First thyroid / Now cushings??? Maybe misdiagnosed?

[Chancie]

Hi everyone! I have been reading your forum like a madwoman this past week....I really am confused and hopefully someone can help. I had never even heard of Cushings until recently and really am just starting out on this journey.

I have a 9 1/2 old golden retriever, Chance. In September he started acting off. Really bizzare behavior from a very active dog who hikes 5-7 miles on a regular basis and swims like crazy...I would have to drag him on his walks and he was always tired. Then, heavy drooling began plus facial droop. I suspected a stroke. (must mention, his skin got very pigmented, like a black rash). Vet diagnosed low thyroid and put him on .9 of Thyroid chewables two times a day. The vet said his levels were so extrememly low they ran the test two times to make sure the reading was accurate. wow, what a difference, within a two weeks I had my dog back. He was leading the way on the walks, skin better, just back to my boy again. But immediately he started drinking whole bowls of water at every meal and actully not finishing his meal (unusal for my guy). He also started peeing like crazy outside, minutes at a time. When he went back after two months his thyroid levels were normal--but high normal.

I continued on with the original does (even though he lost 16 well needed pounds) even though his thirst, panting and peeing continued to be well above his past normal behavior. Then he started to have peeing accidents in the house...totally out of the norm. He always had great control. With vets permission I began to cut his thyroid pills because I thought we could lower his levels to mid-low normal. But the accidents got worse. By last week he would pee several times in the house a day. One night he basically peed every hour on the hour! The next day we went back to the vet. She suspected Cushings and did the all day test. Results said Cushings and she wants to start him on the Vectrol (spelling) next week.

It just seems too wierd to me that he never had these problems until he started on the Thyroid chewables. This morning I skipped his dose and he has not had one accident in the house.

Does anyone have any advise? (he does have the pot belly appearance) Could the thyroid chewables cause a false positive or mimick cushings. Or--as my vet said, the cushings was a cause of the thyroid issue? Help, so confused!

[Somesie]

People with much more experience than I have will be along to help, so try to stay calm and you will come through all of this with a lot of support.

I just wanted to tell you that my experience has been somewhat similar, in that the vet diagnosed low thyroid and prescribed meds, for us to then be told a month later by two different vets that he wasn't tested thoroughly enough (only total t4 was done) and should never have been medicated on that basis alone.

The same vet also conclusively diagnosed Cushing's, and even specified that it was adrenal-dependent, and prescribed Vetoryl. I knew by then, because of the folks here, that there was NO WAY she could know that yet. Further testing has shown that he does not, in fact, have Cushing's, and Vetoryl could very well have made his symptoms worse or even caused new, potentially dangerous problems.

All this, by way of telling you that you are on the right track in coming here. If you have the results of the test you had done (sounds like the LDDS, based on your description), please post the results...that will speed things along for you. Was a creatinine/cortisol urine test done? That cannot diagnose, but is pretty accurate in ruling out Cushing's.

Post whatever results you have, and somebody smarter than I will be along soon to help. In the meanwhile, though, try not to panic. As you may have read, Cushing's is very slow to progress so that fact is in our favor, giving you some time to catch your breath, learn a bunch, and move forward with confidence, rather than in fear. OK?

By the way...yes, Cushing's can cause thyroid problems, but he could have low thyroid from something else other than Cushing's, too. Has he had any hair loss? Before the thyroid meds, was his appetite normal? Did he, or does he now, have excessive appetite or hair loss since the meds?

I wouldn't be ready to medicate just yet if I were you. Let's find out a little more first. Hold on...help is on the way!!!

Best,
Jenn

[mytil]

Hi and welcome from me.

I am sorry your Chance is having these troubles. My first thought would be has he been check for diabetes?

This amount of drinking is indicative of Cushing's but the leaving some of his meal is not. I know that thyroid conditions and their symptoms can mimic some of Cushing's symptoms, but so can diabetes.

As Jenn mentioned, please post all those results of the tests performed that made your vet diagnose Cushing's.

Keep us posted
Terry

[Harley PoMMom]

Hi and welcome to the family!

Thyroid issues and Cushing's do share many of the same symptoms. Hyperthyroidism can cause excessive thirst/urination, increased appetite, and sometimes weight-loss.

The timing of the test for the thyroid level is critical and should be done 4-6 hours post pill. Was a freeT4 test done and was this done 4-6 hours post pill?

If you could get copies of all tests that were done on Chance and post any abnormalities listed, here, that would help us to provide you with more meaningful feedback.

Please know we will help in any way we can so do not hesitate to ask any and all questions.

Love and hugs,
Lori

[lulusmom]

Hi and welcome to the forum.

Cushing's symptoms don't show up over night and it is too coincidental that Chance's increase in drinking and peeing, apparently his only symptom associated with cushing's, started after treatment for hypothyroidism. Lori has already mentioned that it is very important that testing be done within 4 to 6 hours after giving the pill so if this was not done, I would suspect that results are inaccurate, making it highly likely that Chance has gone from "hypo"thyroid to "hyper"thyroid. This makes perfect sense as Polyuria (excessive peeing) and Polydipsia (excessive drinking) are the hallmark symptoms of hyperthyroidism.

Looking forward to seeing test results.

Glynda

[Chancie]

Hi everyone!
I'm so glad my membership was approved and people are responding to my story! BTW- Chance just got up from sleeping the night through and after peeing for about 5 minutes drank a whole bowl of water but left his breakfast in his dish...which has been the norm since starting the thyroid chewable. I am going to skip this mornings dose again and just give him his evening and see how today goes as far as accidents in the house.

I will call the vet tomorrow and have her email me all of his tests and post them here, I do know the vet tested for Diabetes (no fasting though, not sure if that would skew results) and the results were negative. He originally wanted to do a test for another form of diabetes which would have required a 12 water depravation and 2 urine samples. We were going to do that next when his accidents got out of control and we had to see another vet in the practice who diagnosed cushings.

