13-year-old Husky with possible Cushing's

[Kris]

Hello, all. I am new here and want to start by saying thank you to everyone. I have been reading this forum for the past couple of weeks—since we received a possible Cushing’s diagnosis for our dog, Cali—and am so grateful for all of the amazing information and support this site offers. I am in awe of your knowledge and compassion. Thank you again.

Here are Cali’s details:

Cali is a female (spayed) Siberian Husky. She will be 14 years old in August and weighs 57 pounds. She has had muscle weakness, especially in her hind legs, for the last couple of years. Additionally, over the past 6-8 months or so, she has presented with PU/PD, increased appetite, excessive panting, wheeziness/somewhat labored breathing, lethargy, listlessness, skin growths, and recurrent UTIs that are very resistant to treatment. (One note about her appetite: she has never been that interested in food and was never much of an eater, so I’d say now she is eating more like a normal dog but isn't ravenous or anything, though it is certainly a marked increase for her.) She doesn’t appear to have hair loss (indeed, her hair is coming back nicely from her recent ultrasound) or a potbelly. Her ALT and Alk Phos numbers have been high and climbing over the past few months, which prompted our regular vet, Dr. Mitchell, to recommend an abdominal ultrasound to look for liver cancer. However, we found instead a 1.9cm adrenal tumor on her left adrenal gland.

Based on that finding, Dr. Mitchell said that Cali probably has adrenal-dependent Cushing’s. However, because he doesn’t have much experience treating Cushing’s, he wanted to consult with some other vets who specialize in endocrinology and/or internal medicine.

Based on his discussions with them, he performed an LDDS test, which came back positive for Cushing’s but not necessarily consistent with an ADH since the numbers weren’t all that high and did in fact suppress. So that is where we stand right now. For ease of reference, I’ll set out all of her numbers here:

FS Siberian Husky; 13 yrs, 7 mos; 57 pounds

Bloodwork 1/6/12
ALT (SGPT) 192 (ref 12-118)
Alk Phos 893 (ref 5-131)
Cholesterol 400 (ref 92-324)

Bloodwork 2/11/12
ALT (GPT) 341 (ref 14-151)
Alk Phos 2241 (ref 13-289)
Cholesterol 334 (ref 98-300)

(For her bloodwork, I have included only abnormal results; if you’d like the other numbers, I am very happy to provide them.)

Abdominal Ultrasound 3/1/12
Liver: mildly enlarged with course echotexture and increased echogenicity. No masses or nodules.
Kidneys: both normal in size and shape with normal corticomedullary distinction and no pyeloc[rest of word unintelligible on lab results]. Mild bilateral mineralization of the renal diverticuli.
Urinary bladder: several (3-4) small calculi in the urinary bladder, largest measuring 7mm.
Right adrenal: normal in size and shape.
Left adrenal: 1.9cm hyperechoic nodule on the cranial pole of the left adrenal gland. There was no evidence of vascular invasion by the nodule.
Ultrasonographic diagnosis: There was a left adrenal tumor that could be either a benign adenoma or an early malignancy such as a carcinoma or pheochromocytoma. There was no evidence of regional soft tissue or vascular invasion by the tumor. The right adrenal was normal. There was a suspected benign hepatopathy such as steroid hepatopathy or vacuolar degeneration. Hepatic neoplasia was not suspected. There was mild bilateral nephrocalcinosis and several small calculi in the urinary bladder. The rest of the exam was normal. Recommended biochemical testing for suspected adrenal-dependent hyperandrenocorticism. A left adrenalectomy is likely indicated.

LDDST 3/12/12

Baseline 2.8 ug/dL
4hr: 2.3 ug/dL
8hr: 1.6 ug/dL

After the LDDS test, Dr. Mitchell consulted with Dr. Wilson, an endocrinologist, and says she recommends that we now start Trilostane at 2 mg/kg once a day. However, he also forwarded me the whole e-mail chain of his conversation with Dr. Wilson, and I don’t think that is what she is suggesting at all. Indeed, she says that while the LDDS test is positive for Cushing's, it doesn't tell us whether it's PDH or ADH. She also said that she would expect an AT to have higher cortisols than this and not to suppress this much. Therefore, she says that we need to figure it out with another round of testing.

She says that we could do an HDDS now, and if it suppresses, we’d know that this is PDH and that the nodule on the left adrenal is just incidental. If it doesn’t suppress, however, we're at the same place we are right now—i.e., it could be either PDH or ADH.

Because of the potential for continued confusion, she says that personally, she would do an endogenous ACTH level now and stresses that it must be handled meticulously. Specifically, she explained that it's a labile substance that likes to die in the tube if not handled perfectly and told Dr. Mitchell to see if the lab can send him an aprotonin tube to submit the sample in and then to submit it directly to an endocrine lab (e.g., like at MSU).

Dr. Wilson also says to get a cysto sample and culture automatically, even if the sediment is quiet, to check for an asymptomatic UTI.

In response to all of this information from Dr. Wilson, Dr. Mitchell e-mailed her back asking if we could just start Trilostane now. She said that is fine if the owner is resistant to further investigation. However, I am certainly NOT resistant to further investigation! The only thing I am resistant to is performing an adrenalectomy on Cali at her advanced age and general state of less-than-stellar health. (The doctor who performed the ultrasound recommended the surgery, but given that we don’t even know if it’s ADH or PDH now, this point may very well be moot. Dr. Mitchell and a vet friend of mine both recommended against the surgery, stating that Cali is not a good surgical candidate.)

So this is where we are. I am currently in the process of drafting a response to Dr. Mitchell saying that Dr. Wilson is in fact not recommending Trilostane but instead advocates further testing.

I would love to hear your thoughts—on Cali’s numbers, potential diagnosis, next steps, further testing, or anything you’d like to comment on. Thank you again, so so much. The past couple of weeks have been really rough with many tears, and my heart absolutely breaks at the thought of losing Cali. I want to do all I can to keep her happy, comfortable, and as healthy as possible for as long as possible, and you have all been a tremendous help in letting me know that this is possible. Thank you again—you are all amazing.

Kris (and Cali)

[DCMuffin]

Hi Kris. :) I'm brand new here, too, so I've got absolutely nothing experience-wise to offer you. But, from one newbie to another, I wanted to at least welcome you and wish you the best with what's happening with your sweet Cali. :)

[labblab]

Dear Kris,

Welcome to you and Cali! Having read through your post and Cali's lab results, it does seem to me as though Dr. Wilson is providing sound advice and solid information. From my own reading, I would agree with her that the endogenous ACTH would be the most accurate "next" step to take if you do wish to pursue differential diagnostics re: PDH vs. ADH. However, if you do not feel as though Cali is a surgical candidate, I'm really not sure how much value there is in moving forward with additional testing. If a surgical cure is ruled out, then both forms of Cushing's are treated medically using one or the other of two drugs. Trilostane is one of those drugs, and the initial dose that Dr. Wilson has suggested (approx. 2mg. per kg.) conforms with the recommendations of Dechra (manufacturer of brandname Vetoryl).

