Roxy needs help!

[Roxy]

Hi Everybody - I'm new to this forum but I've read enough of them to know you want lots of info so I'll be as thorough as possible. Roxy is a 10 year old 85 lb boxer-bull mastiff mix. She starting eating, drinking like crazy, panting, having accidents in the house.

10/21 I took her to the vet and she thought she may have Cushings.

10/26 Lab work was sent to MSU and then the ACTH was done after a prelim diagnosis. She was diagnosed w/cushings

11/7 We did the loading dose, she never seemed to slow down her eating but I had a gut feeling that she was loaded after 6 days so I, along w/vet stopped lysodren.

11/15 She had another ACTH test done. Her cortisol levels dropped from 28 to 0.5. The doc sent her home that day and she started vomiting and got very lethargic later that night. I called vet and they had me start the pred. (2 5mg tablets). The vet thought that the stress from the day at the vet (Roxy hates going to the vet) pushed her into an Addison's crisis. So we did 2 tablets for a few days then slowly weaned her down.

12/6 When we went to start the lysodren again she did not take it well. She again got lethartic. So we did the pred again (1 tab per day) then every other day but she never seemed to get her appetite or energy back.

12/13 We did another ACTH test to see what was going on and her cortisol level was 2.8. We're supposed to start lysodren 12/21 but didn't

12/18 We were gone over the weekend and the vet's tech stayed at our house, Roxy had another bad episode when she got very lethartic. Tech called vet 2 pred were given.

12/20 Electrolytes tested Na - 142 mmol/L K 4.7 mmol/L. Percorten given.

Bottom line she is acting more Addison's but #'s don't sustantiate.

Thanks for your help!

[labblab]

Hello and welcome to you and Roxy. I am so sorry about Roxy's problems, but so glad you have joined us. I only have a moment for a quick note, but I totally agree that you should NOT start back with giving any Lysodren at this time!! I'll return later on, and I know that other members will soon be by to write more, too.

Also, I just wanted you to know that I've removed the duplicate thread that was posted on our "How to" forum. You've found exactly the right place to start your thread here on the "Questions" forum ;). This way, we can consolidate all your questions and all future replies here in one spot.

Once again, welcome to you and your baby girl.
Marianne

[Roxy]

By the way, she has pituitary dependent Cushings.

[Squirt's Mom]

Hi and welcome to you and Roxy! :)

Please, do not give any more Lyso for now.

Ok...Roxy is 85 lbs; what was the dose of Lyso (in mg) she was prescribed and how often was she to take it?

Can you get the actual results of all her testing and post them here along with units of measurement (ug/dl, nmol/L, etc) and the normal ranges for that lab? This will help us see what the vets used to originally diagnose her as cushiniod.

Was diabetes (both forms) ruled out? Were thyroid problems ruled out?

Did she have an abdominal ultrasound? If so, what were the result?

Does she have any other health issues that you are aware of? On any other meds, supplements or herbs currently?

Were her liver and kidney values alright on the CBC (blood panel)?

Hang in there! We will question you to pieces for a bit at first but that is so we can get a clearer picture and be able to offer more meaningful feedback. So don't worry about a long post - we love details! ;)

Again, please hold up on the Lyso for now and keep using the Pred as needed.

Hugs,
Leslie and the girls - always

[Roxy]

I have her med. records but her not her bloodwork results except urinalysis from MSU - urine cortisol 351. Urine creatinine 4.6. Urine cortisol/creatinine ration 76H (8-24).

We have no plans to start lysodren at this point. Her loading dose was 2 pills twice a day 500 mg each. Her maintenance dose was supposed to be 1 500 mg pill Monday and Thursday. Currently, she is on 2 (5mg) Pred tablets daily, until the end of the week, then we will reevaluate.

As for her electrolyte check yesterday. The normal range of Na is 142-150. The normal range of K is 3.4-4.9. Roxy was at the extreme normal end of each in opposite directions. These numbers may have been influenced by the pred.

She was ruled out as diabetic, I'm not sure about her thyroid. However, her bloodwork came out as pituitary dependent cushings, plus she had all the symptoms of a cushings dog except her coat wasn't affected.

She has no other health issues at this point. About a year ago, she had a soft tissue spindle cell sarcoma on her leg that was removed fully about a year ago.

