15 yr old male Beagle recent Cushings Diagnosis

[Snowdonia]

Hello everyone. Spencer, my beagle will be 15 next month and he was diagnosed with Cushings about 3 weeks ago. He weighs 32lbs. He had started exhibiting symptoms of cushings about 1 1/2 years ago.. pot belly, panting, even hair thinning on sides of torso, hair loss around nose, excessive water consumption and urination, thinning of skin on belly with blackening, tiny black spots on belly, muscle loss in hind end, squaring head shape. They all didn't happen overnight, but within a couple of months. Around the same time, he had taken a bad fall trying to jump on a chair and subesquently hurt his back. So.. combined with his aging, we figured his overall decline might just be his back injury or simply getting old. He had a minor blood panel done and only his alk phos was high.. over 1200, but no sign of enlarged liver or anything else in particular.
About a year ago, a friend mentioned the possibility of cushings and I mentioned it to my vet, and they said possibly.. and did another minor blood panel and again, only the alk phos was high (this time 2100) but again, we did not do cushings testing and I wasn't exactly concerned about the disease at that stage, as his symptoms although present, weren't all that pressing. My vet agreed the alk phos was very high, but everything else was within normal ranges.
Time continued on and about 4 months ago, the symptoms began progressing (particularly the drinking and urination) and he began to really slow down physically. He also has a very enlarged heart (has been on Vetmedin and Enacard since he was 7) and that has been under pretty good control, but we thought, even if he has cushings, he may not last long enough to treat if his heart is failing.
About a month ago, due to the excessive urination accidents, my husband gave me an ultimatium... do something or put him down. So.. I asked the vet to do blood work and cushings testing. The abnormal blood work came back as:
Alk phos 3111 H (0-175)
ALT (Sgpt) 213 H (<110)
Seg Neutrophils 87 H (60-77)
Lymphocytes 9 L (12-30)
Eosinophils 0.079 L (0.10-1.3)

Everthing else looked really good and his liver still did not feel enlarged (although no ultrasound has been done.) Then they did a urine cortisol test. I do not have the results of that, but it's my understanding it came back as very high. Next they did a LDDS 8 hour test, here are the results:

Cortisol Baseline 2.16 (1.0-5.10)
4 hour post dex 2.46 H (0.0-1.0)
8 hour post dex 2.47 H (0.0-1.0)

The vet said the results were conclusive that he was a cushingoid dog. They started him on Vetoryl 2 weeks ago at a very small dosage of 10mg once a day. They told me to keep an eye out for reactions (vomit, diahrea, lethargy, not eating) and to let them know as soon as I noticed any improvement in clinical symptoms, and then they would do an ACTH(?) test right away.

After two weeks of treatment, he has not had any reactions but he has yet to show any improvement except he seems to have a little more energy, but it's tough to say. He is still urinating 12-15 times a day and drinking about 50-60oz water a day.

The vet has decided to increase his dosage to 10mg in the morning & 10mg at night. They state they want to take it extremely slow due to his age and existing heart condition. The plan is to try this for another week or two and again, I am to watch for reactions & improvement in clincial symtoms. The vet does not seem concerned about what time I give the Vetoryl except that it is about 12 hours apart. There has been no mention of doing an ACTH test until we see some sort of improvement in symptoms.

My questions for you all... does this treatment seem reasonably right and what are your thoughts on a dog with a heart condition being treated (Enacard is an ACE inhibitor.) I am concerned about the timing of giving Vetoryl with his other meds too. (He takes 5mg Vetmedin & 15mg Tramadol in the morning then 2.5mg Vetmedin and 10mg enacard & 15mg Tramadol in the evening.)

I am extremely attached to Spencer. It would absolutely devistate me if I hurt him trying to treat his Cushings. I trust my vet, but I know she is not extremely experienced with using Vetoryl being a relatively newer drug. Any advice would be greatly appreciated.

Diane

[addy]

Hi and Welcome to our forum,

I am glad you found us and others will be along soon to welcome you and give comments and feed back.

