intro zowi (10y/o yorkie) cushing's seeking advice

[yorkiemom1981]

hello everyone and thank you for having this site! my name is carrie and i have 2 yorkies, zowi, and pixie. this is my first time posting here and i am seeking any advice possible for my sweet little zowi, it would be greatly appreciated! the symptoms that led her dr to suspect cushing's were her pot belly appearance, a u.t.i., panting, ravenous appetite, increase in water consumption and urination, potty accidents in the house, seeking cool spots to lay, heat intolerance, and exercise intolerance. in februaury before her diagnosis, she had pre-op bloodwork, and ecg that was all normal and had a dental cleaning. at that time, she was panting and pot bellied. we changed her diet to a low fat food to try to help her lose some weight as per her dr's inscructions. a couple months went by and the other symptoms emerged. here goes as much history as i can provide.... (sorry such a long post!)
zowi is a 10 y/o spayed female yorkshire terrier that weighs 10 lbs.
6/29/2011 diagnosed with atypical cushing's after an endocrine panel to tennessee acth stimulation. high estradiol, cortisol was low pre and normal post
she received a melatonin implant and started 10mg hmr lignans daily and recheck acth in 3 months.
ultrasound revealed an enlarged liver - started denamarin once daily

8/10/2011 skin infection / eye infection – rubbing her head and eyes, losing hair on top of her head and around her eyes. treated with hydrocortisone eye ointment and simplicef and went away in a week, hair has grown back.

9/25/2011 hospitalized with pancreatitis (slight case) / DHP bloodwork and digital radiograph, fluids, cerenia injection, zenaquin 25mg started once daily, famotidine 10mg (pepcid ac) started once daily, hills w/d rx diet for one week - acute vomiting and diarrhea, stomach making noises, lethargic, sitting up in pain, was also constipated. Has also started to have weakness in her back legs now.
9/25/2011 hypothyriodism diagnosis – started L-thyroxine .1mg twice daily / will recheck thyroid in one month.
9/25/2011 hypertriglyceridemia / hyperlipidemia – high cholesterol and triglycerides
9/25/2011 ACTH stimulation test to university of Tennessee - endogenous (real) acth hormone used this time.

10/5/2011 acth results: *most recent results*
~cortisol baseline 49.6 (normal range 2.1-58.8) result post acth 185.5* (normal range 65.0-174.6)
~androstenedione baseline 0.36 (normal range 0.05-0.57) result post acth 2.66 (normal range 0.27-3.97)
~estradiol baseline 144.8* (normal range 30.8-69.9) result post acth 122.7* (normal range 27.9-69.2)
~progesterone baseline 0.25 (normal range 0.03-0.49) result post acth 1.67* (normal range 0.10-1.50)
~17 oh progesterone baseline 0.42 (normal range 0.08-0.77) result post acth 2.07* (normal range 0.40-1.62)
~aldosterone baseline 257.9* (normal range 11-139.9) result post acth 492.1* (normal range 72.9-398.5)
these results indicate presence of increased adrenal activity moderate-significant

10/6/2011 started trilostane 12mg once daily

10/27 endocrine panel to tennessee (results pending)
10/27 thyroid panel recheck results 3.4 normal 1-4 will continue same dosage of l-thyroxine and recheck in 3 months
10/27 blood pressure check - normal
10/27 recheck cholesterol & triglycerides cholesterol has lowered from 450 to 330 but triglycerides has gone up from 500 to 673 will recheck in one month

so, after all that information, some of my ?s are... should zowi be on trilostane??? could it be making her triglycerides increase??? her dr chose trilostane over lysodren because she feels it is safer, even knowing that trilostane can increase intermediate sex steroids that zowi is already high in. she said to give it a try and we could always change her treatment plan if necessary. both meds scare me so much and right now i am so worried about my little furbaby. u of tenn results take 10-14 days for us, so i am very anxious to see how they turn out this time. zowi has not had a ldds test and we do not know if it is adrenal or pituitary, so i'm wondering if that should be the next step for her??? would it be a good idea to have zowi's dr consult over the phone with u of tenn drs after the results are in to see what they recommend more specifically than what is stated on her last results??? (some vets consider items 1-5, 7, 8 of treatment option considerations) trilostane is one of the options and what her dr chose to start with. our curent financial situation is somewhat limiting for zowi to see and be treated by a specialist, but maybe would it be helpful to just have a consult with one??? our dr has not told us we need a specialist. zowi is worth every penny and if taking her to a specialist is our only option, we will have to make it happen somehow, someway. her well being is worth more than any $ in the world, and we have already come this far!!! anyone with any advice or suggestions, i would really love to hear from you!!!
zowi started to be a little more active a couple days after starting trilostane, but her other symptoms remain.