The last thyroid test we did was taken 5 hours after medication and if I recall correctly the reading was something like 3.9 with normal being 3-4, so that was high normal, but like I said I will get the paperwork and post tomorrow. Is there a way to upload the pages or do I just retype everything?

Someslie--Chance has never had hair loss. After thyroid meds his appetite decreased and he lost 16 pounds. (which is good cause he was a bit portly for a golden retriever, he is now 99 pounds)

Thank you all so much for being here for me and my best friend!

[Chancie]

Chance and I hiked for two hours and he did not pee in the house oncde all day---but tonight while I was eating dinner he went into the kitchen (not the door to go out), I thought to smell what was still in threre and he peed on the kitchen floor! :confused: IDK--so confused. Will get the results and post them tomorrow. I am going to give him his thyroid chewable tonight.

[frijole]

Glynda had a valid point and that is if a dog gets too much of the med for hypothyroidism they actually go to the other extreme which is hyperthyroid which can cause the peeing. I would not give the pill tonight as it could be the culprit. Kim

[Somesie]

Specifically, what test was done, and what were its results, for which he was put on thyroid meds? Also, was a UC:CR done, and what were its results?

Appetite decrease and weight loss are not Cushing's symptoms. To the contrary, voracious, obsessive hunger is one of the key indicators of Cushing's. If it's me, I would definitely not consider medicating for Cushing's until you know quite a bit more.

Please let us know those test results when you can. Hang in there!

[Chancie]

I have Chance's test results but can not find the attachment button to post. Can anyone help me?

Thanks!

[Rebelsmom]

You will have to type in the results or scan them and attach them as a hyperlink through a program like photobucket etc.

My boy was diagnosed with low thyroid by his first vet turned out it was cushings and we pulled him off the thyroid meds. But he had been having all the symptoms of cushings when he was diagnosed, the first vet just missed it.

[Chancie]

http://www.scribd.com/doc/92707868/Chance-Test-Results

[Chancie]

I tried to upload Chance's results with little luck so tomorrow at lunch I will just retype the pertinent results and hopefully if something needs clarified I can just fill in.

To update, yesterday Chance had one accident in the house and then this morning when he was alon from 7:30-10:00 he peed again in the house. (strangely enough he stays at my dad's house from aroun 10:00-5:30 and never had an accident....maybe he is more comfortable doing that in his own home:()

I have scheduled an appointment on Thursday with the vet who originally diagnosed him with thyroid issues (same practice) to go over all results. I will also be requesting a diabetes test for diabetes insepidius (sp?) prior to starting him on cushings meds. That vet originally said we would go there on the next step. If he feels that cushings dx is correct I am thinking of requesting starting out on a smaller dosage instead of the high dose. Not for cost, but maybe starting lower and building up would be the best way to go. Still very confused. I am so appreciative of everyone who takes the time to read this and comment.

[frijole]

http://www.scribd.com/doc/92707868/Chance-Test-Results

BUMPING THIS UP for anyone who knows how to read/interpret thyroid tests. Open this attachment and you will see results from 3 tests including a Free T.

Sorry I can't help but am sure someone can here! Kim

[Sage]

"If he feels that cushings dx is correct I am thinking of requesting starting out on a smaller dosage instead of the high dose. Not for cost, but maybe starting lower and building up would be the best way to go." -Chancie.
...
It is my understanding that with the two most popular Cushing's drugs available, Lysodren and Vetoryl, it is Vetoryl which offers the most flexibility in dosage. My experience with Lysodren for my dog Sage was that during the initial loading phase there was a disadvantage to "starting lower and building up" due to the chance of failing to achieve the objective in knocking down enough adrenal cortex to bring cortisol back into range. The disadvantage being, you have been giving your dog a dose of a powerful chemotherapy drug with nothing to show for it except several ACTH test bills that will just tell you that there is a need to start all over with the higher suggested dose per the dogs body weight.
Vetoryl, from what I have read here, works by prohibiting the synthesis of cortisol, as opposed to destoying the adrenal tissue that is secrecting it. Two drugs, two different actions, and if "starting lower and building up" is in your comfort zone then it sounds like Vetoryl would allow that flexibility much better than Lysodren.
This is just my 2 cents....
Someone please correct me if I am mistaken....

[Harley PoMMom]

I have scheduled an appointment on Thursday with the vet who originally diagnosed him with thyroid issues (same practice) to go over all results. I will also be requesting a diabetes test for diabetes insepidius (sp?) prior to starting him on cushings meds. That vet originally said we would go there on the next step.

The only real "test" for diabetes insipidus is the water deprivation test, which if a dog is suspected of Cushing's, could be fatal. I believe one can try the medicine Desmopressin acetate, which is usually rx'd for DI, and see if it helps instead of doing the water deprivation test.

[mytil]

Here are images of the test results - I tried to make them as readable as possible. :)

Terry

[labblab]

Thanks for posting Chance's labwork (and thanks, Terry, for getting those pdf's loaded ;)). I've had a chance to quickly glance through them, and everything that's there is consistent with Cushing's. If it were me, I do not believe I would even bother going through testing for diabetes insipidus given these other lab results.

First, I believe that Chance's initial thyroid test is consistent with a dog who is suffering from thyroid issues secondary to another condition -- such as Cushing's. His T4 and Free T4 are both very low, and his TSH is low normal. Dogs with primary hypothyroidism typically exhibit elevated TSH levels. With such low T4 and Free T4 levels, it's probaby not a mistake to supplement his thyroid right now. But once starting Cushing's treatment, his thyroid level will need to be monitored closely because his thyroid may rebound and the thyroid med discontinued over time.

As for his other results, the LDDS (8-hour test) is definitely consistent with Cushing's. The pattern of the resuts does not tell you, however, whether the Cushing's is likely to be the result of a pituitary tumor or an adrenal tumor. Further testing would be necessary, such as an abdominal ultrasound. Surgery can be a total cure for adrenal Cushing's, but it is an expensive and major undertaking. If you would consider surgery, however, you may want to further pursue the possibility that Chance's Cushing's is adrenally-based. If not, then you can proceed with the trilostane treatment that your vet has recommended, because trilosotane can be used to treat both pituitary and adrenal Cushing's (as can Lysodren).