I will start of by refering you to Dechra's website which has a wealth of information on it. It will give you an idea on what symptoms you may see improve and when, avergae doses, when ACTH tests need to be scheduled to monitor your pup and cautions of using Vetoryl with Ace inhibtors. If you have not already read through their articles, please start here http://www.dechra-us.com

10 mgs is a very low dose to start for the Spencer's weight and I understand your vet's caution. She should have scheduled an ACTH test 10-14 days from starting the drug. It may be that at the low dose, Spencer's cortisol is not reduced enough to improve his symptoms.

I will leave the comment of using Vetoryl with a heart condition to more knowledgable members.

You are wise to be an adovocate for Spencer, especially if your vet is unfamiliar with the drug.

Please look through our research section. The more you learn, the better to cope with the disease.

Hang in there. We are here to help any way we can.

Hugs,
Addy

[Squirt's Mom]

Hi Diane and welcome to you and Spencer! :)

We use Lysodren at our house but I am sure our Trilo moms and dads will be along soon to share with you.

First, your vet's inexperience with Trilo is showing. ;) An ACTH needs to be done 10-14 days after starting the med for the first time, and 10-14 days after each dose change thereafter. The test needs to be done within 4 hours of the last pill. So if you give him his med at 8 am, he needs to have an ACTH by noon.

The best starting dose for Trilo, according to UC Davis, is 1mg/kg. while the manufacturer says to start at 3mg/lb. At 10mg/day, it is no wonder you aren't seeing any improvements. ;) Twice a day dosing is not typically considered unless the pup is showing obvious signs of rising cortisol in the evenings AFTER being on once a day dosing for a bit first.

This is what the manufacturer has to say about ACE inhibitors and Vetoryl (Trilostane) -


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.

I am not sure about the timing of these meds but if you called your pharmacist they should be able to tell you.

I am glad you found us. You will find the members here to be very knowledgeable and happy to share. Never hesitate to ask questions. We may not know the answer, but we will help you find it if we don't. You and Spencer are no longer alone on this journey. We will be with you every step of the way.

Hugs,
Leslie and the gang

[littleone1]

Hi Diane,

Corky and I also want to welcome you and Spencer.

Corky had been taking Trilostane for almost two years. His IMS started him at 20mg once a day, which was just about 1mg/pound. As time has gone on, Corky's dosage has had to be increased, as he has an inoperable adrenal tumor, and it's more difficult to keep the cortisol level under control.

I agree with Addy and Leslie about the ACTH stim test. This needs to be done to see where the cortisol level is. I don't have any experience with heart meds, so I really can't offer any advice as to their effect with using Trilostane.

Terri

[labblab]

Hi Diane,

Welcome to you and Spencer! In answer to your question about Spencer's trilostane dosing, I just wanted to offer a few thoughts. Dosing protocols have evolved over time, and I do believe that the most current initial dosing recommendations now offered out by U.C. Davis and Dechra are 1 mg./kilogram and 1 mg/pound, respectively. So for a dog of Spencer's weight, Davis would have started him on approx. 15 mg., and Dechra would have started him on approx. 30 mg. Here is a link to a reply on our Resource forum that contains a summary of the Davis protocol (located at the bottom of the reply):

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

And here is a link to Dechra's U.S. Product Insert for Vetoryl:

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

Dechra's Product Insert discusses an initial dosing range of 1-3 mg./lb. And the published dosing chart in the Product Insert actually lists 60 mg. for a dog of Spencer's weight. But for a while now, their technical reps have been verbally advising vets to start at the very lowest end of the range -- at 1 mg./lb.

So with both protocols, 10 mg. would have been a conservative starting point. Given Spencer's age and health status, this makes sense. But as the others have noted, it could also certainly explain why you have not seen improvement in his symptoms. Increasing his total daily dose now to 20 mg. seems like a reasonable move. And you could find specialists on both sides of the question as to whether once vs. twice daily dosing would be preferable in his situation. Since you are switching to twice daily dosing, your vet is right about the 12-hour interval. But one important point to keep in mind is that all doses should be give with food since the drug will otherwise not be metabolized properly. And also, as has been pointed out above, the morning dose should be given at a time that will allow an ACTH test to be performed within a time frame of 4-6 hours after dosing.

