Introducing Sally - A Cushings Mystery ? (9 y/o basset hound)

[keronut]

Glad to be part of the forum. I am confused and need help outside of my veterinarian.

Sally, my 9 year old basset hound, has been diagnosed with Cushings Disease. At age two-three, she fell ill and I took her to a specialist who diagnosed her via an ultrasound and biopsy with a small liver and hepatitis. We put her on Denosyl and Prednisone for treatment. Her appetite and spunk returned rather quickly. I had to take her off prednisone as her appetite had responded quickly to the medicine. She has only been on prednisone for a couple of weeks each time, maybe 2 times. Through the years she has only had a couple of spells where the liver enzymes were elevated and she exhibited the same initial symptoms. She has always been very spunky and hyper (like a puppy).

Recently, she has undergone some elevated stress in her life. She lost her basset buddy Ginger a couple of weeks ago. She now was alone the first time in her life. We went on a trip right after putting Ginger to sleep and left her at home alone (with care of relatives of course) for three days . This stressed her out more. When we returned from the trip, she was exhibiting the symptoms of what I knew as elevated liver enzymes again. Those symptoms are shivering at the front end, lack of appetite (no vomiting), depressed, and real thirsty.

I took her to the vet to see what can be done as I felt she was under tremendous stress and anxiety. The vet did the blood work and the enzymes were a little elevated with one being way off the chart which rendered a blood test to be sent off to determine if Cushings Disease was present. It came back positive.

He explained all this mess to me regarding Cushings. I find no symptoms in Sally of what he was telling me (Huge apatite, Hair loss, Skin problems, excessive urination, pot-bellied appearance, loss of muscle mass excessive water consumption, ect..., ) , except the thirst thing, which left me confused completely. He did not have the proper dosage of Vetoryl for her so I continued her on daily denosyl, milk thistle and beta glucan.

She was showing some real good progress and then I administered on Christmas morning the Vetoryl. The next morning she fell sick again and vomited everything up, including her 2nd dosage of Vetoryl. I have had her off of it for a couple of days and she has returned to a great appetite again today. I need some help on what steps to take. My vet unfortunately is like a medical doctor and believes in harsh drugs. I kind of am upset because the drug insert in bold letters say DO NOT GIVE TO DOGS WITH LIVER DISEASE. I called my vet back on this one and he explained that Sally's blood work shows her liver is functioning and has not been in a hepatic state for several years now and the drug would be safe.

Since she got sick after 24 hrs of giving her the first pill, I have quit the medicine. The big thing I am reading on Cushings is the frequent urination, excessive thirst and appetite. Sally does not exhibit frequent urination and actually quit eating which is the indicator the liver enzymes are out of wack. I think the test showed up positive for Cushings based upon her recent stress. She was impacted by the loss of her buddy and us being gone for three days, much less sitting at a vet office for a few hours before they drew blood. Is this normal for Cushings??? and should I take her somewhere else when things settle down a little bit for her and be re-tested? I really love my Sally. Please help. :confused:

[StarDeb55]

I am so sorry that Sally is going through all of this. I'm sure we can help you sort this out. I need to ask you quite a few questions so we can get a good idea of exactly what is going on so we can give you the most appropriate feedback from the group's collective experience.

The most important question I need to ask is whether or not Sally is currently on prednisone, & was the Cushing's testing that was done, done while she was on prednisone? There is a type of cushing's called iatrogenic that is induced by long term administration of steroids which I am very concerned may be the case with Sally. The way to correct the problem is to slowly reduce the dose of prednisone until you can stop it. You can't abruptly stop pred because you have to give the adrenal glands time to recover & start making the cortisol that Sally needs to be healthy.

Secondly, do you know the name of the test that was done to make the cushing's diagnosis? Can you post the actual results? Was only a single test done to make the diagnosis? We would also like to see the results of any routine labwork such as a senior wellness panel or super chemsitry panel. Please post only the abnormal results, along with normal ranges & reporting units. If you don't have copies of Sally's results, your vet should be happy to provide them. Most forum members do keep files on their pups at home as you never know when the file might come in handy, especially if you end up at a strange vet.

Right now, without more specific information, it's hard to say what's going on with Sally. IMO, a Cushing's diagnosis may be highly questionable, especially if Sally is still on pred. Please DO NOT give any more trilostane as giving either of the 2 standard medications used to treat Cushing's to a healthy pup can cause serious complications to the point of being life-threatening. The golden rule around here is you do not give the medication to a pup who is ill in any manner especially vomiting, diarrhea, & lethargy. All of these symptoms can be signs of a low cortisol emergency.

