Phebe-my eleven-year-old Shetland sheepdog

[Phebe]

Hello, forum folks. I'm so glad to find you.

I've been surfing the web trying to find out more information on Cushings that will help my Shetland sheepdog, Phebe. Her vet diagnosed her in May after initially discovering a thryoid issue. She's been on vetoryl for almost a week and is starting to show signs of lethargy and has some difficulty getting to her feet. I felt really conflicted about starting the drug: the side-effects sound very frightening. Now I'm wondering if I made the right choice. My confidence in her doctor's diagnosis is not 100%. (She had her on a strong dose of thryroxin for her thryroid problem, but didn't test her levels until more than two months later. Phebe's thryoid count was elevated by that time. Thankfully, she's already established an appointment to check Phebe's reaction to the vetoryl a week from Monday.)

Phebe is the sweetest dog, and it's difficult to see her in so much discomfort.

I'm looking forward to reading through the forum posts to find out advice in how to manage Phebe's illness.

[Roxee's Dad]

Dear Phebe's human, :)

First I would like to welcome you to K9cushing's. You will receive a lot of help from our many experienced members, information, experience and hand holding :):);) I only have a minute to post but saw your thread in moderation. Please check you e-mail for a confirming e-mail. Until you confirm, your post's will remain in moderation until released by an admin or moderator.

Once again, welcome to you and Phebe.

[labblab]

She's been on vetoryl for almost a week and is starting to show signs of lethargy and has some difficulty getting to her feet... Thankfully, she's already established an appointment to check Phebe's reaction to the vetoryl a week from Monday.)

Hi and Welcome to you and Phebe!

I'm going to jump right in with both feet and tell you that if Phebe is acting lethargic and is having trouble standing, she may already be overdosed on the Vetoryl and changes may need to be made immediately. Do you have access to your vet today? If so, I strongly encourage you to call in and report what's going on with her. Either way, you'd best hold off on giving her any more Vetoryl until you've had a chance to consult with your vet. Given your description of her behavior, it is better to err on the side of caution and hold off on a couple of doses rather than to risk bottoming out her cortisol.

Did your vet give you any prednisone to administer to Phebe in the event that her cortisol drops too low while on the medication? If not, I'd caution you to check to find an emergency vet that is open over the weekend, just in case Phebe were to worsen even more before Monday. Usually, dogs being treated with Vetoryl will rebound from an overload simply by discontinuing the medication for a time. But since this is a weekend, I just want to make sure that you are prepared in advance in the event that Phebe needs some additional help. Here is a link to a lot of information about Vetoryl treatment and monitoring:

http://www.k9cushings.com/forum/showthread.php?t=185

When you get to that link, definitely click on the "Product Insert" information, and you'll be able to read more about the cautions associated with overdosing including lethargy, weakness, vomiting, diarrhea, lack of appetite, etc. If Phebe were to be severely overdosed, then she would need temporary steroid replacement for the cortisol that she is missing, either in an oral or IV form.

How much does Phebe weigh, and what dose of Vetoryl is she taking? Also, can you tell us more about the testing that has been done to diagnose her Cushing's? Also, what were her symptoms prior to starting the Vetoryl and had there been any improvement prior to her lethargy setting in?

Sorry for so many questions, but your answers will help us give you the best feedback that we can. So we'll be waiting to hear back!

Marianne

P.S. Your membership has now been officially approved, so all of your posts from this point onward will be immediately visible after you submit them. :)

[apollo6]

well come Phebe and you.
I'm Apollo's mom. I am very new at this, I just started my little guy on Trilostane, Friday. But with a lot of research, questions. I can tell you my experience, read my thread -Apollo-Vetroyl/Trilostane-I took about a few weeks before I made my decision, I read up all I could on Cushing's Disease(tried to weed out the quack sites promising a cure ), read information on the Vetroyl -Decha website. Did most of the tests to diagnose what kind of cushings Apollo has, checked for all the symptoms, which Apollo has all. Asked Senior members for input . Still questioned if I was doing enough tests, etc. Went to first one IMO, did not like, decided to try another IMO , had a long meeting , with a list of questions I had, read up on different treatments available. Decided did not want to start Apollo on a high dosage after reading about dosage appropriate for which weight. Even while waiting to get the medicine I still had a list of questions, worry, called the IMO, again for more input, and got support here to start treatment. There are no silly questions. They are our babies and we just want is best for them. It is normal to be afraid, watch any unusual out of the ordinary signs, call the vet immediately. You know your dog best.

[Harley PoMMom]

Hi and welcome from me and my boy Harley! 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.