And as for an ACTH test, I do agree that both of these protocols (U.C. Davis and Dechra) recommend testing after approx. two weeks into treatment or after a dosing change. Since Spencer has shown no ill effects on the 10 mg. dose and it was so conservative to begin with, I personally don't feel anxious about the lack of testing so far. But now that you are doubling the dose, I would want a test performed after a couple of weeks on the higher dose, regardless of whether or not he is showing improvement. The greater risk from increasing his dose comes from the possibility that his cortisol level may drop too low. And due to the increased risk associated with the aldosterone-lowering effects of the ACE-inhibitor, you will want to make sure that
his electrolytes are checked at the same time.

Do take a look at the links above, and then let us know what additional questions come to mind.

Marianne

[Snowdonia]

Thank you all so very much for your kind greetings and advice. It sincerely moves me to tears knowing there are complete strangers willing to help us with this very scary situation. You have no idea how much it means to me and again I thank you from the bottom of my heart. You all seem to have a great deal of experience and while that makes me sad you have had to go through this too, is very reassuring that we are in good hands.

I will definitely have the vet do an ACTH test this upcoming week and I will enquire about their opinion on once a day vs. twice a day doses. I am also trying to locate an internal medicine specialist for a second opinion but I'm not sure one exists in my area (Southwest Florida.)

We started the twice a day dosing this morning (planning on 6am/6pm) and until I am able to get clarification on the timing of his other meds from a pharmacist (particulary the ACE inhibitor) I'm going to tenatively try for 4-5hours after the Vetoryl.

Diane & Spence

[Snowdonia]

Hello. Update on Spencer. I was able to locate an internist with cushings experience and had a consult. They too suggested a ACTH test now that Spence had been on 20mg (10/10) for a couple of weeks. There has been no improvement in clinical signs, but he did have a few days of diarrhea earlier this week that disappeared with a 3 day course of metrondiazinole. (sp?) No lethargy, no vomit, strong appetite. The ACTH results were

Baseline 4.8
Post 18

Vet says to increase to 30mg day (20/10) with a goal of 3-7.5 on the post ACTH test. He weighs 33lbs.

Also, I spoke to my pharmacist and he said he felt his concern with using Vetoryl and an ACE inhibitor would most likely be only a when a diuretic was used in combination too.

Any opinions are greatly appreciated. Considering his LDDS test results in my first post, does this sound like Adrenal or Pituitary?

Kind regards,
Diana & Spence

[labblab]

Hi again, Diana!

I believe that Spencer's LDDS results could be consistent with either pituitary or adrenal Cushing's, so you would have to perform additional testing in order to make that determination. An abdominal ultrasound would be one of the diagnostic possibilities because any abnormalities in the images of the adrenal glands will help distinguish between the two types of Cushing's. Also, an ultrasound will allow you to view the status of Spencer's other major organs, as well. However, trilosane is used to treat adrenal as well as pituitary Cushing's. So unless you would consider surgery in the event that Spencer has the adrenal form of the disease (which would be a major undertaking), his treatment probably wouldn't change regardless of the type of Cushing's. Here is a link that explains how to interpret LDDS test results:

http://veterinarymedicine.dvm360.com/vetmed/Medicine/ClinQuiz-Interpreting-low-dose-dexamethasone-suppr/ArticleStandard/Article/detail/580093

Given his monitoring ACTH results, the dosing increase sounds like a good plan. Once again, though, I would ask that his basic blood chemistries ("electrolytes") be checked at the same time as the ACTH tests are performed. This is a relatively inexpensive blood test and will help confirm that the combination of the trilostane and the ACE inhibitor is not having an adverse effect on his system.

Good luck, and please do keep updating us!
Marianne

[Snowdonia]

Thank you Marianne. I will definitely have the electrolytes tested at the same time as the next ACTH if not sooner. The situation with Spencer appears to be headed in the wrong direction. He has become more hyper.. Which appears good, except he paces in the evenings and is up a lot of the night. His drinking has actually increased and his urination is on pace to exceed 20 times in 24 hours, which is an increase from 12-15 average daily.

