New Member - Teddy 13 year old has had Cushings for two years

[akusfan1]

My dog Teddy is a 13 year old 90 pound chow/golden retriever who has had Cushings for 2 years. He has a holistic vet who has never used medications to treat Cushings, relying instead on Chinese herbs and other supplements. These have not stopped the advance of Cushings symptoms and so I have asked the vet to start Vetoryl. Unfortunately her first prescription of 60 mg proved to be too high and produced lethargy. We stopped that and I am now waiting for the second prescription which will probably be 30 mg. In the waiting period Teddy's muscle wasting has gotten so bad he can not get up. I would like to know if anyone has seen recovery using Vetoryl from muscle wasting that is this bad. The initial trial of Vetoryl quickly took care of the drinking/peeing problem and the intense appetite. In addition to the muscle wasting Teddy also has skin problems and hair loss. I understand it may take 3 to 6 months for those to clear but I am concerned about muscle wasting.

[Harley PoMMom]

Hi and welcome to you and Teddy,

Sorry for the circumstances that brought you here but very glad you found us.

Muscle wasting is due to the catabolic effect of cortisol and hopefully when the elevated cortisol is under control you should see some improvement, but slowly.

Could you provide us with some more information about the Cushing's diagnosis, such as getting copies of all tests that were done and posting the abnormalities here. Does Teddy have any other health issues? Is he taking any other herbs/medicines/supplements?

Here's a handy link with information about Vetoryl/Trilostane: Dechra's U.S. Product Insert. (http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf)

Please know we will help in any way we can so feel free to ask any and all questions.

Love and hugs,
Lori

[labblab]

Hello and welcome from me, too.

I am sincerely hoping that your vet is performing monitoring ACTH stimulation testing in order to assess Teddy's cortisol level. Since you are suspecting that the 60 mg. dose was too high based on lethargy, I am worried that Teddy's inability to get up may be related to cortisol that is too low rather than too high. This is called an Addisonian condition. It is definitely true that muscle wasting results from uncontrolled Cushing's. But that is a chronic problem that develops over time; it seems unlikely that it would suddenly worsen right after having been treated with Vetoryl unless he has been off the drug for some time. For how long a time was Teddy taking the Vetoryl, and for how long a time has he been without it?

Not only should Teddy's cortisol status be checked by an ACTH test, but his basic blood chemistries need to be monitored, as well. Vetoryl has the potential to cause an imbalance in the sodium and potassium levels that can actually be life-threatening. How is Teddy aside from the mobility issue -- is he still eating and drinking normally? Any vomiting or diarrhea?

Vetoryl is not like a natural herb or supplement that is judged solely on how the dog appears or behaves. The monitoring blood tests are critical for the safety of the dog. So I am hoping that Teddy's cortisol and blood levels have already been checked and they are OK. If not, that should be done as quickly as possible. Please do let us know about this.

Marianne

[Squirt's Mom]

Hi and welcome to you and Teddy, :)

I am glad you found us! I have some questions as well. :p

Could you please tell us what herbs/supplements were used to try to treat the Cushing's and how long they were stopped before the Vetoryl (Trilostane) was started? There is a possibility of drug interactions and contradictions with herbs and pharmaceutical meds so it is important to make sure the herbs were completely out of his system.

Lori and Marianne have covered the tests results to diagnose Cushing's and the need to be sure where his cortisol is now via an ACTH. His signs could truly be from the dose that was too high so if his electrolytes and cortisol were not checked, it would be very good to consider it now. ;)

I want you to know that you and Teddy found us and look forward to learning more as time passes. Ya'll will never be alone on this journey. We will walk with you every step of the way. Never hesitate to ask questions and we will do our best to help you understand - or research together to try to find the answer.

Hugs,
Leslie and the gang

[lulusmom]

Hi and a belated welcome to you and Teddy.

My second cushdog had severe muscle wasting and could hardly stand up by the time we got him on treatment. This did improve but it took several months. We discovered rather quickly that Jojo had arthritis which was being masked by the high cortisol. Since Teddy was on vetoryl, even for a short time, cortisol could have dropped enough to unmask arthritis/joint problems that perhaps you weren't aware of. Has your vet xrayed him and manipulated his joints to rule out hip displaysia/arthritis?