No u/s was done. As far as I know, her liver and kidneys are fine.

[jrepac]

How is Roxy doing now that she is off the lyso and taking the pred daily? Is she coming around? I do hope she is doing better; I've been in your shoes and it is not fun.

It may be that she cannot tolerate the lysodren (or just responds badly). However, you may want to rule out possible misdiagnosis of Cushings....which is also possible. But from the numbers you posted, it seems like Cushings. This is just a very hard disease to diagnose and pups respond differently to the various treatments.

Maybe Roxy will respond better to trilostane? Has your vet mentioned that drug to you?

Jeff & Angel Mandy.

[Roxy]

She also had the high and low dexamethasone test but I can't tell based on these med. records what the numbers are??? I don't think they were included in my records but I may be wrong.

[Squirt's Mom]

Hi again,

Cushing's is one of, if not THE, most difficult disease to diagnose in dogs. There are many other conditions that mimic Cushing's, sharing the same signs, like diabetes (DM and DI), hypothyroidism, liver disease, kidney disease to name a few. In addition, cortisol is released naturally in the body anytime stress is present, internal or external. So it is possible to get false-positives and false-negatives on the Cushing's tests. For these reasons, it is very important to rule out all other possibilities when considering Cushing's. Point in case -

My Squirt was diagnosed as PDH via five Cushing's tests - LDDS, HDDS, ACTH, ultrasound and UTK panel. All positive for PDH. BUT a splenic tumor was found on an ultrasound and once it was removed, her cortisol returned to normal. Her cortisol had been elevated due to the tumor and caused false-positives on ALL her tests.

We have also seen, many times unfortunately, vets who don't know beans about Cushing's which is why we ask for test results. Too many times we have heard, "The results were normal" only to find when we saw the actual results they were far from normal and explained the problems the pup was experiencing. On the flip side, we have seen pups diagnosed as having Cushing's and start treatment only to have adverse reactions to it then when we see the test results, they don't support the diagnosis of Cushing's again explaining the pups problems with treatment.


Urine creatinine 4.6. Urine cortisol/creatinine ration 76H (8-24)

This is alarming to me. Typically, normal creatinine range is 0.4-1.4. Is this the normal range given on your results from the lab? Based on a range of 0.4-1.4, at 4.6 Roxy's is very high and could indicate kidney problems. Did you vet mention anything to you about this value? The ratio can be high due to the BUN but the BUN can be affected by many things and controlled to a great degree. A high creatinine value, however, can mean kidney damage. Double check the normal ranges for the creatinine value and if Roxy's is that high, you might want to discuss this with your vet asap.

I highly recommend an abdominal ultrasound. Not only as a diagnostic tool for the Cushing's but to get a look at her other organs as well. As one of our members says, this test is the biggest bang for your buck because it provides so much info. ;)

Hugs,
Leslie and the girls - always

[Roxy]

The vet suggested that if Roxy doesn't respond well to the injection yesterday, we may need to see a vet specialist. She seemed to perk up last night and seems to be doing better today but she spit out her pred. this morning which I found later so I hope we got the full dose in her! She must have got it hidden in her jowls! STINKER!!!

At this point we aren't sure what she has...addison's/cushings?? Her numbers just aren't adding up w/her behavior!

I would be shocked if her cushings diagnosis was wrong, she seemed to have a textbook case of it. I did some reading up when it was a possibility and when the bloodwork confirmed it I wasn't surprised at all. I'm not sure what to do at this point.

[Roxy]

Isn't a high creatinine level an indication of cushings?? I'll ask my vet about her kidneys.

[Roxy]

Her last urinalysis

appear - clear
color - light yellow
odor - strong
sp gravity - 1.020
glucose - neg
bilirubin - neg
ketones - neg
blood - neg
ph - 5
protein - neg
urob - normal
nitrite - neg
leukocytes - neg
wbc - none
rbc - none
epi cell - occas.
bacteria - 3-4+
casts - none
crystals - none

[lulusmom]

Hi and welcome to you and Roxy.

As Leslie warned already, we do ask a lot of questions initially and I have a few of my own as well as a comment or two. Please see text in blue below:




11/7 We did the loading dose, she never seemed to slow down her eating but I had a gut feeling that she was loaded after 6 days so I, along w/vet stopped lysodren.

