She just had a bite half an hour ago, and it is now at 177, so I'm withholding it. until the evening.
I guess it's the Cushing that makes things unpredictable…
Without the precious information here, I wouldn't have known any better and she might have gone into hypoglycemia…

So!
I'm ready for another round of education!
The syringes I'm using are whole-unit scale.
From what I got from the link of the SLGL, a dose is kept for a couple of WEEKS! I started with 1 unit and a couple of days later I increased to 1.5, and now I'm at 2. The vet had recommended 3 units. So, I'll need to go really slower, but now that I've got the glucometer, and that I start getting a hold of it (and Aida gets more accepting of getting pricked), it'll be easier to assess. I'll email my vet the first results that I've got so far tomorrow, with the hope that she comes back to me - she might be on vacation! …always think the worst of everyone…

LC=Low Carb yes!
I do give them food with a mix of fermentable and non-fermentable fiber, but I avoid starches as much as possible. Feloro has always tended to easily have diarrhea, and Aida constipation, but since I've introduced this type of diet they're both doing so much better! Of course, one can never be sure of what exactly the carbs in the commercial food consist of, it's never really specified (here in Europe at least, we don't even get told the percentage of carbs, we just get a % of fiber and nothing about what type of fibers!) But I don't have the time to cook for them often enough to ensure sufficient supply in the freezer - hence the combination of homemade and commercial. I want to believe that the food I'm cooking for them has a low glycemic profile. I hope I'm not wrong!

Carol & Rico thanks!! I'll most probably manifest myself when faced with the reality of the Greek vets!

 

Oh we were writing simultaneously!
Yes, Levothyroxine is best absorbed on an empty stomach, the worldwide Guru of feline hyper- and hypothyroidism has conducted and published several studies on the subject!
Thank you for looking it up though! There is a fantastic group, that runs parallel to Tanya`s CKD group, for hyper- and hypo cats, they've given me tremendously precious advice and I've managed to get my vet to learn something on this topic that is so unfamiliar to vets!

 

@Daphne and Aida
Daphne I'm no expert on dosing but when following the SLGS method
It says
Hold the dose for at least a week:

• Unless your cat won’t eat or you suspect hypoglycemia
• Unless your kitty falls below 90 mg/dL (5 mmol/L). If kitty falls below 90 mg/dL (5 mmol/L) decrease the dose by 0.25 unit immediately.

After 1 week at a given dose perform a 12 hour curve, testing every 2 hours OR perform an 18 hour curve, testing every 3 hours. Note: Random spot checks are often helpful to "fill in the blanks" on kitty's spreadsheet. The goal is to learn how low the current dose is dropping kitty prior to making dose adjustments.

• If nadirs are more than 150 mg/dl (8.3 mmol/L), increase the dose by 0.25 unit
• If nadirs are between 90 (5 mmol/L) and 149 mg/dl (8.2 mmolunit
• 
  
• maintain the same dose
• If nadirs are below 90 mg/dl (5mmol/L), decrease the dose by 0.25 unit

Aida did drop below 90 twice I see I'm going to tag a few members and see if they suggest to lower her dose

Tagging some members for you

 

Hi ladies, I know @Daphne and Aida kitty Aida is on prozinc she lives in France
I just wanted to ask you a question. She's following SLGS and I see Aida has dropped under 90 twice if you look at her SS
Shouldn't she reduce the dose.
I wish she could find some U-40 syringes with half unit marking in France ,she's using the ones with whole units whole units per her post #25
I'm wondering if she can use either of these, to make it easier for her found it on the UK information

VetUK U40 syringes:https://www.vetuk.co.uk/veterinary-...nsulin-syringe-with-needle-box-of-100-p-11335
Sol-Vet U40 syringes:https://www.petdrugsonline.co.uk/sol-m-u40-insulin-caninsulin-syringes-0-5ml

Thank you ladies, I'm just trying to help her out
@Suzanne & Darcy
@Bron and Sheba (GA)
@Bandit's Mom
@Wendy&Neko

 

Diane thank you so much for clarifying the SLGS method! Im going to print that one!

