My Zoe has Pituitary Cushings- Zoe has crossed The Bridge

[Lee Ann]

Zoe is my 12 year old Border Collie/Aussie mix. We rescued each other from the animal shelter 6 years ago. Zoe had heartworms, etc and had only seen the vet one time in her life. Treated her for everything at adoption time. Her only health issue has been incontinence which is now controlled with DES 1mg., once a week. I live in Western Ky and the vet care is very basic and costly. It has been a frustrating year due to the symptoms Zoe has been showing, excessive water drinking of almost 7 quarts a day, heavy panting, hair loss on hind area, cataracts worsening, extreme hunger, Chronic UTI's, along with a huffing-gag cough that is becoming more labored. During the last month, I insisted on checking her heart and lungs. My vet finally agreed to do an EKG, chest Xray and send the results to a specialist. Yes, she has fluid in her lungs and is going into Congestive Heart failure, (CHF). For this health issue she takes the following:
Furosemide 20mg BID (twice a day)
Benazepril 10 QD (once a day)
Theo-Dur 200 mg BID
I added 12,000 mg Cranberry capsule
A few weeks later, I wrote down all the other symptoms and insisted my vet do a low dose dex test to see if it was possible that cushings was to blame for these other symptoms. The test was done and results were read by Michigan State DCPAH diagnostic. The results supported the pituitery dependent cushings. The results are as follows;
cortisol baseline - 110 Reference range 15-110
cortisol low dose dex 4 hr- 48 (high) Ref 0-30
cortisol low dose dex 8 hr- 108 (high)Ref 0-30
Her blood work levels that are high are as follows:
ALKP was 241
Chol was 412
HCT 57%
HGB 18.8 g/dl
Grans 12.5
% grans =86%
neut- normal
EOS- high at 3.0
All other blood tests were within normal range.
Zoe coughing was improving after the vet added the Lasix (furosemide) to her meds.
Now, she is faced with Cushings. I researched everything I could get my hands on about new treatments. I found this Vetoryl and felt it would be a good fit for Zoe. I found the best price online at the Drs Foster and SMith pharmacy. It was $70 for 30 tablets of 60mg. My vet wanted almost twice that. I ordered 2 boxes and made a gameplan for Zoe's treatment, but the Vetoryl package insert says Ace inhibitors and Lasix can be a dangerous combo. So, after reading the Univ. of Ca article about their clinical trial, I decided to simply start with ONE 60 mg Vetoryl ( that is 1/2 the recommended dose for her weight of 57 pounds) and stop the Lasix (furosemide) It has been 10 days and she is tolerating the meds well but her coughing is worse. She sleeps alot. No other neg. side effects with vetoryl. I also have added melatonine 5mg, twice a day. A friend in Florida's vet told me to try this.
In 2 weeks I have scheduled an electrolyte test and the ACTH tests. Together these tests will be around $200+ so I am not going to be able to get these done per the guidelines, but maybe every 3 months.
Currently, I am fostering a border collie/german shep mix and Zoe still wants to walk everyday with 9 month old Ruby, who has been pretty good to my old girl. I work with 2 rescue groups in the area, so I have a good relationship with my vet, but I get frustrated at the lack of continuing education about new treatment options of different disease states. I am going to take a risk and start giving Zoe 1/2 of the Lasix dose in the evening. I am afraid her CHD will kill her before the Cushings if I don't get the fluid under control in her lungs.
The Univ of Tn Vet center is about 5 hours from here so trying to take her there for regular treatments is not feasible. If anyone has any info on cost effect ongoing testing, I am open, ANY ideas of better treatment options, throw them out there. I just want Zoe to be comfortable and happy for as long as she has left. She has been a remarkable, loyal friend and I don't want her to spend her final years being poked, prodded, and miserable, she deserves better.
Thank you for letting me vent.

[apollo6]

Dear Lee Ann
First welcome. Others will come along and ask you questions.
I am attaching a brief link on cushing, there are three types of cushings.
http://www.acvim.org/websites/acvim/index.php?p=228
read about the symptoms , test to take.
Realize you have some time to decide on which treatment option to take.