I think requesting a referral to an internal medicine specialist who can get this sorted out for you would be the ideal thing to do.

Looking forward to hearing more.

Debbie

[keronut]

I will have to get her recent test results. She has always had elevated liver enzymes due to her condition at birth. The blood test was an ACTH ?? which was reviewed by a specialty clinic that my vet sends off to. She is not on Prednisone and has not been for over two and one half years now. She has only had Prednisone treatment (short term) probably three times in 6 years. We only used it for a couple of weeks to boost her appetite when her liver enzymes were too elevated, at which point we would also increase her Denosyl dosage to level her out again. The enzymes are always on a high level but have been manageable.

[Squirt's Mom]

Hi and welcome to you and Sally,

Please, stop the Trilo for now. Based on Sally's reaction to it, 1) she cannot tolerate the dose level or the drug itself or 2) the diagnosis of Cushing's is incorrect. Trilo can be fatal to pups who are not truly Cushinoid and can cause serious problems if the pup is overdosed, including death, so please do not give any more of this drug to Sally right now.

Cushing's is a slow progressing condition so there is no need to rush into treatment, especially based on the few signs she has and on only one test, that was given under stressful conditions.

So put the Trilo away, take a deep breath and relax a bit - it's ok, you really can do that. ;)

While you wait to get copies of the test results for us, why don't you tell us a few more details? We will play 20 questions with you at first. :p How much does Sally weigh? Is she on any other meds, supplements, herbs, ect. at the present? Does she have any health issues other than the liver that you are aware of? Do you have a name we could use?

I know just how scary all this can be at first but it does get better. Cushing's is not an immediate threat nor does it mean Sally's life-span will be shortened. Many cush pups live their complete life-span and some even beyond! We have all been where you are and we all understand the emotional roller-coaster this diagnosis, or just the possibility of this diagnosis, brings with it. But know this, you are not alone, we will be here to help you in any way we can.

Check out our Resource section, too:

K9C Resource section:
http://www.k9cushings.com/forum/forumdisplay.php?f=10

Read as much as you can, ask as many questions as you may have and we will do our best to answer them.

I am glad you found us and hope to learn more in the time to come! Keep your chin up!

Hugs,
Leslie and the girls - always

[Harley PoMMom]

Hi,

Welcome from me and my boy Harley, I am so sorry about your precious girl Ginger, please accept my heartfelt sympathies for your loss. That is the one of the hardest parts of loving these beautiful furbabies, having to say goodbye, my heart goes out to you right now with everything you are having to deal with.

I am so glad you found this forum, altho I am so sorry for the circumstances that brought you here. You have found an amazing group of people who are very knowledgeable about this cushing disease. By the way, what is your name if you don't mind, we are so friendly around here and starting my post out with just "Hi" is so impersonal. :)

Just incase you don't know trilostane and vetoryl are the same thing. We don't want to confuse you. :eek:


Cortisol is a stress hormone, one of the "fight or flight" hormones, so if Sally was really stressed the day she had her ACTH test, which is the test I'm thinking she had???, this could of skewed her results, also any non-adrenal illnesses will cause false positives results on ACTH tests.

Excessive thirst and excessive urination are symptoms of hyperthyroidism and diabetes, which share some of the same symptoms of cushings. This is why cushings is so hard to diagnose and why it is so very important to get a proper diagnosis.

Strong symptoms are a huge part of making the diagnosis, and a Cushing's savy vet will not initiate any treatment without strong symptoms and a proper diagnosis. Not one test can confirm cushings or the type of cushings, thats why you need a qualified GP or IMS for this disease.

Please remember you are not alone on this journey, we are here to help you in any way we can, ask all the questions you want and we will try to answer them the best we can.

Hugs,
Lori

[keronut]

Thanks for bringing to my attention that I have failed to provide my name. I am Janet.

Sally is on Denosyl w/Milk Thistle for her liver function. Thank goodness these drugs have ZERO side effects. Sally also is taking one thyroid pill daily (6mg Thyro Tabs). The only other supplement Sally is on is Beta Glucan, which is an immunity booster. I myself take it. She has been switched to Science Diet for 7+ year dogs. She appears to enjoy this food. The vet did give me some antibiotics (amoxycillin) in case of infection 500mg twice daily for ten days which she is finishing up. Please also note that Sally has been able to take medications without any side effects. She tolerates drugs well. That is why the Trilostane concerns me as 24 hours later, she was set back again and vomited her next day meal. I did then quit the medicine. I read enough on the potency of this drug and did not want to take anymore chances.

