Koby - 8 year old Lab mix - diagnosed with cushings, but having problems?

[jillandkoby4]

Hi! My name is Jill & I absolutely adore my dog Koby. I am having a very difficult time because I need help, but feel as if I am not getting all the answers I need to help my Dog. I am hoping someone here can point me in the right direction.

He was diagnosed with Cushings a couple months ago. He had increased thirst, appetite, urination & UTIs. His vet prescribed Trilostane. He also takes Cosquin for arthritis from his ACL surgery several years ago.

A couple weeks ago I brought him back in because he wasn't eating, would trip/fall/tip to the side, would walk extremely slow, panting & had a difficult time laying down. Before being diagnosed (6 months ago), he was somewhat active & could go for walks. Now, I can barely get him outside. The vet took some xrays & prescribed him Rimadyl, Methocarbamol & Gabapentin. She said the x-rays came back fine & thought maybe he hurt himself. He also only would circle to the right & cried when she was feeling his spine/neck area. So, she told me to rest him for 2 -3 weeks & he should be better?

When I got him home, I only gave him the Gapapentin 2x ...because it made him so incredibly dizzy & confused. I couldn't do it it to him, he was walking into walls & falling all the time. I have continued the Rimadryl & Methocarbamol along with his Trilostane & cosequin. But he doesn't seem to be making a recovery & to make matters worse he is now doing some type of shaking/seizure like motion. I noticed it the past 2 nights. Tonight it happened when he was eating?

I am not sure if he is having a bad reaction to Trilostane or what is happening? Before he was on this drug, he was a lot more active. Last summer he would go for walks & would be running inthe back yard...and now it is like he is 10 years older in the past 6 months?

If any one has any advice I would GREATLY appreciate it. I am going to bring him back to the vet again, but was wondering if you might be able to help me pinpoint something.

THANK YOU THANK YOU THANK YOU!
Jill & Koby!

[Harley PoMMom]

Hi Jill and Koby!

Welcome to you both to our forum, so sorry for the reasons that brought you here but very glad you found us.

In order for us to provide you with meaningful feedback, we need additional information about your sweet boy, ok? If you could get copies of all test/s that were done on Koby and post any abnormalities here that would really help us. We are especially interested in the test/s that were done to confirm his Cushing's diagnosis. When was his last ACTH stimulation test done? Could you post those results here?

I am a bit worried that his cortisol might have dropped too low but really need to know his Trilostane dosage strength and if you are giving this once or twice a day. Also are the ACTH stim tests being done 4-6 hours after his Trilostane dose? Is it being given with food?

Does Koby have any other health issues? Was diabetes and any thyroid issue ruled out?

So sorry for all the questions but like I mentioned, the more information we know about Koby the better we will be able to help you help him. Please know we will help in any way we can so do not hesitate to ask any and all questions.

Love and hugs,
Lori

[jillandkoby4]

Hi Lori,

Thanks for helping. I will try to get some of this information from the vet tomorrow, because i don't know it all. He did the test ACTH test 4- 6 hours after the trilostane, but i can't recall if it was with or without food. I think it was without? His Trilostane is 110mg 1x a day...he is 88 lbs.

The only other health issues he has had are his ACLs & arthritis. They did the ultrasound on him, but I am not sure if they ever tested for diabetes and thyroid. They said the ultrasound was OK, there were a couple spots on his liver, but nothing that caused concern.

I was reading another post about Penny & saw these questions from Leslie & they immediately caught my attention because they are what Koby has been experiencing.!

Do you ever notice her eyes rapidly shifting from side to side when she has the episodes you described as a possible mini seizure? I do't see her eyes because it has only happened a few times, but her body & legs do.

Does she circle - not circling to lay down but just going in circles for no apparent reason? yes! & he does it around me sometimes?

Does she press her head against things like walls, cabinets, furniture? Not pressing against you to be petted but just pressing her head against things. ...he did this tonight after a "mini seizure", I thought it was because he was scared & wanted for me to hold him??

