Possible Cushings Diagnosis - Some questions

[Melissa and Celle]

I've been on the Levemir forum where I've been trying unsuccessfully to get Celle regulated. From 0.5 to 2.5 units we see no improvement and are still moving up after ruling out (I think) somogyi rebound.

My vet said she has elevated cholesterol and ALP and wants to test for Cushings.

Her symptoms are:
-excessive thrist, urination
-unregulated diabetes
-hind leg weakness, muscle wasting
-recurrent UTI
-pot-bellied appearance.

She does not appear to have any of the skin problems that are frequent symptoms.

Celle is 15 years old, and therefore I think surgery is not something we'd consider.

My questions are:
(1) Short of surgery, is there anything to do for Cushings?
(2) If not, do I have anything to gain by doing more testing to confirm this diagnosis?
(3) What is the prognosis and course of the disease? How is the quality of life?
(4) Why are acrocats and those with Cushings on the same board? Assuming she has Cushings, does the acro information also apply?

I'm a little overwhelmed by this news. I feel like I don't even know where to start, so if there is a question I'm forgetting to ask, please answer that one too!

 

[Blue]

Until a few of the people with some experience can reply, I'd say to read up what you can on Cushings to see if anything rings a bell - and some symptoms may well relate to the diabetes. About the two signs that come to my mind are poor coat and very fragile skin. Also, the couple tests that can be done are not great to confirm the diagnosis.

Cushings Info

Also
Cushings Test Info from Dr.Lisa
You may want to ask your vet to peruse VIN if she/he is a member. I am not faulting your vet for the test that was run because it seems like this has never been very clear-cut but here are some excerpts from the VIN consultants with the date of their comments noted:
5/18/10 VIN consultant #1:
The ACTH stim has much lower sensitivity than the LDDS in cats. 60% of cats with hyperadrenocorticism return normal ACTH stim results.
That is, most cats with Cushings will not be picked up by a stim.
(LDDS = low dose dexamethasone suppression test)
6/25/10 VIN consultant #1:
The ACTH stim test is not recommended; it has very low sensitivity for Cushings in cats. The test of choice is a dexamethasone suppression test using the canine high dose.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Other VIN consultants have recommended a UCCR...Urine Cortisol:Creatinine Ratio and while cushings can't be diagnosed simply by an elevation in the UCCR, it can be a useful tool.
The UCCR is a SENSITIVE test for Cushing's (e.g. very few animals with Cushing's would have a negative UCCR), but it is not a SPECIFIC test (e.g. many other diseases will make the UCCR elevate e.g. uncontrolled diabetes could).
So among the screening tests, we usually pick a LDDS to screen cats (using the 'high' dose for a dog DSP).
Adrenal ultrasound is also used since false positives and false negatives can be seen with the LDDS.
So, as you can see, the Dx of cushings is not straight-forward so you should probably keep going with your 'hunt' for answers....IF you and your vet are still concerned about cushings.
Lisa Pierson, dvm

Start there and then you can ask some more questions.

ETA: Looking at your ss, I am wondering why you are increasing dose so slowly. Following protocol, such high numbers should allow you to do increases of .5u every 6 cycles.


"General" Guidelines:
--- Hold the initial starting dose for 5 - 7 days (10 - 14 cycles) unless the numbers tell you otherwise. Kitties experiencing high flat curves or prone to ketones may want to increase the starting dose after 3 days (6 cycles).
--- Each subsequent dose is held for a minimum of 3 days (6 cycles) unless kitty earns a reduction (See: Reducing the dose...).
--- Adjustments to dose are based on nadirs with only some consideration given to preshot numbers.

Increasing the dose...
--- Hold the dose for 3 - 5 days (6 - 10 cycles) if nadirs are less than 200 before increasing the dose.
--- After 3 consecutive days (6 cycles)... if nadirs are greater than 200, but less than 300 increase the dose by 0.25 unit.
--- After 3 consecutive days (6 cycles)... if nadirs are greater than 300 increase the dose by 0.5 unit.

Reducing the dose...
--- If kitty drops below 40 (long term diabetic) or 50 (newly diagnosed diabetic) reduce the dose by 0.25 unit. If kitty has a history of not holding reductions well or if reductions are close together... sneak the dose down by shaving the dose rather than reducing by a full quarter unit. Alternatively, at each newly reduced dose... try to make sure kitty maintains numbers in the normal range for seven days before reducing the dose further.

--- If an attempted reduction fails, go right back up to the last good dose.
--- Try to go from 0.25u to 0.1u before stopping insulin completely.

Random Notes...
Because of the cumulative nature of Lantus and Levemir:
An early shot = a dose increase.
A late shot = a dose reduction.

A "cycle" refers to the period of time between shots. There are 2 cycles in one day when shooting twice a day.