Some of the symptoms of hypothyroidism and diabetes are also shared with cushings. This is why cushings is so hard to diagnose and why it is so very important to get a proper diagnosis. What exactly are Phebe's symptoms?

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, that's why you need a qualified GP or IMS for this disease. What tests were done to confirm Phebe's cushings?

Concerning the thyroid test: If the thyroid test is low or low normal then usually a Free T4 by equilibrium dialysis test is run to differentiate between true hypothyroidism from sick thyroid syndrome.

Sick thyroid syndrome is common among our cush-pups. In this situation the thyroid gland is normal, but there are factors that are suppressing it from secreting a normal amount of thyroxine into the bloodstream. Diseases like Cushing's disease, diabetes mellitus, chronic renal failure, liver disease, and addison's disease can also cause sick thyroid syndrome.

If Phebe is showing signs of lethargy and has some difficulty getting to her feet then, if she were my dog, I would stop the vetoryl and take her to your vet or an emergency clinic. It sounds like her cortisol has gone too low and/or her electrolytes might be unbalanced. According to Dechra's Product Insert:


PRECAUTIONS:
Hypoadrenocorticism can develop at any dose of VETORYL Capsules....A small percentage of dogs may develop corticosteroid withdrawal syndrome within 10 days of starting treatment. This phenomenon results from acute withdrawal of circulating glucocorticoids; clinical signs include weakness, lethargy, anorexia, and weight loss. These clinical signs should be differentiated from an early hypoadrenocortical crisis by measurement of serum
electrolyte concentrations and performance of an ACTH stimulation test. Corticosteroid withdrawal syndrome should respond to cessation of VETORYL Capsules (duration of discontinuation based on the severity of the clinical signs) and restarting at a lower dose.
http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf

We are here for you and Phebe so ask all the questions you want and we will answer them the best we can. :)

Here is a link to Trilostane/Vetoryl Information: http://www.k9cushings.com/forum/showthread.php?t=185

Love and hugs,
Lori

[Phebe]

Thank you all so much for your responses. (I was at a wedding all afternoon, and wasn't able to check back until early evening).

I wish I'd found the forum prior to starting the vetoryl. I am embarrassed to say I am uncertain of the name of the test Phebe's doctor administered. Phebe had to stay at the office for several hours, a dye was injected into her blood, and measurements were taken. I will look for her paperwork and update this message.

This evening, Phebe is eating and drinking normally although she still struggles getting up on laminate/hard-wood floor (but does all right with carpeted areas and outdoor areas).

I will wait to give her the vetoryl until I talk with her doctor on Monday. Thank you all for your advice on that. I will watch her closely this evening and tomorrow to make certain her condition doesn't worsen.

Phebe weighs 35 pounds. She's tall for a Sheltie, but she's is also a little overweight. Her symptoms, prior to diagnosis, were excessive thirst and panting. As I mentioned, she was diagnosed for hypothryroidism. She's had difficulty getting up (which I attributed to aging). The symptom which has baffled me (and which I don't notice in any of the Internet web-sites describing Cushings) is Phebe swings her head from side to side when she is laying down. This doesn't happen all the time. I've never seen her do this while standing. Any time we call her when she's in the middle of the head-swing, she's able to stop. Another odd symptom that has increased recently is a chin quiver.

Thank you again for welcoming me. I'm anxious to look at other posts (now that I'm back from the wedding), and look forward to learning more from all of you.

[frijole]

Well better late than never! :)

Regarding getting up off the floor - a couple of thoughts. Cushings dogs that are not treated suffer muscle loss and for some reason the hind legs get real weak and some actually shake. My dog's did. After treatment that went away.

Also a dog with cushings produces too much cortisol. Cortisol acts as an internal pain reliever! So old dogs like mine don't show signs of arthritis until AFTER treatment begins and their cortisol levels go normal. So it might be wise to start giving fish oil and glucosamine chondrointin (many of us do this) as it seems to help and takes a while to kick in.

Not sure what that head shaking thing could be... new one. Same with the chin quiver... that would seem to be perhaps pain? Not sure.

When you go to the vets simply ask for copies of all tests that were done to diagnose the cushings. Typically it starts with a blood panel and then there are a couple more. There is a 2 hr blood draw called the acth test and an all day 8 hr draw called the LDDS (low dose dex suppression test) Did your vet do a sonogram? Did he tell you what kind of cushings it is?