And ever since I brought him in last week, sometimes he walks to strange corners of the house & tends to "get stuck"?? like he will try to go behind the couch & squeeze into odd places?

I will try to get more information about his test results & post them here too. Thanks for your help!!!! I already feel better knowing that I have someone to talk to!

[Harley PoMMom]

Hi Jill,

I was wondering of you could check your emailbox (or spam folder) for a communication from us. Once you respond to that email, your membership will be finalized, and anything that you post will become visable on the the forum immediately. Until that time, your replies must be manually "approved" by a staff member before they are visable to the public -- so there may be a bit of delay between the time that you write your replies and the time that you actually see them, so sorry for this inconvenience.

[Harley PoMMom]

Head pressing can be an indication of high blood pressure, has Koby's BP been checked recently?

Trilostane has to be given with food to be properly absorbed. If the ACTH stim tests were done while Koby was fasted than the results will be skewed.

[labblab]

Hi Jill,

Welcome to you and Koby, although I'm so sorry he's doing so poorly right now. As Lori has aready asked, it will help us a lot if you can provide the actual numerical results for testing that has been done so far, and especially the results of any monitoring ACTH tests since Koby started on the trilostane. If Koby has been taking the trilo for a couple of months, I'm hoping there have been at least a couple of monitoring ACTH tests.

Also, do you know whether your vet has determined which type of Cushing's Koby is suffering from -- pituitary or adrenal? I don't want to worry you unnecessarily, but several of the problems you've described can be caused by enlargement of a pituitary tumor. Most pituitary tumors that cause Cushing's are not cancerous and remain very tiny. But in some cases, the tumors can expand and place pressure elsewhere in the dog's brain, resulting in neurological abnormalities. Loss of appetite, mental "dullness" or confusion, circling, pacing, pressing the head against hard surfaces, getting "stuck" in corners or closets -- these can all be associated with an enlarging pituitary tumor. Unfortunately, the definitive diagnostic for this is either a CT scan or MRI of the dog's head. These are relatively expensive procedures that most general practice vets are not equipped to perform.

And prior to even considering that kind of diagnostic, probably the first and most important thing would be to have another monitoring ACTH done (if it hasn't been done really recently) in order to make sure that Koby's cortisol level hasn't dropped too low. Low cortisol can also cause a whole host of symptoms and problems. In addition, I think you would also want to check Koby's basic blood chemistries to make sure that nothing is out of whack in that regard. Not only does trilostane lower cortisol, but it also has can lower another hormone, aldosterone, which maintains a healthy balance of potassium and sodium in the body.

Please do let us know as much as you can about Koby's testing thus far. Thanks so much!

Marianne

[jillandkoby4]

Hi Marianne,

They diagnosed him as adrenal.

And another strange thing he has been doing lately is when he eats. he used to eat all his food at once. Now he tends to take a couple bites, then do a circle & come back & then a couple more bites & then circle again & so on. I don't know if this means anything, but he has never done this until recently as well?

I will try to get my information from the vet & schedule another ACTH test as well.

[labblab]

Jill, can you also find out how your vets determined it's adrenal?

Marianne

[jillandkoby4]

Hi

I just got off the phone with vet. I am going to bring him back in today & I also got this information while on the phone with them.

10/25/11 Dexamethasone test
Pre-dex 3.19 ref range 1.84-4
Post dex 1 (4hrs) 1.12 Ref range 0 - 0.5
Post dex 2 (8hrs) 1.00 Ref range 0 -0.5

Blood test: 10/21/11
Glucose (diabetes) 103 range 60 - 125
**Thyroid: T4 showed less than 0.4 range 1-4 That was low?