Sometimes a dose will need to be "fine tuned" by adding some "fat" or "skinny-ing up" the dose.

 

[Blue]

Here's another link with info from Carolyn/Spot

Classifying Cushings

 

[Cheryl & Whiskers (GA)]

Hi Mellisa,

My sweet Witty (Whiskers) had Cushings. The symptoms you mentioned, as you may know are all symptoms of cushings. The one I most noticed on Witty was the pot belly. Something else I noticed was occasionally when we tested her BG on her ear, it would bleed to much on the opposite side of the ear where I had poked it (due to the thin skin). I'm certainly not an expert. I do know there are more than one causes of cushings. Witty had an abdominal utrasound which showed a tumor (which turned out to be malignant) near one of her adrenal glands, this is most likely precipitated the diagnosis of cushings and diabetis if I remember correctly. Witty was diagnosed at the university of Minnesota. She was put on a drug called trilostane. If there is one thing I would like to stress it is that you must be very careful if using this drug, and watch for signs of anorexia (not eating), lethargy. The cat must be taken to a vet immediatly if you see any of these signs. Of course you are not at that stage yet, not even a confirmed diagnosis, and I don't want to upset you. I was very uniformed when Witty was diagnosed and information makes us better prepared.
I will copy in a few of the Cushings cat owners on the board to see if they can help you with more information. Hang in there, the members are here to help you and Celle.

P.S I think cushings is included with Acro and IAA cats because generally they are considered to be at a higher insulin dose than other cats (perhaps someone else can correct me if I am mistaken)

 

[Melissa and Celle]

Thanks everyone for the help. I think her symptoms are probably more indicative of acromegaly than Cushings after reading more, and I'm actually fairly comfortable with that as a diagnosis becuase it fits so well. I think my biggest question still is whether it is worth pursuing a definitive diagnosis. I only want to do it if it would change anything that we'd do for treatment (and we wouldn't do surgery).

She was put on a drug called trilostane. If there is one thing I would like to stress it is that you must be very careful if using this drug, and watch for signs of anorexia (not eating), lethargy. The cat must be taken to a vet immediatly if you see any of these signs.

Did the drug help? Was it worth the additional risk of the drug? From what I've been able to read the drugs don't seem very promising.

ETA: Looking at your ss, I am wondering why you are increasing dose so slowly. Following protocol, such high numbers should allow you to do increases of .5u every 6 cycles.

Since her nadirs are in the 200s, it looks like we shoud only be going up 0.25 units every 6 cycles. No?

 

[Blue]

Melissa,
It may be a better idea for you to rule out Acromegaly and IAA as those tests can be confirmed pretty definitely, but all of the tests for cushing's are many, expensive and none are conclusive.

There are so many symptoms that are similar but cushings usually comes with quite fragile skin; have you noticed skin issues?

The links for the acro and IAA tests are below:

IAA Test
IGF-1 (Acro) Test

If you can print out the above two sheets and take them to your vet, you may be able to rule out the more common conditions.

Note: the dose of 2.5u is still quite low, and there have been other cats who have been as high as 6u BID but still went OTJ (Randi and Max).

 

[Dragonnns]

I think my biggest question still is whether it is worth pursuing a definitive diagnosis. I only want to do it if it would change anything that we'd do for treatment (and we wouldn't do surgery).

If you can afford the tests to diagnose Acromegaly or IAA, I'd do it. Knowing the answers gives you more to go on with insulin dosing as these cats have a functioning pancreas. How low you let your cat's BG go and how aggressively you deal with the diabetic condition are directly related to knowing if your cat is positive for either.

I'd definitely start looking at increasing your kitty's insulin amounts to get out of those high numbers.

Oh! and you asked why Acromegaly, IAA and Cushings kitties are all on the same board. I always assumed it is because these cats aren't actually diabetic in the true sense. Their pancreas works they just have other issues that cause the insulin they do produce to be overwhelmed. These cats tend to need high doses of insulin. Cindy my cat, was up to 14 units when she was treated with SRT and now she is OTJ. Sooty, Perry's cat, is currently getting 56 units twice a day (highest dosed kitty I know of). These numbers would be incredibly scary in a regular diabetic cat.

 

[Phoebe_TiggyGA_NortonGA]

Yes - this group was originally called HIGH DOSE because these conditions _usually_ have the common thread of insulin resistance -- high doses needed.

A few kitties have gone OTJ -- IAA can be beaten, Acro tumor output can fluctuate.

There have not been very many Cushing's cats -- I think maybe 4 in the past 3-4 years compared with dozens of acrocats and ten or so with IAA.