If for your own peace of mind, you would feel more comfortable with clearer diagnostics, then the additional testing would be worth iti to you. But in terms of altering Cali's initial treatment in the absence of surgery, I don't think it will make a significant difference. Does that make sense?

I am so glad you have found us, though! And as I say, it sounds as though Dr. Wilson is providing accurate advice and information. And playing devil's advocate on behalf of Dr. Mitchell, perhaps the reason why he pressed ahead re: medication is because he already knew, in advance, that you would not be considering surgery.

Marianne

[Kris]

Thank you both for the kind welcome and very helpful information!

Marianne, you make perfect sense! Indeed, so much sense that I had a palm-to-forehead "duh" moment after reading your response. I guess I have been so obsessed with having as much information as possible that I thought continued testing was required. But you are right--if we are not considering surgery, then the benefit of further investigation is greatly diminished if not nil. And you are right again about Dr. Mitchell--he knows we haven't been keen on surgery, and he himself has recommended against it, so his recommendation for meds makes all the more sense.

My one question is should we wait to do the UA to look for an asymptomatic UTI, as Dr. Wilson suggests, before starting the Trilostane? I think I remember reading somewhere that UTIs should be treated before starting meds, which would certainly seem to make sense, but I could definitely be wrong.

Thanks again for helping me get my head on straight!

Kris

[labblab]

Kris, my own thought is that when starting out with Cushing's treatment (either trilostane or Lysodren), it is easier to monitor the medication's effect if there are no other new variables added at the same time. For instance, in order to judge the effectiveness of trilostane, you are wanting to see a decrease in symptoms such as excessive thirst and urination. At the same time, you are hoping NOT to see unwanted side effects such as vomiting or diarrhea. So I think it's best if you aren't introducing other new meds (or changing dogfood, instance) right at the same time that you start with the trilostane.

For that reason, if Cali were my own dog, I'd probably wait to see if an antibiotic needs to be prescribed and if it's only needed for a short course, finish that first before starting the trilo. If a longer course of antibiotic is needed, I'd still wait for a week or so before introducing the trilo in addition to the antibiotic. That way, I'd know how the antibiotic was affecting Cali prior to starting the trilostane, too. But you can always ask Dr. Wilson's opinion about that.

Marianne

[labblab]

I just wanted to add that, often you will see us recommending that evaluation for a UTI be performed as an important part of the initial diagnostic process -- and therefore, before starting any Cushing's treatment whatsoever. This is because you want to rule out other possible causes for excessive thirst/urination, which are probably the most common external symptoms that prompts owners and vets to consider Cushing's in the first place. Also, it is possible for untreated infections and nonadrenal illnesses to skew the results of the diagnostic Cushing's blood tests.

In Cali's case, I am assuming that Dr. Wilson is not doubtful about the Cushing's diagnosis, in general. But instead, she is just wanting to help eliminate the possibility of a persistent UTI that could complicate treatment. But if you have any questions as to why she is recommending the testing, I'd ask for clarification.

Marianne

[Kris]

Thanks again for the wonderfully sound and informative advice. I will contact our vet to discuss testing for the UTI and to plan for treatment with trilostane. I feel such tremendous relief at having a plan and such an amazing resource in all of you. Thank you again.

[Squirt's Mom]

Urinary bladder: several (3-4) small calculi in the urinary bladder, largest measuring 7mm.

Something else to ask about, Chris.....cush pups are prone to oxalate stones so you will want to know what type of calculi these are and what needs to be done to help with these stones.

Hugs,
Leslie and the gang

[kal′kyələs] pl. calculi
Etymology: L, little stone
1 also called stone. an abnormal stone formed in body tissues by an accumulation of mineral salts. Calculi are usually found in biliary and urinary tracts. Kinds of calculi include biliary calculus and renal calculus.

[Kris]

Hi, again, everyone. First, Leslie, thank you so much for the note about the oxalate stones--I'll definitely ask her vet about them.

So more generally speaking, I’ve been thinking more about Cali and Cushing’s today (I feel like that’s all I think about lately!), and I think part of my unease comes from wondering if Cali has Cushing’s at all. I know it is a very difficult diagnosis to make and that we can’t be 100% sure, so maybe I’m overthinking it. But I was wondering if some of you could give me your thoughts on the diagnosis overall in light of the information below. Thanks so much!

On the pro-Cushing’s side, Cali certainly has a lot of the symptoms as I mentioned in my first post: muscle weakness especially in her hind legs, PU/PD, increased appetite, excessive panting, lethargy, listlessness, skin growths, and recurrent UTIs. Then of course there is her adrenal tumor. So all of this made me feel quite certain of the diagnosis.

However, some things are nagging at me. As I mentioned, she doesn’t have a potbelly or hair loss. She is certainly eating and drinking (and peeing) more, but I don’t know that it’s excessive. She used to eat maybe 1 bowl of food per day plus treats; now she eats 2 bowls of food plus treats. Of course, maybe she’d eat more if I gave it to her, and she does seem more interested in food overall. She used to drink 1-2 bowls of water per day (20 oz each); now she drinks 3-4. Her urination frequency has increased, to be sure—I work from home, and during the day I probably let her out once every hour or two during waking hours, whereas she used to go out only 3 times per day total. However, she doesn’t need to go out during the night (at least she doesn’t make it known that she does), and she hasn’t had any accidents in the house overnight or when she's been left alone for 8 or so hours at a time. I know all dogs don't show all symptoms (thank goodness!), so again, maybe I'm overthinking it.

Back to the pro-Cushing's side, her LDDS test was positive (baseline: 2.8, 4-hour: 2.3, 8-hour: 1.6). However, I have read that this particular test has a relatively high incidence of false positives, especially if the dog is very stressed. And I have no doubt Cali was a basketcase during the test. :) To say she is high-strung is a serious understatement. The girl freaks out over the smallest things—if you sneeze, sometimes even if you sit less than two feet from her, etc. I love her more than words can say, but she can be a challenge. And she absolutely loathes being touched or handled by almost anyone, especially the vet. Plus, all of her vets throughout her life have said she has a low pain threshold and/or is a bit of a drama queen. So her stress level must have been through the roof. Therefore, I wonder about the validity of the test results.

If the test is reliable, though, is it still definitely Cushing’s (as definitive as we can be anyway)? The numbers aren’t that high, and the endocrinologist said that they are more in line with PDH, regardless of the tumor, and that she would have expected more cortisol and less or no suppression for ADH. So while Cali has a tumor, a fact which made me more confident in a Cushing’s diagnosis, apparently that could be a coincidence. Plus, her other adrenal gland hasn’t shrunk.

So these are my nagging thoughts that go back and forth and back and forth. I imagine it’s not good to treat her with trilostane if in fact she doesn’t have Cushing’s, and I don’t want to make her feel worse. I will bring all of this up to our vet but wanted to post it here too—honestly, I think the collective wisdom here might be greater than that of any vet anywhere!