Was Roxy's last full loading dose given on 11/12?


11/15 She had another ACTH test done. Her cortisol levels dropped from 28 to 0.5. The doc sent her home that day and she started vomiting and got very lethargic later that night. I called vet and they had me start the pred. (2 5mg tablets). The vet thought that the stress from the day at the vet (Roxy hates going to the vet) pushed her into an Addison's crisis. So we did 2 tablets for a few days then slowly weaned her down.

Depending on the timing of the acth stim test after the last dose, Roxy could have been even lower than .5 before or after the acth stim test. With a post number that low, it wouldn't take much stress to exhaust what little cortisol reserve Roxy had.

12/6 When we went to start the lysodren again she did not take it well. She again got lethartic. So we did the pred again (1 tab per day) then every other day but she never seemed to get her appetite or energy back.

Did your vet do another stim test to determine if Roxy's cortisol levels had come up enough to start treatment again? Had Roxy's appetite returned to normal at this point? Had any of the other symptoms returned?


12/13 We did another ACTH test to see what was going on and her cortisol level was 2.8. We're supposed to start lysodren 12/21 but didn't

Had Roxy had her full maintenance dose and when was the last dose given before this acth stim test?

12/18 We were gone over the weekend and the vet's tech stayed at our house, Roxy had another bad episode when she got very lethartic. Tech called vet 2 pred were given.

Does Roxy readily respond to the prednisone with increase in appetite and activity?

12/20 Electrolytes tested Na - 142 mmol/L K 4.7 mmol/L. Percorten
given.

Bottom line she is acting more Addison's but #'s don't sustantiate.

I don't want to alarm you but I want you to be aware of all the possible causes of the symptoms you are seeing in Roxy. It could very well be that she doesn't do well with cortisol this low but there is also another possibility. Boxers are a brachycephalic (short nosed) breed and these dogs are more likely to have large pituitary tumors. Growth of these tumors can be excelerated with lysodren treatment. While Roxy's timing doesn't necessarily fit the norm, her symptoms do. Initial symptoms of an expanding macrotumor are much the same as those found in addison's such as inappettance and lethargy. Neurological signs will become apparent as the tumor expands. You may want to discuss this possibility with your vet.

You mentioned in a later post that you are pretty certain that Roxy was diagnosed correctly. I would agree with that. Dogs that are misdiagnosed and have normal adrenal glands are very resistant to lysodren. Roxy was certainly not resistant.

http://www.veterinarypartner.com/Content.plx?P=A&A=638&S=1&SourceID=42

http://avmajournals.avma.org/doi/abs/10.2460/ajvr.67.8.1385
Thanks for your help!

[Roxy]

I don't know how to respond in your text but here are the answers to your questions. Thanks for reading!

Her last loading dose was on 11/12. ACTH test was on the 15th. She has not had lysodren since because she keep having lethargic episodes/ decrease appetite. We did do an ACTH on the 13th to see what was going on. Her cortisol level was 2.8. We were going to start lysodren on Monday but she had a bad weekend so it has been suspended indefinitely.

I have considered the possibility that she has an undiagnosed tumor somewhere because she is a boxer and I have lost 2 boxers to cancer. I'll ask the vet about a pituitary tumor when I talk to her on Thursday. I wasn't aware that lysodren can have that effect. Thanks for the info!

She responds well to the pred. usually within 30 minutes to an hour she is more active and eating. Maybe not 100% but greatly improved.

I think I answered all your responses.....

[lulusmom]

Thanks for the rapid responses. Just a few more questions.

When you restarted the lysodren on 12/6 was her appetite and activity levels normal again? How long had she been off of prednisone before restarting the lysodren?

How long had Roxy been off the prednisone when she had the acth stim test on Dec 13th?

With respect to the creatinine level, please don't panic about the possibility that Roxy may have renal issues. The results you posted are a "urine" creatinine level and urine creatinine levels are not used to check kidney function. Blood chemistry is done to check creatinine and BUN levels for kidney function.

[Roxy]

I gave her 1 pill on 12/6 & almost immediately followed up with the pred because she got lethargic very quickly. She seemed tired on the Sunday before but otherwise was acting good. I can't remember exactly when her last pred was before the 6th but I would guess only a couple of days.