The basic tests are usually a full blood panel, a urinalysis, a ACHT stim TEST and an abdominal ultrasound( this would show if it is adrenal gland base) I will not overload you with a lot of info right now. Before you even start TRilostane, you have some other issues to be addressed with Zoe. The coughing should be addressed.
We will ask you to post the full blood panel records showing the range beside each one. Also how much does Zoe weigh this is very important as to starting dosage. IF it is too high it could be bad.

a link with internal specialist in Ky
http://www.acvim.org/websites/acvim/index.php?p=228
all you have to do is click on their name to find info.
Hugs Sonja and Apollo

[StarDeb55]

Lee Ann, before any of us can give you any good feedback on the labs you have posted, I'm going to have to ask that you edit your post to include the normal ranges for those tests along with the reporting units. We ask for these values also as they can vary from lab to lab. Reporting units are important as most of us in the US are used to seeing cortisol results in mg/dl, Zoe's results look like they might nmol/l.

Debbie

[Lee Ann]

Had to get my magnifying glass out to read these values :)
Results of the Low Dex test- read by Michigan State Endocrinology Dept.
Procedure Reference Range Units
Cortisol Baseline 110 (15-110) nmol/L
Cort Low dose dex 4hr 48 (0-30) " High
Cort Low dose dex 8hr 108 (0-30) nmol/L High

Interpretation:
There is escape from suppression of cortisol concentration by 8 hours after admin. of a low dose of dexamethasone. These results support the presence of pituitery dependent hyperadrenocortisism, provided clinical signs are consistent. However, there is recognition of false positive results on adrenal funtion tests due to a stress response to non-adrenal illness.

This is what the test results paper reads in the above statements.
Blood tests done 3 weeks earlier were as follows:
Test = Results Reference range
ALB 2.9 g/dl 2.2-3.9
ALKP 241 U/L 23-212
ALT 28 U/L 10-100
AMYL 639 500-1500
BUN 16 mg/dl 7-27
Ca 10.8 7.9-12.0
CHOL 412 mg/dl 110-320
CREA 1.0 mg/dl 0.5-1.8
GLOB 4.2 g/dl 2.5-4.5
GLU 85 mg/dl 70-143
PHOS 5.3 mg/dl 2.5-6.8
TBIL 0.5 mg/dl 0.0-0.9
TP 7.0 g/dl 5.2-8.2
HCT 57.0% 37.0-55.0
HGB 18.8 g/dl 12.0-18.0
MCHC 33.0 g/dl 30.0-36.9
WBC 14.6 x10(9)/L 6.0-16.9
GRANS 12.5 x10(9)L 3.3-12.0
%GRANS 86%
Neut 9.5 x10(9)L 2.8-10.5
EOS 3.0 x10(9)L 0.5-1.5
L/M 2.1 x10(9)L 1.1-6.3
%L/M 14%
PLT 431 x10(9) 175-500
Retics 0.2%

Then below this info is a graph that says Buffy Coat profile.

T4 reads 1.2 ug/dL
reference range for this value was
borderline low = 0.8-1.5 ug/dL

Regarding the cough-
Xrays were taken of her chest and heart which shows a slightly enlarged heart and fluid in one of her lungs.
EGK was done, results indicate irregular heartbeat and signs of CHD.
At the time the above test was done(EKG) the following meds were prescribed
cephalexin 500 bid
theo-dur 200 bid
benazepril 10mg QD
Royal Canin precription diet C/D

Zoe had her teeth cleaned last week and Vet said she could still hear fluid in her right lung.
I put all her current drug therapies in the previous posts.
I keep her with me 24/7, so I watch her carefully. She is 12 yrs old and weighs 57 pounds.
Please understand, I am not a wealthy person, but I cut corners in my own life to help Zoe. Just her meds cost over $200 a month so it is all I can do to keep her healthy. I am actually going to ask my personal MD to write me Rx's for the theo-dur, benazapril and lasix because I can get them filled at Walmart for $4 each, which is a HUGE savings over what my vet charges.
I have suggested several times this past year to my vet that I felt Zoe might have either a heart problem or cushings. She of course, thought I was over-reacting. Now I feel horrible that I have let Zoe down and possibly could have avoided some of this. I actually took her to a different vet because of the chronic UTI's she was having last fall. My current vet put her on the Royal canin Bladder food and every 2 weeks after coming off the antibiotic, the UTI would be back. Out of frustration, went to a different vet, who did an ultrasound to rule out bladder stones or something and then told me the skin folds around her pee-pee were covering it up, causing bacteria to grow quickly. He did a laser procedure to remove the "overage". It helped a little bit.
I am considering just simply taking her off everything and let nature takes its course. She is a great companion and she is the most loyal dog I've owned. I do not want her to suffer.

