Goose, a 7 y/o boxer, Pituitary cushing's, Rx'd trilostane

[par19]

Hello my new friends. I am new mom to Goose, a 7 y/o boxer with a gluttony of issues but has been undergoing testing for Cushing's as he fits many of the symptoms. I have been lurking for the past few days in attempt to learn as much as I can, and would like to ask for your opinions on how well I have "digested" the advice from previous posts.

I don't have all the numbers from the tests, but will post the information that I do have, and request the rest from the office tomorrow.

-Blood in urine, in initial urine test

-Enzymes reveal ALK Phos which DVM says could be indicative of Cush.

-Ultrasound: enlarged adrenal glands (both), kidneys appear normal although I recall DVM mentioning kidney levels after blood test were “high”

-Urine Cort/CreatR (UC-CR) 39

-Free T4: Thyroid level is .4. Normal range is btwn .9 – 3.9. Soloxine .6mg prescribed 2x daily. Follow up T4 recommended after 28 days.

-Low Dex Suppression test. DVM says results suggests pituitary based Cushing’s and recommends beginning Trilostane protocol for 78# at 120mg/day with follow up testing at two weeks, one month, 3 mo, etc.

Based on information I have attempted to process on K-9 Cushing’s forum, I would like to suggest/pursue the following treatment and solicit the forum’s feedback;
• Conduct ACTH for “baseline” numbers prior to beginning trilostane (unneccesary or good idea?)
• Discontinue soloxine after repeat T4 test as low thyroid could be secondary condition caused by Cushing’s
• Start Trilostane at 60mg/day. Test ACTH on recommended schedule
• Obtain Rx for prednisone as recommended by forum for crisis/low cortisol scenario.

Your help so far has been immeasurable, and I hope to find it more so as we progress though Goose's treatment.

Pamela

[frijole]

Pamela,

Wow. I am impressed because you are totally getting it! Yes - you must do an acth test. There are instances where the ldds test is wrong. Please post those nos. when you can.

If you do go ahead with the trilo you will want prednisone on hand.

You will want to retest the hypothyroidism (thyroid level) as it might go away once cushings is treated.

I won't comment on dosing amount because I use lysodren. I'm sure someone will. I do know that with trilo you want to start LOW. 120 mgs seems real high to me but someone else can comment on that. How much does Goose weigh?

You are right in that follow up testing is more frequent in the beginning as you might have to make some adjustments to the dosing amounts. I think your vet is reading from a book. ha. Cushings doesn't work that way cuz the dogs are all different. Wish it was that simple.

Glad you found us. YOu will do fine - you are learning fast! Kim

[gpgscott]

Hi Pamela and welcome,

It is usually recommended to have classical Cushing's symtoms such as excessive uptake of water, ravenous appetiete etc..., I am guessing it was symptoms like this that led to the diagnostics which you have had done. It would be helpful to members here replying to you to know of all the symptoms Goose is exhibiting.

Lot's of people lurk for a while to get the 'lay of the land', glad you joined. I would like to add to what Kim said that I think the first ACTH should be sent the UTK (university of Tennessee @ Knoxville) for what they call a full adrenal panel. There are six hormones in all which can cause Cushing's symptoms and this panel assays them all. The main cost in a stim is cortrosyn (the stim agent) and the cost of drawing and preparing the sample and shipping. When your Dr. ships the sample directly to UTK the upcharge over a cortisol only report should not be much over $100.00 and the additional information can be very useful.

Check back frequently, there will be lots of members checking in to welcome you and over support and suggestions.

Best to you both. Scott

[par19]

Thanks Kim & Scott.

Goose's symptoms are as follows: pot belly appearance, excessive thirst, excessive urination, always hungry and "stealing food", patches of dry flaky skin, some with hair loss, depigmentation on eyes and lips, excessive dander/dryness, fur thinning, and genuine lethargy or lack of energy to do almost anything but eat.