We went back to 1 pred tab every other day so she had a pred on Saturday before her ACTH test on Monday but I did not give it to her Monday morning.

[Roxy]

Does anybody know if boxers in general are more likely to over-react to lysodren? I did an internet search and it seems that every case I could find an over-reaction was in a boxer or boxer mix. Also, how long are most dogs on prednisone after an addison episode if they are to recover from addison's and go back to cushings?

Thanks again for everyone's help. It's great to have a place to go to as I try to figure out what is best for Roxy. I love her so much and don't want her to suffer but I want her around as long as possible!!

[jasonhbaum]

Hello. My 8-year old boxer, Sophia, was recently diagnosed with Cushings. We have her on Vetoryl (trilostane) and she has been responding very well. Sophia is on sotalol for her heart. This summer we noticed she was very lethargic, drinking alot, urinating in the bed, wasnt her cuddly self and very rapid breathing at night. We initially thought maybe it was congestive heart failure. After the testing she was diagnosed with pituitary Cushings. She has been on 30mg Vetoryl 2x a day since end of October. She has made a complete turn around. She is playing with our other boxer again. She is back to being a lapdog. Maybe a change in the meds will work for you. The only thing we experienced was a few days of diarrhea when she started the Vetoryl. Vet gave her something for that and she was fine. I have a post on here about Sophia where I posted all of her test results if you want to compare the numbers. Hope everything works out for you. Jason

http://www.k9cushings.com/forum/showthread.php?t=2547

[Roxy]

Thanks Jason. If we ever get back to the point of needing cushings med., I'll ask about trilostane. The Dr had mentioned it as a possibility but recommended the lysodren based on cost and track record.

Anyway, Roxy is doing much better since yesterday afternoon. She actually is a little frisky!!:D She even has ate a little, however, part of what she ate was a steak. Apparently, I've created a food snob!!

[ChristyA]

My Boxer boy was very reactive to lysodren. It seemed like what was to be a small change in another dog was a big change in him. You may want to find an IM specialist in your area that has experience with Trilostane for future reference.
Take Care,
Christy

[Squirt's Mom]

Post deleted.....

[spiritdog6]

Squirtsmom, that is not necessarily so. Dr. B has stated 2-3 weeks can be sufficient when switching. A few other vet papers here on the board say the same thing, 2-3 weeks. And Vetoryl vets told me, 30 days OR a post stim of >9.1

[Squirt's Mom]

Post deleted.......

[Harley PoMMom]

Squirtsmom, that is not necessarily so. Dr. B has stated 2-3 weeks can be sufficient when switching. A few other vet papers here on the board say the same thing, 2-3 weeks. And Vetoryl vets told me, 30 days OR a post stim of >9.1


Editor's Note: Edward C. Feldman, DVM, Dipl. ACVIM, is the chair of the Department of Medicine and Epidemiology at the University of California-Davis School of Veterinary Medicine. He is a co-founder and former president of the Society of Comparative Endocrinology, a special interest group open to all veterinarians, and is a co-author of the Textbook of Veterinary Internal Medicine with Dr. Stephen Ettinger and Canine and Feline Endocrinology and Reproduction with Dr. Richard Nelson


Feldman: Trilostane is my first choice in dogs with an adrenal tumor. My first choice for dogs with pituitary-dependent hyperadrenocorticism is mitotane. However, trilostane at an initial dose of 0.5 mg/kg given twice daily is an excellent second choice. No veterinarian should consider the use of trilostane before thoroughly reading the insert provided with the drug — not the insert for pet owners, the insert for veterinarians. Any dog switched from one to the other should receive no medication for at least six weeks.

http://veterinarynews.dvm360.com/dvm/article/articleDetail.jsp?id=672663&sk=&date=&&pageID=1

Lori

[spiritdog6]

I was incorrect........here is what Dr. Tim Allen from Vetoryl wrote in my email.....note the OR"Specifically, when transitioning from Lysodren
to Vetoryl we normally recommend waiting 30 days or having a post-ACTH
cortisol concentration > 12 mcg/dl before starting Vetoryl."

I was incorrect at >9.1.....it is >12.........

And in the video of Dr. B.........he said 2-3 weeks............