The more we know the more we can help... don't worry - you are no longer alone on this journey. Kim

[Phebe]

Thank you, Kim. Phebe's doctor did the two-hour test but not a sonogram...and she hasn't told us what kind of Cushings Phebe has. I will ask if she (the doctor) can give me this information when I call on Monday. Phebe was taking a pill for arthritis but ran out of the medicine earlier this month. I'll ask about that, too.

Thank you, again.
Lisa

[frijole]

Lisa, Do you remember which med for arthritis? I ask because many of them are not to be given to dogs with cushings. So when you speak with the vet - if he/she isn't sure, make them check to make sure it is safe... I can tell you metacam is not. I gave my dog adequan shots and that worked very well. She lived to be 16 1/2

I will warn you - with cushings there are lots of tests and it will be helpful up the road if you start a journal and create a file. Keep copies of all tests so you can refer to them later.

Again - glad you found us! Kim

[labblab]

Lisa, thanks so much for this additional info. I'm very relieved to hear that Phebe is eating and drinking normally, and appears to be OK other than the difficulty with getting up from the slippery bare floor. With this new info in mind, I'm thinking that Kim may have hit the nail on the head by suggesting that Phebe's trouble with standing could be due to the unmasking of her arthritic issues, rather than a medication overload, per se. So as Kim says, that may be dealt with by adding some supplements or pain relievers. And/or your vet may decide to lower her dose of Vetoryl a bit, in order to allow her body to adjust more gradually to the cortisol decrease. Can you tell us how much Vetoryl she is taking now?

Thanks again!
Marianne

[Phebe]

Phebe takes 10mgs every day. I haven't given her any yet this morning. Would you still advise me to wait to speak with her doctor? (There was some yellow bile/vomit on the rug this moring...but I have given her a new treat recently that may have upset her stomach, too).

Thank you for all your help and advice.

[labblab]

Hi again, Lisa.

10 mg. is a very conservative beginning dose for a dog weighing 35 pounds (Dechra's basic formula is to calculate 1 mg. per pound). So that makes a serious overdose seem less likely to me, especially since you had said that Phebe was otherwise doing well and her difficulty with standing was limited only to the slick floor areas. So up until your most recent reply, I would have felt less nervous about you going ahead and giving her today's dose. But now that you've told us that she has vomited today, I believe I would still hold off on resuming the Vetoryl until you can check in with your vet. You're right, it could just be the treat (and you're learning the hard way that it's probably best to hold off on introducing any new food or treats while Phebe is adjusting to the medication -- it complicates knowing whether it's the treat of the medicine that is causing the problem :o). But keep in mind that I'm not a vet, though, and I'm basically just telling you what I'd do in your same situation. To me, the big issue is mainly that this is the weekend, and so you don't want the situation to go sour at a time when it is not easy to consult with your vet. I've been in that situation TOO many times -- worrying about a sick dog on a Saturday or a Sunday, and just watching the clock until Monday morning comes around! :(

Marianne

[Phebe]

Thanks, Marianne.

I'm glad to hear the dosage is conservative.

She seems to be feeling better this morning, so I'll hold off on giving the vetoryl until Monday morning when I can speak with her doctor.

I do greatly appreciate this forum. Phebe is the sweetest dog we've ever had in the family, and I want to do everything possible to make her feel better.

Lisa

[Phebe]

I'm feeling so frustrated with Phebe's doctor right now. She didn't return my phone call. I waited until Wednesday, hoping she'd get back to me. Eventually, I had to make an appointment to take Phebe in to see her doctor in order to answer my questions regarding treatment. Is there a place on line where I can find recommendations for vets in Oregon who specialize in treating Cushings?

[Squirt's Mom]

Hi Lisa,

Check this link and see if that will help you...

http://www.k9cushings.com/forum/showthread.php?t=182

Hugs,
Leslie and the girls - always

[labblab]

Lisa, I'm sorry you're having such a frustrating time with your vet. Here's a link to a webpage for the American College of Veterinary Internal Medicine which lists Oregon specialists in small animal internal medicine. Perhaps one of these vets might be near you?

http://www.acvim.org/websites/acvim/index.php?p=228

Most often, specialists require a referral from a patient's regular vet. But sometimes this is not the case. And your own vet ought to be willing to provide a referral, regardless, in the event that you want more specialized consultation regarding Phebe's care.

Have you already taken Phebe in for her appointment yet?

Marianne

P.S. I see that Leslie and I were on the same wavelength here :). I had just gone ahead and entered a search for "Oregon," but it's the same website.

[Phebe]

Phebe's scheduled for first thing Thursday morning. Thank you all for your help. I'm going in with a bunch of questions to ask her.