[lulusmom]

Hi and welcome to the forum.

Thank you so much for the comprehensive background on Zowi. Zowi's post stimulated cortisol on the UTK panel is high but anything under 220 (22 ug/dl) is considered borderline and in my layman's opinion, should not be on Trilostane. Can you please post the values for cortisol on the first UTK panel that was done? I'd like to see if cortisol has increased substantially since then. It's possible that Zowi's cortisol will continue to climb but based on the results of the latest UTK panel, her diagnosis should have remained as atypical cushing's. If melatonin and lignans are not effective in reducing the intermediate hormones, a maintenance dose of Lysodren is recommended by UTK.

I noticed the aldosterone is more than mildly elevated and if Zowi were mine, I would want an abdominal ultrasound done to rule out an adrenal tumor. If Zowi has an adrenal tumor, surgery could be a viable option and a complete cure. I would have hoped that your vet would have at least done this before prescribing Trilostane. I have two dogs with cushing's and they treat with a specialist so I know how expensive it can be. If there is any way you can afford it, I think you should definitely consider a consult.

I'm sure sorry for the circumstances that brought you here but I'm glad that you found us. We're here to help in any way we can. Looking forward to hearing more about your precious Zowi.

Glynda

[yorkiemom1981]

hi glynda, and thank you so much for taking the time to respond. i appreciate it so much! i agree with you, i fear we have already gone in the wrong direction. i did not obtain a copy of zowi's first utk panel, but i do know that her dr said cortisol was low pre and normal post. i will call and get that info or even better, go there and get a copy and post that info.
so if zowi did wash out the trilostane and start lysodren, it should only be a maintenance dose, correct? with no loading phrase? as i understand it, the loading phases are especially hard and has been a major concern for me. zowi has been taking 10mg once daily hmr lignans since june and did have a melatonin implant, but looking at her results after 3 months of those, i don't feel they have been effective. we did discuss starting her on oral melatonin to see if it's more effective, but dr said to wait for utk results first.
zowi did have an abdominal ultrasound in june. i do not have a copy of results but i was told everything looked normal with the exception of her liver being enlarged. she had a u.t.i. and protein and hemoglobin in her urine, so the ultrasound was more to rule out stones or masses. enlarged liver was another thing pointing to cushing's, so she had her first acth stim later that week. when i asked the dr if she could have an adrenal tumor, that was the only time she ever mentioned a specialist, and explained that i would need to be referred elsewhere because the tumor could be so small that they would not be able to detect it at her practice. then she explained that if she did have an adrenal tumor, would we consider the surgery given it has a poor prognosis and the high cost of it, when it can be controlled by medication? she didn't sound very encouraging about the surgery and said there are a lot of complications and a 25% chance she would not make it through. she has never said i need a specialist for treatment of cushing's, but did mention it regarding the ultrasound and possible surgery if she was a candidate. i didn't think much else about it as her dr said only a very small percentage of cushing's dogs do have operable adrenal tumors, so it would be highly unlikely that would be the case for zowi and probably a lost cause, but did say i could still find out.
would an ldds test be able to determine if she has an adrenal tumor? should i have that done prior to seeing an ims?
thank you so much for sharing your advice and input. zowi and i are so grateful to have it! especially pointing out the high aldosterone could indicate an adrenal tumor, i definitely did not know that. when i get new utk results, i will post them as well. best wishes to you and your furbabies! thank you thank you!
~ carrie