Glynda

[akusfan1]

I'll try to reply to all of your questions -

Lori - Teddy had ultrasound last year. It showed two enlarged adrenals. He had a Senior Blood Profile with Urinalysis last month
because he had a urinary tract infection. I'm looking for my copy and
will upload when I find it. That's all the testing he has had. He gets a
variety of supplements/herbs - fish oil,astaxanthin, FortiFlora,
Canine Geriatric Basics, cranberry mannose, artemesinin,
thytrophin PMG, L-Glutamine, Dr. Mercola Digestive Enzymes,
and Maitake for Pets
Marianne - Teddy was scheduled for a cortisol check but it didn't happen because the vet doesn't do house calls and I had no way to
get him in. We have now located a visiting vet but Teddy's vet
doesn't feel that he now needs it since he is eating normally and not lethargic. Unfortunately the visiting vet does not do ACTH testing so that will be a problem when it comes time to check on the Vetoryl dosage. Teddy was on 60mg Vetoryl for 8 days and has been
off for 6 days. The muscle wasting was first noticed in December when Teddy was out for a walk and collapsed on the way home. It got worst and just before starting Vetoryl he could barely walk. Now his eating and drinking are normal. No vomiting, some diarrhea today yesterday normal weekend diarrhea.
Leslie - Teddy's herbs were stopped 4 months ago. The last one was Ophiopogon Combination.
Glynda - Teddy doesn't have arthritis. He was x-rayed last year and his joints were checked because I also wondered if he had arthritis because he didn't want to walk for a few days running.

Hope I covered everything - let me know if I missed something, Thanks, Wayne

[akusfan1]

Sorry I missed Lori's question about Teddy's other diseases. Teddy has
food allergies including beef, chicken, white potatoes and sweet potatoes as well as flax and kale. We feed lamb and pork mostly.
Teddy also had a form of bone cancer develop on his right front leg ligaments. It was removed by his vet 6 months ago and he shows no further problems. I believe she got it all when she removed the growth via surgery.

[labblab]

I am so very sorry that Teddy is doing so poorly. I surely understand why you are hoping to bring him some relief, and as quickly as possible. However, under these circumstances, I am very afraid that the Vetoryl has as much potential to seriously harm Teddy as it does to help him.

Vetoryl is such a powerful drug that it should never be given to a dog unless a Cushing's diagnosis has been established as clearly as possible. Diseases other than Cushing's can cause enlarged adrenal glands and also abnormalities in regular blood profiles. That is why diagnostic blood testing that is specific to Cushing's is very important prior to starting the medication. And once the Vetoryl is started, the monitoring blood testing is also so important. Dogs on any dose, at any point in time, can suffer from cortisol levels that can drop dangerously low. And even after the medicine is stopped, it can take some dogs a very long time to recover normal adrenal function.

Teddy sounds as though he is in a very bad way right now if he cannot stand up and you cannot get him in to see a vet. And if he is having diarrhea, that is also a bad sign. The fact that he had bone cancer within the last six months also makes me feel very frightened for him. It is possible that all the cancer was not removed by the surgery, or that some cells had already traveled elsewhere in his body and started a new tumor.

I strongly urge you to have the visiting vet come out as quickly as possible to examine Teddy. Even if that vet cannot perform an ACTH test, he/she should be able to draw a blood sample to check his blood chemistries and cell counts. And a "resting" cortisol level can also be performed from a simple blood draw. Even though it does not give the complete information of an ACTH test, if will at least give an indication as to whether or not Teddy's baseline cortisol falls within the normal range.

As much as you want to help Teddy, I do not think it is at all safe for you to resume the Vetoryl under these circumstances. Please have a vet come out and see him as soon as you can!