Chance's initial UC:CR (urine) testing is also consistent with Cushing's. It looks to me as though his ratio was 170 (listed as "High") and any result over 13.0 would be consistent with Cushing's per the reference range. So if that was indeed his result, I don't know why your vet would have said that Cushing's was not likely.

Finally, the huge elevation in his ALKP, and elevations in his other liver values, cholesterol, and triglycerides are all consistent with Cushing's. So his overall lab profile is pretty much classic Cushing's. From a behavioral standpoint, it sounds as though the only real oddity is a decreased appetite and weight loss. But we have had a few other Cushpups who did the reverse of what is generally expected: had poor appetites prior to starting treatment, and improved appetities once their cortisol levels were lowered. My own Cushpup did exhibit the classic ravenous appetite, but he was also losing weight prior to diagnosis. So there can always be exceptions to the standard pattern.

Given all these results, personally I would feel comfortable beginning treatment with Chance if he were my dog. If you choose, you can gain additional information about the type of Cushing's from performing an abdominal ultrasound. You can also opt to perform an ACTH stimulation test prior to starting treatment. The ACTH is used both as a diagnostic blood test (like the LDDS), and it is also the monitoring blood test that will be performed periodically throughout medication treatment. It is the test that will tell you about Chance's cortisol level. You don't have to do it beforehand, but if you do, it would be one more confirming piece of information and would also help you better judge how quickly the medication is lowering his cortisol from the pretreatment baseline.

Last but not least, if you do start trilostane treatment, the manufacturer of brandname Vetoryl is currently recommending a starting dose that may be lower than what is reflected in their published dosing chart. They recommend using a starting formula of 1 mg. per pound. So using that formula, 180 mg. would be a higher dose than I would feel comfortable with. You are very right -- our experience here is that it is much better to start low and work upward rather than vice versa. This approach minimizes the likelihood of unwanted side effects along the way. If your vet wants you to stick with brandname Vetoryl, I'd probably ask to start Chance off with 90 mg. daily (a combination of a 60 mg. capsule and a 30 mg. capsule). With capsules in that dosing strength, you can then easily adjust upward or downward in 30 mg. increments depending upon his treatment progress and monitoring ACTH results.

Marianne

[Chancie]

Terry-thanks for all the help with loading the test results!
Frijole- Thanks for the bump!
Harleysmom, I knew it was water deprivation, but didn't know it could be fatal! Thanks for the info.

Marianne, thank you so much for looking at Chance's results and taking the time to break it down for me. I really don't remember what the vet said when she called last week so it is helpful to have all this written down for me to read over.

I'm not quite sure if I will get him an ultrasound or just start treatment with the Vetroyl; but, if we do start with the medication I definately will be requesting a lower dose.

This weekend Chance and I are going camping in Virginia for a friend's wedding--I'm not starting him on any medication until after we get back, just in case he has any side effects. Sadly, in all the years he has been my travelling companion this is the first time I am worried about taking him on a trip with his accident issues. But--it is camping--whats a little pee. Hopefully the car ride won't be too much for him, although, he hasn't seemed uncomfortable in the car lately.

Thanks again for all of your comments, I really appreciate that you all took time to read about my boy!

[Somesie]

I hope you both have a great time camping!!

Marianne...sorry to butt in on this post, but I've been following this since the diagnosis pattern was similar to Jordan's, and I have a question for you. First, though...thanks for your response here. It isn't even for my dog, and I feel like I hit the mother-lode of information!!

My question, though, is this...do you know why the UC:CR values for her dog would be different than for Jordan? I can't remember what the exact 'normal' range was, but I know that anything over 33 was considered high for him, where as here you have a reference range where anything higher than 13 is Cushingoid. What gives? If it's a ratio...shouldn't it be the same reference range regardless of the size of the dog? :confused:

Thanks again, and Chance's mom...sorry to bogart your post, I hope you don't mind! Maybe we can both learn something! ;)

Best,
Jenn

[StarDeb55]

Jenn, I'm not Marianne, but can probably answer your question. All labs have different reporting units & normal ranges, especially between the US & Europe. Since you list your location as Germany, I'm assuming that Jordan's labs were done by a vet lab in your area in Germany? If this is the case, I'm almost certain that the reporting units for the UCCR were something like um/L, (micromolar/liter), where Chance's results were in ug/dl (microgram/deciliter). There is probably a formula to convert Jordan's results to the ug/dl, if your interested.

Debbie

[lulusmom]

I have tried for years to find an easy UC:CR formula and found a blurb from a veterinary textbook that confirms the information the lab has included on Chance's results. I'm going to keep that formula for future reference. You must calculate results by using molar (nmol/L) concentrations of cortisol and creatinine so you need to convert those values first. The lab has provided the formula for doing this. I did and dang if I didn't come up with the right results. Chance's ratio was 169.60 rounded up to 170.

I'm also stumped as to why Jordan's UC:CR test shows normal ratio being less than 33. Jenn, if you have a copy Jordan's UC:CR, can you let us know what the values are for the cortisol and creatinine, including the normal reference ranges and reporting units? We'll see how the formula works. I feel bad for hijacking Chance's thread so can you post this information on Jordan's thread?

[labblab]

I may also have contributed to the confusion by writing this morning that Chance's UC:CR ratio was 17.0, when it was actually 170. I was having trouble reading the report really clearly. So even though Antech's cut-off still looks to me to be 13.0, Chance's ratio was significantly higher than I even realized. I'll go back and edit the ratio number in my earlier reply.

Marianne

[Somesie]

Thanks, Ladies! I'll post in Jordan's forum. You all rock.

[Chancie]

I don't mind the thread hijack at all--the more I can learn about Cushings the better!

I spoke with the Vet today and we are going start Chance on 90 mg of Vetroyl next Monday the 14th. She then said we will see how he is responding and bump him up from there if needed. I am nervous but hopeful starting smaller will decrease the risks of side effects. The vet was a little leary and said she preferred to start at the full dose and reduce. She had not heard that the manufacturer may have changed the dosage reccommendation, but stated she will look into in. She seems very empathtic and I do appreciate that she listened to my concerns and is willing to try it this way.