Thank you for listening to my ramblings and for all of your help. Cali and I both appreciate it very much.

Kris

[Harley PoMMom]

It could be possible that Cali has a pheochromocytoma tumor on her adrenal gland. These kind of tumors do share many of the same symptoms of Cushing's. Here is a link about pheochromocytomas: http://www.addl.purdue.edu/newsletters/2007/Spring/CP.htm

Love and hugs,
Lori

[labblab]

I think Lori has made a good point, especially in light of the ultrasound report which itself lists a pheo as a possibility. If Cali does have a pheochromocytoma, then trilostane would not be a recommended treatment. I am not certain whether there are additional noninvasive diagnostics that would be helpful in identifying a pheo -- that would be another question to ask Dr. Wilson. Pheos are not common, but we have had a couple of members here whose dogs have suffered from them. Often, high blood pressure or heart irregularities will accompany pheos.

However, if she does not think a pheo is likely, you're still left with the treatment decision. Unfortunately, Cushing's is not a "tidy" illness for which diagnosis is clear-cut. There really is no single test that can diagnose Cushing's with certainty. So instead, you are left with deciding how likely it is that the symptoms you are seeing are being produced by Cushing's. Part of that process is ruling out other diseases that can cause the same symptoms, which you've done. The next part is seeing whether specific testing is consistent with Cushing's, which you've also done. You could also request an ACTH stimulation test (different from the endogenous ACTH) in addition to the LDDS. As we said above, it is less likely to return a "false positive." And since the ACTH will be used to monitor the trilostane treatment, it can be helpful to know, beforehand, where the cortisol level is prior to starting the drug. But a drawback to the ACTH is that it does not do a good job of identifying the adrenal form of Cushing's. So if that's what Cali does suffer from, it may turn out "negative" even though she has the disease.

So the bottom line is, unfortunately there are few certainties to Cushing's diagnois. Most of the time, you have to go with the odds and the overall big picture. And then carefully monitor and evaluate the drug treatment. If it is not helping or produces unwanted side effects, then it's time to rethink the process. As I said earlier, it does sound as though Dr. Wilson is on the ball. Perhaps you can speak with her directly and clarify your additional questions? If so, I would trust her feedback and recommendations.

Marianne

[Kris]

Thank you all for your kind words and wise advice. I appreciate it SO much. Cali is going in tomorrow for a cystocentesis (about which I am sooooooo nervous), and at that time I plan to follow up with the vet about all of my questions. Thank you again!
Kris and Cali

[marie adams]

Hi Kris, welcome to you and Cali!:)

I so remember all the thought processes I went through in the beginning of Maddie's Cushing's. I knew though without much testing what she had because she had so many of the symptoms. I never had an ultrasound done because she was 11 yrs old and for me I didn't want to put her through that.


I think the collective wisdom here might be greater than that of any vet anywhere! You are so right when it comes to the wisdom of everyone here....:) I felt this way once I found all of them. They guided me through all the tuff times and the good times.

You are family here so feel free to ask questions and vent.

Take care!!

[frijole]

Hi - I'm just letting you know that my baby girl had a pheochromocytoma and was misdiagnosed with cushings... I'll spare you the story... if you suspect it might be a pheo feel free to send me a PM and perhaps I can save you alot of money on testing. They are very rare - extremely rare. Take care , Kim

[frijole]

I just wanted to add to this thread that there is no pheochromocytoma test. I was told that Annie exhibited all signs of having a pheo but since the blood pressure tests taken at K State did not indicate high blood pressure they could not classify the tumor as being a pheo. They said I should continue monitoring and have her tested during the next episode - in short she did have high blood pressure - but only when the tumor was active.

That is what makes diagnosing so difficult - the tumor can be active for seconds, minutes but rarely for long so by the time you get to a vet the dog is acting normal and you look like a fool when you say " she can't walk, she was breathing like she was in cardiac arrest, etc"

Sharing this in hopes it helps you and others going thru the process. I agree with Marianne - if it is a pheo - trilostane is not the solution and could make things worse.

Has your vet done an acth test? I would LOVE to see the results to see if the pre number is high like Annie's consistently were. Not like a normal cush dogs.

Annie's ldds tests all had perfect curves like a pituitary cush dog would have ;) confused the hell out of everyone... So you aren't alone!!!

[Kris]

Hello, again, everyone. I thought I’d check in about Cali, even though we don’t have any huge news. A vet tech called yesterday and said that there is indeed bacteria in her urine (Cali had a cystocentesis last weekend) and that the strain is particularly resistant to treatment. They didn’t have any other information and said they’d get back to us when they get the full results—these results were just preliminary. So I assume some antibiotics are in Cali's future.

I sent all her info to a friend of a friend, who is a vet, and—bless his heart—he studied it all and did a ton of research. His take is that it’s PDH and recommends an ACTH stim test (nope, Kim, we haven’t had one yet, but I will be sure to post the results when we do!). He also said to get a referral to an IMS from my regular vet and that is what he does for his Cushing’s patients so my vet shouldn’t have any issues with that request.

Speaking of our regular vet, he still hasn’t gotten back to us about all of our questions. It is not in my nature to be confrontational in the slightest, but I have to advocate for Cali, so I guess I have to be far more insistent with him. In his defense, he probably feels that there aren’t really any questions to be answered since nothing is really clear-cut about Cushing’s or pheos.

I also just want to confirm that he has definitely ruled out other potential causes of her symptoms (again, to the extent anything can be definite). Her glucose is normal, so I guess it’s not diabetes. Her kidneys were normal on the ultrasound, so I suppose that means kidney disease is out. I don’t know if he’s tested her thyroid. He did say her gallbladder is “sludgy,” but he also said that that is to be expected at her age. He probably has ruled everything else out, so I guess we are just looking for one last confirmation before we start her on trilo, if that's the route we go.

I would love to consult with Dr. Wilson, but she is just a vet he’s been talking to on a message board, so I don’t have her contact information. Plus, she is in Seattle, and we are in Chicago. Given the size of Chicago, though, I have no doubt that there are some great internal medicine specialists here, so—knock on wood—hopefully we'll find one soon.

I do have a few quick questions for you amazing Cushing’s experts: Would it be worthwhile to get the UTK panel done? Is it helpful at all in trying to differentiate Cushing’s from a pheo, or not so much? Also, I am assuming I should make sure our vet has ruled out thyroid problems and confirm that her gallbladder sludge truly isn’t an issue. If you have anything to add about those points, just let me know. Also, Cali has been particularly wheezy lately; she's had that symptom for quite a while, but it's more pronounced lately. I believe I have read that that can be a symptom of Cushing's, but I was just wondering if any of the members here have any experience with it. Of course, she never seems to have the symptom on the days she goes to the vet! Oh, I have also asked the vet to get back to me about the calculi in Cali’s bladder since they could be oxalate stones (thank you, Leslie, for that tip) and will let you all know what I find out.

Thanks again for all your wonderful help and support. I truly don’t know what I would have done without finding you all!