He's been much better as far as his energy level since starting the soloxine and will engage in some play and attention seeking, but is still a mellow boy.

I have to talk to my DVM because I want clarification on how diabetes insipidus or hyperthyroid is ruled out since some of the symptoms are similar. I'm assuming the ACTH test would confirm the Cushing's, but will it rule out the other conditions? Obviously, the lab results from all prior testing would help since I am no expert and only going on what I've been told. I will post those once I have them in hand.

I have not grilled my DVM/clinic for qualifications, although I do know they are new to the Rx for trilo. He may be the first patient they have taking it.

I appreciate the input. Goose weighs 78 pounds. Thanks again.
Pamela.

[Nathalie]

Hi Pamela,

“-Free T4: Thyroid level is .4. Normal range is btwn .9 – 3.9. Soloxine .6mg prescribed 2x daily. Follow up T4 recommended after 28 days.”

You are probably aware of this, but just in case … Soloxine needs to be given away from food, either 1h before or 2h after feeding.
When checking for therapeutic response after 4-6 weeks a Free T4 needs to be done 4-6h post pilling in am.

“• Discontinue soloxine after repeat T4 test as low thyroid could be secondary condition caused by Cushing’s”

Free T4 is less affected by high circulating cortisol then T4 – at 0.4 it is very low and there is a good chance that Goose has primary hypothyroidism.
If you want to find out whether or not this is the case, you will need to get good control on the Cushings first, then discontinue Soloxine for 4-6 weeks and preferably do a Full Thyroid panel at that point in time. Reason being, it does take 4 – 6 weeks for thyroid function to return to ‘normal’ after discontinuing Soloxine, whether it was low or adequate.

Hope this helps,
Nathalie

[zoesmom]

Hey Pamela -

Welcome to you and Goose. I gotta say - you are ahead of the game for someone who's just starting out. With Goose - at 78 lbs - I agree that I'd be more comfortable with him starting at a lower trilo dose - 60 mg, for instance, sounds more reasonable. You can always increase down the road. My Zo was 84 lbs. when she started (she also was our vets first trilo patient, back in '06) and the vet rx'd a rather ambitious dose (180 mg bid). Although that was then considered a mid-range dose for her size, she immediately fell into trouble. They've since lowered the rec. starting doses quite a bit.

Anyway, we had to stop and restart at lower and lower doses several times, before we reached one she could tolerate (45 mg bid.) We then gradually increased back up to 120 mg over many weeks time (maybe 2 - 3 mos.) and she then was able to handle it. In fact, she eventually took even more than that original 180 mg that caused her so much trouble at first. So start low and go slow . . . a good motto.

Zoe was also hypothyroid - well before the cushings. She took .8 mg thyroxine and a few weeks into the trilo tx, she did show signs of being hyperthyroid (i.e. - getting too much thyroxine). We didn't stop that drug and then wait to retest, however. But a simple T4 did indicate that she needed a reduction in her thyroxine. Ultimately, she did not have sick euthyroid (where the hypo level goes away, once the cushings is controlled.) So she did have to continue on thryroxine - but her dose was always lower after that.

It does indeed sound like Goose has cushings and the only additional test I'd suggest is the one you mentioned. The ACTH. It can further validate the diagnosis . . . and knowing where his cortisol is at now will give you a measure of his progress, once treatment begins. The adrenal panel from UTK is a good test as it will tell you - in addition to cortisol - if any of his secondary adrenal hormones might be involved. But it isn't an absolute necessity, although doing it now might avoid confusion down the road . . . as a handful of dogs will continue to have symptoms on trilo - simply because of those other hormones being out of whack.

And yes, ddo ask for the pred. Some vets resist giving it for use with trilo, but a little arm twisting will probably work. Just let the vet know that you understand the circumstances when its use would be warranted and that you would feel better having it around, just in case. After all, adverse reactions don't always follow the clock or the calendar (can happen during non-office hours, weekends, etc.)