I forgot to ask her if Chance could still keep taking his supplements, but I am sure I will speak with her when I pick up his medicine. If anyone has advise about it, he takes Connectin (joint supplement) and salmon oil. I also give him aspirin occasionally when we have long hikes planned.

Also, should I change his food/diet? Right now he eats Fromm Chicken...I have tried grain free and he hated it. Is there a special food or diet or supplement I should be adding?

Thanks again ladies, I'm so glad that I found this wonderful site!

[labblab]

Here's a link directed to veterinarians that you can point out re: the advisability of starting out at the low end of Dechra's initial dosing range of 1-3 mg. per pound:

http://www.dechra-us.com/Cushings-Syndrome/Veterinarians/Prescribing-VETORYL-1.aspx

And the relevant quote:


Starting Dose

VETORYL Capsules should be administered orally once daily in the morning with food. Administration with food will significantly increase the rate and extent of absorption of VETORYL.

Ideally, the starting dose to aim for is 1.0 to 3.0 mg/lb (2.2 to 6.7 mg/kg) once a day based on body weight and capsule size. When calculating dosage, it is suggested to round down. Start at the low end of this range. If you have any questions on dosing, contact Dechra Technical Support at 866-933-2472 or support@dechra.com.

[Chancie]

Thank you so much Marianne! I will print this out for my vet as well. She was very interested in hearing about the dosage info that I told her about.

Once again, there are no words to thank you for taking the time to read about Chance and help ease my concerns. I hope one day to be able to pay it forward:)

[frijole]

I hope one day to be able to pay it forward:)
:D:D:D:D Be careful! I said the same thing 7 yrs ago when this group saved my dog Haley from 'vet hell' and have been here ever since. :D:D:D:D

We are glad to help and it truly is the members who hang around to help others out that make this place special. It also gives you faith in mankind - heck where else do you get this kind of treatment for free?! :eek::eek::confused::confused::eek::eek::eek::D:D: D:D:D:D
Kim

[mytil]

Ditto to what Kim said .... (mine was 9 yrs ago)

Keep us posted on your boy.

Terry

[Chancie]

Good morning all!

Chance has been sleeping all night without having to go out since those bad couple of nights last week. But, weirdly, this morning after I let him out I saw what look liked a little bit of pee on the floor. When I went to let him back in he was laying on the deck, as he got up pee just kinda leaked all over and his belly was wet. (It wasn't like a stream of urine, but it was a goodly amount) Is this normal for a dog with Cushings? I'm a little freaked out because it seemed he didn't even know he did it. I asked him if he wanted to go back to the yard, but he wanted in.

[lulusmom]

Good morning to you too.

The answer to your question is yes, some dogs with cushing's do pee in their sleep. Here is an excerpt of a paper written by Dr. Edward Feldman, a renown endocrine specialist, that touches on the subject. The excerpt comes from a list of symptoms associated with cushing's.


1. Development of profound excesses in urine volume. Many of these dogs urinate for longer time periods than normal or they urinate more frequently. Some produce so much urine that there is leakage when the pet sleeps. Many previously "housebroken" pets begin urinating indoors. In conjunction with the production of excess urine is excess thirst, which is usually not as worrisome to pet owners as the urination problem.

The article is a good read so if interested, here's the url:

http://www.acvim.org/websites/acvim/index.php?p=209

[mytil]

On a side bar note to this peeing, I would like to point out that some dogs who experience this lose of control feel profoundly "embarrassed" (for lack of a better term) about it. Mine did. She knew what she did was not normal (and uncomfortable) and she wanted to go inside and hide. Dogs can feel emotions just like us humans.

Keep us posted
Terry

[Chancie]

I do think Chance is ashamed about his accidents--he seems a little down and won't make as much eye contact, but that could be me reading into things! He did have two accidents at my dad's today:(

I forgot to add to my original post that when the Vet originally thought his liver was enlarged prior to dx (just from feeling his stomach), however, after an x-ray she said he just had an extremely enlarged bladder. Is that normal with Cushings? Could that be pointing to adreanal instead of pituatary?

Well, I have to go clean up after dinner, although Chance took care of the heavy lifting for me! I gave him the crockpot to finish the pork, sauerkraut and applesauce:D He is spoiled! He might turn his nose up at his food but he will eat mine anyday!

Thanks again everyone and have a great night!

[Chancie]

Chance's peeing is just getting worse! He constantly is leaking urine and will pee on himself while laying down even when he is awake. It also seems as if his belly is getting larger. He woke up this morning soaking wet on his belly, hind legs and rear.

He also is eating less of his food than ever. He does this weird head bop thing when he looks at his food dish, almost like he is nodding at it, then he ignores it and just drinks. He still will eat his three cups mostly, but, it takes him all day. My dad also said that he turned down pretzels today.

Does this all sound normal for Cushings? I am now second guessing myself and imagining all kinds of scenarios....like what if he has a tumor that is making his stomach so large and making him pee? Uggghhh!! His drinking is still up though!

I'm going to pick up his meds in the morning tomorrow and hopefully will get to speak with the vet.

[frijole]

The peeing could be cushings OR something else. The lack of hunger is the OPPOSITE of cushings. I personally don't think your dog has cushings. Is there a specialist or teaching hospital near you that you could visit? I think you need more testing done and by someone with more experience. Kim

[StarDeb55]

I haven't posted to you before but have been following Chance's story. I, too, am concerned about the accuracy of the diagnosis, & sincerely hope you will seek vet care from someone with more experience with Cushing's as Kim has mentioned.


I gave him the crockpot to finish the pork, sauerkraut and applesauce He is spoiled! He might turn his nose up at his food but he will eat mine anyday!