Marianne

[akusfan1]

Marianne - I'm starting to agree with you. The traveling vet is coming on Saturday afternoon to do a cortisol level check and to do a basic blood chemistry blood test. I also asked her to check Teddy's blood pressure. In addition she will start the first of weekly acupuncture treatments on Teddy's legs. Teddy's regular vet did write a prescription for 30 mg Vetoryl but didn't want me to give it until she sees the results of the blood work. If I read you correctly you are worried that Teddy may not have Cushings but something else. I worry that he has Cushings and something else. He had all the classic signs of Cushings
as well as this jelly like bm problem. The real problem is that if we can't get a solution to his leg problem I will have to put him down. He can't live the rest of his life on the floor and not able to move. Right now the only path I can see is using Vetoryl at some point. If he has another problem (Addison's caused by the overdose) we'll address that. If he has cancer that has spread then we are done.

[labblab]

Dear Wayne,

I'm really glad the vet is coming tomorrow. I'm so sorry that Teddy is in such a bad way, and understand the really tough choices you are facing. And you may be right, too -- that Teddy does have Cushing's in addition to something else. But if the additional problem is compromising his liver or kidneys, for instance, the Vetoryl will not be metabolized properly and is unsafe for him to have. So it does become a complicated issue.

We will be so anxious to hear the vet's report after he sees Teddy. Please let us know as soon as you can, OK?

Marianne

[Squirt's Mom]

Hi Wayne,

Just popping to let you know I am thinking of you and Teddy and praying for the best outcome possible - a treatable diagnosis and many more years together.

Please know that we are here any time you wish to talk. We understand what a difficult position you may find yourself in and are here to lend an ear and shoulders any time.

Hugs,
Leslie and the gang

[marie adams]

Hi Wayne and Teddy--Welcome!!! :)

I am sorry for the belated welcome, but so glad you have found our forum. It was a life saver for me because of the knowledge and support you are already receiving.:)

Please keep asking your questions and sharing your thoughts--you are in good hands!!!:)

Take care!

[jmac]

Hi Wayne,

I know I am late in welcoming you, but I just caught up on your thread. I am so glad to hear a vet will be coming to check on Teddy. It sounds like he is not doing well.

You have already gotten great advice, and we will be here with you to support you with whatever you need to do for Teddy. Please let us know what the vet finds out.

Julie & Hannah

[akusfan1]

I just received Teddy's blood work report. The blood was drawn 2/25.
The report follows (cortisol level is the last line)
Total Protein 5.9 5.0-7.4 g/dL
Albumin 3.3 2.7-4.4 g/dL
Globulin 2.6 1.6-3.6 g/dL
Albumin/Globulin Ratio 1.3 0.8-2.0 Ratio
AST (SGOT) 37 15-66 U/L
ALT (SGPT) 126 12-118 U/L HIGH
Alk Phosphatase 932 5-131 U/L HIGH
Total Bilirubin 0.1 0.1-0.3 mg/dL
Urea Nitrogen 68 6-31 mg/dL HIGH
Creatinine 1.5 0.5-1.6 mg/dL
BUN/Creatinine Ratio 45 4-27 Ratio HIGH
Phosphorus 7.1 2.5-6.0 mg/dL HIGH
Glucose 122 70-138 mg/dL
Calcium 9.6 8.9-11.4 mg/dL
Corrected Calcium 9.8
Sodium 146 139-154 mEq/L
Potassium 4.3 3.6-5.5 mEq/L
Na/K Ratio 34
Chloride 105 102-120 mEq/L
Cholesterol 250 92-324 mg/dL
CPK 151 59-895 U/L
Comment
Hemolysis 1+ No significant interference.
CBC
WBC 12.3 4.0-15.5 103/μL
RBC 7.71 4.8-9.3 106/μL
Hemoglobin 17.3 12.1-20.3 g/dL
Hematocrit 59.1 36-60 %
Page 1 of 2
Accession No.
NYAB46497808
Doctor
Erwin
Owner
Porter
Pet Name
Teddy
Test Results Adult Reference Range L Normal H
MCV 77 58-79 fL
MCH 22.4 19-28 pg
MCHC 29.3 30-38 g/dL LOW
Platelet Count 341 170-400 103/μL
Platelet EST Adequate Adequate
Differential Absolute %
Neutrophils 10455 85 2060-10600 /uL
Bands 0 0 0-300 /uL
Lymphocytes 984 8 690-4500 /uL
Monocytes 738 6 0-840 /uL
Eosinophils 123 1 0-1200 /uL
Basophils 0 0 0-150 /uL
Cortisol (ACTH)
Cortisol Sample 1 5.4 1.0-5.0 μg/dL HIGH

[Harley PoMMom]

Have you've been seeing a continuous rise in his creatinine? With a high normal creatinine, elevated BUN, and high phosphorus, I am inclined to think that a kidney issue is brewing.