11/02 Ultrasound: "found large liver" ??- I think they thought this could have been from his UTI...but will ask at appt today. Adrenal was the "upper limit of normal size w/no masses"

12/16/11: ACTH fasted for this test
Pre: 0.651 range 1.8 - 4
Post: 1.84 range 6 - 16
His trilostane pills were adjusted after this. But realized we should request another one to make sure the adjusted amount is working correctly?

Any advice anyone has would be greatly appreciated.

[labblab]

Jill, I have only a moment to post right now, so I apologize for being brief -- I will try to come back later to post some important links for you to read. But I'm really anxious to catch you before you take Koby in to the vet today, because in order to be accurate, an ACTH test should be performed within 4-6 hours of being dosed, and needs to be given along with food. If that can't be done today, you'll want to wait until tomorrow. I'll post a link later on that helps explain why.

And secondly, yes, that does sound like a very low thyroid result and that may be contributing to Koby's problems:


Neurologic signs might be seen, and include dullness, mood swings, muscle wasting on the head, facial paralysis, head tilt, disorientation, muscle weakness or paralysis, and lameness. On very rare occasions there will be seizures, and coma. Two specific diseases associated with hypothyroidism are megaesophagus and laryngeal paralysis. A loss of smell and taste are also possible.

Low thyroid can cometimes be secondary to Cushing's and expected to improve with Cushing's treatment. But I think that with a T4 level that low, your vet needs to do some more complex thyroid testing to see if thyroid supplementation is needed, regardless of the Cushing's. So I'm worried about both Koby's cortisol and thyroid levels.

I'll come back and write more later...

Marianne

[marie adams]

Hi Jill and welcome to you and Koby,

It is so hard to see your buddy having problems. I am so sorry you and Koby have to go through this--We all know that feeling.

With posting the results the experts can give you great advice.

I only know how the ACTH test results should look because that is the only test I did with my Maddie Girl. In My Opinion they look low, but I am not an expert. What was the change in dosage the vet made--up or down.

Marianne or Lori will be by to give you better info--you are in good hands.

Hang in there you will get the answers here.

[labblab]

Jill, I just added another reply to your thread, too. It's on the bottom of "Page 1" -- I just want to make sure you see it before heading to the vet.

And as Marie has asked, please do tell us what the trilo dosing adjustment was. The December ACTH result would probably have been even lower had Koby not been fasted for the test, and it was already almost at the bottom of the desired range for a dog being treated with the drug...

Marianne

[labblab]

And one more thing -- can you double check the reference range for the normal values at 4 and 8 hours on Koby's LDDS test?


10/25/11 Dexamethasone test
Pre-dex 3.19 ref range 1.84-4
Post dex 1 (4hrs) 1.12 Ref range 0 - 0.5
Post dex 2 (8hrs) 1.00 Ref range 0 -0.5

What you've written down is 0 - 0.5, but with all the lab reports that I've seen, the "normal" range is usually between 0 and 1.4 or 1.5. So now I'm also worried that the LDDS might not have been "positive" for Cushing's in the first place, and Koby's primary problem all along has perhaps been untreated low thyroid!

[jillandkoby4]

Thank you Marie & Marianne.

His prescriptions for Trilostane was 130 mg on 11/03/11 lowered to 110 mg in December. And he has been on the 110mg since then without any further testing.

From what the technician told me earlier about the Dex test, those ranges are the same I wrote down. And actually, I did make a mistake. His postdex2 at 8 hours was 1.99 (not 1.00 like I typed) & it says ref range was 0 - 0.5. I can double check this when I go in at 2pm EST.

I talked to another vet on the phone a couple weeks ago & she suggested looking into his thyroid more, but my Doctor thought that he might have hurt himself instead since he wimpered at some of the test she did on him. She also found a "fatty tumor" on his lymphnode. She had a cytology done on that, but it came back normal. She thought that the fatty tumor could have been bothering him & that is why he was uncomfortable. But I think that it could be something more & the thyroid information Marianne posted looks like it could be what is bothering him.

