Cushing’s and Diabetes

RE: Cushing’s and Diabetes

Andrew Kent — Fri, 01 Jan 2021 21:59:36 GMT

Hi Fable,

sorry to hear the outcome here but never an unreasonable decision with these complex cases.

[quote userid="11623" url="~/001/veterinary-clinical/small-animal/medicine/f/expert-help/29548/cushing-s-and-diabetes/227356#227356"]Am I right in thinking that the HDDS test would allow differentiation between PDH and ADH? [/quote]

HDDST can be a differentiating test but is almost never performed now due to availability of other options such as abdominal imaging and endogenous ACTH.

[quote userid="11623" url="~/001/veterinary-clinical/small-animal/medicine/f/expert-help/29548/cushing-s-and-diabetes/227356#227356"]What would be the benefits of twice daily dosing of the trilostane with regards to stabilising the diabetes? [/quote]

Twice daily dosing probably provides more stable drug levels over a 24 hour period so maybe better control. In fact evidence suggests, where funds allow, twice daily dosing is probably preferred in all HAC cases, allowing better control of clinical signs and often lower total doses.

Andy

RE: Cushing’s and Diabetes

Fable — Sun, 20 Dec 2020 01:39:25 GMT

Thank you Andy and Chris for your replies. Unfortunately, the outcome here was that I euthanased the dog as the owners did not wish to treat another chronic condition and felt she had been through enough already having had some serious issues with gastric ulceration a couple of months ago. The costs were also going to end up being over $500 a month just for the Vetoryl and Caninsulin alone and, like many of my patients here in NZ, she was not insured.

I will admit I had not determined the origin of her hyperadrenocorticism as pituitary or adrenal. We tend to use ACTH stim as our diagnostic test of choice here (although not so much recently with the lack of availability of Synacthen). Am I right in thinking that the HDDS test would allow differentiation between PDH and ADH?

I can appreciate that adrenalectomy would be a good option to resolve the Cushing's if it were adrenal in origin, but I'm not sure anyone in my clinic would be confident enough to try such a procedure and our referral options are rather limited! What would be the benefits of twice daily dosing of the trilostane with regards to stabilising the diabetes?

Many thanks again.

RE: Cushing’s and Diabetes

Christopher Scudder — Sat, 19 Dec 2020 08:50:38 GMT

Hiya,

I agree with Andy.

As a background, there are reports that roughly 10 to 15% of dogs with hyperadrenocorticism have diabetes mellitus, and roughly 10% of diabetic dogs have hyperadrenocorticism. So althogh not the most common presentation, it's does happen from time to time. Having hyperadrenocorticism and diabetes mellitus is associated with poorer survival than having diabetes alone.

My personal preference to help stabilise the diabetes would be try to move to twice daily trilostane therapy after the owner has got used to doing the insulin injections. It might also be worth reviewing the original diagnosis of the hyperadrenocorticism to determine if it was likely to be pituitary or adrenal in origin. If adrenal dependent then an adrenalectomy could be considered. If unsure, it might be worth considering an abdominal ultrasound, as although the adrenal glands may have enlarged due to trilostane, if you have one large adrenal gland (>2cm) then adrenal dependent disease might be likely, and adrenalectomy may resolve the hyperadrenocorticism.

Caninsulin is absolutely fine to start with.

Best wishes,

Chris

RE: Cushing’s and Diabetes

Andrew Kent — Fri, 18 Dec 2020 21:23:13 GMT

Hi Fable,

Apologies for the slow reply. Diabetes is certainly recognised in association with Cushing's. In some ways this case is the easier way round (ie the Cushing's was diagnosed first) as hopefully that means that aspect is already well controlled. Otherwise we may find the diabetes difficult to stabilise.

In the first instance you should start treating the diabetes however you are most comfortable (Caninsulin is fine) and see how you get on. Hopefully it will stabilise well with no issues but we depending how well controlled the Cushing's is we might see a degree of insulin resistance.

Do keep us posted with how you go.

Andy