[Squirt's Mom]

Cortisol (ACTH)
Cortisol Sample 1
5.4 1.0-5.0 μg/dL HIGH

A normal range for a pup treated with Lysodren is 1.0 - 5.0

Below are the normal ranges for a pup on Trilostane.


Good control is indicated by favorable clinical signs as well as post-ACTH serum cortisol of 1.45-9.1 μg/dL (40-250 nmol/L).
http://www.dechra-us.com/files//dechraUSA/downloads/Client%20Literature/47901_VETORYL_10mg_Diag_Testing_brochure_4pg_3_1_p s.pdf

So a post number of 5.4 ug/dl is perfect for a Trilo pup! :) But (ain't there always a "but"?! :D) but, the question now becomes how long has Teddy been off the Trilo....or has he been off?

What did the vet have to say before they left? Any diagnosis other than Cushing's? Did they say anything about his kidney function? BUN is elevated and that will make the ratio between it and the creatinine higher but the BUN can be affected by many things and often controlled to a degree. Creatinine is a fair indicator of organ damage and can not as easily be lowered - tho my Trinket has proven that it can happen! ;)

Hopefully those who can interpret these much better than I will be along soon but I primarily wanted to point out the cortisol readings.

Hugs,
Leslie and the gang

[labblab]

I just want to clarify that the cortisol reading of 5.4 is solely a baseline or resting cortisol reading, right? From what you wrote earlier, the visiting vet was not capable of performing an ACTH stim test. If that is the case, we cannot plug that reading into Dechra's post-ACTH monitoring protocol, but at least it assures us that low cortisol is NOT likely to be Teddy's problem. So it looks as though it is one puzzle piece that we can account for.

Marianne

[akusfan1]

Please forgive the previous post - I reposted Teddy's results from 2/25.
The following is Teddy's blood work from 1/26 when he was suffering from a uti and was put on 3 weeks of Clavamox.