Regarding the IGF-1 and IAA tests -- the only lab in North America that runs these tests is in Michigan. Have your vet send the blood samples directly to minimize cost and give the best chance of successful shipping. (don't want the blood cooking for 3 days in some UPS truck)

 

[Blue]

Since her nadirs are in the 200s, it looks like we shoud only be going up 0.25 units every 6 cycles. No?

You could say that you get some 200's but not near enough to say that .25u increases are sufficient.
If you look at Celle's ss, you are not seeing any progress as the dose increases. By 3rd cycle at 2.5u, your curve shows all 300s and amps is 473. It's like every time you increase, you think you are getting better numbers on the 1st shot, but then the 300s come back, the resistance pulls against your efforts. I think you should consider making your increases more .5u until you start to see some real progress.

Question for you: is your vet mostly a dog vet? I ask as I was told that cushing's is much more common with dogs, but not with cats, so maybe your vet is thinking along the same lines as for dogs?

Also, you would want to test for acro and IAA first, but you can wait until you get to a higher dose. 2.5u is still fairly low so you may want to wait until you work your way up to more close to say 5u BID but in the meantime, you could talk to your vet about the two tests. The results for these tests are definite; the cushing's tests are not.

 

[Melissa and Celle]

Thanks everyone again for all the help!

There are so many symptoms that are similar but cushings usually comes with quite fragile skin; have you noticed skin issues?

No, no skin issues. This is what made me think acromegaly rather than Cushings. I read somewhere on this site that this symptom can often distinguish the two.

You could say that you get some 200's but not near enough to say that .25u increases are sufficient.
If you look at Celle's ss, you are not seeing any progress as the dose increases. By 3rd cycle at 2.5u, your curve shows all 300s and amps is 473. It's like every time you increase, you think you are getting better numbers on the 1st shot, but then the 300s come back, the resistance pulls against your efforts. I think you should consider making your increases more .5u until you start to see some real progress.

Do you mean that it takes a certain amount of increase to break through the resistance rather than just a certain dose?

I don't know if it is relevant, but when Celle was on Lantus, she went up to 5 units before we had a breakthrough and then she settled back down to 3 (with not very good control) before we switched to Levemir. The problem with Lantus is we kept occasionally getting scary low numbers so we backed off until we had a dose that didn't work well enough. We aren't around to test during the day, so we need some confidence that our dose isn't going to cause a hypo episode. Not that we're approaching that now. I bring this up just for some context on where we were before.

Since we're getting pretty close to the 3 units, I feel a little worried about moving up faster than 0.25 every 3 days. Of course, I realize that with her numbers as high as they are not moving up fast enough is cause for worry too. :?

uestion for you: is your vet mostly a dog vet? I ask as I was told that cushing's is much more common with dogs, but not with cats, so maybe your vet is thinking along the same lines as for dogs?

No, she has lots of cats. She even told me how rare Cushings is for cats and that she's only had 1 patient in 14 years.

Also, you would want to test for acro and IAA first, but you can wait until you get to a higher dose. 2.5u is still fairly low so you may want to wait until you work your way up to more close to say 5u BID but in the meantime, you could talk to your vet about the two tests. The results for these tests are definite; the cushing's tests are not.

Do you mean that acro and IAA are only really suspected if we need to go up that high?

 

[Blue]

Thanks everyone again for all the help!

There are so many symptoms that are similar but cushings usually comes with quite fragile skin; have you noticed skin issues?

No, no skin issues. This is what made me think acromegaly rather than Cushings. I read somewhere on this site that this symptom can often distinguish the two.

OK that's good. I was told that sometimes there are no skin issues but I wanted to ask and be sure. Still could be Cushings, but best to check the more common 2 conditions.

You could say that you get some 200's but not near enough to say that .25u increases are sufficient.
If you look at Celle's ss, you are not seeing any progress as the dose increases. By 3rd cycle at 2.5u, your curve shows all 300s and amps is 473. It's like every time you increase, you think you are getting better numbers on the 1st shot, but then the 300s come back, the resistance pulls against your efforts. I think you should consider making your increases more .5u until you start to see some real progress.

Do you mean that it takes a certain amount of increase to break through the resistance rather than just a certain dose?

It truly depends on the cat and what conditions exist. I have 2 acros, and one is also IAA positive. Many times the BG numbers can be like a tug of war, and if you have some IAA in the picture, it can be a struggle. As for how long it takes to recognize a dose change, again, it depends on the cat. One of mine, Shadoe, reacts in a few shots, but Oliver can take up to 5 shots or more. Because you may be dealing with a functional pancreas, you likely won't see a certain dose being good enough for a length of time. Think of standing on land which is a regular diabetic, or floating on water with waves causing changes which is an acro/IAA. I do think that I have broken through the IAA resistance with Oliver but he will always be acro.