I don't know of Sally to have any other health issues. I had a complete blood work test from another vet in September of this year and everything looked fine except the liver enzymes again were a little elevated. This has always been Sally's case. We are just trying to keep the enzyme level as low as possible. The blood tests over the course of her problem has shown elevation but not to a point to be of concern considering her condition.

Sally weighed in at 52 pounds last week. Her last visit in September she weighed 53 pounds.

[Harley PoMMom]

What dose of vetoryl did your vet put Sally on?

[keronut]

He put her on 60mg to be given once daily. Just one pill a day.

[littleone1]

Hi Janet,

Corky and I would also like to welcome you and Sally. You have found a wonderful group of very caring, supportive, and knowledgeable people.

I'm sorry Sally is experiencing difficulties. I hope you will be able to get answers to many of your questions. I see that you already got some good advice.


Terri

[SasAndYunah]

Hi Janet,

welcome from me as well :) You have received some great advice and remarks already on the Cushing's but I wanted to comment a bit on the level of the liver enzymes. Elevated liver enzymes as such is not a medical condition. One cannot treat high liver enzymes since high liver enzymes are the result of something else going on (could be a zillion things). So, first you have to figure out what is causing the elevated liver enzymes, then treat that condition and as a result, the liver enzymes will drop.

Also, some dogs will have some elevated liver enzymes their entire life and for those dogs that's considered normal. So depending on how much the liver enzymes are elevated, it could be that (with just some elevation) Sally has a naturally higher level.

Just wanted to explain some more about the seriousness (or not) of elevated liver enzymes...and that it is never something that should be looked at solely. Meaning, a slight elevation could be normal in some dogs and more extreme elevations always call for further investigation what is causing the levels to rise that much...

Hope this has helped some in understanding some of the things :)

Saskia and Yunah :)

[Franklin'sMum]

Hi Janet

Welcome to you and Sally from Franklin and I. Deepest sympathies on the loss of your precious Ginger.

Jane and Franklin xx
________
Lovely Wendie (http://www.lovelywendie99.com/)

[labblab]

Hi Janet,

I, too, would hold off on giving Sally any more Vetoryl until or unless additional diagnostics are performed. Given Sally's history, I think that a repeat abdominal ultrasound might be really helpful. As was the case when Sally was young, I would again want the ultrasound to be performed by a specialist using high-resolution equipment (few GP vets have state-of-the-art sonography machines). You should receive feedback about Sally's liver and other major organs, as well as possible abnormalities with her adrenal glands (which could shed further light on a Cushing's diagnosis).

I can only reinforce what you already know -- the experts stress that the key aspect of any Cushing's diagnosis is the symptom profile. In the absence of symptoms, blood test results are always suspect since they can be skewed by other factors.

Do you still have access to a specialist in whom you have confidence?

Marianne

[lulusmom]

Hi Janet and welcome to you and Sally

I've made a few comments in response to your two posts. Please see blue text below.


Glad to be part of the forum. I am confused and need help outside of my veterinarian. Sally, my 9 year old basset hound, has been diagnosed with Cushings Disease. At age two-three, she fell ill and I took her to a specialist who diagnosed her via an ultrasound and biopsy with a small liver and hepatitis. We put her on Denosyl and Prednisone for treatment. Her appetite and spunk returned rather quickly. I had to take her off prednisone as her appetite had responded quickly to the medicine. She has only been on prednisone for a couple of weeks each time, maybe 2 times. Through the years she has only had a couple of spells where the liver enzymes were elevated and she exhibited the same initial symptoms. She has always been very spunky and hyper (like a puppy).

Sounds like Sally has chronic hepatitis which is not always curable, depending on the damage to the liver, but it can be controlled with regular blood work and medication. I had a little Maltese that crashed on me out of the blue and was ultimately diagnosed with chronic hepatitis. You were lucky that Sally bounced back as quickly as she did because my little one’s recovery was very, very slow. My dog required routine check ups after that. It’s been a long time so I forgot what meds she was on but I do know she was on prednisone or prednisolone for a while.

Recently, she has undergone some elevated stress in her life. She lost her basset buddy Ginger a couple of weeks ago. She now was alone the first time in her life. We went on a trip right after putting Ginger to sleep and left her at home alone (with care of relatives of course) for three days. This stressed her out more. When we returned from the trip, she was exhibiting the symptoms of what I knew as elevated liver enzymes again. Those symptoms are shivering at the front end, lack of appetite (no vomiting), depressed, and real thirsty.