[yorkiemom1981]

zowi was started on 12mg once a day of trilostane oct 6th and had an endocrine panel to tenn 10/27 to monitor this treatment. based on the results, (post cortisol below normal) our regular vet decreased zowi's dosage of trilostane to 10mg once a day, starting today nov. 8th. (before we were using capsules and the new dosage came in tablets.) i have been very concerned with this course of treatment because zowi's acth results (included in my signature, before starting trilostane) had elevated sex steroids, but her dr has assured me that treating cortisol is more important and that we should not treat her sex steroids because they have less of a bad effect on her system than cortisol. also, trilostane having fewer side effects than lysodren was another reason for this course of treatment. doing research and getting advice here makes me wonder if we are on the right track... here are the latest acth results completed 11/03/2011

cortisol baseline 62.9* (normal range 2.1-58.8) result post acth *49.6 (normal range 65.0-174.6)
androstenedione baseline 4.04* (normal range 0.05-0.57) result post acth 3.40 (normal range 0.27-3.97)
estradiol baseline 107.4* (normal range 30.8-69.9) result post acth 88.4* (normal range 27.9-69.2)
progesterone baseline 1.34* (normal range 0.03-0.49) result post acth 1.81* (normal range 0.10-1.50)
17 oh progesterone baseline 5.35* (normal range 0.08-0.77) result post acth 7.54* (normal range 0.40-1.62)
aldosterone baseline 137.3 (normal range 11-139.9) result post acth 143.2 (normal range 72.9-398.5)
~these results indicate presence of increased adrenal activity. (moderate)

i would like to know names of specialists in the chicago area that anyone might have had a good personal experience with in the treatment of cushing's. or would i have to let my gp vet decide that? i have looked some up, but would feel better getting a personal recommendation from someone so i know that they're knowledgable in this particular area if it is possible. it would be greatly appreciated! i plan on asking for a referral for a second opinion, but i need to decide how i should best go about asking since my vet has never mentioned giong to a specialist, with the exception of adrenal surgery if zowi has adrenal cushing's. she seems confident that we are on the right path to control.

if anyone has any insight on these results or zowi's course of treatment, your input would be greatly appreciated. zowi will be going in for another abdominal ultrasound at her regular drs office later this week (possibly as early as wednesday) and i plan on asking for the referral that day.
thank you so much!!!

[Squirt's Mom]

Hi Carrie,

Personally, I don't support Trilo use in pups with elevated intermediate hormones - even tho the current consensus seems to agree with your vet's take -


...her dr has assured me that treating cortisol is more important and that we should not treat her sex steroids because they have less of a bad effect on her system than cortisol.

I continue to give UTK, the leaders in research in Atypical Cushing's, the benefit of the doubt; and they say Lysodren is preferred for these pups over Trilostane because Trilo will always elevate one or more of the intermediates.

In Zowi's case, her cortisol is borderline on the first UTK panel, and below normal on this most recent one. Trilostane should never be given to a pup with normal cortisol - and with a borderline result, I personally would not use Trilo even in a pup with normal intermediates.

I also want to clear up a misunderstanding often touted by vets - Trilostane is NOT safer than Lysodren - it has the exact same potential for damage as Lyso. What makes it seem safer is the fact that Trilo does not stay in the body as long as Lyso so when there is a crisis, and they do occur with Trilo, the cortisol rebounds more quickly.

If Zowi were mine, I would certainly have the ultrasound done, I would seek an IMS, I would continue the lignans and melatonin but stop the Trilo. I would allow her a month to make sure the Trilo is out of her system then have another UTK panel run; then I would insist she start a maintenance dose of Lysodren along with the lignans and melatonin...IF the UTK panel shows she needs more.

Now, having said all of that, we have pups with elevated intermediates who do just fine on Trilo. ;) But I have to throw my 2 cents worth in! :D

I know you will do the right thing for Zowi whatever that may be. You are doing a great job of learning and seeking the best path for her! Keep up the good work!

Hugs,
Leslie and the gang

[lulusmom]

9/25/2011 hospitalized with pancreatitis (slight case) / DHP bloodwork and digital radiograph, fluids, cerenia injection, zenaquin 25mg started once daily, famotidine 10mg (pepcid ac) started once daily, hills w/d rx diet for one week - acute vomiting and diarrhea, stomach making noises, lethargic, sitting up in pain, was also constipated. Has also started to have weakness in her back legs now.
9/25/2011 hypothyriodism diagnosis – started L-thyroxine .1mg twice daily / will recheck thyroid in one month.
9/25/2011 hypertriglyceridemia / hyperlipidemia – high cholesterol and triglycerides
9/25/2011 ACTH stimulation test to university of Tennessee - endogenous (real) acth hormone used this time.