[spiritdog6]

http://veterinarymedicine.dvm360.com/vetmed/Medicine/Trilostane-dosing-and-monitoring-recommendations-4/ArticleStandard/Article/detail/567360

[lulusmom]

Thanks for answering my questions and I apologize for the delay in acknowledging them. I am relieved to hear that Roxy did not have any prednisone for more than 24 hours before her last stim test. My concern was that perhaps the post stim of 2.8 ug/dl could have been a lot less if the prednisone had not cleared Roxy's system. How is Roxy doing today?

I see there has been some discussion regarding appropriate washout periods when switching from Lysodren to Trilostane and vice versa. You may have already figured out through your own research that nothing about cushing's is predictable and one size definitely does not fit all. This also applies to washout periods as evidenced by the fact that even the most experienced specialists in endocrinology like Dr. David Bruyette and Dr. Edward Feldman don't follow the same timelines. I do believe, however, that these timelines are not set in stone for either one of these specialists, as symptoms are just as important in determining an appropriate washout period as they are in making a diagnosis. Sensitivity and the length of time on the drug that is being discontinued are also big factors.

Trilostane and Lysodren are not prescribed to treat a pituitary or adrenal tumor, they are prescribed to treat the troublesome symptoms of the disease. This is why when I switched my dogs from Lysodren to Trilostane we did not start the Trilostane until both were symptomatic again. My dogs' sensitivity to the drug, as well as the rate at which their adrenals regenerated are totally different. Jojo loaded faster and became symptomatic much sooner than Lulu after discontinuing the Lysodren. As I recall, he became symptomatic well before 30 days and well before stimulated cortisol reached 20 ug/dl. Lulu, however, did not become symptomatic again until her post stim was well over 20 ug/dl and that took three months. There is no doubt in my mind that had I followed Dr. Allen's or Dr. Bruyette's guidelines instead of those set by Lulu's specialist (based on cortisol levels and symptoms), Lulu would have been in very serious trouble rather quickly. In my opinion the criteria for when to start treatment after a washout period is the same as starting treatment after diagnosis. No symptoms, no treatment.

[spiritdog6]

Side never lost symptoms on Lyso, but that IMS wanted to put him on a maintenance dosage, so I fired that IMS. My new IMS continued Lyso treatment(loading) for another week, guess what? The symptoms stayed and the numbers went up! Switching to Trilo just11 days later, was the ONLY relief we have had in 7 months... we are close to having the correct dosage, I am quoting my IMS after an ultrasound of Side "Lyso NEVER would have worked on this dog".

Dr. Tim Allen stated in my email "Specifically, when transitioning from Lysodren
to Vetoryl we normally recommend waiting 30 days or having a post-ACTH
cortisol concentration > 12 mcg/dl before starting Vetoryl." So he has a different approach/different numbers that he goes by as well. So had I waited 30 days (washout), or waited for his number to be >20, it just would have prolonged our suffering. Each dog is different, and it is up to the owner to know their dog, and know the symptoms.

[lulusmom]

The symptoms stayed and the numbers went up! Switching to Trilo just11 days later, was the ONLY relief we have had in 7 months... we are close to having the correct dosage, I am quoting my IMS after an ultrasound of Side "Lyso NEVER would have worked on this dog".


Can you tell us what your IMS saw on the ultrasound imaging that indicated to him that Lysodren never would have worked for Side?

Sorry for sort of hijacking Roxy's thread but sharing our experiences and asking questions is how we learn. It's all good.

Glynda

[Roxy]

Roxy is taking 1 pred everyday indefinitely. We are going back to the vet in a week to recheck her electrolytes. She is acting much more normal this week - eating, more energetic. I have a feeling her
"cushing" symptoms may return so I will discuss with the vet trying something other than lysodren. I have a feeling that boxers in general are more susceptible to lysodren based on various searches that I've done. We still aren't sure if she is permanently Addison's but I don't think she is. Based on her electrolytes next week and my conversation with the Dr, I may get a second opinion from a specialist that my vet offered for me. Thanks for all the info and concern. It has helped!

[Squirt's Mom]

I am glad to hear that Roxy is acting and feeling better! I hope she isn't Addison's for good but it can be handled just as Cushing's can be....with education, attentiveness and, most importantly, TLC. ;)

Let us know what the doc says next week about the 'lytes!

Hugs,
Leslie and the girls - always