I read this earlier today, & thought about this quite a bit. First of all, please don't misunderstand, I'm not being critical of the people food that you give Chance, I do it with my own dogs at times. I do want to alert you to the fact that Cushpups are very prone to developing pancreatitis, so you may want to avoid giving Chance any "special treats" that may have a high fat content such as pork.

Debbie

[labblab]

Have you been measuring the amount of water that Chance drinks each day? It would be interesting to see how much he is exceeding the norm. Plus, if you do start the Vetoryl, monitoring his water intake can help you judge the effectiveness of the drug. It sounds as though he is drinking A LOT at this point. You've mentioned he has an enlarged bladder which can result from excessive urine production. Plus, I noticed that the creatinine measurement on his UC:CR was lower than normal. This would also be consistent with very dilute, excessive urine.

No question but that his lack of appetite is worrisome. But just taking a stab in the dark, maybe the poor boy's belly is so full of water all the time now that it is actually impinging on his appetite.

Even though there are some oddities about his presentation, if Chance were my dog, I do believe I'd still move forward with giving the Vetoryl a trial run (at the lower dose we discussed). You can always stop it at any time, but I would be very anxious to see if it helps curb the thirst/urination. However, you do still have two additional testing options prior to starting treatment: the ACTH stim test, and also an abdominal ultrasound. I am assuming that Chance's liver abnormalities are the result of his Cushing's. But primary liver disease/illness can always be a possibility, too, especially for a dog who doesn't want to eat. An ultrasound can provide a lot of helpful info regarding the state of the adrenal glands, liver, and other internal organs.

Marianne

[Chancie]

Thanks Marriane, you may be right about so much water making him too full to eat his food. He always drinks a whole bowl before his meal, so that could be it. I will start measuring his water, good idea. I just knows he drinks about three bowls a day with me, and probably another one during the day at my dad's. (big dog bowls)


I am going forward with trying the low dose Vectroyl and moniter his progress. If I don't see improvement in two weeks I will move on with the Ultrasoud.

Kim, we have a really good specialist hospital here, Pittsburgh Veterniary Specialist, that is where Chance would have to go for his Ultrasound. So that would be the next step.

Thanks again everyone!

[Chancie]

Hi all!
Just wanted to stop in and give an update on my buddy. By last Friday his peeing was out of control! I decided there was no way I could take him away for the weekend the way he was. It wouldn't be fair to anyone (especially him) to have him pee nonstop in the cabin. I went to the Vet and got him started on the Vetoryl.

The vet again tried to have him put on the 180 dose a day. I insisted on starting on the 90 and am so glad I did! I gave him the pill immediately with food and he still peed alot that afternoon, but by that night he stopped. Not one accident in the house, no leaking! Nothing! He continues to be accident free and today was day four.

He is drinking less, but still drinking, I am trying to track his consumption. He is still not eating all of his food, he seems to be eating the same amount as he was the past few months. Probably around 2 - 2 1/2 cups a day....but he doesn't turn a snack down!

Hopefully we are on the right track. Any tips or things I need to watch for? No vomiting, no upset stomach yet. He always seems pretty mellow, so it would be hard to say if he was lethargic, but he seems to want more affection! Which, he kinda shunned the past few weeks! We went on a 7 1/2 mile hike on Saturday which wiped him out for the weekend, but was back to himself at the park today!

Fingers crossed:o Can the drug really have started working that quickly? Could he possibly be getting too much?

-Barbara

Moderator's Note: I have merged your update on Chance into Chance's original thread. Normally, we prefer to keep all posts on a pup in a single thread as it makes it easier for other members to refer back to the pup's history, if needed.

Opps--thanks for moving it:-)

[labblab]

Wow!! I'm SOOOOOOOO glad to hear about the improvement!!

And yes, it is possible for the drug to be having a positive effect this quickly. My own Cushpup cut back on his drinking and urination by the second day of treatment. Many times this is not the case, but it can happen and it is surely a joyful event when it does!

Definitely continue with the updates, OK? Until his first monitoring ACTH test, you won't know for certain as to how much his cortisol level has dropped. But as long as you do not see any worrisome symptoms such as diarrhea or vomiting, etc. -- I think you're good to go. Also, since you ARE seeing improvement, even if his cortisol level is not yet within the target therapeutic range at the time of his first ACTH test, please tell your vet that you want to wait at least until the 30-day mark before increasing his dose. The cortisol can continue to drift downward during the first month of treatment, and it is wisest to wait to make an increase until you know what the "basement" is going to be on any given dose. I just remain worried that she's going to remain anxious to put Chance on a higher dose as soon as she can...

Here's a link to Dechra's Treatment and Monitoring Flowchart that you can even print out for her. As you'll see, as long as the dog's cortisol level is greater than 1.45 ug/dl at the time of the first two-week test, they recommend leaving the dose unchanged until the 30-day mark.

http://www.dechra-us.com/files//dechraUSA/downloads/Client%20Literature/47902_VETORYL_10mg_Treatment_and_Monitoring_Brochu re_Update_3_2_ps.pdf

Marianne

[Chancie]

Thanks Marianne! I pretty thrilled myself! I can't believe how quickly the pills kicked in!

I for sure do not want to raise his dosage anytime soon. In fact, if after a month his numbers still are not correct do you reccommend a higher dose? I would think if he is symptom free that would be all the matters, or am I wrong?

Also, the vet did not mention testing him at the two-week mark, however, she did state she would be speaking with me this week. Do you think I need to schedule the testing for next week? It almost seemed as if she was going to wait a month before testing depending on his clinical behavior. The vet also informed me that the next tests would be in and out of the office not a whole day there. Is that what the ACHT test is like?

Thanks again for everything and also for the link:o

Barbara

[labblab]

Historically, standard protocol has been to perform the first test after approx. two weeks. As you've seen, this is still what Dechra recommends, and it is the "gold standard" in terms of the most precise picture of the dog's cortisol production. However, given the current expectation that levels do tend to continue to drift downward during the first month or so, I have recently read that some specialists are reserving the full ACTH stimulation test for the 30-day mark, and instead eyeballing the dog and also checking the resting cortisol and electrolytes at the two-week mark. Those tests require only a simple blood draw. The ACTH stimulation test takes 1-2 hours to perform and two blood draws. First, the resting cortisol is measured. Then a stimulating agent is injected, and then a second blood sample is taken.