Kris

[frijole]

Hi it's me again. :D

Funny you should ask that question because I considered doing the UTK panel at one point. I never did and I am glad I saved the money. To answer your question - no it does not determine whether the tumor is a pheo. It measure levels of cortisol (the acth test) and it measures sex hormones.

Now all of these can be elevated as a result of a pheo but in no way does the test diagnose a pheo.

Without a doubt, if I were to spend a penny more, if I were you I would find the absolute best specialist in the area and go there. Teaching hospitals are typically less expensive which is why I'd search there first - plus they can be leading edge, depending on the school of course.

Hope this helps.

Kim

[labblab]

Dear Kris,

I agree with Kim re: both her suggestions. I wouldn't bother with the UTK panel, either. Since the LDDS suggests that Cali suffers from elevated cortisol, it is most likely that she also has elevations in some of her intermediate adrenal hormones, too (elevated intermediates typically accompany elevated cortisol). So the panel really won't tell you anything that you wouldn't already suspect.

And I also agree about the IMS referral. In case this is helpful, here's a link to a website that will list all credentialed specialists in your area:

http://www.acvim.org/websites/acvim/index.php?p=3

As far as additional testing, the ACTH stim test would certainly be reasonable and perhaps very helpful. As I wrote above, it doesn't do such a good job with diagnosing adrenal Cushing's. But it is less likely than the LDDS to return a "positive" result if Cali doesn't really have Cushing's at all. So if you test her and she's positive, that's one more validating result (plus you'll have a baseline cortisol level for beginning treatment). If she's negative, then that's even more reason for seeking feedback from a specialist.

Thanks so much for updating us, and I'll be really anxious to know how things proceed for you girls.

Marianne

[Squirt's Mom]

Hi Chris,

Sounds like you have it going on! :cool: I approached Squirt's diagnosis in a similar manner - thoroughly testing for everything I could think of, and it saved her life by finding that tumor on her spleen. Determining any other issues and addressing them first is important and you are doing a good job at that.

The UTK panel is a good test when needed. It is needed when the pup exhibits Cushing's signs but all the conventional tests show normal cortisol levels. This is when the UTK is put to use, as the intermediate, or sex, hormones can cause the same signs as conventional Cushing's which has elevated cortisol - the form the UTK panel looks for, Atypical Cushing's, has normal cortisol levels. So, I agree - save your money on this test. ;)

Somewhere in the deep, dark recesses of my feeble mind I seem to recall that Cushing's can weaken the structure, or musculature, of the trachea - which might account for the wheezing. I will try to find the reference to that...or come back and let you know my mental librarian screwed up again. :p

My Squirt also has sludge and I have use Burdock Root for that. There are other medications available that can help, too, if needed.

Keep up the good work!
Hugs,
Leslie and the gang

[Kris]

Hi, again! Thanks for all the great advice and wonderful support. You guys are the best. And Leslie, I sooooo know what you mean about your mental librarian—mine seems to keep losing things as well. Maybe they need a vacation :)

I thought I’d check in about Cali since we’ve made a little progress…well, sorta. She is almost two weeks through her three-week course of amoxicillin for her UTI, so things are going smoothly there. We’ll get another culture done about a week after her antibiotics end.

The most interesting piece of news is that her UCCR came back negative, giving us all quite a surprise. According to our vet, “It came back @ 1.4 nmol/mmol. Per our diagnostic lab anything under 5.0 nmol/mmol suggests that Cushing's is unlikely, therefore we must consider that Cali might not have Cushing's.” So if my understanding is correct, this is a little more evidence in the pheo column. Also, I just learned from my husband today that Cali did in fact have borderline high blood pressure when they tested it a couple weeks ago, though they said the results were unreliable due to her stress. But at least that is another piece for our ever-growing puzzle.

Our vet suggests doing the ACTH stim test and sending her thyroid panel to MSU as our next steps. I am trying to get these scheduled for next weekend and will definitely post all the results when we get them. Thank you again for being here for us. Knowing I can come here and check in with all of you wonderful people means the world to me. Thank you so much.

Best,
Kris and Cali

[Kris]

Hello, everyone! I hope you and your Cush-babies are all doing great. I thought I’d check in as we just got the ACTH stim results for Cali. I’ll list these below, as well as her other test results so you don’t have to search the thread if you want to see all of them:

ACTH Stim Test:
Baseline Cortisol 3.1 ug/dL (ref range 1.0- 5.0ug/dL)
1-hour Cortisol 23.5 ug/dL (ref range 10-20ug/dL)

UC:Cr Test:
1.4 nmol/mmol (up to 5.0nmol/mmol is normal)

LDDS Test:
Baseline 2.8 ug/dL
4hr: 2.3 ug/dL
8hr: 1.6 ug/dL

So we have a positive LDDS, a negative UC:Cr, and a borderline positive ACTH. According to our vet, this does not give us the slam dunk we were looking for, so he’s going to consult with an IMS. We are still waiting for the results of the thyroid panel.

On the homefront, Cali has been having a rough couple of weeks: her breathing is even wheezier than usual, and she is falling a lot. Previously, she was falling maybe once every 2-3 weeks (where her hind legs just give out), but now that is happening almost every day. When it happens on the hardwood floor, she cannot get up on her own, though on carpet she can pull herself back up with her front legs. It’s absolutely heartbreaking to see. It just about kills me.

So this is the latest. I don’t know if I have any specific questions—still digesting it all—but I wanted to post this in case you brilliant Cushing’s experts had any thoughts. Thanks so much for your continued support—it means everything to us.

Kris and Cali

[labblab]

Hi Kris,

I'll definitely be interested to hear the opinion of the IMS. But I am thinking that the ACTH and LDDS results will end up "trumping" the negative UC:CR. It is true that Cali's post-ACTH result is not highly elevated, but if the diagnostic cut-off point for the lab is 20 ug/dl, then Cali's result of 23.5 would seemingly be considered a positive for Cushing's. Although the UC:CR is a good test in theory, we've been warned by at least one veterinary endocrinologist that UC:CR testing based upon one single urine sample can be of questionable value (he recommends testing a pooled sample containing urine from three consecutive mornings). So I'm guessing the results of the ACTH and the LDDS will carry more weight with the IMS. But time will tell -- and I will be very interested to hear what the IMS says!

Marianne

[labblab]

Hi Kris,

Just wondering if you've gotten the thyroid results back yet? How's sweet Cali doing?

Marianne

[Kris]

Oh, thanks so much for checking in, Marianne. That is so kind of you. I really appreciate it. We did indeed get her thyroid results back, and everything was within normal ranges. If you’d like me to post anything specific from the test, just let me know. (Just as an aside, I don’t remember if I mentioned this before or not, but we also had the specific gravity of her urine tested, and it was 1.026, which my vet said was normal.)