Just one more thing - ask for all past and future test results and keep them in a file at home. (Also, please post the LDDS results here, when you get them.) A knowledgeable owner and a vet who is willing to listen and learn, along with you - or refer you to an IMS when they don't know the answers - are the best recipe for success when it comes to treating cushings. It does sound like your vet has a fairly good handle on things - except, possibly, for that recommended starting dose being a little high. Cushings is very treatable. Zo's cushings was controlled for 4 years with trilostane. Do keep posting and asking questions. Sue

PS - I wouldn't worry about the DI at this point. It requires a totally different test (water dep or trial period on the treatment). Given the cushings symptoms and results, you would only need to do those if Goose's PD/PU didn't resolve on trilo. Only a very small % of dogs have both cushings and DI. Cush dogs generally have a low urine specific gravity so that wouldn't mean much at this point. Oh, but the blood in the urine? Did they do a culture and sensitivity on his urine to rule out a uti. Cush pups can be prone to those. If he were to have a uti, you'd want to hold off on starting the trilo until that was treated.

[par19]

Thank you for your help and suggestions. I appreciate the feedback.

All UTD lab test results:

Dexamethsaone Suppression
Pre-Dexamethasone 4.0, Reference Range 1.0 – 6.0 up/dL
Post 4 HR Dex 0.6, Less than 1.5ug/dL
Post 8 Dex 2.9, Less than 1.5 ug/dL

Urine Cortisol 7.0 ug/dL

Urine Cortisol/Creatine Urine Creatine 55.6

Urine Cortisol/Creat Ratio 39

Free T4-ed (ng/dL) <0.2 (0.7 – 3.7 ng/dL)
Free T4-ed (pmol/L) <2.6 9.0 – 47.4 pmol/L

Senior Screen (Chem 25) Result Reference Range
Alk Phosphatase 345 10 – 150 U/L
ALT (SGPT) 94 5 – 107 U/L
AST (SGOT) 23 5 – 55 U/L
CK 211 10 – 200 U/L
GGT 5 0 – 14 U/L
Albumin 2.3 2.5 – 4.0 g/dL
Total Protein 7.1 5.1 – 7.8 g/dL
Globulin 4.8 2.1 – 4.5 g/dL
Total Bilirubin 0.0 0.0 – 0.4 mg/dL
Direct Bilirubin 0.0 0.0 – 0.2 mg/dL
BUN 24 7 – 27 mg/dL
Creatinine 1.2 0.4 – 1.8 mg/dL
Cholesterol 366 112 – 328 mg/dL
Glucose 120 60 – 125 mg/dL
Calcium 9.7 8.2 – 12.4/dL
Phosphorus 6.7 2.1 – 5.3 mg/dL
TCO2 (Bicarbonate) 23 17 – 24 mEg/L
Chloride 110 105 – 115 mEq/L
Potassium 5.1 4.0 – 5.6 mEq/L
Sodium 148 141 – 156 mEq/L
A/G 0.5 0.6 – 1.6
Indirect Bilirubin 0.0 0 – 0.3 mg/dL
NA/K Ratio 29 27 – 40
Hemolysis Index N (no significant effect)
Lipemia Index + (no significant effect)
Anion Gap 20 12 – 24 mEq/L

Senior Screen T4 Result 0.4 Ref Range 0.9 – 3.9 ug/dL
Senior Screen
CBC Comprehensive
Result Reference Range
WBC 8.4 5.7 – 16.3 Thous./uL
RBC 6.00 5.5 – 8.5 Million/uL
HGB 15.0 12 – 18 g/dL
HCT 42.9 37
MCV 72 60 – 77 fL
MCH 25.0 19.5 – 26.0 pg
MCHC 35.0 32 – 36 g/dL
Neutrophil SEG 90 60 – 70%
Lymphocytes 5 12 – 30%
Monocytes 4 3 – 10%
Eosinophil 1 2 – 10%
Basophil 0 0 – 1%
Auto Platelet 462 164 – 510 thous./uL
Polychromasia Slight
Absolute Neutrophil SEG 7560 3000 – 11500 / uL
Absolute Lymphocyte 420 1000 – 4800 / uL
Absolute Monocyte 336 150 – 1350 / uL
Absolute Eosinophil 84 100 – 1250 / uL
Absolute Basophil 0 0 – 100 / uL