My vet did come back to me, she was indeed on vacation. She approved everything, and told me that if Aida is too low before administering the insulin, I should go ahead and give her but a lower dose: 1U.

We have an appointment next week

she was not very keen about the idea of getting an Emla cream to numb the sting area, she said it can only be used from time to time. It’s a script medicine in France, but it OTC in Germany and I live 30min away from the border… just in case.

But I’ve gotten better with pricking her, and she starts to realise that it’s not that bad, pfew!!

 

I am so sorry - for some reason, tags don't always notify me even though I have everything set to email notifications. So I sometimes only see that I've been tagged when I open the forum for something else.

Did you follow up the LDDST with an ACTH-stim test? The LDDST is often inconclusive in cats, although it's a good diagnostic in dogs. It can be run as an HDDST (high-dose dexamethasone suppression test) which tends to work better for cats, but I don't think I know any vets that suggest that over the ACTH-stim. If you have access to an internal medicine specialist, that would be your best option. Also, did the ultrasound not show one of the adrenals as enlarged (and potentially irregularly-shaped)? If so, that may be reason enough for removal - again, an IM specialist would be your best option to determine that. Our Roxi never had blood work to diagnose. Her IM looked at her ultrasound, looked at the cat, and was able to definitively diagnose without additional blood work. However, her adrenal tumor was very large and her Cushing's was advanced to the point where she had developed a couple of small skin tears.

You can see very variable numbers with an adrenal-based Cushing's cat. The tumor on the adrenal that causes the Cushing's can "pulse" the excess steroid production on and off intermittently. So while you can sometimes need a very high dose at times (Roxi's dose maxed out at 10.5 units every 12 hours before her adrenalectomy), when that tumor pulses off you can suddenly see very low numbers as a result of the high insulin dose. This is definitely something to be aware of - as time goes on and the tumor grows, you need to be very proactive with testing to catch both the very high and very low numbers. Unfortunately, without removal of the diseased adrenal, there's no way of avoiding that because you still have to dose appropriately to keep the very high numbers down when the tumor is at maximum steroid production.

Please do hit me up with any other questions you may have. Hopefully now I've commented on the post, those notifications will come through, but I will check back to make sure.

 

April, thank you for your feedback!

Actually we did the high-dose dexamethasone suppression test, as advised by the AAHA guidelines (dexamethasone IV dosing at 0.1 mg/kg). I've asked the vet to send me the results, haven't got them yet. However, she told me that the first 4 hours serum cortisol levels confirmed Cushing, but not the 8 hours, so she asked the resident clinician where the test was sent to, and they came back to her saying that she probably doesn't have Cushing, as it is the least probable illness in cats, and that the enlarged adrenal gland in the ultrasound was most probably caused by the diabetes.

Which is of course completely inaccurate… It is well-documented that diabetes does not cause adrenal gland enlargements in cats!
And actually, the results confirm a pituitary-dependent hyperadrenocorticism!

But I feel that vet care in France is sooooooo lacking, so backward, so bad… I don't know how exactly to approach my vet without offending her, I cannot send her the studies that disprove it all, I really don't know if I'm not better off waiting to go to Greece? Or consult with a vet elsewhere in another country, like I did for Feloro? No idea where to find such a specialist…

For now, I'm monitoring her BG and slowly upping her insulin. The vet had said to start with 3 units, I'm glad I didn't follow her advice because she's been on 0.75, and I just upped it to 1 unit. Since yesterday, she's had some aberrant BG readings, which make me wonder if it's my fridge that spoiled the insulin or if it's her adrenal gland's cortisol production…Not sure how to approach the vet… It's one of the best clinics in this city, the other one doesn't take in new clients, and all the rest are simply very very bad vets.

