Possible diabetic Westie, coughing

RE: Possible diabetic Westie, coughing

Thomas Johnson — Tue, 04 Dec 2018 18:43:46 GMT

An update on this case, sorry for the delay, I was off work last week. The dog is fairly bright, eating and drinking normally, and her skin disease is still well controlled just on Apoquel 5.4mg sid (0.5mg/kg), with Easotic in her right ear once weekly. She still has crackles on auscultation of both left and right lungfields, but they haven't got any worse since coming off the Medrone. Her owner reports that she has one episode of coughing in the morning, and then occasionally another one later in the day if she gets over-excited, and she is going for walks as normal. Her blood glucose was 5.3mmol/L. Her owner is reluctant to do a lot of further investigations at the moment, and as she seems stable I am comfortable with waiting and seeing how she gets on. I am planning to see her back in about a month.

RE: Possible diabetic Westie, coughing

Anthony Todd — Mon, 03 Dec 2018 19:57:07 GMT

[quote user="robloxley"]I follow this thread with interest as I also have a diabetic, atopic, coughing old westie that I'm dealing with: just throwing more steroids at it worsens his diabetic control (polyuria becomes problematic for dog and owner), apoquel controls some of his skin symptoms (and pneumonia was a side effect that hadn't stuck in my mind), and we've come to the conclusion of a bit of steroids alongside other medication to try and balance risks/benefits.[/quote]

I'm prepared to bet that the steroid dosage is excessive, and too often, ie not as necessary, for a start!

[all the regimes on here, usually given as an example of the dire effects of steroids, are as such!].

Which is why his polyuria becomes problematic....

To be fair westies are steroid sensitive so I would suggest giving the lower end of the dosage scale, 'cos they really do poly-urinate....

As an aside the advice to "dose as necessary" doesn't seem to have taken on.

Steroids are not like most drugs and you don't need continuous [barbiturates] just as necessary, if necessary.

Like the gambling ads; "if the cough stops, stop, [or don't give any more!"]

Just dose, a jab to start and prove, then tabs only as necessary as I have been saying on here for years [by now], and let us know!

But no, a prolonged course, well after cough relief,with all the side effects which then cascades onto vet surgeon.org as the dire effects, and "well known" of the dreaded 'roids!.....

Coughs perpetuate themselves as. I hope all modvets know, so stopping what we knew as "the cough cycle" is key, and very effective.

Why would I hammer on about regimes that didn't work??

RE: Possible diabetic Westie, coughing

Rob Loxley — Mon, 03 Dec 2018 18:26:37 GMT

[quote user="Anthony Todd"]read what has been said again, and carefully...[/quote]

I did read what has been said and feel that some more investigation is indicated.

[quote user="Anthony Todd"]The irony is that modvets criticise, and with all sorts of theoretical reasons and objections, usually involving another test, but have never done it or used it[/quote]

I follow this thread with interest as I also have a diabetic, atopic, coughing old westie that I'm dealing with: just throwing more steroids at it worsens his diabetic control (polyuria becomes problematic for dog and owner), apoquel controls some of his skin symptoms (and pneumonia was a side effect that hadn't stuck in my mind), and we've come to the conclusion of a bit of steroids alongside other medication to try and balance risks/benefits.

RE: Possible diabetic Westie, coughing

Anthony Todd — Mon, 03 Dec 2018 17:39:18 GMT

[quote user="robloxley"]Maybe you should move with the times?[/quote]

Not wanting to be solely argumentative, but read what has been said again, and carefully...

I wasn't worried about pneumonia because the animalS [and many] all stopped coughing and seemed better, which, BITD, was the criteria many, or all, dinovets followed.

The irony is that modvets criticise, and with all sorts of theoretical reasons and objections, usually involving another test, but have never done it or used it, too many theoretical objections which, in the real client, and my, world, don't matter.

Why, just once or twice, don't one of you whiz-kids try the "old" way and prove me wrong.

[Just seen a heart specialist at the superb Watford General who told us "warfarin" has been superceded by apixaban, vastly superior, so I'm moving with the times.]

PS [to more howls or ridicule]

If any of you get a coughing dog [usually] that the owner despairs will ever stop coughing, and late at night, give it a jab of dex and see.

Before retorts, continue with whatever diagnostic procedure or medication as well of course.

RE: Possible diabetic Westie, coughing

Rob Loxley — Mon, 03 Dec 2018 17:09:04 GMT

[quote user="Anthony Todd"]

I can't see what could be a risky GA reveal that would be therapeutically significant?

I can't see the advantage of apoquel, particularly with this risk of a severe pneumonia??

But things have moved on, I'm assured.

[/quote]

Maybe you should move with the times? If you're worried about pneumonia then maybe a chest xray and BAL might be useful?

RE: Possible diabetic Westie, coughing

Anthony Todd — Mon, 03 Dec 2018 11:36:24 GMT

[quote user="Emily Rainbow"]

I would also be very aware of the potential for horrible/obscure pneumonia’s from the concurrent use of steroids and apoquel.