Thanks for the tips! I will keep you updated!! I APPRECIATE IT. It is so nice to finally have someone to talk to about this!! :)

[jillandkoby4]

After looking at the Dextests...if the technician told me the wrong range for the 8hr test & we use the range that Marianne suggested 0 - 1.4or1.5 with Koby's result being 1.99 he was still high. I typed it wrong the first time, I am sorry for the mistakes. So, he probably was diagnosed correctly for cushings, but I wonder if his thyroid needs treatment as well?

[Harley PoMMom]

In the presence of other non-adrenal illnesses, such as diabetes and thyroid issues, the LDDS test can create false positive results. This is the reason why non-adrenal illnesses should be ruled out and since not one test is 100% accurate at diagnosing Cushing's, more than one Cushing's diagnostic test should be done to validate a Cushing's diagnosis.

[tankers]

I am so sorry to hear about Koby. My 8 year old BT has been diagnosed too. It's difficult trying to figure this all out. What dose did they first start Kolby on? 110mg seems very high.

[jillandkoby4]

Update on Koby's appt today:

They are doing the full blood test to check his thyroid & liver levels. I also plan on bringing him in a couple days for an ACTH exam.

The vet agreed that he is still pain. He checked his blood pressure & it was a little bit high but she thought it was from his stress at the appt (he's a big baby & doesn't like to go to the vet). :) She did a neurological exam too. & I don't know what the official term for it is, but she tried stretching his neck side to side & felt/pressed down his spine. Very sad to say, that he was still in quite a bit of pain in his neck when he went to the left. She thinks that it is degenerative disc disease & refilled his pain meds/muscle relaxers for me.

I am hoping that he will feel better after more rest. He has improved & tends to be moving around a little bit better, but he is still scared to do stairs & his neck. Saying some extra prayers for him tonight.

Will get the results from his blood test tomorrow & am interested to see what the results for the thyroid & liver are.

[jillandkoby4]

Hi!

Sorry, I haven't been online lately. We have had an ill relative and haven't had much free time. Thank you to all who have been supportive. It is wonderful to have this group, you are all very kind.

I have a few updates on Koby. Sadly, he is still having issues, but I believe it could be related to his meds. The results from his last ACTH were:
pre 0.602 range 1.8 - 4
post 1.54 range 6 - 16 (these seems incredibly low to me?)
At this time he was on 110mg of trilostane. After this test, they removed him from the trilostane for 1 week. For the first few days after i stopped the medicine, He was SOOOO good!! All of the confusion, circling, lack of appetitte, leg issues disappeared & he was the best I had seen him in a several months. Then his cushings signs reappeared & I started him on 90mg of trilostane a couple weeks ago. Since then, he has slowly started to get more confused, panting, lethargic & leg issues have all started to come back and are getting worse each day.

Am I niave to think that these signs could be related to the trilostane? I feel like he seems to be "overdosed". I am going to call on Monday to see if we can do another ACTH test, but he has only been on the 90mg for 2 weeks. Has anyone else run into these issues?

I read that giving a dog a smaller dose 2x a day instead of 1x a day can help with side effects. He is 88 lbs & He was originally put on 130 mg, then lowered to 110 mg & now lowered to 90mg...but I feel like he is acting like a dog that is drugged, anyone who sees him comments about how "distant & zoned out he is".

Thanks for any help! You guys are the BEST!
Jill & Koby

PS: His full Thyroid Panel came back "normal". They said that 1 area of it was a little low, but that the vet & Cornell both associated that it was because of his cushings.

[labblab]

Jill, from what you are describing, I would suspect that the 90 mg. is still too big a dose for Koby. And although the need for an additional dosing change is frustrating, it is not unusual. Some dogs require several "tweaks" in order to arrive at their optimal dose. Since all of these unwanted effects cleared up during the time Koby's first break from the trilostane, it makes sense that they are indeed drug-related. So if it were me, I'd again withhold the trilostane for several days while contacting your vet and making arrangements for another dosing decrease.

Marianne