Zoe, Weimaraner 9 years old, suspected Cushings

[dawn57]

Hi,

I'm so glad to have found this site. Our 9 year old female Weimaraner was due to have her teeth cleaned a few weeks ago, but we had noticed she seemed to be panting a little more, so we took her to the vet before the appointment to make sure she didn't have some problem.

The vet put her on antibiotics thinking it might be respiratory, but she didn't improve, so we had them draw blood and run a urinalysis. Everything was normal but her liver enzymes. They were evidently off the chart. I'm not sure which enzyme it was, but he told me the level should be in the 150 range at most and her's was 4500. We waited and repeated the test a week later and the result was 5300.
So our vet is recommending a specialist and says he suspects Cushings because in the last couple weeks her thirst has markedly increased, she's always hungry and has taken to counter cruising, and she had 2 nighttime accidents (which had never happened before.)

After the latest results came in on Saturday, he told us he's referring us to a vet specialist. After reading about the disease online I'd say her new symptoms (thirst, unrination, swollen belly) seem to be inline with Cushings. Assuming it is Cushings, I'd like to know how often one has to visit the vet for monitoring of the meds and bloodwork if your dog is on one of the Cushings medications. And also, do the extemely high numbers from her blood work indicate late stage disease, or do the numbers fluctuate, increase/decrease, apart from disease prognosis.

Thanks for any info.

[frijole]

Welcome! Glad you found us and that you are working with a specialist.

It would be helpful if you could confirm the numbers from the blood panel and give us any components that were high or low. (we'll also need the range for normal since labs vary) Also the unit of measure.

I am assuming that the liver enzyme you are referring to is the ALK PHOS reading. This is a sign of potential cushings but could be diabetes, hypothyroidism etc - all have similar symptoms. So several tests need to be done before you can verify a cushings diagnosis.

Are you asking about the number of visits/tests out of concern for using the specialist? Specialists can work with a local vet so that they oversee the process with your vet doing the work. They just have to communicate very well.

Best thing you can do is what you are doing and that is read up as much as you can to get up to speed on the disease and testing. You are Weim's voice right now. We have a fantastic reference section. I'll link you to the intro material to get you started.

Please tell us more about Weim and your situation. Also know you can ask us anything - no question is a bad one here. :p We have been done this path ourselves and understand.

Again, welcome! Kim
http://www.k9cushings.com/forum/showthread.php?t=180

PS Higher number can mean your dog has had cushings for a longer period of time but not always. Most cush dogs have it for years before being diagnosed. The dental visit is often how it is discovered. Most dogs do wonderfully when treated so don't let the high number scare you.

[labblab]

Hi and welcome from me, too!

Kim has already covered a lot of territory with her excellent info and questions. I just wanted to add that I think it's wonderful that your vet is referring you to a specialist right from the get-go. Many otherwise excellent general practice vets just don't have a lot of experience with Cushing's. So it is totally to their credit when they refer patients to specialists who have more expertise in that area. And as Kim has already said, once a diagnosis and treatment plan is in place, it may very well be that your regular vet will wish to generally oversee your dog's care, but with regular input and feedback from the specialist.

The bulk of the testing and vet visits are at the front-end, when the diagnosis is being made and when the dog is being stabilized on whichever medication is selected (Lysodren and trilostane are the most effective). After that point, blood testing for monitoring purposes is usually done quarterly throughout a year, and then later on perhaps only every six months or so.

We'll be very anxious to learn more about your dog and the additional diagnostics as they are performed. And as Kim has said, with effective treatment, Cushpups are able to resume and live out their normal lifespans with an excellent quality of life.

Once again, welcome!
Marianne

[dawn57]

Thanks for the replies. I'll have to get a copy of the reports and let you know the numbers. Evidently, it's just the one result that's off...he either said AST or ALT, and he did say it's so far off that the lab repeated the test both times because they couldn't believe the number they were getting.

BTW, I see everyone put their dog's name and I put Weim. We have Weimaraners (thus the Weim)...the dog's name is Zoe.