During the initial days of treatment, really your greatest worry is making sure that the dog is not being overdosed. Apparently there is reason to believe that as long as the resting cortisol is higher than around 2.0 ug/dl and the electrolytes (blood chemistries) are all normal, it is unlikely that this would be the case. In that way, the more involved and expensive ACTH test is reserved until the 30-day mark, when you should have a better idea as to the long-term effect of the current dosing. Your vet may be adopting this type of approach. But either way, it will be good for you to talk with her in order to find out her current gameplan.

And in terms of optimal dosing, it is definitely the case that you should not just be chasing ideal numbers. But there may be reasons why lower numbers may be desirable even if you are seeing outward improvement. The jury is still out as to whether or not the hidden systemic damage that Cushing's can cause (like to the liver and kidneys, etc.) is truly halted when circulating cortisol is allowed to remain higher rather than lower. So the ideal dose for Chance will probably end up being a combination of factors.

Marianne

[Chancie]

Yesterday and today Chance seems pretty tired. Now he is normally a mellow dog at home, always has been. But his tail wagging greeting has not been happening. He still jumps up for a treat or walk. But yesterday on his walk, although he led the way, he was slower than usual.

Today at the park he picked the shortest path to the water, went down and drank, and took the same short path back to the car. I cound't coax him to go around the loop at all.

Everything else is normal, his poop is soft, but it has been ever since he started the Thyroid chewables.

Could this be an effect of the Vetroyl? Is it a sign of too much?

Thanks for any imput!

Barbara

[frijole]

Barbara, You are doing great.. and yes the lethargy (change in energy) and the soft poo can be signs of too much trilo so keep a close eye for lack of appetite and reduction in water also... simply quit giving it if you have any concerns and schedule an acth test. I don't think it has anything to do with the thyroid pills.

You will know if Chance has gone too low. Keep watching and asking questions. Kim

[arockkid]

I am new here and actually came to ask my own questions, but your dog sounds so similar to my situation I thought I'd respond...

Everything sounded the same, the drinking/peeing, looking at food and not eating, low thyroid....
We did every test known to man, and it turned out via MRI to be a non-functional pituitary tumor....it can mimic hypothyroid, many (but not all) symptoms of Cushing's, and a little diabetes insipidis....but is actually just a large benign tumor that was causing pressure in his brain...

so he is now on prednisone, primor, doxycycline and an herbal combo called 'statis of the mansion of the mind' and is doing a lot better.

The difference (as is my understanding) is that functional tumors (that cause Cushing's) can be tiny, but secrete hormones, making everything go awry, where the non-functional tend to be large, putting pressure on important things, causing everything to go awry.

Other people here will be able to steer you better, as I don't know much about the lab results, but this is maybe worth considering and asking about.

[labblab]

Hello to you, "arockkid," and I do hope that you will start a new thread so that we can talk to you directly about your dog. I think I would learn some new things, myself! Over the years, I've been familiar with both functional and nonfunctional adrenal tumors. But I assumed that for the most part, pituitary tumors were always functional (meaning, as you say, that they secreted hormones). From your comments and doing some quick Googling, I see that I have more to learn.

However, in Chance's case, I don't think he would fall into the category of a nonfunctional pituitary tumor due to his "positive" LDDS and UC:CR results. These establish the fact that cortisol is being over-produced, which would result from a functional tumor that is characteristic of conventional Cushing's.

But please do start a new thread for your own dog. We'd love to have the chance to learn more about you both!

Marianne

[Somesie]

I, too, would love to hear a bit more about your pup, arockkid. I'm now googling like crazy, but it would be great to know the specifics of your story, as our boy Jordan has many (most) of the classic Cushing's symptoms but his cortisol is not elevated. We've had a borderline ACTH stim, and negative everything else (UCCR, ultrasound, LDDS). I would really appreciate if you would share a little about the diagnostic process you went through, as well as the details of your pup's recovery thus far, if you have the time.

Marianne...from what you've read so far about these non-functional tumors, any thoughts as it relates to Jordan?

Thanks,
Jenn

[labblab]

I'm going to be very bold and go ahead and make a copy of "arockkid's" earlier post so as to start a new thread on his/her behalf. And that way, we can continue this discussion about nonfunctional pituitary tumors on the new thread, and Barbara and Chance can reclaim their own thread here once again. ;) :)

Okey-doke, I've set up the new thread, and here's the link:

http://www.k9cushings.com/forum/showthread.php?p=75751#post75751

Marianne

[Chancie]

Hi all! Hope all is well! I learn something new from this place everyday!
Chance is going in to the Vet's on Friday for his 2 week blood work. They are only doing a blood draw for Cortisol levels this week. He has been pretty normal except for acting a little tired. Sunday we went to my friend's house. She has two old english sheepdogs that Chance loves! They all grew up together and normally Chance is very excited to visit. As soon as we got there he just went into their garage and laid on the floor. He had no interest in saying hi to his friends or the people. Very strange for him.....My dad said he was pretty lethargic yesterday too. It is almost like he has up and down days. Not sure what to think.
Should I ask about reducing his dose to 60mg? He is drinking a normal amount of water, probably 6 cups a day plus what he sucks down from the creek at the park! He is eating his normal amount of food, but never asks for treats. He used to want a buffalo bone in the evening. (He would bark in my face until I got up from the couch to get it out of the freezer). He hasn't had any interest in snacks since before all these problems started:( I have started giving him canned pumpkin with his food and his bm's have firmed a bit--still soft but not diahrea. (sp?)

Any tips would be helpful!