ALK.
PHOSPHATASE
2207 10 - 150 U/L HIGH
ALT (SGPT) 404 5 - 107 U/L HIGH
AST (SGOT) 59 5 - 55 U/L HIGH
CK 175 10 - 200 U/L
GGT 36 1 0 - 14 U/L HIGH
AMYLASE 505 450 - 1240 U/L
LIPASE 470 100 - 750 U/L
ALBUMIN 3.4 2.5 - 4.0 g/dL
TOTAL PROTEIN 6.8 5.1 - 7.8 g/dL
GLOBULIN 3.4 2.1 - 4.5 g/dL
TOTAL BILIRUBIN 0.2 0.0 - 0.4 mg/dL
DIRECT BILIRUBIN 0.1 0.0 - 0.2 mg/dL
BUN 51 7 - 27 mg/dL HIGH
CREATININE 1.1 0.4 - 1.8 mg/dL
CHOLESTEROL 309 112 - 328 mg/dL
GLUCOSE 84 60 - 125 mg/dL
CALCIUM 9.0 8.2 - 12.4 mg/dL
PHOSPHORUS 5.7 2.1 - 6.3 mg/dL
TCO2
(BICARBONATE)
21 17 - 24 mEq/L
CHLORIDE 104 105 - 115 mEq/L LOW
POTASSIUM 4.6 4.0 - 5.6 mEq/L
SODIUM 144 141 - 156 mEq/L
A/G RATIO 1.0 0.6 - 1.6
B/C RATIO 46.4
INDIRECT BILIRUBIN 0.1 0 - 0.3 mg/dL
NA/K RATIO 31 27 - 40
HEMOLYSIS INDEX ABN 2
LIPEMIA INDEX ABN 3
ANION GAP 24 12 - 24 mEq/L
Comments:
1. RESULT VERIFIED BY REPEAT ANALYSIS
2. Unable to report serum indexes on this sample.
3. Unable to report serum indexes on this sample.
SENIOR PROFILE : T4
IDEXX Reference Laboratories Client: PORTER Patient: TEDDY
Page 2 of 3
Test Result Reference Range Low Normal High
T4 1.1 1 1.0 - 4.0 ug/dL
Comments:
1. Interpretive ranges:
<1.0 Low
1.0-4.0 Normal
>4.0 High
2.1-5.4 Therapeutic
Dogs with no clinical signs of hypothyroidism and results within the
normal reference range are likely euthyroid. Dogs with low T4
concentrations may be hypothyroid or "euthyroid sick". Occasionally,
hypothyroid dogs can have T4 concentrations that are low normal. Dogs
with clinical signs of hypothyroidism and low or low normal T4
concentrations may be evaluated further by submission of free T4 and
canine TSH. A high T4 concentration in a clinically normal dog is
likely variation of normal; however elevations may occur secondary to
thyroid autoantibodies or rarely thyroid neoplasia. For dogs on
thyroid supplement, acceptable 4-6 hour post pill total T4
concentrations generally fall within the higher end or slightly above
the reference range.
SENIOR PROFILE : CBC COMPREHENSIVE
Test Result Reference Range Low Normal High
WBC 13.2 5.7 - 16.3 K/uL
RBC 9.06 5.5 - 8.5 M/uL HIGH
HGB 20.9 12 - 18 g/dL HIGH
HCT 60.6 37 - 55 % HIGH
MCV 67 60 - 77 fL
MCH 23.1 19.5 - 26.0 pg
MCHC 34.5 32 - 36 g/dL
NEUTROPHIL SEG 88 60 - 77 % HIGH
LYMPHOCYTES 6 12 - 30 % LOW
MONOCYTES 6 3 - 10 %
EOSINOPHIL 0 2 - 10 %
BASOPHIL 0 0 - 1 %
AUTO PLATELET 476 164 - 510 K/uL
REMARKS SLIDE REVIEWED MICROSCOPICALLY.
NO PARASITES SEEN
ABSOLUTE
NEUTROPHIL SEG
11616 3000 - 11500 /uL HIGH
ABSOLUTE
LYMPHOCYTE
792 1000 - 4800 /uL LOW
ABSOLUTE
MONOCYTE
792 150 - 1350 /uL
ABSOLUTE
EOSINOPHIL
0 100 - 1250 /uL
ABSOLUTE
BASOPHIL
0 0 - 100 /uL
SENIOR PROFILE : URINALYSIS
Test Result Reference Range Low Normal High
COLLECTION
METHOD
FREE-CATCH
COLOR YELLOW
IDEXX Reference Laboratories Client: PORTER Patient: TEDDY
Page 3 of 3
CLARITY CLOUDY
SPECIFIC GRAVITY 1.009
GLUCOSE NEGATIVE
BILIRUBIN NEGATIVE
KETONES NEGATIVE
BLOOD 2+ HIGH
PH 7.0
PROTEIN 2+ (200-300 mg/dL) 1
WBC 30-50 0 - 5 HPF HIGH
RBC 20-30 0 - 5 HPF HIGH
BACTERIA NONE SEEN HPF
EPI CELL 2+ (3-5) HPF
MUCUS NONE SEEN
CASTS NONE SEEN HPF
CRYSTALS NONE SEEN HPF
OTHER AMORPHOUS DEBRIS
UROBILINOGEN NORMAL
Comments:
1. Protein test is performed and confirmed by the sulfosalicylic acid
test.

[akusfan1]

Replies to questions -
1. Yes - it looks like BUN and creatinine are trending up. I'll discuss this with Teddy's vet when she calls. The traveling vet has made no comment on it so far.
2. Leslie the 5.4 is with no Vetoryl - Teddy has been off it for two weeks.
3.Marianne - You are correct - see #2.

It looks like the liver numbers have come down some. The question is should I start up the Vetoryl at 30 mg. I'm waiting for the regular vet to give me a call on that point.

[Squirt's Mom]

Then Marianne is right - this is a resting cortisol, not an ACTH so those normal ranges for a Trilo pup do not apply.