Apoquel continued at the BID dose range has been reported to cause some horrible fungal/bacteria pneumonias.

GA: full thoracic xrays and scope + BAL would probably be my first step.

[/quote]

I used intermittent pred as necessary for years on cardiac coughing dogs [as well as dige and diuretics] with good results and no side effects, in fact I could guarantee that it would stop the cough immediately overnight.

I can't see what could be a risky GA reveal that would be therapeutically significant?

I can't see the advantage of apoquel, particularly with this risk of a severe pneumonia??

But things have moved on, I'm assured.

RE: Possible diabetic Westie, coughing

Emily Rainbow — Mon, 03 Dec 2018 07:20:06 GMT

I would also be very aware of the potential for horrible/obscure pneumonia’s from the concurrent use of steroids and apoquel.

Apoquel continued at the BID dose range has been reported to cause some horrible fungal/bacteria pneumonias.

GA: full thoracic xrays and scope + BAL would probably be my first step.

RE: Possible diabetic Westie, coughing

Sarah Keir — Sat, 01 Dec 2018 13:45:26 GMT

[quote user="Martin Atkinson"]

[quote user="robloxley"]

[quote user="Dinu Catilina"]

[quote user="Martin Atkinson"]It used to be used as a drug of last resort when the cocktail of ACEi, Pimobendan, diuretics, spironolactone, anti-arhythmics etc etc had maxed out/failed and is quite useful but is now being used as a drug of first choice is cases of heart failure due to pulmonary fibrosis. [/quote]

Pulmonary fibrosis or pulmonary stenosis?

[/quote]

Pulmonary hypertension?

[/quote]^^^

[/quote]

Martin Atkinson - how do you diagnose pulmonary hypertension?

RE: Possible diabetic Westie, coughing

Anthony Dennison — Fri, 30 Nov 2018 23:09:31 GMT

[quote user="Thomas Johnson"]This was my thinking as well, I was just surprised that the diabetes, if it was iatrogenic from the Medrone, resolved so quickly.[/quote]

May not have been diabetes, but an insulin resistance?

[quote user="Sarah Keir"]How are general practitioners diagnosing pulmonary hypertension?[/quote]

By referring to a cardiologist and seeing what they say

RE: Possible diabetic Westie, coughing

Sarah Keir — Wed, 28 Nov 2018 12:35:10 GMT

How are general practitioners diagnosing pulmonary hypertension?

RE: Possible diabetic Westie, coughing

Martin Atkinson — Mon, 26 Nov 2018 09:01:25 GMT

[quote user="robloxley"]

[quote user="Dinu Catilina"]

Pulmonary fibrosis or pulmonary stenosis?

[/quote]

Pulmonary hypertension?

[/quote]^^^

RE: Possible diabetic Westie, coughing

Rob Loxley — Mon, 26 Nov 2018 08:43:18 GMT

[quote user="Dinu Catilina"]

Pulmonary fibrosis or pulmonary stenosis?

[/quote]

Pulmonary hypertension?

RE: Possible diabetic Westie, coughing

Dinu Catilina — Mon, 26 Nov 2018 00:24:38 GMT

Pulmonary fibrosis or pulmonary stenosis?

RE: Possible diabetic Westie, coughing

Martin Atkinson — Fri, 23 Nov 2018 09:11:29 GMT

[quote user="Thomas Johnson"]

[quote user="Utlendigur"]Sildenafil? (for idiopathic pulmonary fibrosis)[/quote]

I wasn't aware it could be used for that!

[/quote]It used to be used as a drug of last resort when the cocktail of ACEi, Pimobendan, diuretics, spironolactone, anti-arhythmics etc etc had maxed out/failed and is quite useful but is now being used as a drug of first choice is cases of heart failure due to pulmonary fibrosis. Forget the smutty overtones it was after all first developed as a cardiac drug before its side effects became better known.

RE: Possible diabetic Westie, coughing

Thomas Johnson — Fri, 23 Nov 2018 08:32:05 GMT

[quote user="Utlendigur"]There was quite a good recent webinar on using inhaled steroids for respiratory disease on Webinar Vet (5/11/18)[/quote]

Thanks, I'll have a look.

[quote user="Utlendigur"]

Was a fructosamine done?

[/quote]

No, I thought about it, but as the glucose values were pretty much normal all day the dog was with us I decided not to. It's still in my mind to do it if the dog still looks like it might be diabetic when I see it back.

[quote user="Utlendigur"]Did the skin problems start 18mnths ago (quite late?) or just the current apoquel/medrone treatment?[/quote]

She'd had intermittent skin problems for several years, but they got worse about 2 years ago and she stabilised on the Medrone and Apoquel about 18 months ago.

[quote user="Utlendigur"]Sildenafil? (for idiopathic pulmonary fibrosis)[/quote]

I wasn't aware it could be used for that!