Our regular vet, Dr. Mitchell, also consulted with Dr. Wilson, the IMS, and just got back to us; he said that Dr. Wilson was perplexed by Cali’s test results as well (positive LDDS, negative UCCR, positive ACTH) but that they both think that we should start Cali on a low dose of trilostane and see if she responds. So it sounds like your prediction was spot-on, Marianne--that the LDDS and ACTH trump the UCCR. It looks like we will be starting her on 60mg probably by the end of the week (Cali weighs 61 pounds right now). Dr. Mitchell also said that a follow-up ACTH stim test is usually recommended 10-14 days after starting trilostane but that maybe we just should just see how Cali does instead. I don’t know about you, but I am not comfortable with that approach. I think I’d like the test just to be safe.

Cali girl is still having a rough time—panting a ton, really wheezy (especially when coming inside from chilly temperatures), quite unsteady on her hind legs. She’s also not eating or drinking quite as much as she has been, though she is still happy to eat lots of treats. :) I’ve mentioned her labored breathing to the vet, but he doesn’t seem too worried about it. I am, though, of course. Nothing surprising there! :) I know there may be nothing we can do about it, but if anyone has any thoughts on treatment options, please let me know. I was wondering if there was something like an asthma medication or bronchodilator that anyone has had experience with. But I guess we’d still need to get to the bottom of the cause with the vet first.

So that is where we are now. I am just hoping so hard that the trilostane can give her some relief. Fingers, toes, everything crossed. Thanks again for all the help and wonderful support. You all are the absolute best.

Kris and Cali

[Kris]

Good morning, everyone,

So Cali has been on Vetoryl for 6 days now (60mg once per day; she weighs about 58 pounds) and was tolerating it relatively well. She certainly didn't appear to feel great for the first 4 or 6 hours after her dose, but other than that, she didn't seem to have any side effects. Indeed, just last night, my husband and I noted that she seemed to be feeling much better overall, was in better spirits, etc.

However, this morning we discovered that she had had diarrhea and vomited during the night. It wasn't a large amount, though I don't know at what point during the night this occurred and if it will continue throughout the morning/day. My question is, do I discontinue the Vetoryl? I read that Dechra says to withhold medicine and take your dog to the vet immediately if the dog shows any adverse reactions. And I would absolutely stop the meds and get her to the vet asap if she seemed weak, had trouble getting up, etc. But I just don't know if some diarrhea and nausea warrant stopping the drug and/or taking her to the vet, especially since so many dogs seem to suffer those common side effects. Of course, I will do whatever is best for Cali, though! Stop the meds, get her to the vet, move heaven and earth--whatever it takes.

I am sure the answer to this question is on the board many times, but I thought I'd ask you wonderful people first; I figure someone here could answer me before I can find the answer (though I will try to find it). :)

Thank you for everything!

All our best,
Kris and Cali

[labblab]

Hi Kris,

So sorry for this turn of events! Yes, definitely, you should discontinue the Vetoryl for the time being and go ahead and call your vet to let him know what has happened. He may ask you to bring Cali in right away, or he may tell you to monitor her for the next few hours in order to see how she's doing. If she otherwise appears to be fine, he may be content with just withholding the Vetoryl for the time being. But if she worsens in any way, she should be seen so that an ACTH test can be performed in order to make sure her cortisol level has not dropped to an unsafe level.

It may be the case that the 60 mg. dose is too much for her to handle, and that a smaller dose will be warranted. But for the time being, the most important thing is to stop the med and notify your vet.

Marianne

[Kris]

Marianne, thank you for the fast reply! I appreciate it sooooo much. I contacted the vet, though I didn't get to speak to him directly. I left a message with reception and also e-mailed him, so hopefully he'll get back to me soon. I am a bit concerned about needing an ACTH stim test, though, as the last time I spoke to him, he said he wasn't sure he had enough cortrosyn for Cali's next test (scheduled for May 19) and said that it's hard to come by. So I hope he's found some. Sigh.

On a positive note, though Cali had some more diarrhea this morning, she seems pretty darn chipper and is eating food and drinking water. I'll take those as good signs! Hopefully we won't need an emergency ACTH stim test after all. I canceled my appointments for today, so that I can stay home and monitor her closely. Knock on wood that we've seen the last of these side effects. Thank you again for getting back to me!

[labblab]

I think her positive behaviors are good signs, too. Do you have Vetoryl only in 60 mg. capsules? As long as the vomiting and diarrhea stops and she otherwise remains well, one strategy might be to hold the Vetoryl entirely for a couple of days and then start back at a lower dose for 10-14 days prior to performing the ACTH test (assuming that she continues to do fine during the interim).

Marianne

[Kris]

Yeah, I have only 60 mg capsules. My vet has us order them from Drs. Foster and Smith, and I just checked--the next dosage down is 30 mg. I'd be happy to order those, but I'm wondering if that is too much of a jump down in dosage. As I understand it, if we want different dosages than the ones typically offered, we'd have to get it compounded, is that right? She resting now and has had no more diarrhea or vomiting--yay!

[labblab]

Vetoryl also comes in 10 mg. capsules, so to that extent, you can combine capsules of different doses to arrive at intermediate strengths. Otherwise, you would need to have strengths custom-made for you through a compounding pharmacy.

[Kris]

Thanks, Marianne--that does seem obvious in hindsight. :) Cali has me so frazzled, the obvious escapes me. I heard back from the vet, and he said he's not sure that Cali's illness has anything to do with the trilostane and that he's seen a lot of dogs with vomiting and diarrhea this week. He said she may have picked up a bacterial infection. He also said that he doesn't have enough cortrosyn for Cali's upcoming ACTH stim test on the 19th and that we'll have to reschedule the test for when he gets more in. This all concerns me a bit as it seems pretty likely that the trilostane would be to blame for her sickness since diarrhea and vomiting are two very common side effects. Also, it makes me nervous that he doesn't have necessary components for the ACTH stim test--what if she were really ill and we needed to know her cortisol level? Ugh, hopefully I am worrying for nothing. He also said to give her Pepcid AC for the vomiting, which I guess I can do if she starts back up again. For now she seems stable though--just snoozing the day away.

Thanks for all of your wonderful help!
Kris

[lulusmom]

Hi Kris.

I don't think the obvious has escaped you at all but I can't say the same for your vet. I don't know if he only has a thimble full of knowledge about cushing's or he's trying to put you off because he doesn't have any cortrosyn. Either way, I share your concerns and if it were me, I'd be looking for a new vet.

If a vet starts a patient on Vetoryl or Lysodren, s/he better make sure there is cortrosyn in the cabinet for when it's needed. When you have a dog on vetoryl who starts vomiting and has diarrhea, the very first thing you do is have the pet owner stop treatment and depending on extent of illness, bring the dog in to check electrolytes at the very least. What you don't do is make assumptions that the dog couldn't possibly have low cortisol because there is a canine bug making dogs sick. If as your vet says, that Cali may have a bacterial infection, why didn't he tell you to bring Cali in right away to get her on appropriate antibiotics? Whether it's low cortisol or a bacterial infection, both need to be addressed asap. Since Cali is feeling better since withholding the Trilostane, that's a very good indication that it was the Vetoryl, not a flu type bug, that caused her sickness.