[labblab]

Hi Lee Ann,

I am not a vet, but from my layperson's perspective I would think that right now, the congestive heart failure is the most pressing issue for Zoe. Even though her Cushing's symptoms do affect quality of life for both of you, the CHF has the potential to be more imminently life-threatening. Since there is such a definite contraindication between her cardio-pulmonary meds and the trilostane, in honesty, I would discontinue the trilostane right now and proceed with full dosing of the heart meds in the effort to resolve the fluid overload in her lungs. I would think that the diuretic effect of the Lasix would be especially important for reducing the fluid build-up. I know some people who suffer from CHF, and not only is the condition such a serious health issue, but it also feels very uncomfortable and very frightening --they've decribed it to me as feeling as though they are drowning when they try to breathe :( :(. So in terms of Zoe's own comfort level alone, I would guess that the CHF is much more of an immediate quality of life issue for her right now than is the Cushing's.

If you do opt to continue trilostane treatment or to resume it in the future, you may want to start back at even a lower dose. You are correct that Dechra's published dosing chart indicates a beginning dose of 120 mg. for a dog of Zoe's weight. But from recent direct conversations with their U.S. technical representatives, we now know that they are verbally recommending that dogs be started at no more than 1 mg. per pound. That does correspond with the 60 mg. that you are currently giving Zoe. But the veterinary clinicians at UC Davis recommend starting at no more than 1 mg. per kilogram -- which for Zoe, would translate into 30 mg. daily. Given the risks of negative drug interactions and your concern about ongoing monitoring, I would think that starting at a lower dose would be prudent. Of course, the dilemma for you is that you already have a lot of 60 mg. units on hand. Are they tablets or capsules? If they are tablets, perhaps you can cut them. Unfortunately, capsules should not be opened or split. But perhaps you could find a compounding pharmacy near you that would be willing to "repackage" your capsules into smaller doses.

Last but not least, if and when you do decide to continue with the trilostane, here is a link to an article published last fall in the Journal of the Veterinary Medical Association that discusses a novel trilostane monitoring option involving measurement of baseline cortisol only. This approach is largely experimental, and I have not heard of any vets beyond the article's author (Dr. Audrey Cook) who are using this technique. But as you will see, depending upon the results of the dog's baseline cortisol, the author believes it may be possible to make certain monitoring decisions in the absence of ACTH stimulation. Your vet might want to contact Dr. Cook directly for additional guidance regarding this approach. I do believe that frequent electrolyte checks would also be critical for Zoe due to the risks of the drug interactions. Here's the article link:

http://avmajournals.avma.org/doi/abs/10.2460/javma.237.7.801

Marianne

[Lee Ann]

Marianne,
I cannot thank you enough for this information!!! I have already made a copy of the clinical trial info from the avmajournals and have emailed a copy of it to my vet. My thought process has been on overload and my panic mode is in high gear, so it is time for me to calm down and get a game plan. You just helped me do that. I am headed to the vet shortly to schedule a meeting about Zoe's treatment plan. The heart problem is obvious, you are right, and my vet actually said the same thing. I am stopping the vetoryl today, will give me time to re-order the 30 mg. The frustrating part of all this is that Zoe is responding to the vetoryl, no horrendous water consumption, not ravenous about food, and her hair was actually starting to grow back in places. But her leg weakness is worse. She still insists on walking everyday, I just go a shorter distance, but she is a bit wobbly after gets up from laying down. Wish me luck! I am taking your advice :) Hopefully my vet will appreciate the articles and not take offense, she truly is a lovely woman.