[labblab]

Barbara, since Chance is acting "off," I'd ask the vet to also include a simple test of his "electrolytes" (basic blood chemistries) when they do the ACTH test on Friday. If both the ACTH and blood chemistries are "good," then you can feel much safer that Chance is not truly being overdosed with the trilostane. However, depending on the ACTH results, you may want to see about at least temporarily reducing his dose regardless, in order to allow his system to adjust to the lowering of cortisol more gradually. Here's a related quote from Dechra's Product Insert for Vetoryl:


A small percentage of dogs may develop corticosteroid withdrawal syndrome within 10 days of starting treatment. This phenomenon results from acute withdrawal of circulating glucocorticoids; clinical signs include weakness, lethargy, anorexia, and weight loss1. These clinical signs should be differentiated from an early hypoadrenocortical crisis by measurement of serum electrolyte concentrations and performance of an ACTH stimulation test. Corticosteroid withdrawal syndrome should respond to cessation of VETORYL Capsules (duration of discontinuation based on the severity of the clinical signs) and restarting at a lower dose.

Marianne

[Chancie]

Hi Marriane,

Thanks for the quick response! I will ask them to check his electrolytes on Friday..but they aren't doing the ACTH test, only a simple blood test to check Cortisol levels. My vet wants to wait and have him come back in another two weeks for more bloodwork and to check thyroid levels at that time.

So--if he is acting off and his electrolytes are out of whack then I should ask to reduce the Vetroyl? I know my vet will take issue with a reduction as she didn't want to start him low and really wants to discuss increasing the dosage....:eek:

Hopefully I will get the results on Saturday to post here, although, maybe they do these easier tests in house?

[labblab]

Barbara, does your vet know that Chance is acting so lethargic? If not, I'd give her a call and discuss the Friday testing in advance. As we talked about earlier, I know that some specialists are shifting to performing only a resting cortisol at the two-week mark, but my understanding is that this is only when the dog is behaving normally. If there is a question as to whether the dog is bordering on an Addisonian condition, the "gold standard" for testing is really the ACTH.

And if Chance's testing results are abnormal in any way on Friday -- either cortisol or electrolytes, your vet should automatically be lowering (or temporarily suspending) his trilostane dose. This is not something you should have to ask for -- it is standard treatment protocol.

But so as not to get into a bind on Friday, I'd encourage you to report Chance's behavior to your vet now. This way, she'll have a preview as to what is going on and can adjust the testing accordingly if he has not improved by the end of the week.

Marianne

[Chancie]

Thanks Marriane for your response! I will give her a call in a bit!:)

--Barbara

[Chancie]

Chance has been peeing alot more today and had an accident in the house! (first one since he started on the Vetroyl--two weeks ago Friday) I don't understand what is wrong? Could the medicine not be working as well anymore? Do Cushpups have bad days, or is he backsliding? :confused::(

One final question and I know for sure I am jumping the gun....but if the Vet says Chancie's meds needs to be upped--can I suggest to just up a little once a week, say 90 mg everyday but once an extra 30mg. Or should we jump right to the 120 dose? Or maybe just add a 10 a day???? I really am hesitant to up since he has been better for almost 2 weeks.....Yikes!!!! Just wanting to control his symptoms with the least amount of medication!!!

Thanks all!

Barb and Chance

[Harley PoMMom]

There are other possible reasons for the peeing accidents such as an UTI or diabetes, if it were me I would have these issues ruled out.

If Chance's ACTH stim test comes back within the therapeutic ranges and other health issues are ruled out, an dosage increase would be reasonable. Since I prefer to error on the side of caution I would only increase Chance's dosage by 10 mg. Also if Chance's symptoms seem to appear later in the evening maybe twice-a-day dosing could be considered.

Love and hugs,
Lori

[Chancie]

Thanks Lori -- I am definately going to ask about upping dose slowly!

Hi all! Chance goes tomorrow for his bloodwork. Below is the note I am giving the office for the vet. If anyone can think of things I should add please feel free to give me suggestions. Thanks again all! Barbara

Dr. ---,

Please check his electrolytes today.

Chance has been very tired lately. VERY TIRED!!! Not even getting up or looking up to greet me. (he will still bounce up for a treat or a walk at the park) He also has much less of an appetite. He will eat his three cups a day (2 feedings of 1 1/2 cups), however, he doesn't eat it all at once. He nibbles at breakfast, usually waits to eat his dinner until around 8 or 9. He will beg me for my food, but definately not like he normally does. He is not as focused when I am cooking or eating. He also does not bug me for his normal nightly snacks of buffalo marrow bones or Dingo bones. He has not "asked" for a treat since his Cushings symptoms started. This is very weird behavior from a dog who was in the habit of having an after dinner snack.

Chance has also thrown up 1x. (last Thursday night, just a little)

He has dramatically slowed his drinking and was accident free until this past Wednesday. He peed once in the house and now seems to be peeing outside alot more. He is still not drinking as much, but his peeing lasts longer and he has to go immediately when we get out of the car--even if we were just at the park.

His bowel movements have been soft since he started on the Thyroid pills--sometimes it seems he strains, occasionally there is a little blood in them. (but that has been the case before he started the Vetroyl, I think from the straining) I have started to give him a couple of spoons of fiber cereal and pumpkin and it seems to help.

If we do need to increase his dose (which scares me because I am afraid it makes him tired), can we just bump it by 10mg at a time to see his reaction since he has been accident free? Also, I am anxious to have his thyroid levels rechecked to make sure I am properly dosing him.

Thank you again for all of your work with my baby!

[lulusmom]

Unless it's pretty evident that a dog isn't responding well to the current dose of Vetoryl, it may not be a good idea to make a change in dosing this early on in treatment. Cortisol usually continues to drop in the first 30 days so if the post stimulated cortisol is close to the therapeutic range of 1.5 to 9.1 ug/dl, I personally wouldn't consider changing the dose until the 30 day acth stimulation test results are in.

Glynda

[labblab]

Barbara, are you still planning on only having a baseline cortisol level drawn tomorrow as opposed to a full ACTH? If so, given the possible symptoms of cortisol withdrawal that you are describing -- if it were me -- I would flat-out object to a Vetoryl increase at this stage. Regardless of the increased urination, Chance's worrisome lethargy would totally scare me off from upping his trilostane at this time.