We've been referred to this specialist practice before. We have to see an opthamologist a few years ago at the specialty practice, but have been instructed to call the internist this go.

Yes, I was asking about the trips because the vet specialist is aways from us (our local vet's just 15 minutes away.) Since we've used the specialist vet before (for eyes, but still it's the same practice) we remember the amount of time it consumed to drive up there and wait to be seen, they didn't seem to run on schedule like our local vet. So I was wondering how we were going to manage with the time constraints it takes to see that vet, if we had to continue it on a long term basis.

Thanks for all your help. I'll check back in when I get a copy of the labs.

[Harley PoMMom]

Hi and welcome to you and your pup from me and my boy Harley! Cushings is slow progressing disease, many dogs go years before they get a proper diagnosis and once these dogs start recieving the life-saving rx meds that are properly given to them, they can and usually do live their normal life span.

Like Kim has mentioned, ALP (Alkaline Phosphatase) is usually always very elevated in our cush-pups. The ALP is not liver specific but the ALT (Alanine Transferase) is more so, do you have this number? Alot of us use liver supplements, which we have approval by our vets...Milk Thistle or Denamarin. We have seen liver enzyme levels drop with these supplements. Please ask your vet/IMS about this.

Other non-adrenal illnesses like diabetes and hypothyroidism do share some of the same symptoms of Cushings. It is vital that these do get ruled out before any cushings tests are performed because non-adrenal illnesses in a dog can create false positives on Cushings tests.

I think it is wonderful of your vet to send you to an IMS. An IMS sees alot more cases than an GP and an IMS has the state-of-the-art equipment, like ultrasound machines which can see them tiny adrenal glands and other organs in the dogs body. Harley's GP has an ultrasound machine in their office but Harley's GP told me that it can not pick-up and show what his IMS's ultrasound machine can.

I know this is a frightening and scary journey you are starting out on but we are here for you and your pup, so ask all the questions you want and we will answer them the best we can, ok. :)

Love and hugs,
Lori

[labblab]

BTW, I see everyone put their dog's name and I put Weim. We have Weimaraners (thus the Weim)...the dog's name is Zoe.

I went ahead and took the liberty of revising your thread title to add Zoe's name. :)

Just let me or any other staff member know if you'd like your title to read differently. Unfortunately, members cannot edit their thread titles themselves. But we Administrators or Moderators would be happy to make the change.

Marianne

[Roxee's Dad]

Hi and welcome from me too:)

Very glad that you are going through a proper diagnosis but to answer one of your questions:


Yes, I was asking about the trips because the vet specialist is aways from us (our local vet's just 15 minutes away.) Since we've used the specialist vet before (for eyes, but still it's the same practice) we remember the amount of time it consumed to drive up there and wait to be seen, they didn't seem to run on schedule like our local vet. So I was wondering how we were going to manage with the time constraints it takes to see that vet, if we had to continue it on a long term basis.

Once you have the diagnosis and start treatment, Zoe can be monitored by your local vet via scheduled ACTH stim test and your vet can consult with Zoe's IMS for any changes or adjustments in treatment. Should save you some time and money.

Looking forward to hearing more about Zoe and the rest of the gang. :)

[dawn57]

Hi everyone,

Thanks for all the replies. I have a bit of an update and a question.

We did see the specialist and they did some additional testing and determined it was Cushings. He also put her on Proin for the sleep incontinence, and that started to work immediately, so no more accidents.

Zoe weighs around 75 lbs., but the specialist wanted to take a conservative approach and started her on 30 mg AM and 30 mg PM of Trilostane. We've been using that for about 5 days and I had some email exchanges with him yesterday, as he wanted an update on her progress. (side note: why can't human docs be like vets, and do the email thing, we emailed back and forth discussing her case yesterday, and it was easy and convenient...maybe it's the confidenciality thing that keeps human docs from that, but it'd be nice, LOL)

Anyhoo, he says at this point in the game it's our decision to make if we think the dose is working, to our satisfaction, or if we want to up the dose. Her "normal" dose for her weight would be 60 mg AM/60 mg PM. Since she really hasn't shown any improvement in her symptoms, i.e. water drinking, hunger, etc. I discussed with him the idea of upping her morning dose to 60 and her evening leaving at 30 for a couple weeks to see if that makes a difference. He thought that would be a good call. Then if no difference is noted going to the 60/60 dose. He eventually is going to run another test, but cautioned us, in the meantime to look for cortisol deficiency.