[Sabre's Mum]

I absolutely agree with Glynda.

My vet was a little like yours. BUT I had very little choice in changing (went through all the possiblities but had to just make do with what I had). I found out along the way that they never stocked the Synacthen for the ACTH and had rather stern words to the vet that it wasn't acceptable. They either need to have it in stock when they have a cushings treated dog. What happened in the end with us was that we always need to order it 24 hours in advance but they had access to it at another clinic in town if it was needed urgently. Not perfect but better than none.

Angela

[Sage]

Quick question of clarification:
Is the vomiting and diarrhea a side effect of the drug (trilo) itself, or the potential low level of cortisol due to the drug doings it’s job?
Meaning, can it be a side effect of the drug even if the cortisol levels are in range or even still high?
(Not to diminish the potential seriousness of any side effects…just wondering)
…
My 2 cents:
Go find a professional who can give Cali an ACTH as soon as possible and discontinue all Cushing’s medication. Even if the vomiting and diarrhea subsides. You don’t need to transfer the entire case just to get an ACTH test and if your Vet disagrees, then I agree with “Lulusmom” and perhaps you should transfer Cali’s treatment to a person who is better prepared for the demands of a Cushing’s dog.

PS:
Also, when we were using Lysodren, we used a pill cutter to halve the tablets and even quarter them and the tablets had indents to make this easy and accurate, assuming the active ingredients were evenly dispersed in each tablet.

[labblab]

Quick question of clarification:
Is the vomiting and diarrhea a side effect of the drug (trilo) itself, or the potential low level of cortisol due to the drug doings it’s job?
Meaning, can it be a side effect of the drug even if the cortisol levels are in range or even still high?
(Not to diminish the potential seriousness of any side effects…just wondering)

Yup, vomiting and diarrhea are among the most common adverse reactions to the drug itself (even when cortisol levels are fine), as well as also being possible signals that the cortisol level has dropped too low. Blood testing is the only way to know for certain whether the cortisol level is OK. So if a dog persists with vomiting/diarrhea or otherwise appears to be lethargic and "off," without a doubt the most certain course is to proceed with testing immediately. But if a dog is otherwise behaving normally (eating, drinking, perky), then it becomes less likely that there has actually been an unsafe drop in cortisol. And so, in my own layperson's mind, it becomes a judgement call as to whether or not to test on the spot.

I know that I am personally influenced by the fact that my own Cushpup, a Labrador retriever, had a classic "garbage gut" from eating anything and everything he could find, and he had frequent bouts of both diarrhea and vomiting. If we had performed ACTH tests every time he had a GI upset, we would have been bankrupt :o. But the timing is also a consideration -- if a dog has demonstrated stability on a given dose via ACTH testing, then there may be less cause for concern than during the initial time period when appropriate dosing is such a question mark.

Having said all this, I totally agree with the others that it is crucial that a vet overseeing Cushing's care should be able to perform an ACTH test whenever it is called for. Or arrangements must be in place for an alternative provider to perform the test. So whether or not Cali is in need of that testing right now, I would not feel comfortable continuing with trilostane treatment until I knew that a suitable testing plan was in place.

And one other sidebar for other members who may be wondering -- Vetoryl comes in capsule form, and the manufacturer has strong warnings against opening the capsules and splitting the contents. So unlike scored tablets, Vetoryl capsules shouldn't be manipulated by the owner in terms of dosing.

Marianne

[Kris]

Thank you all for your wonderfully informative input. Seriously, I know I sound like a broken record, but I don't know what I'd do without you. First thing tomorrow morning, I am going to talk to her vet and tell him that he either has to make alternate arrangements for the testing or refer us to another vet, preferably an IMS. We live in Chicago, for heaven's sake, there has to be some cortrosyn in this city somewhere! Moreover, there has to be a vet versed in Cushing's. In any event, we are going to make sure that Cali can get an ACTH stim test on demand (or as close as possible) if needed. On a positive note, our girl is doing much better--she's had no more diarrhea or vomiting, is eating treats and drinking water, and seems pretty perky. Thank goodness!

Thank you all again. You are AMAZING.

Kris

[Sage]

Thanks for the explanation Marianne.
I am glad to hear Cali appears to be emerging from this little episode. I guess when we are forced to climb Mt. Cushing’s, it is very important to know your guide is well equipped and resourceful before you hook up and head out.

[Kris]

Hello, everyone! I just wanted to pop in to let you know that Cali did end up having her ACTH stim test on May 19 as originally planned (after starting Vetoryl on May 3, being off May 10 and 11 due to vomiting and diarrhea, and restarting on May 12). There were some issues, to be sure--as I mentioned here, the vet didn't have any cortrosyn when Cali became ill and didn't think he'd have any by the 19th. Luckily his order came in. Also, the day before the test, they called to say that Cali MUST be fasted for the test and that the lab even said so. Based on the information I learned here and from Dechra as well, I called them back to say that that is not at all the case, and they basically seemed to say fine, don't fast her then. So we didn't. :) She had her pill at 10:30am with breakfast and went in for her test at 2:30pm. Here are her numbers from the vet:

Pre (baseline cortisol): 3.1mcg/dL (1.0-5.0)
Post: 4.5 mcg/dL (8-17)

According to the vet, the lab said that with regard to animals on trilostane, pre and post cortisol levels between 1.5-9.1 mcg/dL indicate optimal control.

So it sounds like she's in a good spot, numerically speaking. Our vet does want to know how she's doing clinically as well, though I don't know if I have any profound insight on that front. Her eating/drinking/peeing had all decreased before we even started the trilostane, though I don't know why. She had the UTI I mentioned before, and then, for whatever reason, she just did not seem to feel well at all even after the UTI was cured. So immediately preceding starting the medicine, her most problematic symptoms were panting, wheeziness, and hind-leg weakness. Those symptoms do all seem to have improved, I would say. I hope I am not imagining things. :) I know she hasn't fallen in probably two weeks, so that's great. And she definitely seems to be feeling better overall--she seems pretty happy, is eating and drinking regularly (though not excessively), and doesn't seem to have those really down hours after her Vetoryl dose anymore.

On the topic of our vet and the whole not-having-any-cortrosyn debacle, we did ask for a referral to an IMS whose practice is attached to a 24-hour emergency hospital, so I just have to follow up with that doctor.

So all in all, I think things are going well, if I'm not missing anything. Thanks, as always, for all of your help and support!

Kris and Cali

[lulusmom]

Hi Kris,

That's a great report and the stim numbers look really good; however, we've seen cortisol continue to drop in the first 30 days so keep an eye on Cali for signs of low cortisol. Obvious signs would be vomiting, diarrhea, loss of appetite, extreme lethargy. Keep up the good work!

Glyna

[Kris]

Hello, again, everyone! I just wanted to check in as it’s been a while. Cali had another ACTH stim test on June 9, so I wanted to pop in to share the results.