10/5/2011 acth results: *most recent results*
~cortisol baseline 49.6 (normal range 2.1-58.8) result post acth 185.5* (normal range 65.0-174.6)
~androstenedione baseline 0.36 (normal range 0.05-0.57) result post acth 2.66 (normal range 0.27-3.97)
~estradiol baseline 144.8* (normal range 30.8-69.9) result post acth 122.7* (normal range 27.9-69.2)
~progesterone baseline 0.25 (normal range 0.03-0.49) result post acth 1.67* (normal range 0.10-1.50)
~17 oh progesterone baseline 0.42 (normal range 0.08-0.77) result post acth 2.07* (normal range 0.40-1.62)
~aldosterone baseline 257.9* (normal range 11-139.9) result post acth 492.1* (normal range 72.9-398.5)
these results indicate presence of increased adrenal activity moderate-significant


Hi Carrie,

I totally missed something very important when I read your first post which causes even greater concern about a proper diagnosis. Unless your dates are incorrect, Zowi was diagnosed with hypothyroidism and the blood draw for the UTK was done on the same day Zowi was admitted to the hospital with pancreatitis. If that is correct, the hypothyroid diagnosis would be very questionable, as pancreatitis, or any non-thyroidal illness like cushing’s, can cause abnormal findings, namely low T-4 and T-3. This would not be primary hypothyroidism but rather something called Sick Euthyroid Syndrome. This condition usually corrects itself when the underlying condition has resolved or is brought under control. If the blood draw for the UTK panel was done when Zowi was hospitalized, there is little doubt that all of the adrenal hormones would have been elevated by the severe stress and inflammation caused by the pancreatitis. Can you please confirm those timelines?



zowi did have an abdominal ultrasound in june. i do not have a copy of results but i was told everything looked normal with the exception of her liver being enlarged. she had a u.t.i. and protein and hemoglobin in her urine, so the ultrasound was more to rule out stones or masses. enlarged liver was another thing pointing to cushing's, so she had her first acth stim later that week.

Zowi’s estradiol, both pre and post stimulation are rather high and I wanted to point out that this adrenal hormone can cause the same liver abnormalities, bloodwork & urine abnormalities and symptoms as those of dogs who have typical cushing’s (excess cortisol). For this reason, unless your vet did diagnostics such as an LDDS or ACTH stimulation test that was consistent with cushing’s, Zowi’s diagnosis should have remained as atypical and no Trilostane should have been prescribed. I mentioned previously that the post stimulated cortisol pre treatment was not consistent with cushing’s, it was barely borderline.



when i asked the dr if she could have an adrenal tumor, that was the only time she ever mentioned a specialist, and explained that i would need to be referred elsewhere because the tumor could be so small that they would not be able to detect it at her practice. then she explained that if she did have an adrenal tumor, would we consider the surgery given it has a poor prognosis and the high cost of it, when it can be controlled by medication? she didn't sound very encouraging about the surgery and said there are a lot of complications and a 25% chance she would not make it through. she has never said i need a specialist for treatment of cushing's, but did mention it regarding the ultrasound and possible surgery if she was a candidate. i didn't think much else about it as her dr said only a very small percentage of cushing's dogs do have operable adrenal tumors, so it would be highly unlikely that would be the case for zowi and probably a lost cause, but did say i could still find out.

Firstly an adrenal tumor cannot always be visualized on an abdominal ultrasound but usually if there is an adrenal tumor, imaging will show one enlarged adrenal gland with the other being much smaller or even completely atrophied from lack of use. Secondly, if Zowi were to have an adrenal tumor, why does your vet feel that she wouldn’t be a good candidate for surgery? Does she have another underlying condition that would disqualify her as a good candidate? Regardless, I believe a board certified surgeon is really the only person qualified to make that call. There have been a number of dogs here who have had successful surgeries with excellent outlooks so I’m also not sure why your vet is convinced the prognosis would be poor.



would an ldds test be able to determine if she has an adrenal tumor? should i have that done prior to seeing an ims?