If Sally was formally diagnosed with chronic hepatitis then, I agree that stress can definitely cause a flare up, which can cause the symptoms you describe. It is very rare that a dog with cushing’s has no appetite and you should never give Vetoryl to a dog that is not eating well.

I took her to the vet to see what can be done as I felt she was under tremendous stress and anxiety. The vet did the blood work and the enzymes were a little elevated with one being way off the chart which rendered a blood test to be sent off to determine if Cushings Disease was present. It came back positive. He explained all this mess to me regarding Cushings. I find no symptoms in Sally of what he was telling me (Huge apatite, Hair loss, Skin problems, excessive urination, pot-bellied appearance, loss of muscle mass excessive water consumption, ect..., ) , except the thirst thing, which left me confused completely.

As well you should have been confused as an experienced vet would never prescribe cushing’s treatment based on one diagnostic test, especially given the known stress that Sally had been under Stress and an underlying illness like chronic liver disease can cause false positive test results. Plus Sally’s only symptom of cushing’s was increased drinking and her liver issue shares this same symptom.

He did not have the proper dosage of Vetoryl for her so I continued her on daily denosyl, milk thistle and beta glucan. She was showing some real good progress and then I administered on Christmas morning the Vetoryl. The next morning she fell sick again and vomited everything up, including her 2nd dosage of Vetoryl. I have had her off of it for a couple of days and she has returned to a great appetite again today. I need some help on what steps to take. My vet unfortunately is like a medical doctor and believes in harsh drugs.

Based on the information you have provided, I tend to believe that your vet is probably inexperienced in diagnosing and treating cushing’s. However, his drug of choice, Vetoryl, is an extremely effective and appropriate treatment, but only if a dog truly has cushing’s. The disease is serious and it requires serious drugs which can be effectively administered with few to no side effects if 1) the prescribing vet is experienced in both diagnosing and treating the disease and 2) the pet owner takes the time to educate themselves so as to take a proactive participation in their dog’s treatment. We can give you lots of help on the education part.

I kind of am upset because the drug insert in bold letters say DO NOT GIVE TO DOGS WITH LIVER DISEASE. I called my vet back on this one and he explained that Sally's blood work shows her liver is functioning and has not been in a hepatic state for several years now and the drug would be safe.

I am confused with your vet’s statement because blood work alone does not tell if the liver is functioning properly and if Sally was previously diagnosed with a chronic liver condition, all of the effective drugs used to treat cushing’s must be used with extreme caution. Can you please tell us the exact diagnosis that was made when Sally first had liver problems? I am assuming that when your vet said that Sally has not been in a hepatic state, he meant that had no recurring liver problems after the first episode when she was 2 or 3 years old? Is that correct?

Since she got sick after 24 hrs of giving her the first pill, I have quit the medicine. The big thing I am reading on Cushings is the frequent urination, excessive thirst and appetite. Sally does not exhibit frequent urination and actually quit eating which is the indicator the liver enzymes are out of wack. I think the test showed up positive for Cushings based upon her recent stress. She was impacted by the loss of her buddy and us being gone for three days, much less sitting at a vet office for a few hours before they drew blood. Is this normal for Cushings??? and should I take her somewhere else when things settle down a little bit for her and be re-tested?

The acth stimulation test does take a few hours. The LDDS test, which is considered the gold standard in testing, is even a bigger ordeal, taking 8 hours to complete; however, the LDDS is more likely to yield a false positive result in the face of stress or nonadrenal illness.

I am very impressed that you have done your homework and are asking very pertinent questions. I would most definitely discontinue the vetoryl and take her to an internal medicine specialist for a complete evaluation. Even though Beagles are a breed that is over-represented with respect to cushing's, based on the information you have provided, I am still not convinced Sally has cushing’s. If she were my dog, I would absolutely not be giving her vetoryl until she has been properly diagnosed and is overtly symptomatic.

If you don't know of an internal medicine specialist in your area, I am listing a link below that might help. If you let us know what city and state you are in, we may have members that can refer you to an experienced vet and/or specialist.

http://www.acvim.org/websites/acvim/index.php?p=3


I really love my Sally.

That is very plain to see and Sally is a lucky girl to have you in her corner. You are a great advocate for her.