Just to recap, Cali (who weighs about 55 pounds) started 60 mg of Vetoryl on May 3, was off May 10 and 11 due to some vomiting and diarrhea, and restarted May 12. Her first post-Vetoryl ACTH stim test was on May 19, with the following results:

Pre (baseline cortisol): 3.1mcg/dL (1.0-5.0)
Post: 4.5 mcg/dL (8-17)

Soon after my last post, we started to see great improvement in Cali—she continued to eat, drink, pee, and pant in normal amounts, wasn’t falling at all, and was just SO much happier. Less lethargic, loving her daily walks, etc. We couldn’t have been happier.

She had her second post-Vetoryl ACTH stim test on June 9, with the following results:

Pre (baseline cortisol): 3.0 mcg/dL (1.0-5.0)
Post: 6.2 mcg/dL (8-17)

So her post number was up a bit but still nothing to be concerned about as far as I understood.

Unfortunately, very soon after her last ACTH stim test, Cali started to regress. Her appetite, thirst, and panting all increased markedly, and she started exhibiting more hind-leg weakness. Seeing her so hungry and so anxious again was heartbreaking. So at this point, we have decided to increase her dose to 70 mg (unless anyone here thinks that is a bad idea, of course!). We are waiting for the new 10 mg pills to add to her 60s, but they should arrive shortly. We’ll start the new dose soon and schedule another ACTH stim test within 14 days. Hopefully this will give her some renewed relief. She is still definitely doing much better than before starting treatment, but we hope to get her back to feeling her best if possible.

I also just wanted to say hi to all the new people here (even newer than I am!) and to reassure you that you have found the best resource possible in this forum. In fact, a friend of a friend who is a vet recently said that I am more knowledgeable about Cushing’s than any vet he knows. And of course, I owe it all to the amazing people here. Also, please know that Cushing’s isn’t a death sentence, though it feels that way at first. I cried and panicked a lot as we were going through the diagnosis process, but as people here reassured me, Cushing’s is highly manageable, and Cush pups can and do live wonderful lives, reaching their full life expectancy, once the disease is under control. You can get your old dog back, I promise. We are still working out some kinks with Cali’s dosing, but even given that, she is so much happier and feeling so much better since starting treatment. It really has felt like a miracle and a gift to have her back.

Thank you all for everything. I’ll check in with her new ACTH stim results after starting her new dose.

Hugs!
Kris and Cali

[Bo's Mom]

Crossing our fingers for Cali....let us know how things go.

[Harley PoMMom]

Hi Kris,

I believe adding the 10 mg is a good idea especially since Cali is exhibiting signs, also having an ACTH stim test within 14 days after the dose increase is a great move and that is what Dechra suggest.

You are doing a wonderful job and please do keep us updated.

Sending hugs to you both, Lori

[Kris]

Hi, all,

It’s me again. We just got the results of Cali’s latest ACTH stim test and blood work, which I thought I’d share. There are also a few issues, it seems, with her results, and I’d love to get your opinion on those. I’ll recap first so that you don’t have to go back through the thread and then will give the latest info. Thanks for reading!

Cali (who weighs about 55 pounds) started 60 mg of Vetoryl on May 3, was off May 10 and 11 due to some vomiting and diarrhea, and restarted May 12. Soon after starting treatment, we saw significant improvement in her Cushing’s symptoms. Her first post-Vetoryl ACTH stim test was on May 19, with the following results:

May 19 test results
Pre (baseline cortisol): 3.1mcg/dL (1.0-5.0)
Post: 4.5 mcg/dL (8-17)

So this was great news! She had her second post-Vetoryl ACTH stim test on June 9, with the following results:

June 9 test results
Pre (baseline cortisol): 3.0 mcg/dL (1.0-5.0)
Post: 6.2 mcg/dL (8-17)

So her post number was up a bit but still nothing to be concerned about as far as I understood. Unfortunately, around the time of the June 9 ACTH stim test, we started to notice some regression—Cali’s appetite, thirst, and panting all increased, and she started exhibiting some of the hind-leg weakness that had so significantly improved. None of these symptoms were as bad as they were before starting treatment, but they were worse than they had been during treatment. So we increased her dose to 70 mg on June 28 and had another ACTH stim test on July 14, with the following results (I should note too that we didn’t feel like we saw any real improvement at the new 70 mg dose):

July 14 test results
Pre (baseline cortisol): 3.1 mcg/dL (1.0-5.0)
Post: 6.9 mcg/dL (8-17)

In addition to the ACTH stim test, we did a full blood panel, and the following numbers came back:

Alk Phos 412 (ref range 5-131)
BUN/Creatinine Ratio 33 (ref range 4-27)
Sodium 147 (ref range 139-154)
Potassium 5.8 (ref range 3.6-5.5)
Na/K Ratio 25 (ref range 27-38)
HCT 35 (ref range 36-60%)
RBC 5.3 (ref range 4.8-9.3)

(There are other numbers as well; please let me know if you’d like me to list any of those.) With reference to these test results, our vet stated the following:

“The CBC: looks good - although the HCT (hematocrit which is a % of red blood cell was slightly decreased); the total RBC was normal, which to me is better indicator of red blood cells in the body. The Alkaline phosphate liver enzyme was decreased significantly from the last value on 2/11/12 - which was 2241 IU/L. This elevation was most likely secondary to the Cushing's. We will monitor the sodium/potassium values; the sodium/potassium ratio is @ 25 - usually less then that we watch for Addison's disease. It might not be a bad idea to quickly check electrolytes in 2-3 weeks.”

So I’m not too concerned that the Alk Phos is high given that it is significantly reduced from the pre-Vetoryl numbers (as is the ALT). And our vet seems to think the HCT number isn’t problematic because the total RBC is normal. I guess I am most concerned with the sodium/potassium value given that is low—and if it were any lower, it apparently could indicate Addison’s. Before we received these results, I was planning to likely increase her dose to 80 mg since we didn’t see improvement after the jump from 60 mg to 70 mg. However, given these test results, I’m not sure that is a good idea. The vet says to keep her at 70 mg but just because her cortisol number is between 1.5 and 9.0 ug/dL. He didn’t mention the fact that her symptoms haven’t improved on the new dose or the impact the latest test results would have on any new dosing decisions, although in fairness, he could very well have considered these factors when coming to the conclusion that her dose should stay the same. I can ask him when I speak to him next, but I wanted to check with you all first so that I can be as educated as possible. :) I would love to hear any opinions or advice you might have. Thanks so much!

Many hugs and thanks,
Kris and Cali

[Kris]

Hello, all,

First, I want to say how heartbroken I am about the recent passings on the board—I broke down in tears when I read of Jordan, Rocky, and the others and send love and hugs and peace to their loved ones. I don’t have the words to adequately express how sorry I am for your losses. You are in my heart and thoughts.

Second, I wanted to give an update on Cali’s status and see if anyone had any thoughts or advice. Cali had bloodwork done last weekend to check a few values, including her Na/K ratio, which was 27 last time, a number the vet said is low and worrisome (her previous bloodwork is in my post above). Unfortunately, that number is even lower now.