He described lethargy, diarrhea, vomiting, etc. but my question would be, do you experts have any other things we should be on the lookout for that would alert us that she's slipping toward Addison's?

Any info would be helpful. Thanks so much for your help.

[labblab]

Zoe weighs around 75 lbs., but the specialist wanted to take a conservative approach and started her on 30 mg AM and 30 mg PM of Trilostane. We've been using that for about 5 days...

Anyhoo, he says at this point in the game it's our decision to make if we think the dose is working, to our satisfaction, or if we want to up the dose. Her "normal" dose for her weight would be 60 mg AM/60 mg PM. Since she really hasn't shown any improvement in her symptoms, i.e. water drinking, hunger, etc. I discussed with him the idea of upping her morning dose to 60 and her evening leaving at 30 for a couple weeks to see if that makes a difference. He thought that would be a good call. Then if no difference is noted going to the 60/60 dose. He eventually is going to run another test, but cautioned us, in the meantime to look for cortisol deficiency.
I'm really glad that you've had additional diagnostic testing, and it will be great when you can give us some more specific info about the tests: which tests were run, and what the actual results were. This information really helps to give us a frame of reference for our subsequent feedback to you.

I also think it's great that the specialist wants to start out conservatively with the trilostane dosing. The 60 mg. daily total is actually almost the very dose that the manufacturers of Vetoryl (Dechra) would currently be recommending for Zoe. Even though their printed Product Insert discusses an initial treatment range of 1-3 mg. per pound, they are verbally revising their recommendation and advising vets and owners to start at the lowest end of the range: at 1 mg. per pound. So for Zoe, that would be 75 mg. daily, or only a little bit higher than where you've started. I do agree, though, that you could probably also "up" her to 90 mg. without thinking that was a hugely high dose -- it's not that big a departure from the 75 mg. Actually, here's a written excerpt from their U.S. website that also states this revised recommendation:


Ideally, the starting dose to aim for is 1.0 to 3.0 mg/lb (2.2 to 6.7 mg/kg) once a day based on body weight and capsule size. When calculating dosage, it is suggested to round down. Start at the low end of this range. If you have any questions on dosing, contact Dechra Technical Support at 866-933-2472 or support@dechra.com.

One big thing that I DON'T feel good about is that your specialist seems to be relying largely on your reports about Zoe's outward behavior in order to make dosing decisions. Dechra's published protocol (as well as accepted Cushing's treatment practice) is that in order to safely make dosing decisions, formalized lab testing must accompany visual reports of behavior. With some dogs, cortisol levels can drop quite low and electrolyte imbalances can occur without a lot of previous outward warning. It's important to stay on top of the "inward" action of the trilostane, too.

Dechra recommends that an ACTH test, plus a check of the dog's blood chemistries ("electrolytes'), always be perfomed 10-14 days after the initiation of treatment and after any dosing change. Also, the expectation is that the dog's cortisol level will continue to drift downward during the first 30 days of treatment. So unless the initial ACTH test result is either too low, or really high and the dog is not showing any symptom resolution, the recommendation is to leave the dose unchanged during the first 30 days.

Here is a link to Dechra's "Treatment and Monitoring Flowchart" for using trilostane. I strongly encourage you to print this out in its entirety and carefully study it (including the Product Insert at the end). It will give you a lot of important information about the symptoms of overmedication, as well as the appropriate testing and dosing protocols.

http://www.dechra-us.com/File/vetoryl_Treatment_and_Monitoring_Flowchart.pdf

One thing you'll notice is that Dechra recommends starting out with dosing once daily instead of twice daily -- and only shifting to twice daily if the single dose does not appear to control symptoms adequately throughout an entire 24-hour period. However, we do have other members whose specialists prefer twice-daily dosing from the get-go. So your vet is not "alone" with that recommendation. But as for the importance of testing -- for Zoe's safety, I really do think you need to clarify your vet's expectations regarding performing monitoring ACTH/electrolye testing sooner rather than later.