RE: Possible diabetic Westie, coughing

Utlendigur — Thu, 22 Nov 2018 19:04:04 GMT

There was quite a good recent webinar on using inhaled steroids for respiratory disease on Webinar Vet (5/11/18)

Was a fructosamine done?

Did the skin problems start 18mnths ago (quite late?) or just the current apoquel/medrone treatment?

Sildenafil? (for idiopathic pulmonary fibrosis)

RE: Possible diabetic Westie, coughing

Anthony Todd — Wed, 21 Nov 2018 17:03:54 GMT

Lots of references in humans re cortico'roids and resultant but resolving [after cessation] diabetes.

As I believe never saw it in the many animals I had on the 'roids I just wonder whether my always intermittent/as necessary steroid regime didn't give diabetes??

RE: Possible diabetic Westie, coughing

Richard Carter — Wed, 21 Nov 2018 16:49:59 GMT

Type 2 DM? have an elderly labrador that was having HGE on NSAIDs so switched to preds and became uncontrolled DM. Stopped / resolved after about 3 weeks of insulin rx

RE: Possible diabetic Westie, coughing

Thomas Johnson — Wed, 21 Nov 2018 14:52:34 GMT

[quote user="Martin Atkinson"]Iatrogenic DM and raised liver enzymes from the corticoids?! The D&V may have been coincidental but poss. acute pancreatitis - the hyperglycaemia would fit with that as well.[/quote]

This was my thinking as well, I was just surprised that the diabetes, if it was iatrogenic from the Medrone, resolved so quickly.

Interesting thought on the cough starting while it was on Medrone and questioning whether inhaled steroids would work, though I wonder if we would achieve higher doses in the airway with an inhaler. You're right that we need to rule out other causes of the cough, thanks.

RE: Possible diabetic Westie, coughing

Martin Atkinson — Wed, 21 Nov 2018 14:20:31 GMT

Iatrogenic DM and raised liver enzymes from the corticoids?! The D&V may have been coincidental but poss. acute pancreatitis - the hyperglycaemia would fit with that as well.The cough started while on them so an inhaled steroid is not likely to help. You can't make a diagnosis of the cough without at least some radiographs, a NTproBNP would indicate if it's likely cardiogenic or not and a BAL may be useful. Whether you re-start steroids for the skin is a QOL decision but unless the dog has an itch/scratch score of >3.5/5 I would tell the owners that some pruritis is inevitable and desist from giving them.

My experience (a total of 3 dogs) of cytopoint on dogs with suspected atopy is that it didn't work.

RE: Possible diabetic Westie, coughing

Rob Loxley — Wed, 21 Nov 2018 13:39:36 GMT

[quote user="Thomas Johnson"]I think it is likely that she has idiopathic pulmonary fibrosis and I would normally manage her with systemic glucocorticoids, but was wondering if an inhaler might be an option?[/quote]

Guess other differentials exist too (chronic bronchitis, infection, parasitism, neoplasia etc) and worth ruling out?
Inhaled steroids surely worth a try, but equally if not working and the problems from the lung disease warrant it, I'd be happy to use systemic steroids to improve QOL, being aware not ideal for diabetes.

RE: Possible diabetic Westie, coughing

Thomas Johnson — Wed, 21 Nov 2018 12:40:30 GMT

[quote user="Anthony Todd"]

It may have nothing to do with it, but why are people still giving continuous doses of corticosteroids?

The effect will not be needed daily as the effect lasts longer than a day, so a daily dosage is always excessive and unnecessary.

Even the manufacturer suggests alternate daily dosage but I would rather repeat if and when the signs begin to recur.

[/quote]

Previous attempts to reduce the Medrone dose, such as giving it every other day, have led to recurrence of pruritis and skin lesions within a couple of weeks.

[quote user="Anthony Todd"]

PS Apoquel seems to have similar side effects to the above case so the doasage may need review too.

https://petdermatologyclinic.com/apoquel-information/

[/quote]

The clinical signs have all resolved despite the dog continuing to receive the same dose of Apoquel, so I don't think it is part of the problem. Side effects from Apoquel seem to be very rare in my experience.

RE: Possible diabetic Westie, coughing

Anthony Todd — Wed, 21 Nov 2018 11:29:30 GMT

PS Apoquel seems to have similar side effects to the above case so the doasage may need review too.

https://petdermatologyclinic.com/apoquel-information/

RE: Possible diabetic Westie, coughing

Anthony Todd — Wed, 21 Nov 2018 11:21:45 GMT

[quote user="Thomas Johnson"]Medrone 4mg sid, [/quote]

It may have nothing to do with it, but why are people still giving continuous doses of corticosteroids?

The effect will not be needed daily as the effect lasts longer than a day, so a daily dosage is always excessive and unnecessary.

Even the manufacturer suggests alternate daily dosage but I would rather repeat if and when the signs begin to recur.

Of course continuous corticosteroids and diabetes are well knwn to be connected.