Senior Screen Urinalysis
Color Yellow
Clarity Cloudy
Specific Gravity 1.026
Glucose Negative
Bilrubin Negative
Ketones Negative
Blood Trace Negative (H – High)
PH 7.5
Protein 2+ (200 -300 mg/dL) Negative / trace
*protein test is performed and confirmed by the sulfosalicylic acid test
WBC 2-5 0-5 HPF
RBC 6-10 0-5 HPF
Bacteria Rare (<8/HPF)
EPI Cell 1+ (1-2) HPF
Mucus, casts, crystals “none seen”. Urobilnogen = normal.

[zoesmom]

Just quickly glancing over those test results, the ALK PH and cholesterol are high (but not too excessive yet) tho' the ALT is not. The urine cort:creatinine is high, which only means that further cush testing was needed. These, along with the LDDS, suggest probable cushings, tho' Goose is possibly in the early stages still. But he does seem to have multiple symptoms and enlarged adrenals so that's further evidence. The one thing that was a little bit of surprise was his USG on the urine. It was respectable - not really low at all for a cush pup. Surprising (and also a good sign that he probably does not have DI) And thyroid is low, but again, that could simply be from the cushings. Has he already started on the thyroxine?? And it looks like no bacteria in the urine so what did the vet say could be the cause of the blood in the urine?

A couple other things slightly out of range, but will let Debbie (StarDeb) comment on those, if she sees anything notable. She's a lab tech and can interpret that stuff a lot better than me. Still would recommend the ACTH before starting tx. One other suggestion, if you haven't already ordered or picked up the trilostane. If you order a combo of strengths to start, it is a lot easier to tweak the dosing - up or down - if necessary. And it OFTEN is necessary in the beginnning!! For somebody like Goose, you could use 60 and 30 mgs (or even 60 and 15 mgs) to do that. Later, once he is stable with good cortisol #'s on his monitoring ACTH tests, you can just order one strength. I found that www.pethealthpharmacy online had some of the best prices for trilo and they will compound to any strengths you want. They ship quickly (3 or so days) and have good customer service. If you plan to buy from your vet, you are probably paying a HUGE markup. Sue

PS - Goose's LDDS does point to PDH as does the bi-lateral enlargement of the adrenals. Here's my favorite explanation for interpreting the LDDS and as you can see, Goose meets 2 of the 3 criteria for PDH:
The 8-hour plasma cortisol
is used as a screening test for hyperadrenocorticism, with
concentrations >1.4 μg/dl being consistent with (not confirming)
the diagnosis of Cushing's syndrome. This test is relatively
sensitive and specific, but not perfect. Approximately
90% of dogs with Cushing's syndrome have an 8 hour postdexamethasone
plasma cortisol concentration >1.4 μg/dland another 6 to 8% have values of 0.9 - 1.3 μg/dl.

The results of a low dose test can also aid in discriminating PDH
from ACT, using three criteria: 1) an 8 hour plasma cortisol
>1.4 μg/dl but <50% of the basal value; 2) a 4 hour plasma
cortisol concentration <1.0 μg/dl; and 3) a 4 hour plasma
cortisol concentration <50% of the basal value. If a dog has
Cushing's and it meets any of these three criteria, it most likely
has PDH. Approximately 65% of dogs with naturally
occurring PDH demonstrate suppression, as defined by these
three criteria. A dog with Cushing's that fails to meet any of
these three criteria could have either PDH or ACT. However,
if it has two relatively equal sized adrenals on abdominal
ultrasonography, it most likely has PDH.