Here are her most recent numbers from August 4, 2012:

AST (SGOT): 14 (15-66 IU/L) (low)
ALT (SGPT): 68 (12-118 IU/L)
Alk Phos: 335 (5-131 IU/L) (high)
BUN: 35 (6-31 mg/dL) (high)
Creatinine: 1.1 (0.5-1.6 mg/dL)
BUN/Creatinine ratio: 32 (4-27) (high)
Sodium: 145 (139-154 mEq/L)
Potassium: 6.3 (3.6-5.5 mEq/L) (high)
Na/K ratio: 23 (27-38) (low)
CPK: 49 (59-895 IU/L) (low)

(There are other numbers as well; please let me know if you'd like me to post any/all of them too.)

Based on what the vet said and the little bit of research I’ve been able to do thus far, a low Na/K ratio like this is often indicative of Addison’s. But this is confusing since her last cortisol numbers were in the acceptable range for a Cushing’s dog (pre: 3.1; post: 6.9). The low ratio number can also indicate kidney problems, I think, and the vet said the BUN number has something to do with that as well. Clearly, I am pretty ignorant about the meaning of these values. I had just wrapped my head around Cushing’s and now feel like I’m starting over to try to figure out what is going on now. :)

As far as symptoms go, she seems about the same, which is to say pretty good over all. Definitely better before starting the Vetoryl. She might have another UTI, though, which we are trying to determine; unfortunately, they couldn’t get a sample when they tried a cysto at her last appointment, so we are scheduling another one.

The vet said he is going to consult with an IM friend and get back to me. In the mean time, I was wondering if anyone here could shed any light on the possible meaning of these numbers.

Many many thanks, as always. Your help is invaluable to us.

Kris and Cali

[Kris]

One tiny clarification: I meant that she seems to be better now than she was before she started the Vetoryl, not that she was better before starting the meds. She's certainly not 100%, but we think we've seen improvement overall. Thanks! :)

[frijole]

Kris, We have a member who is a med tech that hopefully can take a look at these numbers. I assume you wrote out anything that was high or low from the panel.

Please make sure we are aware of any symptoms you are concerned about so we can have that handy when reading the numbers.

Thanks!! Kim

[Kris]

Thanks, Kim!! Yep, I posted everything that was abnormal, as well as the components of any abnormal ratios even if one such component was normal. Re symptoms, it all seems so vague sometimes.... Before we got her bad Na/K ratio, I was actually thinking of upping her Vetoryl dose because I felt she had regressed with her Cushing's symptoms somewhat--she was panting a bit more than she had been, showing a bit more hind-leg weakness, eating and drinking a bit more. Not back to pre-Vetoryl levels but more than since treatment started. However, in light of the Na/K ratio, we didn't increase the dose and are indeed wondering if it needs to be lowered, despite her good cortisol number. So confusing. Oh, I also should note that she is on Metacam (a 40-pound dose daily) and had been getting an Adequan injection every other week until very recently (she got the injection where she was doing water therapy, but we are not sure if we are continuing the therapy so are unsure about what to do re the Adequan). Thanks for checking in, Kim--I really appreciate it.
Kris

[molly muffin]

Hi Kris,
I wanted to check in with you and see how things are going. We haven't forgotten about you.
I wouldn't raise the dose while Cali is going through what could be a prestage to moving to Addisons.
Perhaps even lowering it wouldn't be a bad idea. Do let us know how Cali continues to do.
Hopefully someone who knows more about the lab results than I do will be by soon.

Hugs,
Sharlene

[Kris]

Hi, Sharlene--thanks so much for your note and for your thoughts on lowering the dose of Vetoryl. I was just wondering about that myself. Cali now takes a 60mg pill plus a 10mg pill, and I was thinking I'd cut out the 10mg pill and see if that helps bring her Na/K ratio back into the normal range. Sounds like it's worth a shot. Thanks again for checking in on us--hopefully we can solve this mystery soon! I'm still waiting to hear from her vet about his conversation with a specialist; my fingers are crossed for some good news. :)

[Squirt's Mom]

Hi Kris,

I wish I could help with the lab results you posted but that is beyond my scope of understanding. But I want you to know that I am reading along and sending you the best wishes.

Let us know what the vet says.
Hugs,
Leslie and the gang

[labblab]

Hi Kris,

I am no expert re: these lab values, so I'm just taking a stab in the dark. But from looking at Cali's profile, it looks as though her sodium level is normal, and that it is elevated potassium that is throwing the ratio out of whack. I just Googled "hyperkalemia" (high potassium), and not that Wikipedia is the most reliable resource :o, but I see that the use of NSAIDS can increase potassium levels in humans because they can interfere with urinary excretion:

http://en.wikipedia.org/wiki/Hyperkalemia

So I'm just wondering whether the Metacam may be contributing at all. Also, is Cali taking any other medications? Trilostane itself does have the potential to lower aldosterone, which it turn increases potassium levels. And when trilostane is used in combination with certain other drugs (certain diuretics or blood pressure meds, for instance), the potassium-elevating effects can increase further.

Marianne

[Kris]

Leslie, thanks so much for the support--it means so much to us. And Marianne, thanks for the theories about Cali's elevated potassium levels--sounds reasonable to me! I have already sent a note to the vet summarizing what you said--I figure it can't hurt and indeed might help a great deal. I don't think he is not terribly versed in Cushing's, and Cali's recent blood work is stumping us all, so all theories are on the table at this point. I will keep you all posted about what we learn. Thank you again.

Love and hugs,
Kris and Cali

[Squirt's Mom]

Just bumping up....

[Kris]

Good morning, everyone,
I don't have any concrete answers really, but I did finally hear from the vet. First, he said Marianne's ideas were good ones. He said that although he has never come across evidence of NSAIDs raising potassium levels in dogs, he will continue to check. He said in his opinion, the increased potassium levels are a result of the trilostane's mechanism of action and that we should check Cali's electrolytes every month. Also, when my husband took Cali in for her cysto last weekend, the vet told him that he had spoken to his specialist friend and that he (the specialist) said that Cali's ratio isn't anything to worry about. I'm not sure I'm convinced of that, but I am trying to remain calm. :) I did lower Cali's trilostane dose back down to 60mg and am now giving her the 40# dose of Metacam every other day instead of every day, just to be safe. I guess we will see if that is helping the next time we check her electrolytes, which will be in a couple of weeks. The good news is that he cysto came back negative, though, so that's great! I don't know what is up with all the licking, but I am glad she doesn't have another UTI. Thanks again for all the support. I will let you know if I hear anything new and keep you posted about her upcoming test results. Thanks again!
Kris and Cali

[molly muffin]

Kris, it sounds like your vet is really open to researching and speaking with other specialist/vets about what is going on with Cali. That is very good to hear. I hope that Cali's next test show her electrolytes are good! You're so good with her and isn't she a beauty :) I love the avatar picture.
Stay strong!
hugs,
Sharlene