Many thanks for your advices!!

 

@manxcat419

 

The clinician does have a point. Adrenal-based Cushing's is very unusual in cats. However, it does happen - there have been a few cases here on the board including my cat, Roxi. I don't think ruling it out simply because it's unusual is the right thing to do. I've also never heard of diabetes causing one enlarged adrenal gland. That sounds like an attempt to force an explanation that is not based in fact. There are, of course, other conditions that can affect the adrenal glands but you would usually see some weirdness even on a standard blood work panel that would give some clues.

Maybe you could ask your vet to just do the ACTH test. If you let her know you are still concerned by the enlarged adrenal and you want to do an extra check on it to make sure. You can also always ask for a second opinion. And there are telemedicine services offered by some internal medicine specialists that you may be able to use, either in Europe or in the USA. I'm not sure that Greece will offer anything all that much different. Our (usually excellent) vet had dismissed the idea of Cushing's for Roxi for quite some time. Even after she developed a skin tear and they noticed an enlarged adrenal when using the ultrasound for a cystocentesis, I had to insist that I was sure it was Cushing's and that we needed a referral to a specialist. They had dismissed it because of how rare it is. So I'm not sure that your experience so far is all that uncommon no matter where you are in the world. I understand that doesn't make you feel any better, but I do think missing the possibility is fairly common because most general practice vets are focused on the things they see regularly. This works very well most of the time. But as you know, some cats don't follow the regular pattern of things that can go wrong.

If you've stored the insulin correctly, I think the insulin is fine. In the early stages of Cushing's, we had times when Roxi wasn't on insulin at all because her numbers were too low. She also did a weird thing and no-one has been able to confirm whether it was because of the Cushing's or not. When we would get blood work done at the vet, when she was under stress, her glucose would read much lower. For most cats, stress makes the glucose higher. Of course the vet would then want her off insulin, but when we got her home her glucose would go back up. So I think that having aberrant readings may just be part of the Cushing's process.

 

You're right, on all points! Sorry, I guess I needed to vent my frustration!
Really sorry!

About the weird BG readings, I wonder if it could maybe be connected to constipation? She gets a very light dose of Miralax daily to help her poo, but sometimes it's not sufficient. She didn't poo for 2 days and the readings were high. She pooed in the early hours today and her BG readings are back on track. Could it be connected? One of my weird questions that I will definitely ask the vet! They must be laughing so hard at my questions!

I've found a couple of addresses for specialist clinics in Europe that could perform either surgeries (hypophysectomy or adrenalectomy). And I'll let my vet know that I'm still preoccupied about the ultrasound findings, that I would like to further explore the reasons behind them.

Many many thanks for your message and your patience!

 

This is a safe place to vent. We've all been through frustrating times when we're not sure what to do next. That's why this forum is so great - there's almost always someone who's been through the same thing and has some ideas for you.

Yes, weird readings can be connected to constipation. Anything that causes discomfort or distress to our cats can affect their BG levels. When you notice a pattern, it's good to ask about it - I'm sure your vet appreciates you being so observant and trying to piece the clues together.

Great news that you've been able to find some specialist clinics. Either surgery is definitely one for a specialist - there are a few GP vets who will try, but I would always want a specialist surgeon for anything so tricky.

 

For hypophysectomy, the Royal Vet Clinic in London is the gold standard. They have dealt with a number of Cushing's kitties, though the majority of their surgery cases are acromegaly. The folks at RVC's Diabetic Remission Clinic are incredibly helpful and respond to emails to them. I believe there is also clinic in Ultrect, Netherlands that also has experience. I'd love to know of any other you've found.

You might want to poke around our forum here: Acromegaly / IAA / Cushings Cats
This is a link to a thread on adrenal Cushings, including the last poster (and MD), who has had two!! kitties with adrenal tumours. In my post #2 on this thread, I also linked some papers, in case you hadn't seen them yet.