You are not going to harm him by waiting a couple more weeks for an increase, even if it turns out that his cortisol is still running higher than the desired therapeutic range. But in the absence of a full ACTH, you cannot know with any certainty whether or not this is the case. The researcher who first wrote about the use of baseline cortisols stated clearly that baseline readings may have value in terms of dosing increases ONLY when a dog is clinically appearing to be well. Chance is not a dog who sounds well right now.

My own preference would be to perform a full ACTH now. In the absence of that, I would refuse to allow a dosing increase regardless of the baseline results. I would only use the baseline as an indicator if it signals that his cortisol may be too low. And I also agree with you that I'd really want to be knowing whether his thyroid supplementation is at an appropriate level right now. That could also be creating problems for him that are muddying the water.

Marianne

[Chancie]

Hi Marriane,

Thanks for responding--I for sure will not allow an increase at this time. I will insist on the ACTH test in two weeks at his next follow-up.

I had to work today so my Dad took Chance to the Vet's for his bloodwork. He said she read my note and then took him back the tests. I'm not quite sure what all was done until I see the reciept tonight, but he did say it was $200.00, so I know it wasn't just a resting cortisol. (though he wansn't there long enough for the ACTH, I think they were in and out w/in 30 minutes).

Now--the hard part, the wait.....apparantly I will not hear from the Vet until Tuesday as it is a holiday weekend....keeping my fingers crossed that all is well.

Barbara

[Chancie]

Hi CushFriends!

Since that one accident in the house last week Chance's symptoms have abated. He is back to his prediagnoses peeing...drinking is still normal and not excessive but he is still pretty tired and disinterested. I had to drag him in the pool on Sunday for his swim.

I got the test results back and his electrolytes are normal.

His cortisol came back at 5.4 Normal range is 1-5 (doesn't sound too bad to me)
T4 (thyroid) is .6 Normal is 3-5 (extremely low in my opinion!)

I am thinking the thyroid is causing the tiredness???

My vet wants to increase the Vetroyl, and leave the thyroid chewables at the .5 2x a day. I requested we wait and do another test in 2 weeks because as it was pointed out to me here, his levels may still drop w/in the next two weeks. Plus, I really don't want to chase numbers if his symptoms are controlled. Tonight again he did the weird head movement when I put his food down, and did not finish dinner.:confused:

The vet was unsure if the Vetroyl came in 10mg, but I did say that is what I would be comfortable increasing by if we did decide to do so.

Any thoughts friends??? Should I increase his Thyroid chews on my own to see if it makes a difference or just ride it out the next two weeks?

Thanks!!!

Barb and Chancie

[Steph n' Ella]

YES on the thyroid! My Ella's T4 was at .4 at the beginning of May and now she is a million times less lethargic after treating the soloxine!

[labblab]

Hi Barb,

Did the vet explain why she doesn't want to increase the thryoid med? I agree, that level seems awfully low.

I've forgotten whether Chance had specialized thyroid testing done that indicated whether or not his hypothyroidism is a primary problem in and of itself, or whether it is likely secondary to the Cushing's. If it's the latter and your vet is certain in her own mind that she's soon going to be increasing the trilostane, maybe she's thinking that his thyroid levels may come up on their own once his cortisol is lowered more. But either way, I'd ask her to clarify her strategy regarding the thyroid treatment. Because you're right, low thyroid could certainly explain some of his continuing issues.

Marianne

[Chancie]

Hi Marriane,

Chance did not have any special test that indicated that his thyroid problem was caused by the Cushings--that is her theory and she is thinking the levels will improve. I am of the mind that they are too low and his medication should be upped, maybe not to his orignal dose but a little higher.

I am super confused about what to do and how to go about treating him. I really don't think the resting cortisol level was extremely high, and I'm not really wanting to increase his dosage to lower his level under 5 since his main symptom (peeing/drinking) has cleared up, and I do believe his pot belly has gone down. (BTW--I left him alone from 11-5 with NO accidents):D

I need to figure out how to tell the vet that I want for sure to increase the thyroid and leave the Vetroly dose as is. He goes back a week from tomorrow for another blood test....

Thanks again Marriane!

[StarDeb55]

Barb, I haven't posted to you in awhile but the thyroid test that needs to be done to confirm whether or not primary hypothyrodism is in play, or you are simply dealing with sick euthyroid syndrome from the Cushing's, is a free T4 by equilibrium dialysis, free T4 by ED for short. For the past several years, I have a general understanding with my vet that if any of my pup's total or screening T4 comes back low, he is to add on the free T4.

Debbie

[Chancie]

Thanks Debbie:)

[Chancie]

Hope everyone had a great weekend!

Well--Chance had his 1 month blood test and his Cortisol level is now 4.1 -- still on the 90 mg dose of Vetroly 2x a day! So glad I did not increase the dosage.:)

We are supposed to get his full thryoid panel test results tomorrow, hopefully we can up the thyroid chewable to get him a bit more energy.

So, my question is do we try to decrease the Vetroyl? When should he get his levels checked again?

Thanks all!

[lulusmom]

Hi Barb,

Is the 4.1 the post stimulated cortisol? If so, that is a great number and is not too low. Good job! You cannot use the lab's normal reference range for a cushdog. Established acceptable range for a dog treating with Vetoryl (Trilostane) is 1.5 to 5.1 but as high as 9.1 can be acceptable as long as symptoms have resolved. I would leave Chances dose right where it is. How are his symptoms right now?

Glynda

[Chancie]

Hi Glynda! -- Yup that was the post stimulated number -- two weeks ago it was 5.4.

Chance's Cushings symtoms I think have totally resolved as far as the peeing/drinking. He still has a little pot belly, but, I always liked my guys a little portly:) Although, since starting these pills a month ago he has lost 4 pounds.

The only thing that I am concerned about is the extreme lethary--but, his thyroid levels were so extrememly low two weeks ago, I am assuming that they have remained the same and we will up his thyroid medication today. Hopefully that will result in more energy!

So, I should be hearing from the vet today and I will let you guys know what she says!

thanks again for all the support!