I don't know if it is relevant, but when Celle was on Lantus, she went up to 5 units before we had a breakthrough and then she settled back down to 3 (with not very good control) before we switched to Levemir. The problem with Lantus is we kept occasionally getting scary low numbers so we backed off until we had a dose that didn't work well enough. We aren't around to test during the day, so we need some confidence that our dose isn't going to cause a hypo episode. Not that we're approaching that now. I bring this up just for some context on where we were before.

While Lantus and Lev are similar, they do have some subtle differences, but one of them is not going to be a big difference in curves. It could just be that Celle's needs changed or the dose of 5u was too high. It is best to be sure that you know exactly how Celle's BG is changing for each dose. Testing's pretty important, especially if you are dealing with some insulin resistance.... think of a faucet - sometimes it's just dripping but other times it is running full. That is how I look at insulin needs for an acro - if the faucet, or GH output, is low/dripping, the pancreas can handle the body's needs so your dose will drop, or, if the faucet, or GH output, is higher/ running, the pancreas needs help because its production won't be enough and your dose goes up.

I will say that I did try Shadoe on lantus after being on Lev and she was much more tense and her discomforts vanished again when I put her back on Lev. I tried the same trial with Oliver but the big lug could care less which insulin, so yeah, you may see better results with Lev.

Since we're getting pretty close to the 3 units, I feel a little worried about moving up faster than 0.25 every 3 days. Of course, I realize that with her numbers as high as they are not moving up fast enough is cause for worry too. :?

OK first thing you need to do is put less focus on the dose and much more focus on how Celle is feeling/acting, and what her BG numbers are. You really need to aim for BG under the 250 mark because numbers above that level are hard on the body. Focus on Celle's BG

uestion for you: is your vet mostly a dog vet? I ask as I was told that cushing's is much more common with dogs, but not with cats, so maybe your vet is thinking along the same lines as for dogs?

No, she has lots of cats. She even told me how rare Cushings is for cats and that she's only had 1 patient in 14 years.

OK perfect. I wanted to be sure.

Also, you would want to test for acro and IAA first, but you can wait until you get to a higher dose. 2.5u is still fairly low so you may want to wait until you work your way up to more close to say 5u BID but in the meantime, you could talk to your vet about the two tests. The results for these tests are definite; the cushing's tests are not.

Do you mean that acro and IAA are only really suspected if we need to go up that high?

Well, you can have the tests done now, but why go with the expense before you see a bit higher of a dose? There really have been some other cats who just need a higher dose. I can give you a perfect example - Randi/Max.
Before Shadoe's acro dx, Shadoe and Max were both climbing up the dose ladder together. When we got to around 6u, Shadoe kept going higher, but Max seemed to hit a dose that broke the pattern. For whatever reason, his dose started to drop and he is now OTJ. Either his pancreas healed enough and took over the job, or maybe he had some resistance that broke. Either way, he got up to higher than Celle was at on Lantus.
For that reason, you have time to make possible arrangements, and get a quote from your vet. Take the printouts for the 2 tests to your vet and ask for a quote, you may find that it is quite expensive total. The shipping is likely the biggest portion of the total - for mine, the FEDEX from Toronto, Ontario to the lab was $200, then tack on the blood draw, and packing and any other vet incidentals.

I would suggest you continue upping the dose, and increases of .5u would be good every 6 cycles. It would be very good if you can do curves when possible. Many people usually do their curves on the weekends, just so they can see how a dose is working. Quite often, I left increases to maybe a Thursday because I would be home on the weekend to do a curve just when the dose change would be kicking in.

 

[Melissa and Celle]

Thank you Gayle! I really appreciate all the explanations.

 

[Cheryl & Whiskers (GA)]

Hi Melissa,

Witty did well on Trilostane for about 3 1/2 weeks, unfortunatly I was not very well informed about taking her to the vet if she stopped eating, so I did not stress it to her caregiver (when we were out of the country for a week). The last two days we were gone Witty stopped eating and the vet our caregiver called told her just to watch Witty (she did not call the University of Minnesota), well when we got home she had not eaten for 2 days, we rushed her to the U of M ER, and she was in the ICU for Fri night, Sat, and Sunday we lost her, we really hoped she would turn around. My husband and I both think (and this is confusing) but Trilostane can reverse cushing into addisons and proper treatment must be given immediatly and it wasn't. The U of M Internal medicine vet said that it would be an easy fix if that happened, I believe you give cortisone, but he didn't stress to us to bring her in immediatly (we would have done so in any event, if we had been home). There just is not a lot of readily available info on Cushings cats. Even so we thought her best chance was the Trilostane. Witty and I and my husband all tried our best. Other cats have done better. The more information you can get the better armed you will be.
Hugs to you and Scritches to Celle.