[Lee Ann]

Marianne,
You advice was spot on!!! My vet actually read your email and looked up the article you sent, wow, she agreed totally and that opened up a real line of communication. We are going with the lasix, ace, and bronchodilator for 2 weeks. No vetoryl right now. Going to check her blood work,vitals, etc. at that time. If she can get the heart situation under control, then we are going to try the 30mg vetoryl QD, monitor her baseline cortisol levels periodically and see how it all works together. I am also giving her 6mg melatonin BID plus her cranberry extract for UTI's. As a bonus, there actually is a compounding pharmacy about 45 miles from me so I am going to check and see if they can repackage my 60mg's into 30's. You have been a blessing. God answers prayers and I am so glad I found this site and YOU!!!! I'll know more in 2 weeks :)
Thank you again, Lee Ann and Zoe

[labblab]

Hi Lee Ann,

I'm really glad if I have been able to help! And I think it's really encouraging that Zoe has responded positively to the trilostane up to this point in time. Hopefully you'll soon be able to get an upper hand on the congestive heart issues and resume the trilostane dosing -- all to Zoe's benefit.

Also, I've done a bit more reading myself, and have learned that Lasix (furosemide) actually may not fall in the category of diuretics that are contraindicated in conjunction with trilostane. Per the U.S. Product Insert for Vetoryl, the potassium-sparing diuretics are identified as being the specific problem, and Lasix instead falls into the classification of being a "loop" diuretic.


Potassium sparing diuretics (e.g. spironolactone) should not be used with VETORYL Capsules, as both drugs have the potential to inhibit aldosterone, increasing the likelihood of hyperkalemia.

This may be another issue to talk over with your vet. Because if there is not an interaction issue between the two drugs, your vet may feel as though there is less of a necessity to wait very long to reintroduce the trilostane, especially at a reduced dosage. I know that Zoe is also taking benazepril, which is an ACE inhibitor and per the Product Insert, should be used with caution alongside trilostane. But there is not an outright prohibition against the combination of the two types of drugs.


Angiotensin-converting enzyme (ACE) inhibitors should be used with caution with VETORYL Capsules, as both drugs have aldosterone-lowering effects which may be additive, impairing the patient’s ability to maintain normal electrolytes, blood volume and renal perfusion.

We do have another member here whose dog has recently experienced kidney problems with this drug combination (I believe her dog had pre-existing kidney issues), but we also have had other members who have done OK with the combination as long as their dogs' electrolytes were closely monitored, and especially at lower doses of both drugs.

And just in case you have not already seen the Product Insert in its entirety, here it is:

http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf

Definitely do keep us updated as to Zoe's progress. And if your vet does decide to contact Dr. Cook, we'll also be really interested to hear any additional elaboration regarding Dr. Cook's article. This has the potential to be a learning experience for us all!

Marianne

[Lee Ann]

Marianne,
In just a few days, adding back the full dose of Lasix has made improvements in Zoe's labored breathing. Dr. Jackson asked me if you were a vet, and I said no, but that obviously you were on top of any and all info regarding Cushings. Being that many vets only use Anipril or simply don't treat for cushings due to costs, the community needs more individuals like you to cut thru the "bull" and get to the "bones" of treatment. Animal pharma is much like human pharma, new drugs like Vetoryl are not utilized quickly due to the adverse events that sometimes don't show up until after the drug launch. Many Vets, and MD's , will wait until the drug has been out for a few years before they go with the new treatments. Being a retired Pharm rep, I understand. Went thru several recalls in my day. I forwarded your info to my vet, esp. the GREAT info about the lasix!! Wow, that gives me even more renewed hope!! And yes, Dr. Jackson called the cortisol testing company and there is a reduced cost for the "baseline" cortisol test. It is still $95.00, but better than $180. We will be using that test instead of the ACTH. AND she will be doing an electrolyte test, which is about $35 so at least the costs are not quite so overwhelming. Now to tackle the recompounding of my 60mg Vetoryl into 30mg. Checking on that today as well. I cannot thank you enough, will keep you in the loop!! Also wanted to point out that it will be interesting to also see if maybe this 5mg melatonin BID will help. Have a great day!!!