Sometimes the LDDS will tell if the dog has pituitary dependent disease but sometimes it doesn’t. If I were in your shoes, I would let an internal medicine specialist determine which additional testing to do to properly confirm a diagnosis.



i have been very concerned with this course of treatment because zowi's acth results (included in my signature, before starting trilostane) had elevated sex steroids, but her dr has assured me that treating cortisol is more important and that we should not treat her sex steroids because they have less of a bad effect on her system than cortisol

I agree that reducing elevated cortisol is more important but only if a dog has elevated cortisol. Zowi’s post stimulated cortisol prior to treatment was not high enough to be deemed consistent with typical cushing’s and Trilsotane should not have been prescribed. In my layman’s opinion, a maintenance dose of Lysodren would have been preferable. Your vets comment sex steroids having less of a bad effect on Zowi is not accurate. Sex steroids, particularly estradiol, can cause the same bad effects as cortisol.


i would like to know names of specialists in the chicago area that anyone might have had a good personal experience with in the treatment of cushing's. or would i have to let my gp vet decide that? i have looked some up, but would feel better getting a personal recommendation from someone so i know that they're knowledgable in this particular area if it is possible. it would be greatly appreciated! i plan on asking for a referral for a second opinion, but i need to decide how i should best go about asking since my vet has never mentioned giong to a specialist, with the exception of adrenal surgery if zowi has adrenal cushing's. she seems confident that we are on the right path to control.

I am hoping others can help you with a name of a good IMS in your area but in case they don’t and you haven’t already found the ACVIM website, here is a screen shot of specialists listed for Illinois:

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


zowi will be going in for another abdominal ultrasound at her regular drs office later this week (possibly as early as wednesday) and i plan on asking for the referral that day.
thank you so much!!!

If I were you, I would ask for the referral and let the specialist you consult with do the abdominal ultrasound as well as any other additional tests that s/he may think is necessary.

[yorkiemom1981]

glynda and leslie, thank you both so very much for the prompt response and for taking the time to respond, i am so grateful! i am so worried about my little girl!
i brought my vet the treatment option considerations printed out from utk to show her their recommendations of not using trilostane for atypicals before starting zowi on trilostane. she told me to give it a try and we could always change meds if necessary. i would definitely want zowi treated in the way u of tenn recommends, since they are the experts.
to clarify dates, zowi became suddenly ill (vomitting, diahrrea) and was hospitalized overnight. she was getting fluids but no food or water for 24 hours due to pancreatitis. the morning we took her in, they did bloodwork (confirmed pancreatitis) and decided to do the acth stim the next morning after she had fasted. so yes, she did have acth stim during her hospitalization, but a previous acth stim done back in june before any treatments were given also had elevated sex steroids, she was diagnosed atypical then and her thyroid was normal (about 3 months before the hospitalization). i am not sure if the the thyroid panel was done the first or second day of her hospitalization. (she only stayed one night.) her total t4 was rechecked one month later after starting thyroxine and the result was 3.7 reference range 1.0-4.0. thank you for pointing out about sick euthyroid syndrome. it scares me to think she's being treated for things she might not need!
our dr is in tomorrow and i am going to get a referral. i have no idea what is best for my baby girl, but i want to find out now so we can get on the right path!
her very first acth stim test 6/2011 had very elevated estradiol too, (cortisol was low pre and normal post) and an enlarged liver was observed during abdominal ultrasound a week before, so i believe the sex steroids are also dangerous. i asked for a copy of it yesterday at the drs office, but when i got home it wasn't in the stack of copies of labs i got. :( also utk says that lysodren might not control estradiol because it can be secreted by tissues other than the adrenals, so this is another concern. she has been taking 10mg daily of hmr lignans since the beginning of june and estradiol is still high.
zowi does not have any underlying medical conditions that would make her unfit for surgery to my knowledge, with the exception of cushing's. she has been a happy, healthy little girl her whole life, until just before she turned 10 and started having the cushing's symptoms. she will be 11 january 21st.
thank you both for responding! thank you for the link to acvim, it will be a great starting point if i don't get a good recommendation from someone. i am making a list of questions for the specialist and both of your posts have been most helpful! i can't thank you enough.
i will send an update when i know more... hugs to you ~ carrie

[Squirt's Mom]

Hi Carrie,

What works on estradiol that is produced outside the adrenal glands is the combination of lignans and melatonin. If I understand you, Zowi is only on lignans? If that is the case, it is unlikely the estradiol will be affected. Glynda wrote a great explanation of how these work when I asked a while back; I will try to find that post and share it with you tomorrow.