I know the vet took it extremely slow, but we're 6 weeks in without a shred of clinical improvement. This is agonizing. My husband is threatening to divorce me, and the dog is ruining the house. I'm trying so hard to keep positive and keep fighting for Spence, but at times I feel like giving up. I often find myself holding back tears.

Sorry, just had to vent..

Diana

[Squirt's Mom]

Hi Diana,

It can be tough on so many levels when we have a cush baby, and a partner/family who doesn't understand just makes things that much worse. I understand so well and am sorry you are having to deal with such negative attitudes. :( Sometimes it feels like all I have done for the last thee+ years is fight - this disease, doctors, government, friends and family. But when I look into my Sweet Bebe's eyes and when I see her bouncing around feeling spry and happy again, none of that matters. To be able to see this, I will march into battle with anyone at any time for her. And even tho the very ones who love me the most have hurt me terribly with the things they have said, I have come to understand they are missing something we have. A quality that allows us to experience the purest of loves, the deepest of devotions. In knowing this, pity instead of hurt or anger is what I feel toward them. They will never know the connections that can be formed between human and animal, and that is sad.

It sounds like Spencer's dose isn't at the right level yet since you are still seeing so many strong signs. He is due for an ACTH soon, isn't he? The dose changed around the 3rd? If so, he will need the ACTH around the 13th-15th. I would get the electrolytes checked then, too.

I'm lazy this morning - has he been checked for hypothyroidism? It can cause the same signs as Cushing's.

Two tips to share - First, slippery elm bark is GREAT for diarrhea and other digestive upsets and has none of the side effects as the metronidazole. I use it with my Trinket who has colitis and use it myself for IBS. We have two pups here who lost their appetites due to other illnesses and the SEB has helped them as well. Here are some links about it so you can check it out for Spencer -

http://www.littlebigcat.com/index.php?

http://www.webmd.com/drugs/drug-21295-slippery+elm+bark+Oral.aspx?drugid=21295&drugname=slippery+elm+bark+Oral&source=2

http://www.drugdigest.org/wps/portal/!ut/p/c1/dY1JDoJAFETP4gl-K0Zg2WCUnpwasGVDiCEtKqPKdHr1AFTtXlKvIIJfi6TNdPLOyi J5goJoFRtoi9DWJQHaEAMRyxMWx6cfncP5v1jFaCIYwc4r8xQu EJmTHmsBYVE2-f-vzdIOfFBoGcv7UO192bNR6w-7NkLa6YELk3L3RnhSBVIYNAxujIvm7AwV9V2TjsJay5KF-iGZnBN-8Qb10qOtcHtX2KmpXfdQPYquO-LZF-o8m30!/dl2/d1/L0lDU0dZcHBpZ3BSQ2dwUkNncFJBL29Ob2dBRUlZSWdHRUFJUk FNSWhSaEVBd2dGT1FZRGdwQ2tyQ0FZUUxSdEdWcXpyT1ZZQSEv NEEwYWNVWEpNbTRvZVNaTHhSOGt5ZmlnRUEhIS83XzMwRzAwR0 NJVTBGSTMwSThITThMQVIzMDgyL2hlcmJzL2R2aG5hbWUvU2xp cHBlcnkgZWxtL2R2aGlkLzQxMDAvbWV0aG9kL2Zvcldobw!!/

Second, to help protect your house until he gets regulated you can use belly bands. They are bands that wrap around a male dog's belly, covering the important part :p, and act as a diaper. You can find them at PetCo, PetSmart, etc. WalMart and such may even have them.

Have things like infections been ruled out as a possible cause for the loss of control? This is one of the most common signs of cortisol being out of control but it is good to make sure nothing else could be the cause.

Honey, you can vent any time you wish. We are family and you are safe here always, as are your tears. I cannot tell you the number of times I have come here totally devastated only to find the comfort and understanding I needed to keep going, to keep fighting. Keep reminding yourself that you are special, that you were given a bigger soul capable of love beyond the comprehension of most. And know that you are not alone, ever.

Hugs,
Leslie and the gang