[labblab]

Lee Ann, I'll be keeping my fingers crossed for you and Zoe! Also, I do want to caution you that there may still be times when the complete ACTH is both warranted and necessary in terms of Zoe's monitoring. I do believe that this experimental research advises that baseline cortisol monitoring has the potential to be sufficient only in the event that the result falls within a fairly narrow range and all symptoms are resolved. Again, for Zoe's safety, I think it would really be a good idea for your vet to directly contact Dr. Cook for additional feedback and guidance in this regard. FYI, here's an additional write-up regarding the research:

http://veterinarymedicine.dvm360.com/vetmed/Medicine/A-simpler-way-to-monitor-adrenal-function-in-patie/ArticleStandard/Article/detail/698185

Marianne

[Lee Ann]

Marianne,
Took Zoe back to the Vet on thursday, Dr. Jackson listened to her lungs and she could still hear alot of crackling ( fluid) in her right lung. Her heart issues are taking a front seat to the cushings treatment right now. She has upped the dose of lasix from 20mg BID to 20mg TID to see if she can get the fluid under control. She will stay on everything except the Vetoryl until further notice. Maybe the melatonin will still give her a bit of help. Nice article in my subscription to The Whole Dog Journal this month concerning new procedures for the Pit-depend-Cushings type. Will keep you posted when we get to re-start the Vetoryl, hopefully in a few weeks :)

[Lee Ann]

Marianne,
Sadly, my Zoe passed away. the heart failure is what hurt her more than the Cushings. I so much appreciate all of your advice and caring instructions. What a great site for those of us willing to go the extra mile.
Another cost savings I discovered during this process was checking with my local pharmacist about what Zoe's medicines, the lasix, ace inhibitor, and broncho- dilator medicines would cost thru his pharmacy and it was a HUGE savings thru that human pharmacy. I simply asked my vet to call in Zoe's prescriptions to the pharmacy and it was no big deal. But I had to ask. Please tell all of your clients to always check the cash price for dog med's because they are usually human drugs.
sincerely, Lee Ann

[Squirt's Mom]

Dear Lee Ann,

My heart goes out to you as you mourn your sweet Zoe. You were working so hard to make her life as wonderful as possible and I know she appreciates all you did for her.

Please know we are here if you need to talk. We understand the pain you are feeling.

Our deepest sympathies,
Leslie, Squirt, Trinket, Brick and our Angels, Ruby and Crystal

[littleone1]

I'm sorry for your loss, Lee Ann. My thoughts and prayers are with you.

Terri

[Cindy Thoman]

Lee Ann, I am so sorry for your loss. My thoughts and prayers are with you. Sounds like you and Zoe were very blessed to have found each other.

xoxo,
Cindy, Alex and Bear

[lulusmom]

Le Ann, I am so terribly sorry for your loss. My thoughts and prayers are with you.

Godspeed sweet Zoe

Glynda

[addy]

Lee Ann I am so sad to see this posting. Words escape me.

God Speed sweet Zoe. You will be missed dearly.

Love,
Addy

[apollo6]

Lee Ann
Like the rest I am so sorry for your lose. May your Zoe be a rest and watching over you.
God bless
Sonja and Apollo

[labblab]

Dear Lee Ann,

I join the others in my sorrow over Zoe's passing. But I want to thank you so much for returning to tell us what has happened. Zoe will always be remembered here, and we will be so glad to see you whenever you may choose to come back to us. You are both members of our family, and shall always remain so. We join you in honoring Zoe's life and her spirit, today and every day.

With many hugs in loving memory of your sweet girl,
Marianne

[bgdavis]

Lee Ann,

I'm so sorry to hear of Zoe's passing. She was one lucky girl to have had you rescue her and love her for the last half of her life. She will be with you always.

Bonnie and Angel Criss

[Casey's Mom]

I am so sorry to hear of your loss Lee Ann, warm healing hugs are being sent your way.

[k9diabetes]

I am so sorry to learn of Zoe's passing. Having lived with a dog with multiple health issues, including serious heart problems, I know what a struggle the two of you went through. It is even harder to lose them when you have fought so hard to help them.

Godspeed to Zoe,

Natalie