[Phebe]

I finally spoke with Phebe's doctor Thursday morning. I'd had to schedule an appointment to speak with her, so I decided not to take Phebe with me. Phebe has a difficult time at the vet's office, and I didn't want to give her unneeded stress.

The doctor suspects that Phebe has pituitary based Cushings. The test she conducted was the ACTH stimulation test. Her test results were 5.32 ug/dl pre-serum; 29.2 ug/dl post serum.

I asked that Phebe be administered the 8-hour LDDS test to verify the results and an appointment has been made for a week from today.

Several weeks ago, her doctor lowered the dosage of her thyroid medication. Since that time, she doesn't seem to be panting as much, and her trips to her water bowl have gone down. Those were the two most obvious Cushings symptoms that Phebe presented.

I still wonder if she was over-medicated for her thyroid issues. Would that have an effect on her ACTH results?

Thank you all for your help and encouragement.

Lisa
:)

[labblab]

I asked that Phebe be administered the 8-hour LDDS test to verify the results and an appointment has been made for a week from today.

Lisa, I just wanted to raise one question for you re: the LDDS test. Are you planning to administer Vetoryl in the meantime? I do not know the answer to this myself, but I'm wondering whether Vetoryl may affect the results of the test? The LDDS is a diagnostic test that is typically administered prior to beginning treatment. So you may want to double-check prior to giving Phebe any more Vetoryl during this intervening week.

As far as the thyroid medication and the ACTH, I am not aware of any interference there. My boy was also on thyroid meds at the time of his ACTH testing, and I don't recall it being an issue.

Marianne

[Phebe]

I haven't given Phebe the Vetoryl since this weekend. I'm going to wait for the second test to confirm. It's what I should have done in the first place.

Lisa

[littleone1]

Hi Lisa,

I also wanted to mention that Corky was on thyroid medication when he had all of his stim tests , the LDDS, and the full adrenal panel. He had the LDDS test done before he started treatment with Trilo.

Terri

[Phebe]

Phebe's doctor called today with the results of her LDDS test. Her results were within normal ranges. Although I am extremely relieved that Phebe doesn't appear to have Cushings, I am very concerned that her doctor put her on such potent medicine without a thorough evaluation.

I want to thank all of you for coming to Phebe's aid and offering me such excellent advice. If I had kept Phebe on the veteroyl, I don't know if she'd be here today.

In the coming months, I will closely monitor Phebe's condition (and look for a more conservative doctor).

Thank you all again for welcoming Phebe and me and being such wonderful advocates for dogs with Cushings and the owners who love them.

[Casey's Mom]

Wonderful news Lisa!!! Hugs to you and Phebe. . . .

Love and hugs,

[Lisamarie]

It's been a year since Phebe's tests came back with a negative result for Cushings, but in that time her health has continued to deterioriate.

In late spring, I found a hard lump on her hip. The doctor removed the lump, had it tested, and found it was cancerous. Thankfully, it is spindel cell carcenoma and hasn't shown any signs of returning.

When the doctor ran Phebe's blood to make sure she was strong enough for (teeth-cleaning and) the lumpectomy, she found that Phebe's liver counts were very high. She again questioned whether Phebe did indeed have Cushings.

Phebe has been on PPA for urinary incontinence. She takes thyroid medicine morning and night. The doctor also recommended a herb called Body Sore for arthritis.

Many of the symptoms of Cushings seem to be more pronounced now. Her eyes appear sunken; she struggles to get up. She has never been aggressive about food, but suddenly has become grabby. Her jaw quivers when she is nervous (and her anxiety is worse, by far, than its ever been).

Given her age, the cancer, and all these factors, would a firm Cushings' diagnosis make a difference? Last year the pills the doctor attempted to give her had so many side-effects, I hate to think of starting them again.

I just want to make her comfortable and content (as much as possible).

[labblab]

Welcome back to you and Phebe, although I am very sorry about her worsening health issues. I'm afraid it is hard to give you a straight answer to your question, because it seems as though there are still a lot of question marks as to what exactly is causing Phebe's problems. :o

Generally, I would tell people that a firm diagnosis of Cushing's (and accompanying treatment) can be very helpful for a dog of Phebe's age. And my personal hope is that the cancer diagnosis will be a moot point either way since the tumor has not shown any signs of returning.

For me, though, the question mark is the nature of Phebe's problems -- do they really fit the picture for Cushing's, or is it something else or a combination of "something else's?" And if it is something else, will that skew the Cushing's testing? Cushing's certainly does elevate liver values, but so do other disorders. Hypothyroidism can be secondary to Cushing's, but it can also arise on its own. The difficulty getting up may be arthritis rather than muscle wasting associated with Cushing's. Food aggression is a hallmark of Cushing's, but the jaw quivering and increasing anxiety -- no, not really.