Marianne

[dawn57]

Hi Marianne,

Thanks for the info, very helpful.

I thought I just posted a reply, but it must have disappeared into the "internets", LOL.

In our vets defense, he's working with us. I recently had surgery and am homebound for awhile, and I'm usually the one who takes the dogs to the vet. So my husband would have to get off 1/2 a day (which is about how long it takes to get to the specialist, have the appt. and get back)...so the vet's giving us some leeway, although he did mention running another ACTH test to check and see if the Trilostane is working.

I don't have the ACTH numbers from the specialist, but the numbers that alarmed our vet and sent us to the specialist were the ALP numbers. Normal was 5-131 and her first bloodwork showed a level of 4580, the restest a week later showed it elevated to 5823. Everything else was normal, on the first test, but the second test showed elevation in SGPT.

I'll have to call the specialist and ask them what her numbers were on the ACTH.

Thanks again for the advice.

[labblab]

I surely do understand the financial burdens associated with treatment. :o

However, if you feel as though you must hold off on the blood testing, I strongly encourage you to proceed very conservatively with any dosing increases. Since you've started off on the 60 mg. total daily dosing, I would wait at least a full two weeks before even increasing to the 90 mg. And I would not increase beyond that for at least another month and at least one ACTH/electrolyte test. A noted veterinary endocrinologist who is a member here has cautioned us that dogs who are dosed twice-daily run a greater chance of suffering from cortisol levels that drop too low. And if Zoe were to suffer from an Addisonian crash, you would end up paying a high price, both financially and emotionally. :(

Do keep us updated, and ask us about any issues that arise along the way!

Marianne

[zoesmom]

Hi and a belated welcome -

As you can see, I'm partial to dogs named Zoe. My girl was dx'd at age 9 and weighed just slightly more than your Zoe, at that time.

The dose you are using is very conservative for your Zoe's size so I wouldn't expect there to be any negative response. My Zo was started much higher (dosing guidelines have since been lowered). She weighed about 79 lbs, if I recall correctly, and began at 180 mg but soon developed the diarrhea and lethargy. Over the next two or three weeks, and with multiple stops and starts, we had to lower her dose down to 45 mg sid. She did fine on that dose, and your Zo is at 30 mg bid so just a little different, but not much. A dog who is headed for addison's, however, might lose their appetite or have trouble with weak legs/getting up, or even act depressed (like Zoe withdrew and would lie in out of the way places) . . . before the more severe signs show up. So I'd watch for those things. But really, doubt if they will happen, given the very cautious dose.

Personally, from my own experience with my Zoe, I prefer to see a dog started on the conservative end, and then worked up to a higher dose if needed. That 45 mg for my Zoe was slowly increased over the course of the next two or three months, to get her cortisol down to where it needed to be. She then stayed at 120 mg for awhile but in time, took even more than that. At the end (we had to let her go in March, at age 13, but not because of the cushings), she was back up to that 180 mg - and at twice a day. Having eased her into it slowly, she was then able to tolerate that dose that originally made her so sick.

But I do agree with Marianne. I wouldn't go much past the 10-14 day mark for that first monitoring ACTH test. If the 30 mg bid isn't quite doing the trick for her, then testing sooner rather than later would allow you to bump Zoe's dose up and get her into the therapeutic range that much sooner.

It's also possible that once her drinking comes under control, she may not even need that proin. My Zo took proin from the time she was one so she was incontinent all her life and we were never able to stop the proin. But it sounds like your Zoe may have developed the incontinence in response to an increase in her drinking from the cushings. Every now and then, after we began the trilo, I would skip a proin as an experiment, but it was clear that wasn't going to work in our case. Anyway, I would expect things to go very smoothly for your Zoe. Do keep us updated. Sue