Don't be too upset with your vet - she has done quite well actually. I have been absolutely appalled at some of the things we have heard here about vets...and had a few bad run-ins myself. You are luckier than some, trust me! The most important thing, IMHO, is that the vet be willing to listen and work with you as a team as well as educate. ;)

Hugs,
Leslie and the gang

[lulusmom]

Hi Carrie,

The UTK adrenal panel done in September should not have been done until Zowi had recovered from her bout of pancreatitis before doing the stim test. I am totally confused as to why your vet would do this and I would not be happy about paying for that test. It is highly probable that the post stimulated cortisol, as well as the adrenal hormones reflected on the UTK panel were exaggerated due to stress, so I am even more convinced that Zowi does not have typical cushing's and should not be on Trilostane. A vet should never do cortisol tests on any dog with an unresolved underlying medical condition and Zowi was still in the hospital for pancreatitis which was diagnosed less than 24 hours before drawing blood for the UTK adrenal panel. :confused: I am very, very happy that you are going to ask for a referral to a specialist.

[yorkiemom1981]

hello leslie and glynda, and again thank you so much for your help. zowi's dr was not in yesterday (she is usually there on weds) so i did not get to make any progress..... we are hoping to today....
leslie, yes zowi is currently only taking lignans without melatonin. her dr said she is going to discontinue use of melatonin implants in her practice because they are less effective than taking oral melatonin in her experience. she said she also heard this from an endocrinologist at a recent lecture she attended. i asked for what dosage of melatonin zowi should be taking orally and she said she does not want to treat the sex steroids at this time, but to continue lignans. again, this doesn't make much sense to me. i am not that upset with her because she has been a really wonderful vet, i have been bringing my pets to her for 11 years now and i have followed her moving back and forth between 2 sister hospitals. she is now a partner at her current location. the person who recommended her to me years ago has followed her to 4 different locations and has been pleased with her for over 15 years! i want her to continue to be our primary care dr and i do want her involved in zowi's care still, even though i disagree with our current course of action. hopefully, she will be happy to hear from a specialist and willing to go with their course of treatment and by doing so, i will keep her as our primary. this is also very important if i get referred to the u of il in urbana because it is 3 hours each way from where we live. chicago is a bit closer, but maybe she would be better off going to the university and i am surely willing to take zowi there. i have seen many other vets in times she was unavailable and i am never pleased with them lol. i will try to search for glynda's explanation of lignans and melatonin on this sight and read it. thanks for mentioning that!
glynda, this makes perfect sense to me. the 1st 2 acth stims did not show high cortisol, but this one did (although very borderline) so of course it was caused by the stress of illness. i also agree with paying for that test. $205 and waiting almost 2 weeks for invalid information is aggravating to say the least. i will run this by her dr even though i don't see much of a point and i just want to hear from a specialist at this point. the morning she was admitted, when i woke up (first thing i do every day is call zowi to make sure she's ok), the second i laid eyes on zowi, i knew she was a very sick girl. you could just see it in her eyes and in her disposition. then i found the evidence (vomit, diahrrea) and offered her food just to see if she would take it and she ran away from it! major red flag for my girl. she will eagerly eat anything at any given time and never, ever runs away from food. i was so scared i was going to lose her! thank god i didn't. the next day she got to come home and was back to wanting to eat the house down! up until about a year and a half ago, i free fed zowi and she was never overweight or ate too much but when she started to gain weight, i stopped doing that and i started feeding her on a schedule per dr's orders because she needed to lose some weight. she also developed food agression.
again - thank you both soooo much for taking the time to respond and to help my girl! i cannot even tell you how grateful i am. zowi said to send you lots and lots of puppy kisses from her!!!!! i will update......

[Mar]

I'm just posting to say that you should follow Lulu's Mom advice because she's always right:)