I know Phebe previously had diagnostic blood tests for Cushing's, and the ACTH came out positive while the LDDS was negative. One drawback to the blood tests, though, is that other nonadrenal illness can result in "false" positives. Given all of Phebe's problems, I'm going to throw out another diagnostic for your consideration: an abdominal ultrasound. If it were me, I think I might ask for that before any repeated blood testing. The adrenal glands are hard to visualize, so the ultrasound needs to be performed by a certified technician on high-resolution equipment. But the appearance of the adrenal glands can offer support to a Cushing's diagnosis, and the ultrasound can also reveal helpful info about Phebe's other internal organs. And it can reveal whether there may be some other organ abnormality or problem going on, unrelated to Cushing's.

I know that an ultrasound is not cheap, but the information may help guide further decisions on your part. I hope other folks will also stop by and offer their own thoughts or suggestions which may be totally different from mine. But I do think that an ultrasound might be the place where I would start.

Marianne

[Squirt's Mom]

Hi,

Good to hear from you again! :)

Marianne has done a great job of explaining the difficulties and options in Cushing's testing in Phebe's case. My own Squirt tested positive on five different Cushing's tests but a tumor was also found on her spleen. When it was removed, her cortisol returned to normal. Squirt is a prime example of a non-adrenal illness causing false positives. ;)

She is also a prime example of the value of an abdominal ultrasound. If she hadn't had this test that tumor would have ruptured, more than likely taking her life. The U/S is the one test I think every pup should have when there is reason to think something serious is going on and especially when answers aren't clear cut. ;)

Something I did find about the PPA -

http://www.dogaware.com/articles/wdjincontinence.html#treatment


Most dogs tolerate PPA without any problems, but side effects can include irritability, nervousness, panting, restlessness, rapid heartbeat, and excitability. PPA should not be given to dogs with high blood pressure or heart disease.

It's possible the trembling jaw and anxiety could be due to the PPA. If her BP hasn't been checked, this might also be something to look into.

So, agreeing with Marianne, I would seek an U/S for sure, probably have the BP checked at the same time, and talk to her vet about the possible side effects of the PPA before putting her through any more labs right now. ;)

Keep in touch and let us know how things are going!

Hugs,
Leslie and the gang

[Lisamarie]

Thank you all for feedback. I'm sorry I had to change my account to a different username (a year away does seem to dim the memory a bit).

We've already cut Phebe's PPA pills in half earlier this summer; she doesn't seem quite as restless as she had before that change. Her anxiety (the trembling jaw) started prior to being put on PPA. It's something her doctors can not explain. I've looked all over the Internet to try to find some cause for it but haven't been successful.

I have very mixed feelings about subjecting Phebe to additional vet visits. Her anxiety has increased so much in the past year, I really have to weigh the consequences. We'd have to travel quite a distance to find a vet able to give her an ultrasound.

I do appreciate, very much, all of your feedback and ideas. It's given me a lot to think about in the upcoming weeks.

[Sophie]

Is it possible the jaw trembling and trouble getting up could be neurological symptoms due to the hypothyroidism?

One of my previous dogs Zane, the sweetest border collie in the world, had hypothyroidism. He was a rescue I adopted as a senior and his hypothyroidism hadn't been treated for way too long. It was the worst case of hypothyroidism my vet had ever seen. He had lost a lot of function in his back legs, which was neurological based on the way he would drag his back paws and criss-cross them when he walked. He also had a very difficult time getting up.

Neurological issues are symptom of the hypothyroidism. Here is a quote from The Mayo clinic website...

"Peripheral neuropathy is damage to your peripheral nerves — the nerves that carry information between your brain and spinal cord and the rest of your body, such as your arms and legs. Peripheral neuropathy may be caused by severe, long-term, untreated hypothyroidism. Although the association between hypothyroidism and peripheral neuropathy isn't fully understood, it's known that hypothyroidism can cause fluid retention resulting in swollen tissues that exert pressure on peripheral nerves."

[Lisamarie]

Phebe just started her thyroid medicine last year a little before the initial Cushings false positive. Maybe she has had long-term thyroid problems. She's certainly having difficulties getting up (and appears to have issues with one of her back legs in particular).

Thank you for responding. She's the sweetest dog we've ever had in the family, and I hate that her health is continuing to deterioriate.