I would definitely be asking about kidney function before starting any treatment for Cushing's. Vetoryl is contraindicated in renal impaired pups so we need to make sure they are functioning as they should first.

We do have some members who are quite good at reading these labs and I hope one of them will be able to drop in and go over these results with you soon.

Hang in there! You're doing a good job for your boy!

Hugs,
Leslie and the gang

[akusfan1]

First of all thanks to the people who posted the new comments saying that they are thinking about Teddy and me. I spoke with Teddy's vet about Teddy's latest blood work. Today I also received email from a consulting holistic vet that I have used in the past. I reviewed his recommendations with Teddy's vet also. Bottom line is we decided to
defer the use of Vetoryl 30mg and start giving the consulting holistic vet's recommendation of Tremella 14 tabs and Tortoise Shell tabs each two tabs twice a day. The consulting vet said I should see an improvement in Teddy in 14 days or less. As Teddy's vet said I can always go back to the Vetoryl 30 mg if necessary. I think she wants to avoid the risk of using the Vetoryl if possible.

[StarDeb55]

Wayne, Marianne asked me to stop by & look at Teddy's labwork. I am a lab tech with 30+ years experience, so I'm used to looking at these numbers. First some general comments. Most of the elevations from the 2/25 labs are consistent with Cushing's. We have seen even higher alk phos results on other members pups, so this really doesn't raise a red flag for me. What does raise a red flag, & I believe Lori has already mentioned this is the elevated BUN/creatinine ratio. You now have two sets of labs that show this elevation which now is very concerning for possible kidney disease in Teddy. If memory serves, dogs, in general, can lose something like 70% of their renal function before they will start showing symptoms of renal problems & renal failure. If Teddy were my pup, I would be questioning his vets about renal problems. If the renal issues are found early enough, there are effective treatments available.

[akusfan1]

StarDeb55 - Thanks for the analysis - I called Teddy's vet and she reviewed the blood work with me. She told me in cases like this she looks more at creatinine than BUN. Also the blood work was done by
two different labs so the numbers do not directly talk to each other.
She said there is one piece of the puzzle missing and that is another urine analysis with culture. She would like to know specific gravity and she suspects that Teddy may not be fully over the uti that he had a few
weeks ago. I have arranged for the traveling vet to come back for the urine test. The vet says she will keep an eye on the kidney situation but she says the main concern at this point is to get Teddy back on his feet. Again thanks for your analysis.

[jmac]

Hi-
I was just able to stop by and catch up on Teddy. I'm glad to hear you have been in contact with your vets and that you are all working on helping Teddy.

I just wanted to briefly mention the kidney levels as well. My dog had a very slightly elevated BUN on a couple of consecutive blood tests, but it was just barely off. After the first one, my vet explained that this could be dehydration. Her creatinine and BUN-creatinine ratio were both normal. We still did blood work again in 6 weeks to monitor it. At this point, the BUN was the same. He was not concerned again because the other values were normal. He said as soon as you see more than one kidney level outside the normal range on more than one test, he would be concerned. He also explained what you have already heard: a dog will not show signs of kidney problems until the kidneys are severely damaged. There are ways to help treat a dog with kidney issues, including something as simple as changing the diet. I would persist with possible issues with the kidneys. I would even do some online searches to read more about kidney disease in dogs. I think it is worth pursuing that now.

Thinking of you and Teddy,

Julie & Hannah

[akusfan1]

I checked with the consulting holistic vet and Tremella 14 is also helpful for a dog's kidneys. In two or three weeks the traveling vet will be by for another blood test to check on cortisol levels and BUN/creatinine.
In the meantime Teddy will get acupuncture and a try at swim therapy.
He has never been in the water so that will be a gamble.

[akusfan1]

Teddy update - he really likes swimming. I've taken him two times a week for the last two weeks and he is stronger now. The Tremella 14
has started to work - he seems like a happier dog now, more alert.
I ordered a Doggon Wheels wheelchair which came today. Tomorrow
Teddy will give it a try. Sure hope he likes it and is able to walk using it.
The traveling vet was here today and told me not to use the back stirrups - she thinks his back legs have gotten stronger and he may be able to move without them. We'll see.