Please help. :confused:

Cushing's is a confusing disease but we're here to help and try to unconfuse you; however, please be warned that I have been known to make things even more confusing. The good news is that somebody is usually around to clean up behind me. :D



I will have to get her recent test results. She has always had elevated liver enzymes due to her condition at birth. The blood test was an ACTH ?? which was reviewed by a specialty clinic that my vet sends off to.

An acth stimulation test is most often sent to a lab for testing and an interpretation as most vets offices are not equipped to run the tests inhouse. Are you sure your vet sent the bloodwork to a specialty clinic or a lab? I don’t believe that an internal medicine specialist would advise your vet to start vetoryl treatment in light of few, if any, symptoms associated with cushing’s.

She is not on Prednisone and has not been for over two and one half years now. She has only had Prednisone treatment (short term) probably three times in 6 years. We only used it for a couple of weeks to boost her appetite when her liver enzymes were too elevated, at which point we would also increase her Denosyl dosage to level her out again. The enzymes are always on a high level but have been manageable.

We'll all be looking forward to a lot more information on your sweet Sally. In the meantime, here is a link to some really good reading on "the diagnostic approach to asymptomatic dogs with elevated liver enzyme activities":

http://veterinarymedicine.dvm360.com/vetmed/Medicine/ArticleStandard/Article/detail/325515

Glynda

[keronut]

Thanks for all the help you folks have provided so far. I am going to get a second opinion on Sally from somewhere. I want to act like I know exactly what is going on and what I need to ask for to be done. Please let me know what specific test I would need to request. I plan to make an appointment date tomorrow. Is the ultrasound or another blood test the most effective? Should I wait another week or so since she is seeming to settle down from her very stressed out state?? She had her last test as stated in previous posts one week ago today.

Thanks again for the help. I am starting to feel a little better now. You all have been a blessing to me. ;)

Janet

[Squirt's Mom]

Hi Janet,

BTW, I just love the avatar with one kissing the other! :) That is so, so cute! Which one is Sally? and who is her buddy?

As for testing, if it were me I would first concentrate on finding out if there is a liver disease in play. Just put Cushing's on a back burner for now and make sure the liver isn't the issue...or that some other unknown isn't happening. If she hasn't had an abdominal ultrasound recently (in the last 2-3 months), that is one test I would do now. Make sure it is done on a high-resolution machine or you are just wasting your time and $$. The US will give them a good look at not only the adrenals but other organs as well.

My Squirt was first diagnosed with PDH - meaning she had a form of Cushing's caused by a pituitary tumor. But an ultrasound found a tumor on her spleen; once it was removed her cortisol went back to normal and has remained there. The cortisol levels were elevated as her body tried to deal with the added stress of that tumor, which led to all her testing to confirm the PDH diagnosis - even tho now that seems to be incorrect after the tumor is gone. So I would highly recommend an US for Sally. Your vet should be able to refer you to an IMS who can do the US.

Keep your chin up!
Hugs,
Leslie and the girls - always

[keronut]

Squirt's Mom,

I love the pic too. The kisser or lemon/white one is Ginger who left me a couple of weeks ago to go to Doggy Heaven. Sally is the tri-color. :)

Thanks for the info. Will get this test done.

[keronut]

Hi to all!

Had Sally tested yesterday for Thyroid problems due to previous post. She has been on Thyroid meds most of her life. She went using two 6mg a day to one 6mg per day. Her thyroid T4 panel was way high. I think the vet told me a normal range was 0-2.5 and hers was 6. They want to take her off this medicine and re-test in a month for liver, cushings, etc. I need help on how to ween a dog off this med if any of you have had experience.

The vet said to miss dosage tomorrow and then use 1/2 every other day for three days. Does this sound right to any of you out there?? We are going to work on this and see what happens. I will have her re-tested for the Cushing's in a month. She also explained that the Thyroid and Cushings can have some similar symptoms.

Any help would be appreciated. This is a new VET for me now.

Thanks much.

[Nathalie]

I can't comment on the 'weaning off' protocol but I checked my correspondence I had with Dr. Jean Dodds and according to her
"if you stop the thyroxine even after years of therapy, it takes 5-6 weeks for the pituitary-thyroid axis to be reactivated to its original capacity [whether low or normal] . "

Hence, if it where me I would wait at least 6 weeks before doing at least a FT4 and a T4 test to check thyroid function.

Also, thyroid replacemnt should always be given 2 x per day because it has a 12-14 h half-life.
Every 12h, one hour before or 2 hour after meals.

Nathalie