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Insulinoma In A Dog

by dmtdvm13 - April 18, 2018 View Case Report

Buddy is a CM 10 Yr old hound X. He has been diagnosed with an insulinoma after 1 episode of weakness and ataxia on a walk in March 2018. This was confirmed by insulin/glucose testing and he had a CT scan and MRI. I do not have records from the referral hospital, but the owner told me they did not visualize anything in the pancreas but also there might be an area of mets to the liver?

Buddy has a previous hx of contracting leptospirosis in 2015. Prior to the diagnosis of insulinoma, he presented for PU/PD and decreased appetite. On ultrasound he had a small liver and elevated liver values as follows: ALT 695 (12-118)
AP 442 (5-131)
GGT 37 (1-12)
T.Br 0.6 (0.1-0.3)

He had elevated Bile Acids pre 59.1 (<13)
post 122.2 (<25)
FNA of liver showed chronic active cholangiohepatitis.

The only other medical issues are some itchy skin during a few summers. And 1 lick granuloma in the past on a front leg.

He is currently on LD diet, Denamarin, Ursodiol, and 15 mg pred Bid (this for the insulinoma)

His liver values and bile acids have returned to normal.

His TCVM exam: He looks great. Shiny, thick haircoat. Less energy than he used to have. He is PU/PD from the pred. No V/D/C/S. He does tend to prefer cooler temps. He is very friendly and social, loves people, kids and other dogs. Does suffer from separation anxiety.

His Tongue is pale pink/lavender, swollen with a white coating.
Pulse- is moderate strength and maybe slippery?
Active pts are BL20,21.

He doesn't scream damp heat (except for maybe the increased liver values and PU/PD from pred) I'm not sure if something like LJZT and adding GXZYT for potential mets would be appropriate. Or something to address the mild damp heat. SMS?

Thoughts please?.....

by naturevet

April 25, 2018

Hi Diane,

Sorry for the delayed reply. I have a few thoughts. The first is Xiao Chai Hu Tang. As you know, it is an anti-cancer formula and fits the previous liver enzyme elevations; history of Lepto; spring onset; PU/PD (due to a Triple Burner obstruction); preference for cool; biliary disease; and ongoing Qi deficiency signs.

XCHT is not a good fit for the Blood deficiency symptoms of a small liver and an amazingly complete response to prednisone, but it can be combined with Si Wu Tang in a 2:1 XCHT:SWT ratio to give Chai Hu Si Wu Tang. At that point, all the bases are covered except for any potential Dampness, such as the puffy tongue. Note, though, that moderate slippery-feeling pulses can indicate Blood deficiency, too.

So 65g of XCHT plus 35g Si Wu Tang would be my top pick, especially if an acupuncture treatment to GB points improved the pulse.

A runner-up consideration would be Xiao Yao San, particularly if we just focused on the liver findings, the relative ease with which the liver enzymes were lowered, the pulse, the tongue, and the Spleen points you found.

All that being said, Damp Heat formulas are always a good first choice in insulinoma, because they tend to increase blood glucose to the point that you may not even need pred. In that case, despite the moderate pulse, I'd reach for the Natural Path or Kan Essentials versions of Long Dan Xie Gan Tang, since it opens the TB; addresses PU and PD; is suited to a hot patient; and tonifies Blood when using the versions mentioned above; and can address high liver enzymes. It is not as vigorously anti-cancer, though, but you could combine it with Chai Hu Si Wu Tang for a pretty complete and balanced effect.

Given that the LDXGT is a pretty committed formula (and thus may induce side effects if we're wrong), I'd introduce the formulas one at a time if you go that route, and start with CHSWT. It may be that the Huang Qin and Ren Shen content of the formula is sufficient to regulate blood glucose, so that the LDXGT is not needed.

Hopefully in all that waffling you see a strategy that intuitively feels good to you. Please let us know how it all goes

Steve

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